Practice Management


Pay Now or Pay Later...Expanding into Three Clinics and the Cost!
Practice Management
Written by Tim Gober, DC   
Monday, 25 March 2013 21:02
growthaheadsign
G
ood staff will do. Imagine you were planning on building a health care empire.  Would you have time to be so picky about hiring new staff that you would delay months just to find that perfect staff member?  Would you have time to constantly turn over your staff? This process is costly, decreases morale, and ultimately slows you down from achieving your goal.  Hire people who have the basic qualities that any employee should possess.  Beyond that, it is your responsibility to see to it that they are trained properly to serve their purpose.  Great companies tend to create a noticeable culture amongst their employees, and the company's expectations and standards are built into that culture.  A new employee working with such a company should quickly understand what is expected of them regarding work ethic, punctuality, detail, and customer service.  Once these basics are in place, training on their job specifics is simply a function of planning and time.  Be patient, have fun with them, encourage and guide them, and redirect when necessary.  Remember, you are building an empire and you don't have time to lose them and start the process over.  A word of caution:  If your hiring standards are too high, and so few will do in order for your company to be successful, you should reconsider your practice model.  Subway was recently named the most profitable fast food chain, with locations in 85 countries, 150,000 employees, and total annual sales of 9 billion dollars 1.  The simplicity of Subway's business model has been the key to their success.  If they relied on only hiring that one-in-a-million staff member, they never would have grown to the top so quickly.
 
Slow down to speed up.  Commit early to training an associate D.C. as a future clinic director.  Most clinic owners resist this step, since it usually decreases profits in the short term.  Of course the associate D.C. isn't as good as the owner, and they make more errors.  However, if you are patient and dedicated to the training process, the return is substantial because it allows you to replace yourself in the business.  It frees you up to spend the bulk of your time working on the business, not in the business.  Is it more important that you perform the hands-on care yourself, or would you rather be responsible for exponentially more patients receiving care because of the practice you have created?  Not only are extra patients receiving care, expansion also creates more jobs, and more opportunities for advancement within your company.  You win, your employees win, and the patients win.  Have you ever heard that learning how to play golf and tennis is a good idea, since both sports can be played into your elder years?  Well, learning how to train and manage another doctor to run your clinic successfully follows the same concept.  The sooner you learn this vital skill set, the sooner you will be positioned to expand more successfully.  Pay for this experience now, and not later.  Who knows what can happen later.  You have the opportunity to do it now, so get started. 
 

Quick response ads and spinal screenings are nothing but short-term solutions.

Branding works, and prostituting does not.  Many D.C.s that fancy themselves as marketing savvy will tell you that long-term branding is ineffective and a waste of money.  This couldn't be further from the truth.  Quick response ads and spinal screenings are nothing but short-term solutions.  They will not positively contribute to your company's reputation.  Think about it:  You are sending the message that you need patients, and are willing to give away or discount services in order to get them.  Instead, focus on developing the qualities that make your business different.  Determine the best platform to send that message.  Then, begin establishing relationships with as many community members as possible.  Start with the most obvious sources, and go from there.  Once you have reached a critical level of branding, multiple sources of referrals will consistently show up.  Everything gets easier.  Just as more patients attract more patients, more professional referrals attract more professional referrals.  How we did it: Our branding started with informational television commercials, none of which offered discounted or free services. In addition, we began building relationships with the primary care providers and specialists in our community.  As our frequency of calls increased, we had to form a separate call center which allowed all incoming calls to be funneled to a separate location.  Next, we began tracking the calls, and the information that process gave us was priceless.  We discovered that many patients were coming from other towns, and when it was time to open a second clinic we already had supporting data to decide on which location made the most sense.
 
The two step satellite process:  We subleased the space of our second clinic, and began a part-time schedule there. We shared staff between the two clinics in order to minimize the transition costs.  After maximizing our part-time schedule with services, we then moved to step two:  Expanding into our own space within the same building, and offering a full-time schedule.  This two-step plan for a satellite clinic allows you to test a new area before committing to a long-term lease, and the expenses that come with staffing and supplying a full-time clinic.  
 
Make a strategic plan.  Start with a practice model that allows for a large profit margin.  For us, it was the integrated health model.  Determine the best fit for you.  
 
