Hospitals Archives

Pa. nurses rally at State Capitol to address workforce crisis

Seeking to solve their workforce crisis, hundreds of Pennsylvania nurses from eight of the region’s largest nurses’ unions and advocacy groups rallied with patients, families, community advocates, and elected officials Tuesday at the State Capitol.

Nurses met with legislators and testified before the Pennsylvania House Health Committee on the need for safe nurse staffing legislation and to urge passage of the Patient Safety Act (HB 106).

Rebecca Hartman, a registered nurse from Allentown, said nurses are happy to work hard and happy to do hard work but want to be able to do the work safely.

“If you make the job doable, more nurses will do it,” she said in a statement. “That’s why we’re here, asking our elected leaders to please help us and pass the Patient Safety Act here in Pennsylvania.”

The bill was introduced in the PA House last Friday in bipartisan cooperation by state Reps. Tom Mehaffie, R-Dauphin, K.C. Tomlinson, R-Bucks, and Bridget Kosierowski, D-Lackawanna, who is a nurse. A companion bill is expected to be introduced in the Senate by state Sen. Maria Collett, D-Montgomery, who is a nurse as well.

“As a legislator, a mom, and a registered nurse of 29 years, I have many concerns about some current healthcare issues,” Kosierowski said. “This proposed legislation that we have worked so hard on allows our nurses to give patients the care that they deserve in a safer environment for all.”

The House Health Committee held a hearing Tuesday to discuss the bill and took testimony from nurses and stakeholders. Among those testifying was Denelle Weller, a registered nurse from Central Pennsylvania.

“When I discuss the needs of our patients, I want this committee to fully understand what it really looks like when staffing is not appropriate or safe,” Weller said. “Basic needs like bathing, toileting, eating, and even drinking cannot be met, especially when a patient is relying on you to assist with these needs.”

Weller said patients can lay in their own urine and feces and develop deep ulcerations on their bodies if not turned and repositioned in bed. The wounds, she added, can become so large and deep that an adult can fit their first into them.

Supporters feel the legislation will help fix the nurse workforce crisis and save lives, as well as saving hospitals and health systems millions of dollars.

Robert Williams, a registered nurse from Northeast Pennsylvania, said studies have shown that safer staffing levels correlate directly to better quality of care and patient outcomes.

“One University of Pennsylvania School of Nursing study in 2021 estimated that the savings due to fewer readmissions and shorter lengths of hospital stays is about $70 million, more than twice what the safe nurse staffing levels would cost,” said Williams.

Nurses believe chronic unsafe staffing has led to high turnover rates at hospitals and unsafe conditions for patients. A recent survey of current and former hospital workers revealed that 90% of respondents reported that their hospitals do not have sufficient staff to handle the workload.

Myra Taylor, a registered nurse, said the problem facing nurses is not new. Even prior to the pandemic, short staffing was cited as the single biggest driver of nurse burnout and turnovers.

“This is something I have seen building over the course of my career and when the pandemic hit, it exposed the long-growing cracks in our healthcare system,” said Taylor. “But we can fix these cracks. We can solve this crisis. We can save our hospitals money and we can save lives while we’re doing it. We just need to pass the Patient Safety Act.”

Among the nurses and others rallying at the Capitol was a coalition of organizations, including the Nurse Alliance of SEIU Healthcare PA, Nurses of Pennsylvania, the Pennsylvania Association of Staff Nurses & Allied Professionals (PASNAP), the Jersey Nurses Economic Security Organization (JNESO), the Pennsylvania State Education Association (PSEA), Council 13 of American Federation of State, County and Municipal Employees (AFSCME), the Health Professionals and Allied Employees (HPAE), and the Pennsylvania Health Access Network (PHAN).

PASSHE takes action to address crucial nursing shortage

To address a critical nursing shortage, Pennsylvania’s State System of Higher Education (PASSHE) is seeking $112 million in state funding to train more students in six in-demand, high-growth jobs, including nurses and physician assistants.

PASSHE universities would use $12.5 million of the $112 million request to create a stronger pipeline of nurses and physician assistants from the classroom to the workforce. To save high-need students and average of $5,000 per year, the universities would use $7 million to provide direct financial aid to nursing and physician assistant students.

The remaining $5.5 million would be used to expand high-cost nursing programs.

