• Out of Network Private Physical Therapy Practices Litzy, Hilton, and Haag Share Their Secrets to Success

    Over the last few years I have had the great opportunity to meet a lot of young, talented #DPTstudents and #FRESHPTs. They are really excited about our great profession and many have a dream to start their own practice; they have an entrepreneurial spirit and passionate drive. And many have said to me, “I want to start my own practice, but I don’t want to deal with health insurance; too complicated – too frustrating – too much of a hassle. I want to inspire people to pay out of pocket for my services.” But many are wondering, “But hey, can I really do this? Can I really start my own private practice in this world of big health care organizations? Will enough people be willing to dig into their billfolds and pay me?

    My response is short & sweet – “Of course you can! Why not??!! But that’s not my world. We do work with health plans all the time. For your dreams . . . you should find out from the real experts.”

    So I reached out to 3 successful, highly respected physical therapists who own their own very cool ‘out-of-network’ practices AND who are SO talented, well . . . their customers come to them with their checkbooks open, credit cards out, and expectations high.

    For good reason.

    So if you are interested in opening an out-of-network practice, check out what these experts have to say.


    OK Out-of-Network Physical Therapy Practice Experts

    Let’s start with the basics . . .

    What is the name of your practice, where are you located, and briefly tell us about your business? Let’s start with the two business partners, Sarah and Sandy. Go for it Sarah.

    Sandy and I own Entropy Physiotherapy and Wellness in Chicago, IL. We created Entropy to offer expert physical therapy in a setting that is not only comfortable, but a setting where our clients don’t just come first, they are able to be full partners in deciding their course of care. We offer ‘traditional’ physical therapy services, with an emphasis on chronic pain and pelvic health, as well as $5 community yoga classes and professional continuing education courses for health and fitness professionals.

    Sounds fun already. When do you open a franchise in the Twin Cities? I’d jump on $5 yoga.

    How bout you, Karen? You have such great podcasts and a strong presence on Twitter, but let’s hear more about your business.

    My practice is named Karen Litzy Physical Therapy, PLLC and I am located in the heart of New York City. My practice is concierge’s style, where I see clients in their home or office. My clientele is mainly orthopedic, chronic pain and some neurological conditions. My clients are not homebound clients, like in a traditional home health practice, but rather they are very busy New Yorkers who would prefer to have someone come to them. As my tagline states, “Karen Litzy Physical Therapy is care that comes home.”

    Wow! Now that IS customer-centered care. It’s only 1190.7 miles from your office to my home. Do you charge for travel expense?

    All right . . . driven business owners . . . entrepreneurs . . . risk takers . . . Let’s get into the nitty gritty. So what or who inspired you to open your own business? Karen, why don’t you go first this time.

    I took inspiration from several of my friends who are personal trainers and were seeing the majority of their clients in the home instead of in the gym. I thought if they could do it then so can I! To be honest, I did not know of any physical therapists with this treatment model outside of the traditional home health agency so it was a lot of learning through experience that got me to where I am today.

    Very innovative. Nice niche you’ve carved out.

    Sarah, how about you?

    I began to become frustrated by the experience my clients were having in the large organization where I practiced. My previous place of employment does amazing work. However, due to changes in the healthcare environment (primarily relating to insurance requirements, limitations and payments), more of my day was spent doing pre-authorizations, and getting notifications that my clients had met their max in therapy benefits. I really felt awful – day after day – explaining that if they wanted to continue care, they would have to pay out of pocket, and the costs at that organization were absolutely cost prohibitive to most.

    Actually, another life experience also inspired me. I lived in Greece for one year, and I experienced a system where there was socialized health care, as well as private sector services. After a less than impressive visit with an ‘in-network’ doc, I went to a private cardiologist. I had an hour with the doctor, who did 3 or 4 tests in the office, and gave me the results and plan of care that day. The cost? The equivalent of about $75 USD. I started thinking ‘how is that even possible???’ I wanted to create a practice where the overhead is low, the bookkeeping simple, and the care affordable. Entropy was the answer!

    That is really cool, Sarah.

    So what inspired you, Sandy?

    The regulations imposed by the insurance industry were my biggest motivator for opening a private practice.