References: 
  1. The Editors of Publications International, Ltd.  How Stuff Works [Internet].  [2007 Sep 15; cited 2013 Feb 7]. Available from: http://money.howstuffworks.com/9-most-successful-fast-food-chains.htm
Tim Gober, D.C. is the President and CEO of The Integration Group, a consulting company specializing in multidisciplinary integration for D.C.s. He is also the owner and founder of The Baltimore Pain Relief Centers. Dr. Gober can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it
 
Small Business Strategy: 4 Vital Tips for Success
Practice Management
Written by Tom Owen III   
Monday, 24 December 2012 04:59
M
uch hard work goes into beginning a new business, and we all know that blood, sweat, and tears are the primary ingredients for success.  However, it takes much more than that to establish a thriving business. In building your chiropractic business, many other factors also come into play. After many years of running a chiropractic business, my partners and I have come to understand that there are a few elements that are absolutely critical to becoming successful. The following four tips should help you fine-tune your chiropractic business and have your message reaching the masses in no time.
  
Choose your Name Carefully
chessboardFirst of all, your business will need a name.  And not just any name, but something people will remember.  A clever, descriptive name is actually a smart business strategy.  The name of your business is key.  Although it is difficult to come up with a name that is descriptive, yet one of kind, many people have had success with this.  For example, Coca-Cola's name comes from the coca leaves and kola nuts used as flavorings in the original drink.  And Google derived its name from the fact that you can find a "Googol" of information from an Internet search engine (a “Googol” is the number “1” followed by 100 zeros.)  Put much thought into your name—it is imperative that people can remember it and recommend it to others via the best kind of free marketing: word-of-mouth. 
 
Promote your Practice
Once you have a name, you will need to advertise and market your business.  Marketing is of utmost importance. Without it, there will be limited or no growth. Marketing your chiropractic business is necessary from the very beginning, and needs to be a continuing part of your overall business strategy. 
 
Direct mail is one of the oldest and most effective ways to reach your market. You can rent or purchase a mailing list and then mail postcards to announce or promote your practice.  Your mailings will go out to areas in the vicinity of your practice.  Your postcard can educate the public on various treatments and services while also advertising your name and location. 
 
In addition to postcards and mailings, the Internet is another great way to draw attention to your business.  These days, people are constantly online, so having a website for your chiropractic business is essential. The website can be simple and does not need to be fancy or expensive. But even a basic website should look professional, should contain a short bio for each doctor or provider, and should list your services, address, and contact information, including email.
 
It’s important to remember that marketing does not stop once you have a steady flow of patients.  To maintain your clients and continue to grow, you must continue to market your business from within your business.  You may consider setting up a monthly theme in your office or a birthday board with patient’s birthdays posted. Periodically emailing your clients with newsletters, updates, and special discounts is another good idea.  Offering occasional promotions, discounts or free screenings is a great way to attract new business and show existing patients that you care. The business strategy here is to encourage patients to strike up conversations about your business.  Again, the best marketing is word-of-mouth, and it’s free!
 
Manage your Business
Regardless of how well you advertise your business, you will only be as successful as your management practices allow.  Before you ever delve into a new business, consider the cost.  Literally sit down and make a basic spreadsheet to consider the upfront cost of beginning your business.  Consider your operational costs, marketing costs, and the costs of your supplies.  Make certain that you have enough capital before you start.
 
Next, consider your cash flow. You need a steady cash flow to continue to thrive each month until your business is steady.  If you need more capital or cash, consider these options: 1) Partnership. A partner can share the cost, but will also share the potential profits. Your partner also needs to be someone with whom you share mutual trust and with whom you get along well. Weigh this option if necessary.  2) Cost cutting. To cut back on initial costs, find employees--perhaps friends or family--who are willing to work for deferred salaries in the beginning.  And postpone any and all purchases as long as possible. 
 
Pamper your Patients
Most importantly, your customers, your patients, are your most valuable assets. Without them, your business is nothing. Once you have a client, you must work hard to keep him by exceeding his expectations. It's much cheaper to keep a client than to attract a new one, so keep clients happy and keep them coming back. Your customers are also your greatest and least expensive mode of marketing. Call them on occasion, just to check on their wellbeing. Get to know them and develop a relationship with them through dialogue in the office. Treat them well and they will spread the word for you.
 
