In addition to covering certain levels of care, the 2017 guidance incorporates other milestones that states must achieve during the term of an IMD SUD waiver (Figure 7).20 These include using evidence-based patient placement criteria; applying nationally recognized provider qualification standards; implementing prescribing guidelines and other strategies to address opioid abuse; and improving care coordination and transitions between levels of care.21 CMSs 2019 IMD SUD waiver evaluation design guidance identifies SUD treatment access and utilization,22 health outcomes,23and opioid-related overdose deaths as three key areas to assess.24. In addition, recent federal legislation provided policy options for substance use disorder services but not specifically for mental health inpatient services. Does Medicaid Cover Mental Health? - Medicare.org States were more likely to report plans to maintain audio-only coverage for mental health and SUD services compared to other, non-behavioral health services. Additionally, the SUPPORT Act directs MACPAC to study Medicaid payments to IMDs in a representative sample of at least two states by January 2020. Keep up with news and updates from the Milbank Memorial Fund. [74] California Health Care Foundation, Medi-Cal Moves Addiction Treatment into the Mainstream: Early Lessons from the Drug Medi-Cal Organized Delivery System Pilots at 4, 5, 6 (Aug. 2018), https://www.chcf.org/wp-content/uploads/2018/08/MediCalMovesAddictionTreatmentToMainstream.pdf. Commonly reported initiatives include mobile crisis response and service initiatives (separate from the ARPA option); crisis hotlines; and crisis diversion, stabilization, and/or receiving centers. [34] NM and WV may have discontinued use of managed care in lieu of authority in FY 2020 due to approval/implementation of Section 1115 IMD SUD waivers. Before applying for an IMD SUD waiver, Virginia reviewed its existing Medicaid SUD benefits to determine what was working well and whether there were other evidence-based services that could be added to the benefit package to establish a robust community-based continuum of care. to ensure short-term residential treatment stays. See, e.g., CMS Special Terms and Conditions, Illinois Behavioral Health Transformation Demonstration, at p.8, section V., 20 (July 1, 2018-June 30, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/il/il-behave-health-transform-ca.pdf; CMS Special Terms and Conditions, Vermont Global Commitment to Health Demonstration at p. 53-54, section XV., 92 (Jan. 1, 2017-Dec. 31, 2021, amended June 6, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/vt-global-commitment-to-health-ca.pdf. On KFFs 21st annual Medicaid budget survey, all responding states reported at least one initiative to expand behavioral health care in Medicaid in state fiscal year (FY) 2021 and/or 2022,1 including crisis service and other benefit expansions, initiatives to expand telehealth and address equity, and managed care changes. This trend tracks with the Biden Administrations identification of behavioral health policy and investments as a key federal Medicaid priority. Idaho, Massachusetts, New Hampshire, New Jersey, North Carolina, and Rhode Island report plans to pursue an IMD mental health waiver in FY 2020, while Alaska, Connecticut, Virginia, and Washington report plans to do so after FY 2020.56. Results from the first year (April 2017 to March 2018) of waiver implementation in Virginia found that the number of outpatient providers billing for ARTS services increased by 173%;75the number of Medicaid enrollees who used SUD treatment services increased by 57%;76and more than 40% of enrollees with SUD received treatment, up from 24% in the prior year.77In the seven counties that began service delivery in 2017, Californias waiver evaluation found that the number of people accessing treatment increased by about 7%.78In the three counties included in the California waivers managed care external quality review report, the number of enrollees receiving SUD services nearly tripled in the first year of waiver implementation, compared to pre-waiver baseline claims data.79 While not yet included in Californias waiver evaluation findings, San Diego County anecdotally reports a 40 to 50% increase in the number of patients receiving SUD treatment services on both an inpatient and outpatient basis since waiver implementation in July 2018, compared to the corresponding month in the prior year. PDF Medicaid and Behavioral Health Services - home.nyc.gov These mobile crisis services generally do not have to be offered statewide and can be targeted to specific groups of enrollees (rather than be available to all Medicaid enrollees). Id. While largely redundant of its existing waiver, the state sees the state plan option as more of a long-term assurance to have IMD payment authority in place. We also use third-party cookies that help us analyze and understand how you use this website. For example, a pregnant woman may see both an obstetrician and an MAT provider on the same day. Virginia requires providers to include