Skilled Nursing Care Facilities

SIC 8051

Companies in this industry

Industry report:

This industry contains establishments primarily engaged in providing inpatient nursing and rehabilitative services to patients who require continuous health care but not hospital services. Care must be ordered by and under the direction of a physician. The staff must include a licensed nurse on duty continuously with a minimum of one full-time registered nurse on duty during each day shift. Included are establishments certified to deliver skilled nursing care under Medicare and Medicaid programs. Skilled care facilities include convalescent homes with continuous nursing care, extended care facilities, mental retardation hospitals, and skilled nursing homes.

Industry Snapshot

In the early 2010s, more than $178 billion was spent on nursing home care annually. Skilled nursing care facilities, which could be for-profit, nonprofit, or government owned, served the nation's fastest growing population segment, those 65 years and older. In 2010, 35 million Americans were over the age of 65, a number that was expected to increase to 20 percent of the population by 2020, with 6.6 million people residing in nursing homes by 2050. The American Health Care Association reported that there were 15,690 certified facilities in 2011, 68 percent of which were for profit, 25 percent nonprofit, and 6 percent government. These facilities housed more than 1.3 million residents, which represented an 87 percent occupancy rate.

According to data gathered by the Federal Inter-agency Forum on Age Related Statistics,' during the twentieth century, the U.S. population of Americans age 65 and over increased from 3 million to 37 million, and the number of oldest-old (those age 85 and over) increased from 100,000 to 5.3 million. Those numbers were expected to spike in 2030 as the baby boomer generation reached retirement age. As a result, the number of Americans 65 years and older was projected to nearly double by 2030 to reach 71.5 million, or nearly 20 percent of the U.S. population. Although growth rates were expected to level off after 2030, increases in the number of oldest-old were expected to continue to rise rapidly between 2030 and 2050 as baby boomers aged into this category. The number of the country's oldest-old was projected to grow from 5.3 million to 21 million. Some estimates, which projected lower death rates, placed the estimate even higher.

Longer life spans, coupled with the trend toward small families with fewer children to share responsibilities for the aged, will mean a greater need for medical health companies. As a result, the nursing home and long-term care industry will continue to grow, but it is unlikely that it will be able to keep pace with the growing demand for quality skilled nursing care. Funding will also be a dilemma as reduced or stagnated government spending is a widespread concern. The future of Medicare, a major source of funding for most facilities, was a major concern at the end of the first decade of the 2000s and in the early 2010s.

Essentially, these figures reveal the scope and populations served by the skilled care nursing industry. Years of innovative reallocation of resources expanded options for long-term care. However, few match the optimum level of skilled nursing care provided for populations with chronic and multiple disabilities. Skilled nursing care, similar to the concept of custodial or convalescent care, represents a long-term vehicle for meeting the comprehensive medical, personal, and social service needs of chronically disabled persons. Twenty-seven percent of long-term stay patients were women and 27 percent were men. Twenty-five percent were over the age of 85 at the time of admission. The average length of stay was 386 days. Skilled nursing facilities also serve as short-stay care centers for those recovering from illnesses or operations. These patients are much more evenly divided between men and women, and the average stay is much shorter, typically about 33 days.

Skilled nursing care services differ in terms of the levels of services provided, patient admission criteria, staffing, and reimbursement mechanisms. Each aspect of the skilled nursing care environment reflects the high level of intensive care. Overall, non-profit, independent facilities consistently gave the best care. All skilled care facilities provide continuous 24-hour care that is prescribed, directed, and executed under the supervision of a medical doctor. Professional performance and supervision by licensed personnel also apply to the provision of ancillary service like physical therapy and other such prescribed services.

One of the trends affecting health care is integration, or integrated delivery systems, whereby patients are tracked over time, spanning all levels of care and fostering alliances among the various care givers. Nursing home regulations, the need for nursing staff, higher care standards, managed care contracts, and rising insurance costs are some of the challenges facing the industry.

Organization and Structure

Skilled nursing care facilities primarily operate under three categories of ownership: for-profit, nonprofit, and government. For-profit skilled care nursing encompasses tax-paying structures operating under proprietary or investor/shareholder ownership by licensed administrators or as a subsidiary of a corporation. Nonprofit ownership includes non-secular church-related nonprofit organizations and secular fraternal or other membership group ownership. Government, or public ownership, includes establishments operated by city, state, or federal governments.