Reducing the financial cost to obtain a degree is a crucial step toward enabling more people to start their education to become nurses and physician assistants. Affordability is particularly important for urban and rural students to have the chance to work at healthcare facilities and hospitals and ease the significant labor shortages the nursing industry is experiencing.

The shortage of nurses and assistant physicians is severely straining the ability of Pennsylvania’s healthcare system to provide patient care. A recent industry survey in Pennsylvania found vacancy rates of 32% for certified registered nurse practitioners and nursing support staff, 30% for registered nurses providing direct care, and 17% for clinical nurse specialists.

As baby boomers age and require increased health care, the shortage of frontline workers is expected to worsen. According to the 2020 National Nursing Workforce Survey conducted by the National Council of State Boards of Nursing, the median age of RNs is 52, indicating a potential wave of retirements within the next 15 years.

Healthcare is the System’s third largest academic program with more than 11,000 students, including 4,680 nursing and physician assistant students, and more than eight and 10 nursing students stay in the state following graduation.

Yet to deal with the needs of Pennsylvania’s aging population, it is expected that by 2030, 34% more physicians will be required, 33% more nurse practitioners, and 9% more nurses.

To further prepare more workers to ease labor shortages, PASSHE is separately requesting $573.5 million, an inflationary increase of $21 million, enabling the Board of Governors to consider freezing basic in-state undergraduate tuition for an unprecedented fifth consecutive year.

Pennsylvania hospitals face financial challenges but hold strong on economic contributions

Pennsylvania hospitals, while facing financial challenges in the post-pandemic world, still support one in 10 jobs and contribute a fifth of the state’s gross domestic product.

A report conducted by the Hospital and Healthsystem Association of Pennsylvania (HAP) shows hospitals are facing financial stress due to increased costs of supplies and labor while facing stagnant payments from insurers, Medicare and Medicaid and stock market losses.

“Hospitals are critical to the health and future of Pennsylvania communities, both because of the essential care they provide and their role as job creators and economic engines,” said Andy Carter, president and CEO of HAP. “Hospitals support family-sustaining jobs throughout all parts of the commonwealth and are often among—if not the—top employers and economic flagships in their communities.”

HAP’s analysis of fiscal year (FY) 2021 data reveals that Pennsylvania hospitals—both directly and through the ripple effects of their economic activity—benefitted their communities and the commonwealth by:

Contributing $168 billion to the state and local economies
Supporting 590,000 jobs throughout the entire commonwealth
Generating $38 billion in wages, salaries, and benefits

The analysis also highlights the strain hospitals are experiencing due to rising expenses, the continued COVID-19 pandemic, a historic workforce shortage, and a national behavioral health crisis and calls attention to the need for investments and policies to support hospitals long-term sustainability.

“In the face of financial stress there is a risk to access to health care,” Carter said. Since 2020, five hospitals have closed and others are facing cutbacks in services to keep the overall operation solvent, he said.

“No one has lived through a pandemic, economic turmoil from the pandemic, and international turmoil that we are seeing today,” Carter said. “Communities are proud of their hospitals and broadly speaking, most are not at risk of closure.”

That said, Carter emphasized that hospitals want to continue to reflect the quality of services offered before COVID-19 and not become a shadow of their former selves.

However, he said, the increased cost of labor, mainly due to a shortage of nurses and nursing support staff; supply cost increases from gauze to high tech equipment; and pharmaceutical increases, hospitals are feeling the squeeze.

Still they are vital to the communities they are in, he said.

Some of the key findings of the analysis include:

Pennsylvania hospital jobs pay, on average, nearly 6% higher than the statewide average wage for all sectors.
Hospitals rank fifth among all Pennsylvania industries for employment and fourth for total annual wages.
59 of Pennsylvania’s 67 counties have at least one hospital among their top 10 employers and in 18 of them, a hospital is the largest employer.

Hospitals are among the top 10 industries directly contributing to Pennsylvania’s economy, ranked ninth between construction and management of companies and enterprises.
Hospitals and universities with hospital-affiliated medical schools secured nearly $1.8 billion in highly competitive federal research funding to advance health care innovation.
Pennsylvania general acute care hospitals reported $866 million in foregone revenue due to uncompensated care.

According to the Pennsylvania Health Care Cost Containment Council, Carter said, 30% of the state’s hospitals reported losing money in 2021 and 15% reported modest earnings. No one, he said, invested in modernization and new offerings.