comprehensive transition plans and coordination of current care and post-discharge plans related to community services in their treatment plan to ensure continuity of care upon discharge with the individuals family, school and community. covers mental health care services you get when you're admitted as a hospital patient. Must ensure that IMD placement will allow for successful community transition. CMS State Medicaid Manual 4309 (C), https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html. [44] The screening must include initial and periodic assessment to determine the appropriate level of care, length of stay, and setting of care for each individual. H.R. For example, psychiatrist services are covered under the required physician services category. The SUPPORT Act partially lifts the IMD payment exclusion by allowing states to use federal Medicaid funds for nonelderly adults receiving IMD SUD services up to 30 days a year,36 from October 2019 through September 2023.37 IMD coverage under the SUPPORT Act option is in addition to IMD services covered under managed care in lieu of authority38 and Section 1115 waivers.39 To receive Medicaid payments under the SUPPORT Act option, IMDs must follow reliable, evidence-based practices and offer at least two forms of medication-assisted treatment (MAT) on-site40 for opioid use disorder. Residential care refers to inpatient mental health services received in a Must develop policies to link residential patients to community-based services. Installed by Google Analytics, _gid cookie stores information on how visitors use a website, while also creating an analytics report of the website's performance. [11] Kaiser Family Foundation, Medicaid Home and Community-Based Services Enrollment and Spending (April 2019), https://www.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/. About half of all responding states reported non-MCO initiatives related to behavioral health screening in FY 2021 and FY 2022. Other recent federal policy options more directly target Medicaid, such as ARPAs expansion of mobile crisis response services, which aim to connect Medicaid enrollees experiencing mental health crises to appropriate community-based care (an option which the proposed BBBA would make permanent). It does not store any personal data. [75] VCU Health Behavior and Poly School of Medicine, An Evaluation Report Prepared for the Va. Dept of Medl Assist. In Patient Care | Mental Health America PDF Medicaid Mental Health and Mental Health Services Plan, effective 10.1 Medicaid is the single largest payer for mental health services in the United States and is increasingly playing a larger role in the reimbursement of substance use disorder services. In 2017, inpatient services were used by just under half (46%) of nonelderly Medicaid adults with SUD who received drug or alcohol treatment in the past year (Figure 1). Additionally, DC and Indiana have submitted pending waiver requests for IMD mental health services under the new guidance, with more states expected to follow. MassHealth Section 1115 Demonstration Amendment Request (Sept. 8, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-pa3.pdf. Services - Psychiatry and Psychology - Mayo Clinic Other notable co-location initiatives in place or planned include: States use a combination of FFS and managed care arrangements to deliver behavioral health care to Medicaid beneficiaries, with these services increasingly being provided by MCOs in recent years (see Appendix A). But opting out of some of these cookies may have an effect on your browsing experience. About two-thirds of responding states indicated they have other, non-ARPA-related crisis service initiatives in place in or planned for FY 2022. Box 3: Overview of Case Study Areas Because waiver evaluations are ongoing and there is limited information about states experiences and outcomes with IMD waivers to date, we conducted case studies in Vermont; San Diego County, California; and Virginia, to provide a snapshot of how these three areas are using IMD waivers and identify common themes and lessons learned. [19] CMS, Strategies to Address the Opioid Epidemic, SMD #17-003 (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf. In contrast, Virginias waiver initially included a 90-day maximum IMD stay, but CMS subsequently removed that provision, recognizing that stays tend to be longer at the lower levels of residential care where the focus is more on supportive services and less on clinical care. The Health Care Authority (HCA) provides funding and oversight for mental health services for people enrolled in Apple Health (Medicaid). Theres no limit to the number of benefit periods you can have, whether youre getting mental health care in a general or psychiatric hospital. Linkedin - Used to track visitors on multiple websites, in order to present relevant advertisement based on the visitor's preferences. PDF Fact Sheet: Medicaid Coverage of Inpatient Psychiatric Treatment for [45] H.R. State Coverage Policies of Mental Health Services for Adults It appears to be a variation of the _gat cookie which is used to limit the amount of data recorded by Google on high traffic volume websites. It is used by Recording filters to identify new user sessions. 