Financial impact of phys”>American Journal of Emergency Medicine (2012) 30, 532-539

Original Contribution

Operational and financial impact of physician screening in the ED^?,??

Olanrewaju A. Soremekun MD ^a,?, Paul D. Biddinger MD ^b,c, Benjamin A. White MD ^b,c, Julia R. Sinclair ^c, Yuchiao Chang PhD ^d, Sarah B. Carignan ^c, David F.M. Brown MD ^b,c

^aDepartment of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA ^bDivision of Emergency Medicine, Harvard Medical School, Boston, MA, USA ^cDepartment of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA ^dDepartment of Medicine, Massachusetts General Hospital, Boston, MA, USA

Received 8 November 2010; revised 29 December 2010; accepted 19 January 2011

Abstract

Background: Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.

Study objective: We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center.

Methods: We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in Left without being seen rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS.

Results: During the first year, we estimate the Contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in Boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%.

Conclusions: In addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.

(C) 2012

^? Prior presentations: none.

^?? Study funding or other financial support: none.

* Corresponding author. Tel.: +1 646 8314970.

E-mail address: [email protected] (O.A. Soremekun).

Introduction

Emergency department (ED) crowding and associated prolongED wait times to access clinicians are issues that face many EDs across the United States and around the world. Previous studies have demonstrated that crowding leads to both

0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2011.01.024

significant delays in the initiation of care for patients presenting to EDs, with all levels of acuity, as well as delays of appropriate treatment for patients with Serious conditions in which prompt treatments have been shown to improve outcomes [1-8].

In addition, longer wait times have been associated with lower patient satisfaction scores and higher rates of patients who leave the ED without being seen (LWBS) [9,10]. Because of these demonstrated decreases in the quality of care and in patient satisfaction, ED crowding and associated prolonged wait times to access care are increasingly being recognized as important public health issues [11].

Nationwide, many hospitals are implementing interven- tions to alleviate the problems of ED crowding and associated prolonged wait times [12,13]. Broadly, these interventions can be grouped into 2 categories based on their impact on the ED flow model [14]: (1) those interventions designed to decrease throughput time (eg, bedside registration, physician screening, and improved laboratory operations) and (2) those interventions aimed at increasing output, especially for admitted patients (eg, Boarding patients in inpatient hallways, smoothing elective surgery schedules, and bed czars).

Physician screening is one form of throughput interven- tion where a designated physician is deployed to intervene early in patients’ ED course to guide triage and/or accelerate the initial evaluation and treatment for patients during a period where patients otherwise would have been waiting for

a bed space in the ED. This intervention, already adopted by some EDs, has been shown to decrease the door-to-medical assessment, ED length of stay , and percentage of patients who LWBS [15-18].

Although the positive operational impact of many of the throughput and output interventions to tackle the problems of crowding have been described in the literature, their impact on ED finances, resource use, and quality have not been well described. In this study, we aim to estimate the financial impact of implementing a physician screening sys- tem in an ED.

Methods

Please see Table 1 for definition of financial and opera- tional terms. Physician screening was fully implemented in December 2007 at our institution. We conducted a retrospec- tive review of 12-months preimplementation and postimple- mentation of a physician screening system performed in an urban tertiary academic center with approximately 90 000 annual visits and an admission rate of approximately 27%. The physical plant of the study center was designed for an annual census of 60 000 visits with an average LOS of 4 hours and was deemed to be at full operational capacity before implementation of the physician screening system.

Table 1 Definition of financial and operational terms

Definitions

Financial terms

Capital expenditure Expenditures on fixed assets that create long-term future benefits. Investments in buildings and equipment are usually considered capital expenditure.

Cash flow Cash received, over time, from an investment or operational activities. Cash flow is usually used to value investments. Total CF = cash flow = ED revenue - ED direct costs - operational costs of screening + inpatient margin contribution of admitted patients - capital expenditure.

Charges Charges defined as the amounts billed for services rendered. Does not represent actual revenue (see below).

Collection rate Collection rate is the percentage of charges that are collected. Collection rate affected by bad debt (portion of receivables that cannot be collected), contractual payment agreements, and an institution’s payor mix.