At the end of the first decade of the 2000s, nonprofit nursing homes, which were either self-financed via retained earnings or tax-exempt debt, began facing a bigger challenge from the for-profit sector. Although many nursing homes faced bankruptcy during the early years of the first decade of the 2000s, through the middle and end of the decade, investor groups began to look favorably on skilled nursing facilities. As a result, the number of for-profit organizations began to increase. The non-profit sector was challenged to manage as efficiently and effectively as the for-profit group. Although the nonprofit sector was relatively stable, larger companies continued to acquire smaller long-term care facilities.

The Association of Health Facility Survey Agencies was concerned with facility licensing and certification programs. The American College of Health Care Administrators certified members' ability to meet and maintain standards of competence. Its affiliated Foundation of American College of Health Care Administrators was concerned with scholarship to improve long-term care and nursing home administration. The National Association of Long Term Care Administrator Boards produced the competence testing exam.

Sources of Skilled Care Revenue.
According to the American Health Care Society, at the end of the first decade of the 2000s, 14 percent of patients relied on Medicare, 64 percent relied on Medicaid, and 22 percent paid for care with private funds or long-term care insurance. The sources of revenue were becoming a more complex picture in as the demographics of skilled nursing centers shifted from a sole focus on long-term acute care of elderly patients to include a growing number of short-stay rehab patients. Of the long-stay residents, 48 percent paid expenses with Medicaid and 45 percent paid with private funds or long-term health care insurance. Medicare paid for 63 percent of expenses for the more than 2 million short-term residents that cycled in and out of skilled nursing facilities during a year.

Medicaid.
Cuts in Medicaid, a federal and state funded program administered by individual states, threatened the stability of this industry in 2011. Nursing homes collected more Medicaid from the federal government than other long-term care facilities, with the federal government spending a total of $109 billion on long-term care services in 2007 from its overall $320 billion Medicaid budget. By 2011, 85 percent of residents in nursing homes were supported by payments from the government. Traditionally, approximately 57 percent of Medicaid payments went to long-term care facilities, and states made up the remaining 43 percent. Originally designed for poverty-level women, children, and the elderly, increased utilization by the elderly has converted long-term care to a majority component of Medicaid. All long-term care patients, however, were not automatically eligible for Medicaid assistance. Eligibility was determined on a number of factors, including, primarily, level of income.

Medicare.
Medicare Hospital Insurance, Part A, assisted in covering costs for skilled nursing home care, excluding convalescent or custodial homes. Traditionally, skilled nursing facilities generally were reluctant to utilize Medicare reimbursement due to complexities associated with Medicare reporting guidelines as well as the Medicare's three-day hospital stay requirement for admission to skilled care facilities. However, by the end of the first decade of the 2000s, Medicare was an increasingly important source of income for skilled nursing facilities. Beginning in the 1990s, nursing homes began converting beds to "subacute" care beds. According to the American Health Care Association's 2009 Annual Report, the number of skilled nursing facilities accepting short-stay rehabilitative care patients grew from 77 percent in 2003 to 87 in 2007. At the end of the first decade of the 2000s, the industry was poised to secure a larger piece of Medicare funding by posing increasing competition to inpatient rehabilitation facilities.

Under this payment system for skilled nursing facilities, Medicare paid for up to 100 days of nursing home care subsequent to an acute care hospital stay of at least three days. Rates were determined in terms of "reasonable" costs, which fell into three categories: routine costs, including daily expenses that a skilled nursing facility incurs; ancillary service costs, including rehabilitation therapy, non-routine medical care, and radiology services; and capital costs, including depreciation, amortization, and interest.

Reimbursement for Medicare and Medicaid required certification of nursing facilities by the funding agencies. The certification process, normally accomplished via inspection, assessed the total spectrum of the facility's capacity to provide optimum skilled care. The certification process represented a challenge for nursing facilities and proved to be a significant hurdle for a considerable number of facilities. The 1987 Omnibus Budget Reconciliation Act's (OBRA) impact changed the course of nursing home enforcement. This federal law was created in response to increasing concern about the industry in the 1980s that arose out of a series of well-publicized accounts of neglect and ill treatment at nursing care facilities.