6, 5052 (a)(2) (creating new Social Security Act 1915 (l)(4)(D)(ii)). H.R. Learn what types of services are covered, find a provider or telehealth service and more. Psychiatric Residential Treatment Facility Providers | CMS Behavioral Diagnostic Assessment & Evaluation Mercy offers 24/7 support for mental health crises through our emergency departments. Inpatient Psychiatric Care | Behavioral Health | Henry Ford Health [16] Waivers issued under the 2015 guidance included specific day limits on IMD stays eligible for federal Medicaid funds: Marylands waiver allows two 30-day stays, while California has approval for two 90-day stays for adults and two 30-day stays for adolescents. For example, while Vermont reports that its IMD SUD waiver is working well, it also is considering pursuing the SUPPORT Act state plan option. Google DoubleClick IDE cookies are used to store information about how the user uses the website to present them with relevant ads and according to the user profile. The cookies is used to store the user consent for the cookies in the category "Necessary". The cookie is used to store the user consent for the cookies in the category "Performance". The Pacific Health Policy Group, Vermont Global Commitment to Health Section 1115 (a) Medicaid Demonstration 11-W-00194/1, Interim Evaluation Report #1, including Evaluation of IMD Expenditures at 82-83 (March 30, 2018), https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf. Kendal Orgera, Senior Data Analyst at KFF, provided analysis of 2020 National Survey on Drug Use and Health. Eleven states reported making recent changes to how behavioral health benefits are delivered under MCO contracts: three states in FY 2021 only, four states in FY 2022 only, and four states in both FY 2021 and 2022. [2] David G. Smith and Judith D. Moore, Medicaid Politics and Policy, at 188-89 (2008); see also CMS State Medicaid Manual 4309 (A)(2), https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html. Despite subsection 73 (1) of the Health Care Consent Act, 1996, the chair shall assign the members of the Board to sit in panels of three or five members . Figure 4 lists factors considered in this determination. State experience with these initiatives can help inform policy choices and design as other states consider similar waivers. Behavioral Health Services | Medicaid R.S.O. Without the waiver, the California Medicaid state plan benefit package is limited to outpatient, intensive outpatient, perinatal residential (non-IMD), and opioid treatment program services. An endowed operating foundation that engages in nonpartisan analysis, collaboration, and communication, with an emphasis on state health policy. Thirty-one states (out of 45 responding) reported that telehealth, especially expanded audio-only coverage, had particular value in maintaining or improving access to behavioral health services. This brief summarizes data from this survey, with key findings including: Some states reported behavioral health initiatives across many areas, often as part of wide-ranging statewide initiatives identified as top priorities for their Medicaid programsexamples include California, Colorado, Massachusetts, Montana, and Washington. Four states (CA, MD, ND, and PA) reported that they do not use this authority, and two states (GA and KS) did not respond to this question. Necessary cookies are absolutely essential for the website to function properly. From 2013 through 2016, Vermonts interim waiver evaluation found that emergency room use within 30-days post-IMD discharge declined compared to emergency room use prior to the IMD admission for both mental health services (with declines ranging from 23 to 44%)84and SUD services (with declines ranging from 39 to 56%).85Psychiatric IMD readmission rates averaged 8% after 30 days over the four years, while SUD readmission rates were under 15% across settings (general hospital detox, IMD detox, and IMD residential) during this period.86 During the first 10 months of waiver implementation in Virginia, the number of emergency department visits related to SUD decreased by 14%, and the number of Medicaid enrollees with an acute inpatient admission related to SUD decreased by 4%.87. Vermont will be able to meet CMSs 30-day statewide average requirement by averaging that facilitys stays with another IMD that has more beds and serves patients with less acute needs. The number of states with Section 1115 IMD SUD payment waivers has increased dramatically since 2017, now comprising over half the states. Mental Health and Addictions - Ministry Programs - Public Information [80] Vermont uses HEDIS measures. The number of Section 1115 IMD SUD waiver approvals has markedly increased since January 2017. [42] State and local funding must remain at the level for the most recent fiscal year prior to SUPPORT Act enactment or the most recently ended fiscal year as of the date the state submits a