Self-Funded

Spencer Smith
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Self-Funded, hosted by Spencer Smith, is the definitive resource for benefits consultants and employers who are ready to challenge the broken healthcare status quo. Each week, you'll get an insider's playbook of actionable strategies from industry leaders that help make healthcare better, together.

  1. A New Way To Predict (And Price) Healthcare Risk

    -1 J

    A New Way To Predict (And Price) Healthcare Risk

    "There’s no bad risk, there’s just mispriced risk... we helped one carrier achieve a 29.1% improvement in their loss ratio just through better risk selection." How do stop-loss carriers and self-funded employers accurately predict which groups are going to run well and which ones are about to see skyrocketing claims? My guest this week is Ali Panjwani, Founder and CEO of Merit Medicine. Ali transitioned from a career in biotech and pharmaceutical public policy, where he helped price and launch complex, rare-disease drugs, to solving one of the biggest problems in self-funded healthcare: predicting catastrophic risk before it happens. In this episode, we dive into the evolution of predictive analytics and medical underwriting. Ali explains how Merit Medicine uses AI and access to a massive database (covering 95% of commercial claims in the US) to project a group's healthcare spend using just a simple census file. We discuss why a group that ran poorly last year might actually be a great risk this year, how to prevent underwriters from "playing on tilt," and the ongoing debate over how to finance multi-million-dollar cell and gene therapies. If you are a benefits consultant, an MGU, or a stop-loss carrier trying to understand how technology is fundamentally changing the way healthcare risk is predicted and priced, this episode is a must-listen. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com/spencer to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: (00:00:00) Intro: The Evolving Landscape of Healthcare Risk(00:04:28) Ali's Background: From Biotech to Public Policy(00:09:47) The Complexity of Launching & Pricing New Drugs(00:13:30) Shifting Focus: Who Actually Pays for Healthcare?(00:16:34) The Data Access Problem for Self-Funded Employers(00:19:50) How Merit Medicine Predicts Risk with Just a Census File(00:23:24) Why Merit Looks Backwards to Predict the Future(00:26:27) How Stop-Loss Carriers & MGUs Use Predictive Analytics(00:29:41) "There Is No Bad Risk, Only Mispriced Risk"(00:33:04) The Danger of Underwriting "On Tilt" (Past vs. Future Claims)(00:37:37) Can Predictive AI Help Apply Specific Lasers?(00:40:10) The Evolution of Underwriting Tech(00:45:04) Proving the Model: A 29.1% Loss Ratio Improvement(00:49:10) The Cell & Gene Therapy Debate: Public Pools vs. Financing(00:55:14) Closing Thoughts: The Future of Predictable Premiums Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

    58 min
  2. March Healthcare Headlines: GLP-1s, PBMs, and The $233M Scam | with Jeff Bak

    -5 J ·  BONUS

    March Healthcare Headlines: GLP-1s, PBMs, and The $233M Scam | with Jeff Bak

    If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's podcasts, headlines, and listener-submitted questions.This month, we're joined by Jeff Bak from Imagine360!Together, we react to the latest headlines from March, including the new CMS rule enforcing actual dollar amounts in hospital price transparency files. We also discuss Medicare expanding coverage for GLP-1s to treat obesity, Roche's massive $65M investment in NVIDIA AI chips for drug discovery, and the Department of Labor's new PBM fee disclosure rules. Plus, we react to the shocking story of two insurance executives sentenced to 20 years for a $233 million ACA enrollment fraud scheme.Then, Jeff and I play a game of "Blind Ranking" where we have to rank the worst practices in health insurance (like PBM spread pricing, ER upcoding, and surprise balance billing) without knowing what is coming next. Finally, we answer a listener question about the viability of ICHRAs (Individual Coverage HRAs) as an alternative to brutal fully-insured renewals in 2026.Thank you to our sponsor, Walk On Clinic! Visit walkonclinic.com to learn more about their on-site health clinics. Chapters:0:00 - Intro & Live Show Announcement3:08 - CMS Enforces Dollar-Amount Price Transparency6:54 - Medicare Expands GLP-1 Coverage to Obesity12:15- Roche Buys $65M in NVIDIA AI Chips for Drug Discovery15:45 - The DOL Proposes New PBM Fee Disclosure Rules19:40 - Insurance Execs Sentenced to 20 Years for $233M ACA Fraud22:20 - Game: Blind Ranking the Worst Practices in Health Insurance30:41 - Ask Spencer: Are ICRAs a Smart Option After Huge Renewals?