One major change effected by OBRA was the survey inspection procedure. Pursuant to OBRA, the Department of Health and Human Services was directed to enter agreements with state survey agencies for assessing nursing facilities' compliance with OBRA's requirements. The results of on-site inspections subsequently determined whether to enter into, deny, renew, or terminate a facility's Medicare/Medicaid participation agreement. To implement this requirement, the Health Care Financing Administration (HCFA), Medicare's then operational arm, which in 2001 became the Centers for Medicare & Medicaid Services (CMS), called a meeting of nursing home industry representatives. They agreed to use an inspection rating instrument featuring a "scope and severity scale." HCFA later revised the plan, deleted the scale, and added fines of as much as $10,000 per day for inspection violations endangering a patient's life. A ruling was also added allowing state takeover of facilities judged as repeat offenders. The industry objected to HCFA's new regulations. Although infrequently applied, being ousted from the Medicare program could cripple a facility. However, an even more punitive aspect of the measures, in the opinion of the nursing industry, was the absence in HCFA revisions of a dispute resolution process whereby providers could explain, clarify, or contest a survey finding. In 1995 HCFA implemented the 1987 Omnibus Budget Reconciliation Act by providing sanctions for nursing home violations. Support services, such as mattress replacements, that were previously considered routine costs became considered ancillary costs.

OBRA also granted nursing homes funds for correcting inspection violations. Inspection deficiencies were to be rectified in adherence to a state designed timetable. If facilities did not rectify deficiencies, federal law required the state to repay the federal government the amount of funds given to the nursing facility. Rather than be saddled with such repayment obligations, states sometimes chose to decertify facilities deemed noncompliant.

Nursing homes were also governed by Occupational Safety and Health Administration (OSHA) regulations, with fines of up to $2,000 per violation. The most frequent violations were lack of written resident care plans, lack of employee training, lack of proper labels for containers, and failure to make material safety data sheets available. Despite these attempts to regulate the nursing home industry, standard of care remains an overarching concern. Steven Levin and John Rushing wrote in GP Solo in 2008, "systemic problems persist in the nursing home industry....Too often these homes are understaffed, and what staff they have is poorly trained and overworked. "

Subacute Skilled Care Nursing Facilities.
For the most fragile patients, many long-term care facilities developed a subacute level of care, described by the American Health Care Association as intensive, licensed, skilled nursing care provided in a distinct part/skilled nursing facility. Many subacute level patients are "heavy care" elderly with respiratory ailments requiring ventilator or intravenous therapy. Because of inadequate Medicare reimbursement for this type of treatment, nursing homes were unwilling to accept these patients.

Background and Development

The cost of one year of care in a nursing home in 2001 was between $30,000 and $80,000 annually. Although costs continued to increase every year, the industry's fiscal status was regarded as somewhat flat. Expansion capital was not readily available to the industry and the concept of expansion was not a significant objective for most of the industry. Nursing home chains recalled the heady conditions of the expansive period during the 1980s. Ballooning profits and expansions contributed to an enthusiastic appraisal of the industry's future.

As companies felt the impact of Medicare price changes, however, members of the industry scaled back expectations. Precariously slim profit margins, due in part to an overload of unprofitable and unnecessary relics from the expansion period, forced companies to scale back to survive. What followed was an austerity phase characterized by budget cuts and unloading unprofitable entities. Many of the innovative strategies of restructuring, diversification, and other cost-saving measures continued as industry foundations into the early years of the first decade of the 2000s. Humana, one of the large chains, added an insurance entity that proved to be a profitable strategy. Other organizations diversified by adding specialized services, and in 1995 the Health Resources Alliance was established to act as a contact point for long-term care clients needing a variety of specialized care facilities.

Although nursing homes may be designated as skilled care nursing care facilities, occupancy patterns for most facilities combined a mix of patients needing skilled and unskilled care. To meet federal and state requirements for skilled nursing care, facilities maintained distinctly separate beds, staffing, records, and other services. Statistically, this organizational pattern, in addition to other factors, determined the demographic approach for documenting the skilled nursing care industry. First, more accurate indicators regarding the skilled care nursing industry emerged from enumeration of the number of beds rather than the number of facilities. Second, because Medicare or Medicaid reimbursement of skilled nursing care depended on certification by these mechanisms, this method allowed yet another means of documentation. Finally, while the predominantly elderly population of skilled care nursing homes formulated a valid sample, the universe of skilled care nursing included all ages of adults, children, and even infants suffering from chronic illness. The National Governors' Association approved a compromise in nursing home coverage for the poor and disabled elderly that would give states greater authority of payments and eligibility.