“There is no single answer to this,” Carter said, but “we have a range of ideas.”

Changes to Medicare and Medicaid payments are vital. Carter said the government needs to increase those payments, or at least stop the cuts. There was a 2% decrease in July. “Hospitals did get a one-time support from the federal government through American Rescue Plan money,” he said.

HAP has requested money from the state’s pandemic funds as well to offset the losses due to COVID, Carter said.

“We also need to improve the workforce,” he said. “We need to increase the numbers going into the pipeline. While this won’t have an immediate impact, it will help three to five years down the line.”

Carter explained that with the nursing shortage, hospitals are turning to temp agencies to hire nurses from across the country or internationally. That comes with a cost, he said.

A survey of HAP members last winter showed that since 2019:

Hourly rates paid to staffing agencies for registered nurses providing direct patient care in medical/surgical and other units have increased by 108% from $59 per hour to $123 per hour while the average number of shifts per day worked by temporary staff increased from five to eleven
Hourly rates paid to staffing agencies for registered nurses providing direct patient care in specialty units have increased by 82% from $66 per hour to $120 per hour while the average number of shifts per day worked by temporary staff increased from four to nine
Hourly rates paid to staffing agencies for nursing support staff (such as certified nurse assistants, patient care assistants, and nurse assistants) have increased by 444% from $9 per hour to $49 per hour while the average number of shifts per day worked by temporary nursing support staff increased from three to five

“Some of this need is abating as some health care workers are returning to the field,” he said.

Another area of concern is telehealth, Carter said. “We need to cut the red tape and make sure providers are paid for telehealth services.”

Carter explained that due to the pandemic, restrictions were lifted for telehealth. Now they are at risk of expiring. But more than that, he said, providers need to be paid for telehealth services, which is not always the case.

The importance of telehealth, he said, is that it makes care easily assessable and helps with staffing issues.

Finally, Carter said payments from insurers and Medicare and Medicaid payments must increase to match what hospitals pay to treat patients.

“We are calling on lawmakers and insurers to step up and join hands so as not to put hospitals at risk,” Carter said.

COVID-era waivers expanding telehealth reimbursements set to end this year

Health care providers supercharged their telemedicine offerings as a result of the pandemic—however, how those providers will be reimbursed for virtual care moving forward is in question.

Prior to the pandemic, most providers did not receive enough reimbursements from insurance companies to justify expanding their telehealth coverage.

That changed when the Centers for Medicare & Medical Services, a federal agency that oversees Medicare and Medicaid programs across the country, introduced leniencies on HIPPA requirements on video software and broadened access to Medicare telehealth services.

Third party payers followed suit by expanding their telehealth service coverage, offering advanced payments to independent health care providers and waiving fees for members using virtual care.

Coverage that was previously based on the discretion of insurance companies, has become common across insurers, said Andy Carter, president and CEO of the Hospital Association of Pennsylvania (HAP).

“The number one impediment to telehealth expansion was that there was no payment model that you could get return on your investment because a lot of insurers wouldn’t pay for telehealth consults or appointments,” said Carter. “COVID changed that dramatically, where immediately public payers and private payers were paying for it across the board.”

In a 2022 report on national survey trends in telehealth use, researchers with the US Office of Health Policy noted that from March to April 2020, telehealth use skyrocketed across the country from 1% to 80% in “places where the pandemic prevalence was high.”

Today, patient usage of telehealth is significantly down from the days of quarantine, with the report finding that percentage had dropped to around 20% among adult respondents to a survey given between Sept. 29 and Oct. 11, 2021.

Providers see telehealth usage remaining much higher than pre-pandemic levels with the focus now turning to how providers and insurers can work together to standardize telehealth.

Standardizing telehealth

HAP has spent years trying to standardize telehealth protocols and practices, particularly when it comes to reimbursing providers for telehealth services.

Their most recent effort on that front has been backing Senate Bill 705, legislation that would require insurers to pay providers no matter if that provider is in that insurers’ network.

Carter said that in the past, the association supported bills that would provide parity between in-person and virtual care, meaning that payers would need to reimburse providers equally for either service, but the association has now agreed to leave pricing to individual payers and providers.