Direct costs Incremental cost of providing care for additional patient.

Discount rate Also referred to as cost of capital. Refers to the cost of a company’s funds. Cost of raising capital for a project.

Used to calculate the value today of funds to be received in future years.

Earnings Difference between adjusted revenue and direct expense. Indirect overhead costs are NOT included in costs. Internal rate of return The discount rate where the NPV of an investment equals zero.

Contribution margin Revenue minus direct cost.

Net present value The value today of future CFs of an investment, using the cost of capital.

Return on investment Ratio of profits gained (or lost) relative to amount invested. Ratio can be expressed in many different ways, for example, NPV, years to break even, internal rate of return.

Revenue Revenue defined as actual payments received, which is based on charges adjusted by collection rate (see above). Revenue = charges x collection rate.

Years to break even Time to recoup initial investment. Operational terms

Percent billable Visits to the ED that can be billed. The LWBS and patient return for follow-up (eg, for removal of stitches, drains) are not billable.

Disposition Refers to the admission, discharge, or transfer of a patient. time to disposition is the time at which the decision is made.

Left without been seen Patients who leave before being evaluated by physician.

Annual growth in ED volume from prior year was 3900 patients (4.5%) with no increase in ED treatment area capacity. The center has 4 adult treatment areas: 1 high-Acuity area, 2 medium acuity areas, and 1 fast-track area. There are also separate dedicated pediatric and acute psychiatric treatment areas. Besides the growth in volume of patients in the postimplementation period and staffing changes directly related to the intervention, no other confounders were identified in the postimplementation period.

Physician screening system was implemented in our institution in December 2007. The hours of operation of the screening system were 11 AM to 11 PM, corresponding to peak arrival rates in the ED. Fig. 1 is a schematic of patient flow with and without the operation of the physician screening system. All patients arriving during the hours of physician screening are initially evaluated by the triage nurse. This triage nurse determines the Acuity of patients and the appropriate location in the ED for the patient to receive care. High-acuity patients are sent directly to the acute care area, bypassing the physician in screening. Low-acuity patients are also sent directly to the fast-track waiting room, also bypassing the physician in screening. The physician in screening evaluates all the medium acuity patients with the following goals: (1) screen all medium acuity patients and identify those patients who may have occult presentations of severe illness where prolonged wait times may lead to worse outcomes, (2) initiate the evaluation and treatment for patients who are deemed able to wait for an ED bed but for whom no bed is immediately available, and (3) accelerate the disposition of a subset of medium acuity patients (ie, arrange for discharge or admission from the ED without use of a treatment area bed in the ED) after initial evaluation and treatment when appropriate. The accelerated disposition of a subset of patients is a key difference between our study center and other physician screening systems in the published literature. This difference requires an additional nurse practitioner to follow up on test results, call appropriate consults, and handle the details required for safe disposition of patients to Inpatient units or home. Along with an

additional nurse practitioner, additional nurses as well as capital resources to redesign the waiting room was needed in our system. The overall intervention allows for a safer functional increase in ED capacity by identifying patients who can be rapidly admitted or discharged and also by carefully deciding which patients in the ED truly need monitored bed spaces and which can wait in an observed internal waiting room.

All adult patients, arriving at all hours, who were triaged to the medium acuity treatment area were potentially affected by the physician screening system and, thus, included in the analysis. Patients triaged to the low-acuity or high-acuity treatment area were excluded from the analysis because they were sent to either the fast-track or the acute care area after they have been evaluated by the triage nurse and without evaluation by the screening physician (see Fig. 1).

The operational performance data were extracted from the computerized Order entry and patient Tracking systems. Operational outcomes measured include ED LOS, time to the Disposition decision, boarding of admitted patients, and percentage of medium acuity patients who LWBS.

Three components of the financial impact of the physician triage were considered: revenue, operational costs, and capital expenditure.