Non-profit nursing homes, self-financed by retained earnings or tax-exempt debt, faced challenges from the for-profit sector, which could raise funds via stock offerings or use stock-option plans to retain managers and staff. This created a growing challenge to effective and efficient management. Small providers banded together to compete for managed care business. The for-profit sector threatened to provide nursing facilities at lower costs and with more services than nonprofit sectors, including assisted living and home care. According to the National Center for Assisted Living, in the late 1990s about 13 percent of all assisted living residents were in nursing facilities.

Nursing homes that are Continuing Care Retirement Communities (CCRCs) sometimes lose residents to HMOs when they are discharged from the hospital and told they must go to an HMO provider. In the mid- and late 1990s, CCRCs were seeking their own contracts with HMOs.

The nursing home population under age 65 totaled about 173,100 in the mid-1990s, with admissions from disablement from mental retardation, chronic disease, or illness incidental to congenital defects, trauma, or accident. With the exception of purely age-related conditions, manifestations of chronic illness and disability were practically the same for both the elderly and younger groups. The resources of nursing homes in the future were expected to need to be expanded to accommodate the projected volume increase of elderly patients presenting these manifestations. Advances in medical science have enabled people to live longer, but higher costs trail longevity. The U.S. Census Bureau projected that by 2025, the number of people over age 85 would climb to 7 million, which was nearly double the 3.4 million over age 85 in the mid-1990s. Because frailty and deterioration intensify with age, nursing homes in the future were expected to have a majority of patients in need of more intensive care. Preparing to offer no less than optimum care for this patient segment means expansion of industry resources accentuating intensive care exclusively offered by skilled nursing systems.

In the late twentieth century, there was a growing interest in substituting skilled nursing facilities for extended hospital care among the managed care plans. In 1996, 12 percent of all Medicare beneficiaries, or 4.5 million people, were enrolled in managed care plans. Major cost savings were achieved by switching patients from hospitals to skilled nursing facilities for convalescing.

The trend toward expansion required financing that became increasingly easier to obtain because of the excellent profit potential. It served the fastest growing segment of the population. Nursing homes were among the most cost-effective providers of health care services. Honesty and accuracy in reporting fiscal, regulatory, management, and marketing portions of a home helped improve loan approval.

In 2000 about 1,500 of the 17,000 nursing homes were financed or owned by real estate investment trusts (REITs). Thirteen REITs invested exclusively in health care, with Meditrust's 1.8 billion portfolio being the largest. Advantages of REIT financing included long-term loans, better rates than banks, and the potential for operators to have a sales/leaseback option.

Changes in the Late 1990s.
The Balanced Budget Act of 1997 (BBA) mandated the phase-in of a prospective payment system (PPS) for nursing homes over a four-year period starting on January 1, 1999. Under PPS, which went into effect in July 1998, Medicare paid nursing homes a fixed per diem per patient based on the acuity level of the patient. Traditionally, the "cost-plus" reimbursement approach reimbursed nursing homes for actual service cost, in addition to a percentage based on capital expenditures and other operating expenses.

In this transitional period, the nursing home industry faced many difficulties as it coped with changes. Small nursing homes particularly suffered because attempts to control costs below the per diem rates resulted in the erosion of operating margin. Generally, nursing facilities with a relatively greater number of residents who were very ill operated less profitably, a situation that potentially threatened their ability to provide patients with adequate care.

The nursing home PPS legislation contributed to a significant decline in many service areas, especially rehabilitation and respiratory therapies and pharmaceutical services. Concerns also remained regarding the ongoing quality of nursing home care. Despite short-term increased government funding in the late 1990s, staffing did not increase. The total daily interaction time between staff and patients fell beginning in 1998. A study by researchers at the University of California reported the most significant decrease was among nurse assistants, which fell 16 percent, from 3.1 hours per patient per day to 2.6 hours. Staffing remained a problem for the nursing home industry, which continued to struggle with high rates of turnover and poor pay, particularly for its nursing assistants. This situation, in turn, tied into the ongoing struggle to ensure quality of care.