state plan amendment to elect the new option, if higher. Other states not included as case studies for this report similarly expanded community-based services either under or in conjunction with their waivers authorizing payment for IMD services, such as West Virginia,63Kansas,64Illinois,65Alaska,66Indiana,67and Wisconsin.68However, at least one state (Kentucky) has restricted access to some community-based services (methadone) while funding IMD services under its waiver.69. Medicaid plays a key role in covering and financing behavioral health care: in 2020, Medicaid covered 23% of nonelderly adults with mental illness, 26% of nonelderly adults with serious mental illness (SMI), and 22% of nonelderly adults with SUD; in comparison, Medicaid covered 18% of the general nonelderly adult population (see Appendix A).3 The COVID-19 pandemic and resulting economic recession have negatively affected mental health and substance use outcomes and exacerbated barriers to care. Additionally, states may report on state-identified metrics. Must use evidence-based patient assessment and placement criteria and provide access to MAT. States can spend a portion of their Medicaid DSH funds on IMD services.35 States must make these payments to offset uncompensated care costs incurred by hospitals that serve a disproportionate number of low-income patients. You also have the option to opt-out of these cookies. Monitoring Metrics for Section 1115 Demonstrations with SUD Policies, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-monitoring-metrics.pdf; see also Medicaid Section 1115 SUD Demonstration Monitoring Report Template, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-monitoring-report-template.pdf; Medicaid Section 1115 SUD Demonstration Monitoring Protocol Template, https://www.medicaid.gov/medicaid/section-1115-demo/evaluation-reports/evaluation-designs-and-reports/index.html. Notably, all three areas had devoted substantial time and resources to expanding and strengthening a robust network of community-based SUD treatment services in addition to IMD services. The cookie is used to store the user consent for the cookies in the category "Performance". Peterson-Milbank Program for Sustainable Health Care Costs, Assessing the Effectiveness of Policies to Improve Access to Primary Care for Underserved Populations, Case Study Analysis: Kanawha County, West Virginia, New Medicaid Proposed Rules Focus on Primary Care, Training the Primary Care Workforce to Deliver Team-Based Care in Underserved Areas: The Teaching Health Center Program, Washington, DC Receives First CMS Approval of Expanded Medicaid Coverage for Inpatient Mental Health Services, Medicaid is more likely to cover additional services, Medicaid is the primary payer for long-term services and supports, Medicaid managed care in lieu of authority, approved or pending IMD SUD payment waiver, approved Section 1115 IMD mental health waiver, https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html, https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/, https://www.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/, https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/, https://www.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/, https://www.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals/, https://www.medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf, https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/il/il-behave-health-transform-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/vt-global-commitment-to-health-ca.pdf, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-implementation-plan-template.pdf, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-monitoring-metrics.pdf, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-monitoring-report-template.pdf, https://www.medicaid.gov/medicaid/section-1115-demo/evaluation-reports/evaluation-designs-and-reports/index.html, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-evaluation-design-tech-assistance.pdf, https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf, https://www.medicaid.gov/federal-policy-guidance/downloads/faq051719.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-pa3.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/nc-medicaid-reform-ca.pdf, https://www.gao.gov/assets/690/686456.pdf, https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/, https://www.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/, https://store.samhsa.gov/shin/content/SMA18-5063FULLDOC/SMA18-5063FULLDOC.pdf, https://www.medicaid.gov/federal-policy-guidance/downloads/cib072619-1012.pdf, https://www.asam.org/resources/the-asam-criteria/about, https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/, https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/Global-Commitment-to-Health/vt-global-commitment-to-health-eval-dsgn-appvl-20190609.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ca/ca-medi-cal-2020-ca.pdf, https://www.chcf.org/wp-content/uploads/2018/08/MediCalMovesAddictionTreatmentToMainstream.