    My first practice, which I eventually sold, was in Ann Arbor Michigan from 2005-2010. I opened that clinic to treat friends and friends of friends who weren’t getting the care they wanted. I wanted a place where I could treat a person without the constraints of the insurance contracts and for a reasonable rate. People liked feeling better and being involved in treatment decisions. And the word spread.

    Once I worked outside of the insurance system, and for myself, I was ruined for tolerance of insurance driven decisions. I tried working for someone else again when I moved to Chicago, but the insurance-based treatment decisions irritated me, and I had to find a way to open my own place again. I am lucky that Sarah Haag shares a vision of what Physical Therapy can be, and we opened Entropy together.

    Ongoing . . . my patients with inconvenient challenges like persistent pain, sexual dysfunction and those who want long term guidance are a constant inspiration to work harder.

    What did you do to prepare to start your practice? Sarah?

    Here are my 4 key points . . .

    • Financial – Prepare for the worst, make sure you have support and a plan.
    • Emotional – Weigh the pros and cons. The simple question I asked myself, ‘Will doing this improve my quality of life or not?’ All of the added work/worry/wonder was totally worth the creation of a work environment I love where I can deliver the services my clients deserve. And there is still a lot of added work/worry/wonder!
    • Legal – In PT school, we were not exposed to much about how PT works as a business. I didn’t understand the foundations of how to start a business, but I certainly didn’t want to break any laws! (this leads to the next point)
    • Know your skillset – I did take some business classes in college, so I had some basic foundation for starting a practice. And I was fortunate enough to find Sandy Hilton. She had experience with running her own practice. We share a vision of what we want Entropy to be, but we offer complimentary skills. If you don’t find a partner (or don’t want one!), know that it is better to pay someone to do a job well rather than do it poorly on your own.

    Great points, Sarah. Sandy – can you add to that?

    I can. Here are 5 key points I can share . . .

    • I knew the environment and policies under which I wanted to work.
    • Business Partner. I knew from previous experience that it was possible, and this time I would have a clever business partner.
    • Location. Location. We determined the location by considering our budget analysis, access to transportation, and community need.
    • Have a Plan. We develop a business plan and had the courage, passion, and time to commit to making our business successful.
    • We decided to take the risk

    By the way, the APTA Private Practice Section has a lovely guide to get started, so you don’t have to reinvent the wheel.

    Sounds like you two are good business partners. If I might add in support of you . . . that is SO important. OK. Karen . . . Ms BIG CITY Slicker. How did you plan?

    I started my practice slowly. I worked a full time job in an outpatient clinic and did the side hustle for 2 years. Then I went part time in the outpatient clinic and completely phased out the ‘outside’ work over a period of another 3 years. It was important for me to know that I could have a consistent flow of patients before I left the clinic job (NYC is a very expensive place to live), plus I enjoyed working with other therapists during the week and I was not ready to give that up completely. About five years ago I did stop the part time clinic and went completely out on my own. I think this is a good way to start a business when you are a #FreshPT.  

    That is a great way to minimize your financial risk when you start up. In other words – be somewhat patient. Tell us the most important things a start up private practice PT should consider.

    In my opinion, the most important things one needs before they start any practice, especially an out of network practice are:

    • Legal Counsel. Find a good lawyer and accountant to ensure you have the right corporate entity for you and your situation.
    • ROI. Be very clear on your ROI – this is how you create a consistent brand:
    • Relevance: What do you do, why do you do it, and why should people care?
    • Originality: What is it about you and your practice that is unique?
    • Impact: How do you make a difference in the lives of your clients and community?
    • Your Market. Really know who your ideal client is. As an entire profession, everyone with a body is our ideal client, but as an individual practitioner you cannot be everything to everyone. So getting crystal clear on who your ideal client is cannot be skipped. Once you know who this client is, you can then direct marketing efforts to that potential client and start to build a sustainable practice.
    • Website – Marketing. Build a great website that represents you and your ROI/Brand.
    • It Takes a Village. Surround yourself with a great “tribe” that truly wants you to succeed. I would recommend finding a group, whether in person or virtual, of like mined entrepreneurs to offer and receive support, ideas, and love. Being a “soloprenuer” (if you are one) can be lonely at times, and it is always great to know that you have your tribe in your corner.
    • Don’t be too Proud. And finally never, ever be afraid to ask for help!