How to End a Roller Coaster Practice
Practice Management
Written by Paul S. Inselman, D.C.   
Thursday, 30 August 2012 00:57
T
he January 5, 2012 CNN Money article “Doctors are Going Broke” stated, “most doctors in private practice have experienced a 10 percent to 15 percent profit leak which can lead to significant losses in their bank account.” Since 2008, the majority of chiropractic practices are down an estimated 25% or more. Unfortunately, the news gets worse. Higher gas prices and more forecasted insurance cuts will continue to create headwinds for the profession.  Since the beginning of time, chiropractors have experienced the proverbial roller coaster practice. This article will provide you with information that will help put an end to the nauseating dips, turns, and uncertainties that a roller coaster practice provides. 
 
rollercoasterYou will only get one chance to make a great first impression and that begins with your consultation. Your consultation will literally make or break your practice. There are two reasons, in my opinion, to perform a consultation. (1) To adhere to the standards of care in case you are ever sued. All professions require that you perform the minimally acceptable standards of care. All first-line health providers are required to perform a proper OPQRST (Onset, Provocative/Palliative, Quality, Radiation, Site, and Timing) consultation and proper examination to arrive at a proper diagnosis and treatment plan. Failure to perform either the consultation or an examination will cause an almost guaranteed loss of your case. 
 
Non-performance of a proper consultation and examination also puts you in jeopardy that an insurance company not only will not have to pay you, but can also ask you to refund monies that they have already paid. (2) To determine why the patient is really there. Our patients will tell us that they are there for neck pain, back pain, or sciatica. Please be aware that they are really there because their neck pain, back pain, or sciatica is precluding them from doing something they want to do; or they are afraid that their neck pain, back pain, or sciatica will prevent them from doing something they want to do.
 
Here is a scary test for you to perform. Go into your clinic after reading this article and ask yourself why Mr. or Mrs. Patient is on your table. If you get answers like neck pain, shoulder pain, or tendonitis, guess what? You missed the boat in your consultation, as you will soon see.
 
It is very important, especially for those doctors practicing greater than five years, to remember to be “human” and to project empathy and sympathy with each and every patient. Why even make mention of that very basic fact? After you have been practicing for awhile, and you have seen thousands of patients and their problems, it is easy for you and me to take it for granted that this is “just another case”. What I want you to remember is that for the patient, the experience is painful, scary, and upsetting. It is also the most important thing in their life at that time. For us not to give them our full attention, complete with the human caring qualities that we would want to receive, is doing our patients a terrible disservice.
 
The mechanics to performing a proper consultation are as follows:
  1. Establish rapport
  2. Establish commonality
  3. Praise them for however they came to your office (walk-in, referral, advertisement)
  4. Start with OPQRST
  5. Categorize the disruption of activity of daily living (ADL)
  6. Ask them what would their life look like if _____ went away?
  7. Keep it human and conversational
  8. Do not make it sound or feel like an interrogation
  9. Be 100% present
  10. Do not allow staff to disturb you unless there is an emergency.
In step number 5 above I suggested that you categorize the disruption of ADL. In my experience, I have found that the majority of patients can be classified into the following categories:

realreasonschartOther doctors that I teach have found the above table to be very helpful in figuring out why a patient is “really” coming for help. Typically, the patient has a real problem of job loss, disability, medication, etc. Or, they have a fear that if their problem continues it will lead to a job loss, disability, medication problem, etc.
 
During the interview with the patient, ask questions about each category and determine if it applies, if it is a real problem, or if they are fearful of the problem. You should always resist the urge to guess why they are really there. You need to know with certainty why they are really coming to you.
 
A great way to practice and train yourself is to role play with friends and family members. Play the game “why am I really here”? The way the game is played is have your partner choose a problem. It can be neck pain, tendonitis, or whatever they choose. Remember, the pain is precluding the patient, or the patient is fearful that the problem will preclude them from doing an activity of daily living.  The object of the game is for you to determine the real reason why the patient is there. The answer will typically be in one of the categories above. Some examples of why the patient is really there that you should come up with are as follows:
  • The patient is here because she has a fear that her migraines will cause her to become addicted to pain meds like her mother.
  • The patient is getting adjusted so they can get back to exercise. Exercise is important to the patient because they suffer with depression. Exercise is the only thing that really keeps them from becoming depressed. The real reason that they are here is to give them the best opportunity to ward off depression.
  • The patient is getting adjusted because they are afraid that if they can’t take care of the house and kids that their spouse will divorce them.
If you are coming up with the patient is here for headaches, you have missed the boat. Go back and keep practicing.
 