    35 min
  3. The New Era Of Cash Pay In Healthcare

    24 MARS

    The New Era Of Cash Pay In Healthcare

    "We are in a $5 trillion US healthcare consumer market with no consumer in it... I basically decided we had been surgically removed from the US healthcare system." My guest this week is Mark Galvin, a serial entrepreneur who successfully funded his own company's healthcare by pairing a $10,000 High Deductible Health Plan with a fully funded HSA and HRA - saving his company 32% and his employees 50%. When he realized that brokers, carriers, and even the state insurance department were financially disincentivized from sharing this strategy, he decided to force transparency into the market himself. In this episode, Mark shares the incredible story of how he secured a DVD containing 100% of New Hampshire’s post-adjudicated claims data and built the first true shopping tool for medical procedures. We discuss his meetings at the White House that helped shape the Transparency in Coverage Rule, the absurdity of $68,000 knee replacements, and his new platform that calculates a "Universally Acceptable Payment Amount" (UAPA) for every provider in the country. If you are an employer, broker, or patient who is tired of flying blind and wants to understand how true cash prices are finally coming to healthcare, this episode is a must-listen. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com/Spencer to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: (00:00:00) Intro: Aligning Financial Incentives in Healthcare  (00:02:41) Mark's Background: Voice Over IP to Healthcare Tech  (00:04:47) The Early Days of Direct Primary Care (DPC)  (00:09:08) Hacking the HDHP: Saving 32% on Premiums  (00:11:28) Why Brokers & Carriers Hate Cost-Saving Strategies (The MLR Problem)  (00:18:33) Discovering the All-Payer Claims Database (APCD)  (00:21:49) The $1,600 vs. $6,800 Nuclear Stress Test  (00:26:00) Building a Commercial Solution to Fight Lobbyists  (00:29:40) The "Proficiency Score": Why Price Does Not Equal Quality  (00:31:48) Scraping EOBs to Build a National Price Database  (00:33:27) The White House Meetings & The Transparency in Coverage Rule  (00:43:03) Inventing "Transparency 2.0" and the UAPA (Cash Pay)  (00:51:13) Shared Savings Rewards: Paying Employees to Shop  (00:53:56) The Future: In-App Repricing and "Tap-to-Pay" at the Doctor  (00:57:52) Can We Shop for 70% of Healthcare?  (01:04:18) Using UAPA as a Full Network Replacement  (01:11:19) The Path to an "Amazon-Like" Healthcare Market  (01:15:19) Closing Thoughts: Why 12% of Shoppers Can Change the System Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

    1 h 19 min
  4. How J&Q Codes Are Sabotaging Your Stop-Loss Renewals

    17 MARS

    How J&Q Codes Are Sabotaging Your Stop-Loss Renewals

    "I've got a patient in Washington state. He's traveling 100 miles every other week to receive an infusion. We moved this patient into the home and saved the plan $700,000 on this one patient...on gout treatment." Why are infusion drugs quietly destroying your health plan's budget? This week, my guest is Rob LaHayne, Co-Founder of Leap Health. We pull back the curtain on one of the most overlooked and expensive categories in healthcare: Specialty Infusion Care. Because these drugs are administered by a medical professional, they are billed through the medical plan under "J&Q Codes" - subjecting them to massive hospital markups and "buy-and-bill" margin games. In this episode, Rob explains how Leap Health is solving this by taking over the supply chain, procuring the drugs transparently without margin, and redirecting patients to their own homes or convenient infusion centers. We discuss how these J&Q codes are often the hidden culprit behind breached stop-loss deductibles and skyrocketing renewals, and why shifting the site of care is a win for both the employer's budget and the patient's quality of life. If you're a benefits consultant trying to figure out why your client's medical spend is out of control, or an employer tired of paying massive hospital markups for necessary medications, you need to understand J&Q codes. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com/Spencer to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: (00:00:00) Intro: The Hidden Problem of J&Q Codes  (00:04:13) Rob's Background & The Genesis of Leap Health  (00:08:24) Why Hospital "Buy-and-Bill" Margins Drive Up Costs  (00:13:22) How Leap Health Provides Transparent, Zero-Margin Pricing  (00:16:31) Shifting Site of Care: The Power of Home Infusions  (00:23:44) Overcoming Headwinds: Patient Engagement & Plan Design  (00:27:01) Taking Over the Supply Chain to Bypass the "BUCA" PBMs  (00:32:51) Stop-Loss Renewals: Why Identifying J&Q Codes is Critical  (00:37:04) Saving $700,000 on a Single Gout Patient  (00:41:39) The Future: Unbundling the Health Plan & "Point Solution Fatigue"  (00:45:41) Closing Thoughts: Why Consultants Must Request J&Q Code Data Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