Two main revenue sources were identified from the physician triage system in our study. The first was an increase in ED functional capacity that allowed for the care of additional medium acuity patients. Before implementation of physician screening, the ED was at full capacity and unable to care for additional medium acuity patients without a decrease in the quality of care provided or an increase in percentage of patients who LWBS. Therefore, the acceler- ated disposition of patients performed under the ED physician screening program allowed for care of additional medium acuity patients (low-acuity patients were excluded from the study), effectively increasing ED bed capacity to provide care for additional patients. The second revenue source was an increase in percent billable because of the decrease in the LWBS rate.

ED Care Beds

High Acuity Area

Medium Acuity Area - A

Triage RN

Physician Screening: 11am -11pm

Post Screening

Screening MD

Medium Acuity Area - B

Fast Track

Disposition

Patient Arrives

Fig. 1 ED patient flow.

Given that actual unit charges and reimbursement rates for ED visits and inpatient admissions are considered to be proprietary at our institution and also unique to our institution given the health care market in our state, we used revenue assumptions that are more representative of the national averages and performed sensitivity analysis around these assumptions to demonstrate the range in value of this intervention.

The following revenue assumptions were made to determine the revenue impact of discharged patients: (1) average charges of $1390 per patient, based on Medical Expenditure Panel Survey, and (2) 35% collection rate, based on rates used in other financial studies and medical expenditure panel survey [19,20]. The direct costs of ED care for discharged patients, as a percentage of revenue, were assumed to be 35%. This level of direct cost is based on prior published reports [21,22].

Given the low rates of admissions in the LWBS population, we assumed no margin contribution from the hospitalization of these patients. The admission rate of the other medium acuity patients was based on the observed rate at the study site. The financial contribution margin of these patients’ total hospital stay was based on published margin contribution of $1000 per admission via the ED [9,23,24]. Annual ED volume growth was assumed to be 3%.

Incremental operational costs associated with physician screening include employee and marginal costs of providing care to patients. During operation, physician triage in our center requires an additional nurse practitioner (NP) who is responsible for following up on test results, ordering subsequent treatments, discharge planning, and arranging for the transition of care to appropriate inpatient teams. In addition to the NP, our system requires an additional 4 registered nurses and 1 clinical assistant. Fully loaded full- time employee rates including benefits were assumed to be physician, $120 per hour; NP, $60 per hour; registered nurses, $40 per hour; and clinical assistant, $20 per hour. Rates were based on national averages from the bureau of labor statistics [25]. Full-time employee salary growth rate was assumed to be 3%.

Our center’s screening program required construction of dedicated clinical examination spaces adjacent to the triage area to permit the screening physician to obtain a medical history in private and to perform an appropriate physical examination. These 4 clinical spaces are integral to the safe acceleration of Disposition decisions for selected patients in our program. The required capital expenditure to create 4 screening rooms, 2 workspaces (one in screening and one in postscreening area), a postscreening internal waiting area, and the associated infrastructure required to monitor and deliver care was $1 200 000 and based on national average hospital construction cost of $188 per square footage. At the study site, there was no increase in the total square footage of the ED but rather remodeling of the waiting area. The 2 workspaces are 500 ft² each and contained 5 workstations. The screening rooms are 100 ft² each and contain a stretcher,

vital sign machine, otoscope and ophthalmoscope, and adjacent sink. The number of rooms was determined based on modeling a LOS in each screening room for each screened patient occupying the room for 20 minutes. The postscreen- ing area (internal waiting room for patients who have been screened by the MD) consists of a 4875 ft² waiting room with space for 5 stretchers and 16 chairs. The postscreening area allows the emergency physician to safely accommodate patients in the ED who can wait in an observed internal waiting room, better preserving the monitored bed spaces for those who truly need them. The postscreening area has equipment that allows for reassessment of vital signs, phlebotomy, and medication administration with a dedicated medication dispensing medicine for the nurses. The depreciation period was assumed to be 5 years. Time to set up physician screening was 12 months.

In our financial model: cash flow (CF) = ED revenue - ED direct costs - operational costs of screening + inpatient margin contribution of admitted patients - capital expendi-

ture. Return on investment (ROI) was calculated based on net present value (NPV) of a 5-year CF stream with no terminal value and a discount rate of 5%. The internal rate of return and years to break even were also calculated. Because multiple assumptions were made to estimate revenue and expenses, a detailed sensitivity analysis was performed to determine the impact of these assumptions on the ROI.