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/va/va-gov-access-plan-gap-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wv/wv-creating-continuum-care-medicaid-enrollees-substance-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ks/ks-kancare-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ak/ak-behavioral-health-demo-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/in-healthy-indiana-plan-support-20-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wi/wi-badgercare-reform-ca.pdf, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ky/ky-health-ca.pdf, http://www.uclaisap.org/dmc-ods-eval/assets/documents/2017-2018%20UCLA%20DMC-ODS%20Evaluation%20Report%2011192018.pdf, https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/ARTSone-yearreport_8.9.18_Final.pdf, https://www.caleqro.com/data/DMC/County%20&%20Annual%20DMC%20Reports/FY%202017-2018%20Reports/Annual%20Report/CalEQRO%20DMC-ODS%20Statewide%20Annual%20Report%20FY17-18%20.pdf, https://www.chcf.org/wp-content/uploads/2018/11/HowMediCalImprovingTreatmentSUD.pdf. Mental-health charity Mind chief executive Sarah Hughes called the announcement "a crucial step in tackling the serious concerns we have about the state of mental health inpatient care in England". These hospitals focus on serving individuals who are in the custody of penal authorities. IMDs do not include institutions for people with intellectual disabilities. Linkedin - Used to track visitors on multiple websites, in order to present relevant advertisement based on the visitor's preferences. 5600 Fishers Lane Rockville, MD 20857 1-877-SAMHSA-7 (1-877-726-4727) They register anonymous statistical data on for example how many times the video is displayed and what settings are used for playback.No sensitive data is collected unless you log in to your google account, in that case your choices are linked with your account, for example if you click like on a video. NH, NJ, IL, VT, WA) note that the state will aim for a statewide average length of stay of 30 days. Your provider should determine which hospital setting you need. CMS Special Terms and Conditions, Alaska Substance Use Disorder and Behavioral Health Program, No. This report provides new data to understand current patterns of Medicaid enrollees' use of inpatient and outpatient substance use disorder (SUD) and mental health treatment services; explains the options for states to access federal Medicaid funds for enrollees receiving IMD services; analyzes current waiver activity; and draws on interviews wit. LinkedIn - Used to store consent of guests regarding the use of cookies for non-essential purposes. 6, 5011-5012. Box 2: Institutional Services and Community Integration Waiving the IMD payment exclusion and expanding institutional services without also ensuring adequate access to community-based services could have implications for states community integration obligations under the Americans with Disabilities Act (ADA) if people with disabilities are inappropriately institutionalized.10The Supreme Courts Olmstead decision found that the unjustified institutionalization of people with disabilities violates the ADA. [62] CMS Special Terms and Conditions, Virginia Governors Access Plan for the Seriously Mentally Ill (GAP) and Addiction and Recovery Treatment Services (ARTS) Delivery System Transformation Demonstration, #11-W-00297/3 (approved Jan. 12, 2015-Dec. 31, 2019, amended Sept. 22, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/va/va-gov-access-plan-gap-ca.pdf. 440.10. For eligible individuals, Medicaid insurance plans can provide coverage for drug and alcohol addiction treatment. This is called mental health parity and requires that rules about copayments, number of visits and pre-authorizations should be similar for accessing mental health and substance use disorder services as they are for . [51] These states include CA, CO, CT, DE, DC, IL, IA, LA, ME, MI, MS, MO, NE, NJ, NC, ND, OH, OR, PA, RI, SC, TX, UT, and WA. 1315 (a). We offer inpatient psychiatric care programs based on age for adults and children age 5 and older with a referral from a healthcare provider: Children and teens program Adult program Learn more about the conditions we treat and our treatment programs. In addition, this data which is the most recently publicly available predates the Affordable Care Acts Medicaid expansion and the opioid epidemics impact over the last six years, and consequently may understate the number of enrollees now utilizing these services in states that have implemented the expansion since 2014.3, Federal law generally bars states from receiving any [Medicaid] payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an [IMD].4 The payment exclusion applies to services provided within an IMD as well as to services provided outside an IMD to nonelderly adult IMD patients. Each room includes a private bathroom . [22] These include increased referrals to and engagement in treatment, increased adherence to treatment, and reduced preventable or medically inappropriate emergency department and inpatient treatment. 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