    Excellent advice, Karen. I love your creative ‘ROI’. You have just tipped the accounting profession on its ear. Knowing YOUR value and YOUR market can’t be overstated. As you said, ‘You can’t be everything to everyone’.

    Great advice from all of you.

    Let’s get into your practice. Tell us about your business model . . . How do you make money anyway? Karen – NY must be a challenge.

    The services I offer are: physical therapy, wellness training, softball pitching instruction, and golf evaluations.

    For the physical therapy sessions I am an out of network provider for all insurance companies. I give the client an invoice and they can then choose to turn that invoice into their insurance company for reimbursement.

    All other services are cash based without the option of insurance reimbursement.

    I also have a podcast, Healthy Wealthy & Smart that has helped generate referrals to my business and I am starting to see some sponsorship money.

    By the way, KL . . . your podcasts are excellent. Hey readers – Healthy, Wealthy & Smart is well worth your time!

    Sandy and Sarah – let’s hear from you together on this one.

    Sandy – We get paid from the people who come to the clinic for therapy. Directly. Each client pays us at the time of service priced on clear fees that are based on the time they are seen.

    We also use an outsourced billing service to provide revenue cycle management for clients with Medicare, VA, and Tricare (the insurance that covers the families of members of the US Military).

    In addition to our direct physical therapy services, we host world-class continuing education courses for health professionals right here in our clinic.

    I also get a bit of revenue from book royalties (Why Pelvic Pain Hurts).   Sarah and I are planning on more educational resources and a unique mentoring option.

    Excellent. I would like to interject here and advise our readers – check out the Entropy website and sign up for their outstanding CE. Check out Sandy’s book as well. In case you missed it above – Why Pelvic Pain Hurts by Sandy Hilton.

    Sarah. Would you like to add a little more about your very cool Entropy? I love randomness.

    Of course. Entropy is primarily a physical therapy clinic. Just to add to what Sandy said, we are out of network for all commercial health insurances. Any person with commercial insurance pays us at the time of service, and we issue them a receipt with the necessary diagnosis and procedure codes for them to submit directly to their own insurance company for reimbursement.

    We also have community yoga classes for $5! This is obviously not our primary source of income, but it gives our clients a safe place to transition confidently into a community fitness setting or a home program. It also doubles as a way to gain exposure in the community.

    Finally, I want to add a bit about our exceptionally innovative continuing education opportunities. We have renowned speakers come from all over the world to share their research and clinical expertise in a comfortable setting, where there is time and space for discussion and collaboration! And unique fun.

    Great stuff Sarah. You and Sandy do have unique CE experiences that I HIGHLY recommend to all. I heard you even had the illustrious Jerry Durham on your docket last year. That’s impressive. He comes with a big price tag and a huge following. Did you tell me he provided cigars for all of his ‘students’?

    OK . . . Back to business. Marketing and sales are critical activities for any business. Without giving away your ‘secret sauce’, how do you market your practice and convince people to buy your services? Sarah Jo Haag . . . you are up next.

    We keep it simple and straightforward: We’re really good at what we do, but we’re not the right fit for everyone. We let referral sources, as well as potential clients know that we will do our best to help them. However, if we’re not the right people, we will help them get to the right provider. We rely more on marketing directly to the consumer of our product and on word of mouth from our current and past clients to spread the word.

    Cool. Makes sense for your type of business. Sandy . . . do you want to add to Sarah’s points.

    Yes. Like Sarah said, our primary marketing is direct referral from current patients, some strong doctor support and referral from other health professionals for complex patients. If we take exceptional care of people, they tell their friends.   We’ve tried a variety of marketing options and the ROI (conventional accounting jargon . . . Return on Investment) is best from direct referral and being a lively and engaged member of the health community. “Be so good that they can’t ignore you”.

    You are good. I would say Great. And it is hard to ignore you.

    Ms Litzy. How do you market in The Big Apple (as opposed to the Mini-Apple where I live).

    The majority of my referrals come from word of mouth marketing and as a result, I rarely have a problem “convincing” people to buy my services. I think of my current and former clients as my brand ambassadors…they go out and spread the word about my business. I also have, in my opinion, a really nice website that reflects the vibe of my business and I think clients sense that. I have been getting more and more patients from the website lately.

    Hmmm. Interesting. Although I thought 3 Twitter Queens would depend more on social media. I get the word of mouth marketing approach. Makes sense. I will do my best to spread the word. I have no doubt your ‘brand ambassadors’ are very loyal.