Continuous outcomes (eg, ED LOS, time to disposition) were summarized with medians and interquartile ranges (IQR), and comparison between groups was done using Wilcoxon rank sum tests. The 95% confidence intervals (CI) of the difference in medians between groups were estimated using the bootstrap samples. The proportion of LWBS was presented with 95% CI and compared using ?2 tests. Two- sided P <= .05 was considered statistically significant. We used Microsoft Excel 2003 (Microsoft, Redmond, WA) for all financial analysis and SAS version 9.2 (SAS Institute Inc, Cary, NC) for all statistical analysis. The institutional review board at the study hospital approved the study protocol.

Results

The characteristics of patients triaged to the medium acuity areas preimplementation and postimplementation of physician screening intervention can be seen in Table 2. Patient characteristics preimplementation and postinterven- tion were similar.

Operational impact

Comparing operational performance preimplementation and postimplementation of physician screening, overall median ED LOS decreased by 26 minutes (95% CI, 21-29 minutes), median time to disposition decreased by 17 minutes (95% CI, 13-19 minutes), and the percentage of

not impacted by the presence of the screening physician, there was minimal change in the median ED LOS or door-to- disposition (see Table 3). During the study period, the screening physician evaluated 29 158 medium acuity patients and arranged for the accelerated disposition of 5253 patients from the screening area directly (see Table 3).

Table 2 Characteristics of patients triaged to medium acuity area-12-months preimplementation and postimplementation of physician screening
		Pre-physician screening	Post-physician screening
	Patient characteristics Total patients	36 011	40 847
	Arrival time, 11 AM to 11 pm	25 698	29 253
	Arrival time, 11 PM -11 AM	10 313	11 594
	Age (y), mean (SD)	46 (23)	44 (24)
	% Male	48.6	48.8
	% Arrival by ambulance Patient volume-hospital visit	29.0 level (% of total)	27.9
1		65 (0.2)	110 (0.3)
2		1850 (5.1)	2492 (6.1)
3		6776 (18.8)	8707 (21.3)
4		9738 (27.0)	10 606 (26.0)
5		15 467 (43.0)	17 324 (42.4)
Critical care		414 (1.1)	419 (1.0)
Not available		1701 (4.7)	1189 (2.9)
	Patient volume-by ED disposi Inpatient	tion (% of total) 10 418 (28.9)	11 361 (27.8)
	ED observation unit	3222 (8.9)	3417 (8.4)
	Discharged	20 478 (56.9)	24 697 (60.5)
	Other	1893 (5.3)	1372 (3.4)

Financial impact

patients who LWBS decreased by 1.41% (95% CI, 2.33%- 2.55%). These operational improvements were seen despite a 16.7% growth in medium acuity volume and no decrease in the level of acuity as measured by either level of visit or admission rates (see Table 2). When comparing the medium acuity area with the high-acuity area during the study period, the median ED LOS and time to disposition decreased by 21 minutes (95% CI, 13-28 minutes) and 23 minutes (95% CI, 18-29 minutes), respectively. In the high-acuity area, an area

Table 3 Operational outcomes-12-months pre-physician screening and post-physician screening

The incremental revenue and operational expense projec- tion generated from physician screening using aforemen- tioned assumptions are depicted in Table 4. In year 1, the estimated ED contribution margin from discharged patients is $1 324 338 (growth in medium acuity patients,

$1 137 234; LWBS patients, $187 104) and the estimated contribution margin from admitted patients is $1 384 718. The estimated operational expense associated with the physician screening system at year 1 is $1 864 104 ($1 624 104 in salary costs; $240 000 in depreciation costs). The total earnings and CF projection at year 1 are

$844 952 and $1 084 952, respectively.

See Table 4 for CF projections. Based on the CF projections and a discount rate of 5%, the NPV of physician screening was $2 816 263 and the internal rate of return is 85%, with time to break even of 13 months.