“We argue that standardization is hugely important,” said Carter. “Insurance is already complicated enough and a patient’s access to care through telehealth should not be a lottery. Parity was a nonstarter for our friends in the insurance community. We agreed to new language as an alternative.”

HAP is also currently in support of House Bill 2419, which would allow for more flexibility for the state to allow providers to offer mental health services through telehealth permanently.

House Bill 2419 has been passed in the House and is currently awaiting consideration in the Senate.

Pennsylvania’s COVID-era waivers that explicitly authorized telehealth services to expand during the pandemic will expire this October.

The waivers were set to expire at the End of June and were extended by the General Assembly on June 30.

The waivers expand access to telehealth services, increase vaccine access, allow hospitals to quickly adapt to emergencies by altering space as needed for influxes of patients, and ease regulatory barriers to clinician licensing.

Pennsylvania does not have any statutes that will prohibit the practice of telemedicine after the waivers expire but payers will be able to stop reimbursing for telehealth.

“Absent the current COVID driven waivers and flexibilities, we won’t sustain telehealth the way we did before COVID,” said Carter. “It’s not supposed to go away. People got used to it.”

Providing care in the virtual space

In the two years since providers have embraced telehealth, virtual care has had a massive impact on how the industry cares for patients.

Providers are now looking at how things like wearable technology and remote patient monitoring can keep tabs on patient health between visits, said Christopher LaCoe, vice president of virtual health at Penn State Health.

“We’ve moved to the point where we have all these opportunities to do checkups for diabetes. We might be able to do that stuff here and then send (the diabetic patient) to the eye doctor and not make them drive to our office,” said LaCoe, adding that educators are now taking telehealth services into consideration when they teach incoming providers. “Medical schools are putting this in their curriculum. They used to say you need to see diabetic (patients) every three months and now they say once a year.”

LaCoe, credited the waivers, calling the changes that happened to telehealth the pandemic’s “silver lining.”

Pittsburgh-based Highmark Health was early to the market on allowing telehealth for its providers, but prior to the pandemic, providers had little guidance on what that should look like, said Dr. Tim Law, vice president and executive medical director at Highmark.

“Highmark said you can do telehealth, but we won’t tell you how to do it—it wasn’t front and center,” said Law, noting that changed quickly during the pandemic. “We put together a virtual care playbook. Five years ago, I don’t think anyone would have thought of doing this. It includes where to find supplies, how to access Bluetooth technology so you can do remote patient monitoring and we show them what states allow providers to work across state borders.”

Highmark provides parity for its covered providers using telehealth with some of the states the payer operates in mandating it.

However, even though some insurers are ahead of the curve with how they support and pay for telehealth with their covered providers, providers outside of a network may find themselves without telehealth reimbursements, said Carter.

“Some insurers will say we provide telehealth to our covered lives. It’s only to the telehealth providers they’ve enrolled in their network,” said Carter. “That’s a model that leaves a lot of people without access to their preferred provider. Someone they know and trust.”

Legislation providing $225 million to PA health care industry awaits signature by Gov. Wolf

A bill allocating $225 million in state relief to support health care professionals and strengthen Pennsylvania’s health care workforce has been approved by both the House and Senate and awaits a signature from Gov. Tom Wolf.

The bill, sponsored by Rep. Clint Owlett, R-Tioga, Bradford and Potter counties, was introduced to the House in early 2021 to establish a task force to “improve the safety, well-being and permanency of substance-exposed infants and other young children adversely affected by their parents’ substance abuse disorders.”

It was approved by the Senate on Tuesday with amendments including $225 million from Pennsylvania’s COVID-19 Response Restricted Account to be given to hospitals and their employees.

The amended bill sets aside: $100 million to be allocated to all Pennsylvania hospitals based on licensed beds for all facilities; $110 million for supplemental payments for critical access hospitals, high Medical Assistance hospitals and behavioral health providers of inpatient services; and $15 million to fund the Student Loan Relief for Nurses Program.

The bill’s amendments were approved by the House today. It will now be sent to Wolf, who said today that he “will be proud to sign this legislation into law.”

“This measure will provide, among other things, much needed funding to help our hospitals in Dauphin, Cumberland and Berks counties address severe workforce shortages while allowing us to offer incentives and recruit and retain top talent,” said Deborah Addo, executive vice president and COO at Penn State Health. “Further, by supporting the Pennsylvania Student Loan Relief for Nurses Program, it will help us to replace nurses who have left the profession in recent years. This action by the General Assembly is a much-needed lifeline for hospitals and behavioral health facilities.”