Another good tip is to video and/or audio tape yourself performing practice consultations, as well as actual consultations. Evaluate for present time consciousness (PTC), quality of your questions, rapport skills, empathy and sympathy projection, and excitement. A great metric to use is: would you be happy if a doctor that you went to performed the same consultation in the same way? (Golden Rule)
 
Performing a complete consultation followed by a solid report of findings will go a long way to helping you ward off a roller coaster practice. It is important to remember that you and I treat patients, not conditions. If we offer treatments that are aimed at repairing disruptions of activities of daily living instead of symptoms, we will stand out head and shoulders above the crowd of other doctors that the patient has seen in the past. You will be the first doctor in the patient’s mind that actually listened and more importantly heard their real complaint. This will lead to more respect, more referrals, and a more solid and enjoyable practice.
 
Dr. Paul S. Inselman, President of Inselmancoaching, is an expert at teaching chiropractors how to build honest, ethical, integrity-based practices based on sound business principles. From 2008-2012 his clients’ practices grew an average rate of 145% while the general profession was down 28%. His 26 years of clinical experience coupled with 10 years of professional coaching has allowed him to help hundreds of chiropractors throughout the nation. He can be reached at 1-888-201-0567 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it
 
What Does It Take to Succeed as an Entrepreneur?
Practice Management
Written by Tom Owen III   
Wednesday, 29 August 2012 23:40
M
aking the decision to open your own chiropractic practice can be both exciting and terrifying. First of all, congratulations on your decision to branch out from the comfort zone you have enjoyed while working for someone else's practice. Taking a leap into the unknown by becoming your own boss is risky, but that risk is an essential ingredient in your success as an entrepreneur. 
 
success9As chiropractors, we are more inclined towards the technical aspects of both our work and lives. Having a love for the technicalities of your work is great! This knowledge, as well as your passion for chiropractic philosophy, is what got you through chiropractic school in the first place. To succeed in running your own practice, however, you will need to harness your inner business person – and business involves both risk-taking and creativity.
 
If you haven't picked up a copy of Michael Gerber's book, The E-Myth, I would highly recommend that you do so. Here, Gerber teaches his readers to not fall victim to a common entrepreneurship myth (or, "E-Myth"). This myth tells us that if we know how to handle the technical side of our business, we have an understanding of the entire business. 
 
A chiropractic business is more than just the technical aspect of service. While it is true that the business would not exist without the service, we have to understand how to manage a business and maintain a customer base in order to succeed. In addition to handling the patients and problems that arise in the moment, we must look ahead and plan for the future.
 
Success tip #1: Know what you need
 
Your particular skill set is what makes your practice possible, but do you have what it takes to turn your skills into a successful business? You may find it necessary to hire help for administrative duties, reception, and billing. The key here is to keep any overhead expense at a minimum. Try to hire employees who are capable of handling multiple tasks, or find software programs that can reduce and simplify administrative or billing work.
 
Success tip #2: Manage your staff
 
Until now, you have only worn one hat – as the chiropractor. When operating your own practice, however, you must also put on the "boss" hat. Though your staff may be trained in skills beyond your particular areas of expertise, it is important that you hire knowledgeable, experienced employees with whom you can work closely and trust. Ask questions and be involved with the business side of your business. It is imperative for the success of your entrepreneurship that you have a solid grasp on what is going on with your accounting books, appointments, etc. at all times. You must also work closely with your staff to ensure good morale and customer service practices. Your administrative staff will likely be the first staff members that your clients will encounter, and first impressions are everything.
 
Success tip #3: Market yourself
 
In order to succeed, you must make yourself known! Develop a mission statement that clearly conveys to your potential clients what it is that you can do for them. Reach out to the public through social media (Facebook, Twitter), radio advertisements, mailers... even go door to door. It's important that you get creative when trying to establish a solid client base. Host an open house, develop special promotions – whatever it takes to get people walking in through your doors.