Sensitivity analysis

A key assumption of the financial analysis is the incremental revenue generated from the growth in medium acuity patients. Fig. 2A demonstrates the impact of this assumption on the NPV.

Setting the ED admission rate to the national average admission rate of 15% [26], the NPV remains positive at

$1 202 391.

Pre-physician screening		Post-physician screening	Difference (95% CI)
Physician in screening Total no. of patients screened Total no. of patients disposition arranged Inpatient (%) ED observation unit (%) Discharged (%) Other (%) Medium acuity patients Median ED LOS, min (IQR) Median time to disposition, min (IQR) % LWBS (95% CI) Median no. of boarders per d (IQR) Median no. of boarding h/d (IQR) High-acuity patients Median ED LOS, min (IQR) Median time to disposition, min (IQR)	NA	29 252
	NA	5125
	NA	182 (3.6)
	NA	574 (11.2)
	NA	3545 (69.2)
	NA	824 (16.1)
	374 (244-559)	348 (219-530)	26 (21-29)
	294 (184-447)	276 (170-423)	17 (13-19)
	3.19 (3.01-3.38)	1.78 (1.65-1.91)	1.41 (2.33-2.55)
	22 (19-26)	23 (18-27)	-1 (-2-1)
	93.0 (56.6-139.3)	100.2 (55.1-150.0)	-7.2 (-17.9-6.2)
	339 (221-525)	333 (219-519)	5 (-2-11)
	159 (87-287)	164 (89-297)	-6 (-12-3)

Total patients
Total growth in medium acuity patients	4981	5130	5284	5443	5606
Total reduction in LWBS	592	609	628	647	666
Total patients-by disposition
Discharged	4188	4313	4443	4576	4713
Admitted	1385	1426	1469	1513	1558

Projected ED charges		$5 821 265	$5 995 473	$6 175 445	$6 361 198	$6 551 750
Projected ED revenues		$2 037 443	$2 098 416	$2 161 406	$2 226 419	$2 293 112
cost of care-direct		($713 105)	($734 445)	($756 492)	($779 247)	($802 589)
Contribution margin-discharged patients		$1 324 338	$1 363 970	$1 404 914	$1 447 173	$1 490 523
Contribution margin-admitted patients		$1 384 718	$1 426 140	$1 468 952	$1 513 154	$1 558 468
Total contribution margin		$2 709 056	$2 790 110	$2 873 866	$2 960 327	$3 048 991
Physician screening expenses Salary		$1 624 104	$1 672 827	$1 723 012	$1 774 702	$1 827 943
Depreciation expense		$240 000	$240 000	$240 000	$240 000	$240 000
Total expenses		$1 864 104	$1 912 827	$1 963 012	$2 014 702	$2 067 943
Total earnings Capital expenditure	($1 200 000)	$844 952	$877 283	$910 854	$945 624	$981 048
CF	($1 200 000)	$1 084 952	$1 117 283	$1 150 854	$1 185 624	$1 221 048
Total NPV	$2 816 263
Internal rate of return	85%
Y to break even	1.1

Using tornado analysis (see Fig. 2B), other key assump- tions driving NPV were identified to be the inpatient contribution margin and ED revenue per patient (charges and collection rate). Setting the inpatient contribution margin to the low range of $700 per admission or the ED revenue per patient to the low range of $300 (ED charges of $1000 per patient and collection rate of 30%), the NPV remains positive at $1 278 420 and $936 832, respectively.

Table 4 Financials: CF and return on investment

Y 0

Volume impact

1

2

3

4

5

Financial impact Discharged patients

$4,000,000

$3,000,000

Discussion

In EDs nationwide, various interventions are being implemented to alleviate crowding, the resulting prolonged wait times, and delays in treatment. These interventions, including use of “bed czars” and boarding patients in inpatient hallways, have had differing levels of success in reducing crowding [12,13].

Base Case

4836 patients;

$2,816,263

$2,000,000

Net Present Value

$1,000,000

3385 patients; 3869 patients;

4352 patients;

$1,883,000

$16,932

$0

$950,196

-$1,000,000

Fig. 2 Sensitivity analysis: impact of incremental capacity on NPV.