Skilled Care in the First Decade of the 2000s.
During the first decade of the 2000s, the two daunting challenges that loomed ahead for skilled nursing homes were the graying, or aging, of America and cuts in government spending. In 2006 more than 18,000 skilled nursing care facilities were operating in the United States. Over the course of one year, an estimated 3.5 million of the nation's elderly spent some amount of time in a nursing home, meaning that 15 percent of the nation's population would have a relative who was living in a long-term care facility. Moreover, the Government Accounting Office (GAO) estimated that with the aging of the baby boom generation, by 2020 one in six Americans will be over the age of 65 and by 2040 there will be approximately 14 million Americans aged 85 or older. Those over 65 will number almost 78 million by 2020 and were expected to be the most likely to utilize skilled nursing or assisted living care.

Government funding was not expected to be able to keep pace with this influx of baby boomers into the long-term care system. For example, Medicare payment cuts in late 2002 caused significant financial problems for several nursing home chains. In 2005, with the proposed Medicare cuts in President George W. Bush's 2006 budget, the National Association for the Support of Long Term Care (NASL) stated that "high quality skilled nursing care is seriously threatened" by the proposed budget, meaning $25 billion in cuts to skilled nursing care over a 10-year period. Added to these cuts was the increasing cost of liability insurance that nursing homes must pay. Beverly Enterprises, a leading nursing home chain, reported that its annual insurance accrual, which is the estimated amount of funds set aside to pay for future settlement claims, rose 50 percent to $66 million, while Kindred's o rose 50 percent to $82 million, and Manor Care's grew 20 percent to $72 million, according to a 2003 CMS report.

The shift in reimbursements caused nursing homes to shift services offered in the middle of the first decade of the 2000s, resulting in more short-term services in addition to long-term residential care services offered. CMS reported that in 2007 Medicare would increase its payments by $560 million, or 3 percent, for patients requiring post-acute services. The CMS also had the ability to disqualify a substandard facility from eligibility for federal funding through Medicare, and in 2005, eight facilities were discontinued.

Despite the relative benefit in government spending and the large potential customer base, the nursing home industry also had growing concerns over the gradual, yet significant, shift in the makeup of its residents. With the advent of assisted-living facilities, which provided support services but not extensive medical services and attracted the more physically and mentally able elderly, nursing homes found that their residents were in poorer health and in need of more advanced, expensive medical care. This situation was provoked by hospitals, which in their own attempt to cut costs discharged patients more quickly and more sick than ever before.

For-profit nursing homes continued to receive scrutiny for their quality of care. In 2007 The New York Times published an article condemning investment firms that were buying large numbers of nursing homes and, in many cases, cutting staff to boost profits. According to the article, the number of residents per registered nurse at investor-own nursing homes was 20, and the national average was 13. Private investment groups owned at least 200,000 beds (12 percent).

In 2009, 67 percent of nursing home facilities were for-profit, 27 percent were nonprofit, and 6 percent were government-owned. According to a 2008 report by the Office of the Inspector General of the Department of Health and Human Services, nonprofit nursing homes had the fewest deficiencies, which were categorized under various subjects such as quality of care, resident assessment, and quality of life. According to the report, a survey conducted in 2007 of 14,872 nursing homes, uncovered 104,665 deficiencies, which was a 10 percent increase since 2005. Overall, 91 percent of nursing homes were found to have deficiencies: 88 percent of nonprofits, 91 percent of government-run facilities, and 94 percent of for-profit facilities.

In December 2008, the Center for Medicare and Medicaid Services implemented a five-star rating system for nursing homes. The long-term care industry was staunchly against the move, stating that the rating system had little direct correlation with residents' and families' feelings of satisfaction regarding a facility's quality of care. Because a low rating can have a direct and significant financial impact on a facility, industry advocates continued to voice their concerns until, in September 2009, the House of Representatives Committee on Energy and Commerce called for a thorough review of the rating system's methodology.