    46 min
  5. Will PBM Reform Actually Happen? | Last Month In Healthcare

    13 MARS ·  BONUS

    Will PBM Reform Actually Happen? | Last Month In Healthcare

    If you'd like your question answered on next month's episode, call/text 469-213-6381 and leave us a voicemail/text.Each month on Last Month In Healthcare, producer Nathaniel joins me to discuss the previous month's headlines and listener-submitted questions.This month, we are officially in the new studio! Nathaniel and I react to the latest headlines from February, including the FTC's landmark settlement with Express Scripts over insulin pricing and the new bipartisan bill aimed at breaking up the "Big Medicine" monopoly of insurers, PBMs, and providers. We also discuss the FDA's crackdown on compounded weight loss drugs (GLP-1s) and the privacy concerns surrounding OpenAI’s new ChatGPT Health feature.Plus, we play a new game called "Drug Cost or Car Payment?" where I try to guess whether a monthly prescription is more expensive than the lease payment on a luxury car (like a Porsche 911 Carrera or a Bugatti Chiron). Finally, we answer a listener question about the absolute minimum employee headcount required to go fully self-funded in 2026.Thank you to our sponsor, Walk On Clinic! Chapters:0:00 - Intro: Welcome to the New Studio!1:24 - "PBM Reform Comes To Washington"2:25 - FTC / Express Scripts Settlement5:19 - The Bill to "Break Up Big Medicine"6:34 - The FDA Cracks Down on Compounded GLP-1s7:55 - OpenAI Launches ChatGPT Health12:14 - Game: Drug Cost vs. Car Payment?18:33 - Ask Spencer: Minimum Headcount to Go Self-Funded?

    21 min
  6. Building The TPA Of The Future

    10 MARS

    Building The TPA Of The Future

    "We don't view ourselves as a TPA, we view ourselves more as a platform... our goal is to simplify and reduce the barriers of entry into the TPA space." The role of the Third-Party Administrator is undergoing a massive evolution. No longer just a back-office claims processor, the modern TPA is being asked to serve as the high-tech, high-touch "nucleus" of the entire health plan. My guest this week is Vinny Esposito, CEO of Reflect Health (formerly S&S Health). Drawing on a decade of experience in the hedge fund world, Vinny recognized a massive opportunity to bring scalable, asset-light infrastructure to the self-funded market. Today, Reflect Health acts almost like the "Intel Inside" of the industry, licensing its proprietary claims technology to other TPAs and health plans. In this episode, we explore exactly what it takes to build the TPA of the future. We discuss how to solve "point solution fatigue" through a centralized marketplace, the mechanics behind infusion drug carve-outs, and how to successfully deploy dynamic deductibles to incentivize better care routing. Vinny also shares his bold vision for "frictionless claims" paid instantly at the point of service, moving us closer to an Amazon-style shopping experience for healthcare. If you want to understand the technological and administrative innovations driving the self-funded market forward, this episode provides the blueprint. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: (00:00:00) Intro: Competing on Service in the TPA Market  (00:01:56) Meet Vinny Esposito & Reflect Health  (00:03:35) Rebranding from S&S Health  (00:07:32) From Hedge Funds to Healthcare Disruption  (00:11:05) The Platform Model: Licensing Tech to Other TPAs  (00:15:05) The Marketplace & Infusion Drug Carve-Outs  (00:19:14) How the TPA Role is Expanding (The "Nucleus")  (00:24:12) Direct Contracting, RBP, and DPC Integration  (00:29:15) Dynamic Deductibles & Tiered Networks  (00:33:25) Curing "Point Solution Fatigue"  (00:41:09) The Future of Stop-Loss and Preventative Care  (00:45:44) The Fiduciary Breaking Point & 80% Renewals  (00:50:26) Frictionless Claims & Amazon-Style Healthcare Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

    57 min
  7. Why Venture Capital Is Betting Against Insurance Carriers in 2026

    3 MARS

    Why Venture Capital Is Betting Against Insurance Carriers in 2026

    “Show me an incentive structure and I'll show you human behavior... until employers realize they have more power than they give themselves credit for, this can't continue." My guest this week is Norm Volsky, Managing Partner at DRI and Founder of MVP Growth Partners. Norm has spent the last decade as one of the top executive recruiters in the digital health and employer benefits space - placing the commercial teams that helped build unicorns like Livongo and Hinge Health. In this episode, Norm explains why the next wave of healthcare innovation isn't about adding more "point solutions" to an already fatigued market. Instead, smart money is betting on companies that carve out high-margin, inefficient services directly from the major insurance carriers - like radiology, fertility, and specialty infusion. We discuss how Norm built an "army" of over 500 industry executives to crowdsource due diligence, why the traditional VC model fails in healthcare, and why employers and their benefits leaders are finally at a watershed moment where they must demand true fiduciary alignment from their vendors. If you want to know where the smart money is moving in employer healthcare, and why the "BUCA" carriers should be worried, this episode is a must-listen. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: [00:00:00] Intro: Recruiting in the Early Days of Digital Health [00:04:12] The Livongo Story: Selling Healthcare Direct to Employers [00:08:44] What Makes a Great Salesperson in Healthcare? [00:11:46] Spotting the Next Unicorn: The Hinge Health Experience [00:17:28] Private Equity vs. Venture Capital [00:20:00] Using Recruitment Data to Drive VC Investments [00:23:41] The "One Imaging" Pitch & Carving Out Radiology [00:30:40] Building an Army: Crowdsourcing VC Due Diligence [00:36:26] Why MVP Growth Partners Only Invests in "At-Risk" Pricing [00:41:40] Point Solution Fatigue & Identifying the "Good Actors" [00:46:17] Why Employers Must Demand Fiduciary Responsibility [00:50:41] The Future: The Erosion of the Big 3 PBMs and Carriers Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