Upon its passage in the Senate on Tuesday, the amended bill received support across the state for its promise to deliver support to health care professionals following two years on the front lines of the pandemic.

“There was an industry-wide health care staffing shortage before the pandemic, which has now become a crisis that threatens to affect patient care,” said Andy Carter, president and CEO of the Hospital and Healthsystem Association of Pennsylvania. “House Bill 253 will support health care professionals immediately and begin to address some long-term challenges of the staffing crisis. This investment in our health care heroes will help Pennsylvania’s health care system provide high-quality care now and in the future.”

Pre-COVID report: ‘Pa. hospitals supported one in nine jobs’

Pennsylvania’s hospitals fueled $143 billion in total economic impact and supported one in nine jobs in the state last year, according to a new report released this week by the Hospital and Healthsystem Association of Pennsylvania (HAP).

The report, released through a white paper and online dashboard, was based on data received from the U.S. Department of Health & Human Services’ fiscal year 2019 hospital cost report and provided to HAP by its member health systems.

Pennsylvania’s health care sector represents 18.6% of the state’s workforce, a 36% increase since 2000, making it the leading employment sector in the state over manufacturing, HAP wrote in the report.

More than 660,000 jobs are powered by the hospital community– 291,000 of which are directly associated with hospitals and health systems and 371,000 through contracted positions supported by hospital spending.

In 2019, hospitals and hospital systems contributed $143 billion in total economic impact in Pennsylvania. The hospitals’ impact included $64.4 billion paid out of employee salaries, wages, and benefits as well as goods and services needed to provide health care services and support hospital operations.

$78.6 billion of that total number was from an additional economic activity from the circulation of hospital dollars throughout the state, the report said.

The report goes on to note that even before the pandemic, Pennsylvania hospitals and health systems were seeing increased financial stress. The report cites a report by the Pennsylvania Health Care Cost Containment Council that states that uncompensated care for Pennsylvania general acute hospitals increased from $750 million in 2018 to $820 million in 2019.

Also in 2019, 34% of hospitals in the state posted negative operating margins and 29% posted operating margins between 0% and 4%.

The pandemic has worsened this financial stress on hospitals exponentially with hospitals across the state losing over $5 billion due to temporary closures and pauses on non-emergency treatment, according to a different HAP report.

Andy Carter, president and CEO of HAP, said that systems will need further support from the federal and state government if they are to recover from the pandemic.

“Our hospitals and health systems—and the hundreds of thousands of incredible employees who keep them caring for everyone—have faced truly extraordinary challenges this year,” said Carter. “For the state’s hospital community to overcome these challenges, and remain the economic engine that we need to recover from the lasting impacts of this crisis, we need continued support from our legislative leaders in Harrisburg and Washington, D.C.”

Hospitals in green-phase counties approved to allow visitors

Hospitals in counties transitioning to the green phase of Pennsylvania’s reopening plan may reopen their facilities to visitors at their own discretion, according to updated guidance released Wednesday by the Wolf administration.

Gov. Tom Wolf’s most recent update to his green-phase guidelines notes that visitation to both prisons and hospitals can resume if they are in one of 18 counties transitioning to green status Friday.

Many hospitals enacted their own visitation rules as early as mid-March. The state’s new guidance gives facilities the option to open their doors to visitors, but reminds those visitors to be diligent about hygiene.

York-based WellSpan Health prohibited all visitations to its hospitals on March 21 save for a few exceptions such as minor patients and patients nearing the end-of-life.

WellSpan plans to begin lifting restrictions at its hospitals when nearby counties begin transitioning to the phase, said Matthew Heckel, a spokesperson for the hospital system.

“Our number one priority during this COVID-19 pandemic has been to keep everyone in our hospitals safe,” Heckel said. “As counties continue the reopening process, the visitation policy for our hospitals and outpatient settings will likely become less restrictive; however, healthy and approved visitors would continue to be required to follow guidelines in place including the wearing of a face covering when in a WellSpan Health facility.”