According to data gathered by the American Health Care Association, during the first decade of the 2000s, the number of skilled nursing facilities declined by approximately 7 percent, from 16,765 in June 2000 to 15,702 in June 2009. However, the number of certified beds available only declined 2 percent, suggesting that the remaining facilities were providing more beds per location. In addition, the number of residents in nursing homes declined annually between 2000 and 2009, from 1.47 million to 1.41 million. The median nursing facility occupancy rate hovered around 88 percent through much of the first decade of the 2000s, reaching a high of 89 percent in 2007 and a low of 87.9 in 2009. The complexity of the needs of nursing home residents continued to rise through the end of the first decade of the 2000s. In 1985 about 50 percent of nursing home residents needed help with five to six activities of daily living (ADLs), a measure used to gauge level of independence; 20 years later, that number had increased to more than 65 percent. Over the same time, residents with ADLs of zero to two decreased from 29 percent to 14 percent.

Current Conditions

Although demand remained high in this industry in the early 2010s, it faced several challenges, including cuts in Medicare provisions, increased competition from assisted living facilities, and a shortage of personnel. In 2011 the Center for Medicare and Medicaid Services Administration cut federal Medicare reimbursement rates more than 11 percent, which, according to Mergers & Acquisitions, would result in a loss of $79 billion over a 10-year period. The same May 2012 article noted that "in order to survive in this highly competitive market place, SNFs must obtain the capital necessary to modernize their facilities and provide adequate care." In order to do this, it was expected that many would have to agree to be acquired or merged with a larger, financially well-endowed company.

Although profits were down at the end of the first decade of the 2000s due to the global economic recession, by 2010 the industry recovered somewhat, only to face the negative effects of Medicare cuts in 2011. A 2012 report by IBISWorld confirmed the predictions in Mergers & Acquisitions, noting that "The aging population will drive growth, as the number of people over 65 is expected to rise. However, decreasing Medicaid and Medicare reimbursement rates and tougher pricing negotiation from private insurance companies will hamper profitability over the next five years."

Industry Leaders

In the early 2010s, ManorCare was an industry leader with approximately 500 nursing homes (under the names of Heartland, Manor Care, and Arden Courts) and outpatient and assisted living facilities in 32 states. The firm reported an estimated $3.9 billion in sales in 2007 and employed 60,000 in 2011. Golden Horizons operated about 300 skilled nursing care centers and 40 assisted living facilities under the name Golden Living. In 2007 the company reported sales of almost $2.5 billion. Kindred Healthcare, a publicly traded firm, operated approximately 226 nursing homes in 28 states as well as 89 long-term acute care hospitals. The company reported sales of $4.2 billion in 2008. In February 2011 the firm expanded with the purchase of RehabCare in a deal worth approximately $900 million.

Workforce

According to the U.S. Bureau of Labor Statistics, the skilled nursing care facility industry employed 1.6 million people in 2011. Healthcare support occupations, including nursing aides, orderlies, and attendants, accounted for 43 percent of all jobs in the early 2010s, with a mean annual salary of $25,020. Healthcare practitioners and technicians accounted for 26 percent of the workforce and had an average salary of $51,590, with registered nurses comprising the largest subcategory of this group, earning an average of $60,830.

Statistically, the highest number of employees per set-up beds characterized nonprofit Medicare-certified facilities. For-profit homes consistently maintained the fewest number of employees per bed.

Compared to other industries, nursing homes had an unusually weighted portion of labor problems emanating from high turnover, staff shortages, low paying jobs, physical job requirements, and volumes of unskilled workers. Skilled nursing home staffing patterns primarily were divided into three categories of administration, nursing, and patient and facility maintenance. All skilled nursing care was supervised or under the direction of a medical director. Patients had the option of selecting their primary physician. Most nursing home patients, however, chose their personal physician rather than the medical director as a primary physician.

Skilled Nursing Home Administrators.
Management of daily facility operations was directed by the skilled home administrator. According to the U.S. Bureau of Labor Statistics, the mean annual salary of full-time managers in 2011 was $81,360.

The skilled nursing care industry suffered from a shortage of registered nurses, as did the overall healthcare industry. According to the American Health Care Association, the vacancy rate for registered nurses in January 2009 was 16.3 percent. The vacancy rate for licensed practical nurses and certified nurse aides was 11.1 and 9.5, respectively. Although salaries could vary significantly based on geographical region, the average annual salary for a registered nurse working in a skilled nursing facility in 2011 was $60,830.

© COPYRIGHT 2018 The Gale Group, Inc. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. For permission to reuse this article, contact the Copyright Clearance Center.

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