    Moving on . . . Besides serving your patients/clients, what do you enjoy the most about being a practice owner and entrepreneur? Let’s stick with the New Yorker . . . What do you think, Karen?

    Of course I love the ability to control my schedule! But aside from that, I think my business model is such a luxury not only for the clients (as I go to them) but also a luxury for me for a few reasons:

    • I never feel rushed when I am working with a client.
    • I give myself ample time between clients to recharge and be fully present for each client.
    • I can go to the gym in the middle of the day when it is less crowded. (This may not seem like a big deal but in NYC is it awesome!!)
    • I can usually eat all my meals at home, which is healthier and cost effective.


    Hey – I want your job, Karen. Do you have any openings? I love it! Especially the control of your own schedule. You can’t put a price tag on flexibility. Speaking of which, can you do anything for tight hamstrings?

    Sarah. What do you like best about being an Entropy Entrepreneur?

    Tough question, Jim. So many things, it’s hard to pick a favorite! But if I have to pick one, it’s this . . . I love being able to have the authority and ability to give each client the best experience possible – from the first phone call to the transition to their choice of plan. That plan can be discharge, or some sort of maintenance plan, to transitioning to be on their ‘flare up management team’. I love working in a setting where the person seeking help can decide when they’re done, and feel confident asking for help when they need it.

    You and Karen have similar ‘likes’. However, I must say, our friend Jerry D. would be disappointed you used the “D-word” (shhhh. discharge).

    Sandy. Your turn.

    I love being able to make clinical decisions based on the person, not on the insurance companies idea of “cost containment” or a questionable metric on the average number of visits per diagnosis. I aim to see a person only as long as is needed, no pressure to see them more than they need, no lectures from ‘the boss’ when they need less than anticipated.

    I also like the freedom to apply the best evidence in the clinic. We don’t own a therapeutic ultrasound machine. Why would we?

    Freedom is a beautiful thing. I see common passions in all 3 of you. And of course you wouldn’t own an ultrasound machine.

    We are getting close to the end of this interview. I hope you are enjoying it as much as I am. So let’s see, where were we . . . oh yeah . . . We all have to take the bad with the good, right? What do you see as the biggest challenge in your business?

    Sandy – what do you think?

    Ironically, the biggest challenge stems from the work ethic. We get people better, and then they don’t need us. We need a steady stream of new patients!

    How about for you, Sarah?

    I’d say the biggest challenges are shifting the public’s view about what Physical Therapy is, what Physical Therapy has to offer, and having people differentiate between ‘healthcare’ and ‘insurance coverage’.   One upside of rising deductibles is that people are looking more at what their healthcare will cost them. Potential clients are asking more questions about the value of what they’re getting out of healthcare. Now it’s up to us as a profession to show what we can do to be of value. #GetPT1st is a movement to help educate the public on what physical therapy is, and what we can do to help, in terms that are meaningful to people who are not healthcare professionals. I think that movement is a good thing.

    I am really glad you brought up #GetPT1st, Sarah. Twitter-folks reading this great interview – check out #GetPT1st and spread the word!

    Karen – what do you have to say about this?

    Right now my biggest challenge is doing it all myself. That will be remedied this year! I am looking for an intern to help with the podcast and I will most likely be hiring at least one physical therapist for the PT side of the business.

    Valid challenges. No doubt. But it sure seems like you all are facing them head on.

    I am both a basketball and health care reform junkie. In fact, I’m not sure what I spend more time doing, reading about ACOs or preparing for my March Madness NCAA pool. I won’t ask you to pick this year’s Final 4, but I do have a question for you about our reforming health care system. I keep reading about and experiencing the move to ‘value based’ models. How do you define VALUE in your practice?

    Sarah Haag.

    I actually think that it’s up to the consumer to define value. It’s our job to offer a service that others will find valuable. Entropy is offering 2 experts in physical therapy to be on your team to reach your goals. We offer individualized top quality care, in a private and comfortable setting, with transparent pricing and policies. If the consumer finds something else more valuable, then that will likely be a better fit for them.

    Karen Litzy.