Hospitals need better partnership with Wolf, lawmakers to protect Pennsylvanians

Hospitals are the front line for providing health care during the COVID-19 pandemic, yet there is a lack of partnership with the Pennsylvania state government to protect hospitals, health care workers and the communities they serve.

Throughout this pandemic, The Hospital and Healthsystem Association of Pennsylvan

ia has worked in partnership with the Department of Health and other state agenci

es to protect the health of the people of Pennsylvania. But we have not always felt the support of elected officials during this time.

A telemedicine bill that would have provided greater access to care was vetoed.
An executive order establishing medical liability protections did not include hospitals.
And the response to a request for financial relief to support hospitals as they face economic challenges of more than $10 billion was only a short-term loan program.

There’s no point in planning for a resurgence of COVID-19 if we cannot protect the hospitals that will potentially be gearing back up to hold that front line again in a few short months. The hospitals and health systems of this commonwealth stood to protect patients during this public health crisis, and now we are asking the governor and General Assembly to stand with us.

Pennsylvania’s hospitals are hubs of community health, teachers of tomorrow’s doctors and nurses, leaders in medical research, and community economic anchors, and they support more than 650,000 people with jobs. They are among the largest employers in 85 percent of Pennsylvania’s counties, and they contributed more than $136 billion to the state economy in 2018.

A loss of more than $10 billion and the lack of important protections will create a ripple effect on the physical and economic health of communities across the state. This is why we need the governor and General Assembly to support Pennsylvania hospitals.

Andy Carter is president and CEO of The Hospital and Healthsystem Association of Pennsylvania.

Survey: Nation’s hospitals lack access to COVID-19 testing supplies

Hospitals across the country are experiencing a widespread lack of access to COVID-19 testing supplies, according to a survey from the U.S. Department of Health and Human Services.

The survey, conducted through phone interviews with 323 hospital administrators throughout the nation from March 23 to March 27, is intended to help federal and state agencies adapt to the short- and long-term implications hospitals are facing during this crisis.

In addition to a lack of testing supplies, hospitals are experiencing a delay in receiving COVID-19 test results, the survey reports.

Securing personal protective equipment also continues to be a problem, as well as the conflicting guidance in how to use the PPEs.

The report also found that hospitals are facing financial challenges because of cutbacks in elective procedures, which accounts for a substantial portion of their revenue. Overall, hospitals are seeking more support from the federal government to help manage their finances.

The full report can be read here.

New hospitals join Pennsylvania’s Rural Health Model

Pennsylvania Department of Health Secretary Dr. Rachel Levine announces the first rural hospitals to take part in the state’s Rural Health Model in March. PHOTO/ IOANNIS PASHAKIS

Eight more hospitals across the state will be joining a state initiative created to help rural hospitals receive the funding they need to stay open.

This March, the Pennsylvania Department of Health launched its Rural Health Model, a payment model that asks insurers to pay hospitals through fixed monthly payments instead of by patient.

Hospitals are commonly reimbursed by insurers through a fee-for-service model where the insurer pays the hospital each time a patient visits. For hospitals operating in rural populations with unpredictable admissions, the lack of funding during slow periods can end in closure.

In the program’s initial rollout, five insurance companies agreed to change their funding model for five Pennsylvania hospitals.

The department announced on Thursday that eight more hospitals have been approved for the program and Hartford, Connecticut-based Aetna has agreed to join the program as its sixth insurer.

“The Rural Health Model is a transformative step that changes the financial model for hospitals in rural areas,” Secretary of Health Dr. Rachel Levine said. “This is a step that will help achieve financial stability for these facilities and aims to improve the overall health of the community.”

The newest hospitals joining the model include: Armstrong County Memorial Hospital in Armstrong County, Chan Soon-Shiong Medical Center at Windber in Somerset County, Fulton County Medical Center in Fulton County, Greene hospital in Greene County, Punxsutawney Area hospital in Jefferson County, Tyrone Hospital in Blair County and Washington Hospital and Monongahela Valley Hospital in Washington County.

Insurers pay the hospitals based on how much they paid the hospitals when they were using the fee-for-service model. Aetna will be joining the program along with Gateway Health Plan, Geisinger Health Plan, Highmark Blue Cross Blue Shield, Medicare and UPMC Health Plan.

The department plans to grow the model from 13 hospitals to 30 by 2021 with the ultimate goal of bringing all of Pennsylvania’s 67 rural hospitals under the model.

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