Success tip #4: Maintain your clients

Never become comfortable with the status quo.

 
Once the people are making appointments, the ball is in your court. This is your time to shine with your technical expertise and ability to help others. Make customer service a priority in order to retain your clients. Again, it is key here that your entire staff is on board with keeping clients happy. From answering phones to answering questions, you and your employees should all represent your practice with eloquence, authority, and knowledge. You will find that the majority of your new business will come from reviews and referrals, so it is essential to your entrepreneurship that you maintain 100% customer satisfaction.
 
Success tip #5: Educate and expand
 
Besides recommending you to other prospective clients, happy patients can aid in the growth of your entrepreneurship in other ways. Though you may be taking care of one problem for a client, they may not realize how many other ways you can improve their health and quality of life. It is your job to educate your patrons on the various services and educational products that you can offer to them. This is a mutually beneficial tool that will both increase your revenue and your customer satisfaction.
 
Remember that of utmost importance in your journey into chiropractic entrepreneurship is your constant passion for your work and your business. Never become comfortable with the status-quo.To keep your practice vibrant and successful, you must always work to improve and grow your business.
 
Anatomy of a Practice Consultant Buyer Beware: How to Choose the Right One
Practice Management
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.   
Wednesday, 29 August 2012 23:05
Disclosure: I am a practice consultant and, after 31 years in the industry, I have been on both sides of the fence. I see and speak to many new consultants in the industry and some are excellent, yet I see many leading doctors down a "slippery slope." Beyond the emotional choice, too many doctors do not have enough tools to make an informed choice. This document is dedicated to giving doctors additional tools to guide and protect themselves.    
 
I
 am trusting, eager, believe in my "gut," and hungry to take my practice to the next level. Therefore, I will seek counsel from  many who are smarter than I and I am willing to pay for their knowledge. That was my mantra for many years and I paid handsomely for answers from consultants whom I trusted to bring me to the "promised land" of practice. At one point, I paid 7 years in a row and many, many $1000s to be guided. 
 
risk8My disillusionment and subsequent enlightenment came when I was assigned a consultant who constantly called me for advice on issues he had difficulties with. It was at that time I realized it was time to find a formula to make better decisions. This was a learning experience that I ignored 10 years later and, again, I spent countless $1000s  based upon blind faith that brought me close to total financial ruin because the scheme created did not stand the test of time and I willingly became their guinea pig. They made money and I ended up writing checks to lawyers and carriers.
 
Most consultants in our profession have either stumbled upon or developed formulas in their private practices and feel they can profit from the profession by putting together a similar program in a "canned" package where the message remains constant. That in itself is not a bad thing...for today. The one constant is that everything changes, and, in today's healthcare marketplace, those changes are occurring more rapidly than ever. Therefore, consultants need to be able to change and alter their messages to keep up with those changes. In cash practices, states are passing legislation and updating regulations on how you can bill. 
 
Workers' compensation practices face even bigger challenges as the rules are changing so rapidly that even the carriers can't keep up with the changes. Many states have adopted evidenced-based outcomes as criteria for care. Others are strictly using ICD as criteria and yet others have a formula that is completely arbitrary. Then there are court rulings regarding labor issues that also have to be dealt with.
 
Personal injury is even more intricate. Doctors have to deal with internal insurance company rules, which are arbitrary, but have to be dealt with nonetheless. There are the state regulations and laws which do not change rapidly (except in Florida) and then there are court rulings which literally change on a daily basis, redefining how we need to conduct ourselves in our triage and paperwork. After all of those issues, lawyers representing the patients have issues that must be dealt with on a constant basis. 
 
Managed care is usually more straightforward, yet highly secretive at the same time. The rules are clearly laid out, but they hide their fee structure formula behind a metric based upon their actuarial tables and will not divulge them. It usually requires a court order or subpoena to obtain them. On top of that, they have so many ways not to pay you, a fact you often only discover following the completion of a voluminous amount of paperwork. If you are lucky enough to get paid, you get a fee so low that if every patient was a managed care patient you'd close your doors in financial ruin. 
 
If you  have a consultant for any of the above financial classes, how well versed are they in the process they are consulting you for? I didn't ask if they are good at getting you business because it is relatively EASY to get business and make money. The real issue is: Do you get to keep the money that you make?
 