    I too keep reading about “value based” care and models. In some ways I feel like the more I hear about value based care from so many different perspectives, the more the term “value” starts to lose value. There are many tools out there to measure outcomes and I suppose your bank account can be a measure of client volume, but value is a bit trickier to measure, isn’t it? Just like beauty is in the eye of the beholder I think value is as well.

    How would I define value?? I define my value by how happy I am doing what I do in my business and in my life (many times it is hard to separate the two). I like to think the value of my practice is defined by the incredible word of mouth marketing I receive from current and former clients. I am, most often, the first healthcare practitioner on the call list for my current and former clients, and this shows me that my clients see incredible value in the advice I give and the care they receive. I am ever so grateful and humbled by this on a daily basis.            

    That is beautiful! In the eyes of this beholder.

    Sandy Hilton.

    Value is defined by the consumer or user of a product. If health care (my treatment) is the product, the value must be defined by the user. I aim for comments such as a patient made (paraphrased and modified)

    “I saw you for 106 hours start to finish, at first I thought that was a lot and then I thought: in 106 hours I went from not being able to tolerate sitting or wearing jeans or having sex to enjoying all of that and running too. This was a great use of my time and money”.

    That is value. Value is also in another patient saying

    “I am glad I could do this program mostly on my own, and only came in once a month for updates and the next things to work on. Thank you for not being stuck on 2 -3 times a week”.  

    When Physical Therapists get to design the treatment based on need, with the patient, and make it meaningful…. That is value.

    We could simplify it” “Was this course of treatment worth your time and money?” Yes or No.

    More beauty.

    My accountant and business advisor is a real expert in the area of health care business development. He’s a solid health care businessman. He once told me, “If a business does not grow . . . it dies.” I agree, and we are always in growth mode for our business. What things must you do, as a business owner, to ensure your business ‘grows’? Let’s go back to The Really BIG City. Karen. What do you think?

    I think it is all about having the right mindset. I have a mindset that is always open to creative possibilities. I think if you are always open to new and innovative ideas you will continue to grow. I am also always networking and making new connections. You never know who that person will be that will be a game changer in your life and business!    

    Sarah. What do you think about growth?

    I like that you put ‘grows’ in quotes. Define growth? I think that in the last 3 years our idea of how we want to grow (I prefer the term develop….) has changed a bit. I think we’re still quite young as a business. We have our eyes set to the future, with a few thoughts on ways we can make a positive impact not just in Chicago, but in the world of Physical Therapy. On a smaller scale, we grow and develop just by reviewing what we’re doing, what we’d like to be doing, and doing both of those things as well as possible. We tend to look more at the quality of the services we’re offering and compare it to the non-tangibles that we want to get out of what we do, then set a financial goal after that. We agreed when we opened Entropy that we obviously need to make money, but if we can’t make money in a way we feel good about, then we should do something different.

    Sandy. Do you have similar views?

    Growth can be defined as learning the best evidence and letting go of techniques shown to be inefficient or ineffective. Growth can be in growing into new patient populations, or new community outreach opportunity. Growth can be a library of patient information that is accurate, builds self-efficacy and refutes the Scare Marketing of “text neck” or “sitting disease”. Growth can be becoming the premier destination for continuing education of the highest quality and that promotes solid clinical decision-making skills. Growth needs to be fun.

    You all have varying views of “growth”, yet you show similarities in that you are outside the typical way of thinking about business growth. Thanks for sharing.

    You all are located in bustling, high energy, hip cities (understandable since you are all bustling, high energy, and SUPER hip PTs) . . . but do you need to be in The Big City to have a successful out of network practice like yours, or could a young entrepreneurial PT start a practice like yours in a small city or non-bustling town? Sandy, let’s start with you.

    Absolutely! An out of network clinic could work anywhere with an open market. A successful business fills a need. Anywhere with people who hurt, and who are not getting better, and who can not afford to waste months or years not making progress can use a motivated out of network private practice.
    It is naïve to ignore the “in-house” referral requirements of some hospital systems and ACOs. When health professionals either actively or passively block access to independent practitioners (it happens), then the playing field is not even. That has more to do with ethics and fairness than the size or hipness of the city. I think that robust movements of community education can teach people to not put up with delayed care, long waiting times or lack of progress.

    Awesome. Sarah.