Physician screening is one intervention that has demonstrated operational benefits improving the through- put of ED patients [15-18]. In our system, this physician serves 3 purposes. First and foremost, the physician serves to screen all patients who have been triaged as medium acuity to identify those patients who may have occult presentations of severe illness in which prolonged wait time might lead to poor outcomes. When such patients are identified by the screening physician, they are transferred immediately to a staffed ED bed. Second, the screening physician initiates early testing and treatment for patients who are deemed able to wait for an ED bed when no bed is available. Third, the triage physician identifies patients who can be either discharged or admitted from the screening area directly without going to a treatment area and using an ED bay.

Several of the operational benefits we have demonstrated in this study are similar to those found in prior published reports. At our center, physician triage led to a 7% decrease in time to disposition and ED LOS. These operational improvements were seen despite a 16.7% increase in the total volume, an increase in the total number of boarded patients, and boarding hours. In addition, such as with prior published reports, our LWBS declined by 45% [15-18]. Of particular note, these operational improvements were achieved in the setting of fixed ED treatment area.

One important operational and financial benefit that is more specific to our model of physician screening is the effective expansion of the capacity of the ED. Redesigning the triage and waiting room space has allowed the screening physician to discharge or admit a subset of medium acuity patients after the appropriate laboratory/ Radiologic tests have been completed and treatment has been rendered without use of an ED bed space. In our study period, this expansion in ED capacity allowed us to absorb the growth of 5000 patients while still improving ED LOS. This improvement in ED LOS equates to significant increase in ED bed availability that can be used to care for additional patients. This operational improvement has been of enormous benefit because our ED continues to face increasing growth in patient volume despite our inability to add more ED beds. Thus, the screening process expanded capacity without an increase in the square footage of the ED.

This study demonstrates that investment in physician screening can lead to incremental margin and be an overall positive financial investment. The ROI, even without including other potential intangible benefits such as patient satisfaction, quality, and safety, is high. Emergency department managers facing growing volume, high LWBS rates, and limited ability to add ED beds may benefit disproportionately from our model and might use similar analysis to support their investment in interventions.

Importantly, the physician screening system appears to improve the operational efficiency of the ED, reducing the time from door to initial physician evaluation and increasing

the sensitivity of the overall triage system to identify patients where prolonged wait times can lead to poor outcomes. In addition, with the screening system, many patients receive their initial diagnostic tests and treatments earlier in their ED course.

Although our study and others have recently produced data to support the operational and Financial benefits of a physician screening system, many questions remain in quantifying the impact of this system on improving the quality of care delivered to patients in the ED. In addition, the impact on resource use, patient satisfaction and experience, and resident education in teaching institutions require further study.

Limitations

There are several limitations to the study. First, this is a single-center study in an urban academic center where the goal of the physician screening program is to support both the early evaluation and initiation of care for all medium acuity patients and the accelerated disposition of selected patients. This needs to be considered before applying these findings because the capital expense, capacity gains, LWBS percentage, admission rates, and ED/inpatient margins may differ significantly depending on the practice setting. Second, it is likely that the growth in visits of medium acuity patients to our ED would have occurred with or without the screening program. However, our system was considered at full capacity and unable to provide care for additional patients without compromising care before the implementation of the screening program. Because EDs around the country are crowded and need increased capacity, this limitation highlights the challenges of ED managers in placing financial value on incremental ED capacity. Third, because actual billing charges and reimbursement rates are considered proprietary, we used several assumptions in this study to project estimates of revenue and expenses; therefore, the ROI calculations are estimates. Emergency department leadership contemplating this intervention must be aware of the appropriate financial assumptions to use for their institution. In addition, we used a sensitivity analysis to demonstrate the range in ROI. Finally, there is always the possibility that the reimbursement environment may change in the future, leading to subsequent changes in the revenue projections and ROI.

Conclusion

At our academic center, although significant investments were needed for implementation of a physician screening program, we experienced an increase in operational efficiency allowing for an increase in our patient care capacity and leading to an overall positive financial impact.

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