A few years ago, one consultant created a scheme for cash practices and then exposed all of his clients to lawsuits for acting as insurance companies without the proper licenses.

Another consultant's advice resulted in almost every client being sued by the carriers for improper corporate structures, costing some doctors millions in legal defense, and in the end many lost their practices. Another consultant strongly recommended the use of certain documentation to overcome the carriers' objections in payment. One doctor he consulted with did get paid, but 5 years later the doctor was sued by the carriers, retrospectively costing the doctor close to a million dollars. He lost his practice. The consultant, who was not a doctor, walked away to spend the doctor's hard earned money, never to be heard from during the lawsuit or any time thereafter.
 
How do you choose the best consultant for your practice? 
 
Here are strong suggestions:
 
1. What are the qualifications of the consultant?
 
This is the most important issue; more so than the subject matter of the consulting program. Your consultant will eventually drive your practice. The only verifiable, valid vetting process is through the consultant's curriculum vitae if he/she is a professional or a résumé for a non-professional. A professional CV is preferable for 2 reasons. First, you want someone who has been where you are and understands the issues from the inside out vs. a spectator who is commenting on a game he/she has no "skin" in. Second, a professional CV is a legal document that cannot be falsified, as that is a felony in most states and can be the cause for loss of license. 
 
2. What is the experience of the consultant?

One doctor he consulted with did get paid, but 5 years later the doctor was sued by the carriers, retrospectively costing the doctor close to a million dollars.

 
Is your potential consultant experienced in the specific field he/she is consulting for and for how long has he/she been one? Too many consultants are only experienced in their personal offices or ancillary fields and that is problematic. Many consultants have figured out a "scheme" to get more patients or extract money from carriers and/or patients without knowing whether or not 5 to 10 years downstream that scheme will stand the test of time and not trigger a lawsuit later in practice or retrospective audits as many schemes do. Remember, your consultant is not responsible for your actions. You have the sole responsibility and, in the end, you alone will be writing that big check for a lawyer to defend you or a refund to the carriers if the consultant is wrong.
 
3. Is the subject matter being taught in line with your practice goals?
 
Simply put, are the teaching materials offered sufficient for you to make the changes you need to positively affect your practice?
 
4. Has the method stood the test of time and done so in your state?
 
How long has this method been employed and by how many? Is it important that the consulting method be deemed successful in my state? Some programs are universal and not state-specific while others have been altered state-by-state. Time is critical to determine the success of a program, and although some "start-ups" will thrive over time, do you want to be the "guinea pig?" In some cases, the answer is yes, but be very discerning. Remember the adage of "a fool and his money.."
 
5. Scour the credentials of the consultants and all that work for them.
 
It always goes back to credentials and not just those of the primary consultant, but everyone in a consulting capacity within their organization. Be alert for telltale signs, such as improper grammar in a signature line. Does he/she sign his/her name Dr. Joe Smith DC?  You can't have a "Dr." in front and a "DC" at the end. Does he/she consult on workers’ compensation despite having run a cash practice for an entire career? Does he/she consult on personal injury with vast experience in "on the job injuries?" Credentials do not lie. You also might end up with an employee of the main consultant working with you. What are his/her credentials?
 
6.  Schemes

Does the consultant build an entire program around a scheme designed to confuse the carriers or alter usual and customary practice standards for you to make money? Unless the program is based upon accepted clinical and practice standards, which include documentation standards, you leave yourself exposed to huge issues downstream. Creating a scheme of "smoke and mirrors" is big in the "get rich quick" programs, and in the end they rarely stand the test of time, instead resulting in a necessity for lawyers to defend you. 
 
If a program is centered around "busting" something vs. learning how to succeed at a higher level of clinical and business excellence, look at other professions and realize they do not have any of these programs, confirming this is just another "get rich quick scheme." 
 
7.  Testimonials

Testimonials drive business. However, be careful as any business owner can get his/her friends to write testimonials. The key is how many testimonials are offered and is there diversity in the messages? Getting an individual referral to talk to is important, but, again, you will be handed the "cream of the crop" for that person's business. Certifying success in this instance is more a function of sheer volume from a diverse geographical location. 
  
 
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