    1 h 3 min
  8. Why Health Plans Pay $10,000+ For Drugs That Don't Even Work

    24 FÉVR.

    Why Health Plans Pay $10,000+ For Drugs That Don't Even Work

    "Why are we paying $10,000 for a $30 drug?" My guest this week is Pramod John, a former Silicon Valley tech entrepreneur who entered the healthcare space to tackle the largest economic problem in the country: skyrocketing healthcare costs. Pramod quickly realized that healthcare's dysfunction is actually not a technology problem - it is a deeply ingrained problem with economic incentives. In this episode, we dive into the murky waters of Pharmacy Benefit Managers (PBMs) and why the traditional model is designed to drive up costs rather than lower them. We discuss the shocking statistics of drug spend (where 2% of people account for 55% of the costs), why FDA approval doesn't always mean a drug is effective (using the infamous Alzheimer's drug as an example), and the implications of recent fiduciary lawsuits like the one against J&J. Pramod explains how we can bring common sense back to healthcare by treating drugs like any other consumer purchase. By utilizing an "open market" drug management model, he argues that we can effectively replace traditional PBMs with transparent transaction processing software - saving plans 30% to 50% without relying on restrictive formularies or rebate games.  Tune in this week for a clear roadmap for how to actually fix the irrational economics of our healthcare system. Thank you to our 2026 sponsors! ParetoHealth: ParetoHealth empowers midsize employers with a long-term solution to reduce volatility and lower overall health benefits costs. Visit ParetoHealth.com to learn more. Samaritan Fund: A program that connects those who need help to the support they need. We are proud to offer the Samaritan Fund Program. Visit SamaritanFundProgram.com to learn more. Vālenz Health: We're Vālenz Health, your partner in improving health literacy, reducing plan spend, and delivering high-value healthcare. Visit ValenzHealth.com to learn more. Imagine360: Imagine360 helps self-funded employers save on healthcare with smarter health plans. Cut expenses by 20-30% with custom solutions. Contact us today at Imagine360.com. Chapters: (00:00:00) Intro: Why We Talk About Cost Instead of Quality  (00:02:42) From Silicon Valley & Defense Tech to McKesson  (00:10:43) Why Healthcare is NOT a Technology Problem  (00:15:53) Fiduciary Responsibility & The J&J Lawsuit  (00:19:03) The Butter Knife vs. Pareto: The Math of Drug Spend  (00:23:54) Building an "Open Market" Alternative to PBMs  (00:29:40) Why Doctors Fly Blind on Drug Pricing & Formularies  (00:35:42) FDA Approval vs. Real-World Efficacy  (00:45:44) How to Actually Fix the Model: The Real-Time "Pause"  (00:58:36) Why International Sourcing & PAPs Aren't the Fix  (01:11:00) Replacing PBMs with Simple Transaction Software Key Links for Social: @SelfFunded on YouTube for video versions of the podcast and much more - https://www.youtube.com/@SelfFunded Listen/watch on Spotify - https://open.spotify.com/show/1TjmrMrkIj0qSmlwAIevKA?si=068a389925474f02 Listen on Apple Podcasts - https://podcasts.apple.com/us/podcast/self-funded-with-spencer/id1566182286 Follow Spencer on LinkedIn - https://www.linkedin.com/in/spencer-smith-self-funded/ Follow Spencer on Instagram - https://www.instagram.com/selffundedwithspencer/

    1 h 17 min
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À propos

Self-Funded, hosted by Spencer Smith, is the definitive resource for benefits consultants and employers who are ready to challenge the broken healthcare status quo. Each week, you'll get an insider's playbook of actionable strategies from industry leaders that help make healthcare better, together.

Informations

  • Création
    Spencer Smith
  • Années d’activité
    2021 - 2026
  • Épisodes
    270
  • Classification
    Tous publics
  • Copyright
    © Spencer Smith
  • Site web de l’émission
    Self-Funded

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