    I don’t think you would need to be in a big city like Chicago or New York. I think that it just depends on what your goals are, and what the market is. The business plan that would work in Chicago may not translate into a small farming community. I think that’s why it’s important to ask ‘what do I want to get out of owning my own business?’. Is it life in a small town? Then start there, look at the market and what you need to be happy and see if the equation balances out.

    Karen. What do you think?

    I think you can have a successful out of network business practice in any setting. You may have to change your pricing or how you market the business, but I think it is possible anywhere! Even if you have a practice that is in network with insurance companies for physical therapy there are so many ways to add cash services to your menu. Some examples are: fitness classes, 1:1 personal training, pilates, yoga, meditation, and lectures.

    Thanks for your perspective on location. I know we have lots of aspiring entrepreneurs in smaller communities.

    Looking forward. Dust off your crystal ball and peer inside. What do you see in the future for your physical therapy business? Sarah.

    I see our continuing education continuing to grow…. We’re working to offer more opportunities for our profession to work with other healthcare/fitness professionals and to think beyond the new technique that will supposedly change the way you practice. 2016 is looking good, but ask me again in 2017!!

    We also have some ideas for mentorship and helping young PTs have options to learn and grow professionally.


    My hope for my business is that I continue to be happy and proud of what I am doing and people continue to see the value I bring to the table. If this is the case then the future for my business will be prosperous and bright.

    That being said, this year I do plan on adding webinars to my online business life and more speaking gigs to my offline business life. I have three speaking engagements booked for this year and am hoping to add some more as the year goes on!


    I see Entropy as a community resource for exceptional therapy, a strong community reputation and an international resource for professional education of the best quality. Think more co-op than corporate, with a philosophy that supports independence and professional growth.

    Great vision. Exciting for you and your businesses. And you are all offer very encouraging messages for the young entrepreneurs in our audience.

    1. Time to wrap it up. Let’s say an aspiring, young physical therapist comes up to you and says, “Hey . . . I’m tired of working for ‘the man’. I want to start my own practice. What is your one bit of advice for me?”

    Karen – lead us off on this one.

    Make sure you are clear on exactly what you want your business and life to look like before you start. Don’t be afraid to push yourself into uncomfortable situations and don’t be afraid of hard work!

    Very cool. Great advice, Karen. Sandy, what do you want to offer?

    Go to PT Pub Night events in your target town and make connections, make contacts on Twitter with #bizPT and get to the local Small Business Association to access all of the free resources. Read up on the Private Practice Association of the APTA and use the resources the APTA provides. Join the APTA and get involved at a state level or a national level. Do your market research and then be sure you can live for some years while it grows. You don’t have to do it alone, but you do have to work. Hard. Find a few mentors, especially one or two that think differently from you.

    Excellent advice. OK, Sarah. Offer you words of wisdom.

    Decide on your definition of ‘success’.

    What is it about working for ‘the man’ do you hate? Can you create a setting where the things you hate aren’t necessary?

    Owning your own practice is work (likely more than you can even imagine!). Knowing that, will owning your own practice improve your quality of life?

    Karen . . . Sandy . . . Sarah. Thank you VERY much! This is great information that you have shared with our readers and me! I’m really impressed! I have learned a lot about you and your businesses in this very short interview. But before we close, I just have a parting question:

    My back has been killing me lately from doing all the heavy lifting involved in writing these blogs. Can I get a free consultation?

    Just kidding. But seriously . . .

    This has been a REAL pleasure, and all of us really appreciate your words of wisdom and advice.

    Thanks again PT Leaders in the Out of Network Business!

    And for all you thousands of TPI Blog readers . . . make sure you follow Karen, Sarah, and Sandy on Twitter (oh yeah . . . @TherapyPartners, too)


    Sarah Haag, DPT         @SarahHaagPT


    Sandy Hilton, DPT         @SandyHiltonPT


    Karen Litzy, DPT           @karenlitzyNYC


    Sign up for Karen’s podcasts Healthy Wealthy and SMART at https://twitter.com/karenlitzyNYC.


    And Check out all the great Classes, Seminars, Learning Experiences, and YOGA at Entropy PhysioTherapy . . . http://entropy-physio.com/.

    I hope you enjoyed the interview with these highly successful women. Be inspired by their entrepreneurial spirit! And as a wise baseball coach once told me . . .

    You can’t steal second with your foot on first base.

    Go for it!

    Keep Learning . . . Keep Leading!

    – Jim


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