October 2017

Read the main articles from the “Health Care Law” issue of COMMUNIQUÉ (October 2017):

Click to download the full 48-page issue PDF file (5 MB) of COMMUNIQUÉ (October 2017 issue).

Also, the printed magazine are practical features and highlights for Nevada attorneys including:

  • “How District Court is handling an onslaught of cases tied to mental health issues” By Chief Judge Elizabeth Gonzalez
  • “The Cleveland Clinic Lou Ruvo Center for Brain Health and the Las Vegas Medical District” By Connie Akridge
  • “Nevada Appellate Court Summaries” by Joe Tommasino, Esq.
  • “Pro Bono Corner: CAP Volunteers Needed” By Noah Malgeri, Esq.

© 2017 The following articles were originally published in Communiqué, the official publication of the Clark County Bar Association. (October 2017). All rights reserved. For permission to reprint this article, contact the publisher Clark County Bar Association, 717 S. 8th Street, Las Vegas, NV 89101. Phone: (702) 387-6011.


The Nevada Medicaid Fraud Control Unit Works to Recover Medicaid Funding From Fraudulent Providers

By Andrew Schulke, Esq. and Connie Akridge, Esq.

Connie Akridge, Esq.
Andrew Schulke, Esq.

It may be hard to believe a rural pharmacy would bill Nevada Medicaid for specialty pharmaceuticals that it did not provide. This, in turn, made the patients/recipients of the “ghost claims” appear to be worse off than they actually were, and fractured the trust of a small community. However, this is one example of fraudulent conduct that Nevada’s Medicaid Fraud Control Unit (MFCU) prosecutes.

Founded in 1991, the MFCU is part of the Office of Attorney General. The MFCU has two major objectives: combating fraud and abuse against the Medicaid system by providers of medical services and supplies and protecting elderly and vulnerable adults in medical facilities from abuse and neglect. It is staffed with nineteen employees, including attorneys, investigators, analysts and support staff, with offices in both Carson City and Las Vegas.

The MFCU is complaint driven. Citizens and agencies provide complaints regarding fraudulent practices by providers and patient harm. Complaints originate from: (i) recipients themselves who complain about the amount/type of services provided; (ii) employees of providers who have witnessed acts of fraud or have been asked to participate in fraudulent acts; (iii) state/federal agencies, including Nevada Medicaid, managed care organizations (MCOs), and the Office of the Inspector General (OIG); (iv) law enforcement; and (v) industry contacts.

I. Cases and investigations

Conduct that constitutes Medicaid fraud may include: (i) services not rendered; (ii) unbundling of services, which occurs when multiple procedure codes are billed separately for a group of procedures that are covered by, and should be billed, under a single comprehensive billing code; and (iii) double billing. Any provider of medical services or supplies may engage in such schemes, including: physicians, dentists, pharmacists, durable medical equipment providers (e.g., wheelchairs, walkers, underpads), mental/behavioral health care providers and facilities, home health care providers, and others.

Recently, the MFCU has been working heavily in the prosecution of fraudulent behavioral health care providers. Services involved in these fraudulent schemes include basic skills training, psychosocial rehabilitation, case management, and biofeedback. As with the MFCU’s other investigations, fraudulent behavioral health schemes require considerable investigative and prosecutorial resources.

In the area of abuse and neglect, the MFCU investigates and prosecutes allegations of patient or resident harm cases that occur in medical facilities. This includes physical altercations by staff upon a resident, failure to provide adequate care, and failure to supervise or safeguard residents. The MFCU has also had successful neglect cases where group home owners, administrators, and/or caregivers placed residents in situations where they could be harmed due to neglectful living conditions.

The MFCU will assign an investigator and attorney to the cases. This allows the attorney and investigator to work hand-in-hand from the beginning stages through the final report, laying out the investigative findings. This cooperative relationship results in the MFCU putting together focused investigations that can turn into successful prosecutions. Often, at the conclusion of its fraud cases, the MFCU collects funds that were illegally obtained and returns them to Nevada Medicaid. In 2016, the Nevada MFCU recovered substantial amounts of money from 14 criminal convictions and 15 civil settlements. See Levinson, R., Office of Inspector General, “Medicaid Fraud Control Units Fiscal Year 2016 Annual Report,” https://oig.hhs.gov/oei/reports/oei-09-17-00210.pdf (last visited September 6, 2017). The MFCU is not restricted to criminal prosecutions, and has been able to resolve some overpayment situations with civil actions.

The MFCU is funded through a grant from the federal government, with a percentage of matching funds from state resources. This is the same method of funding used for other states’ MFCUs. The MFCU may also obtain costs of enforcement associated with cases, which in turn can be used to offset burdens on state funding sources.

II. The exclusion program

Data concerning the MFCU’s convictions is collected by the federal government, OIG. The OIG, in turn, reviews the information for consideration of excluding the defendant from being involved in any business that receives either state or federal funds for the provision of health care. With the number of Medicaid and Medicare recipients in America, this is a serious limitation on their ability to be involved in the healthcare industry.

A conviction of a Medicaid fraud offense may exclude a provider for a minimum of five years. NRS 422.450, et seq. After the exclusion term is over, the excluded party is not automatically reinstated. That provider must petition the OIG for reinstatement, and again, they are not automatically reinstated. This exclusion is nationwide and is maintained by a federal database. See Office of the Inspector General, Search the Exclusions Database, https://exclusions.oig.hhs.gov/ (last visited September 6, 2017).

Providers, on occasion, self-report fraud discovered in the operation of their practice. On these occasions, the MFCU is willing to work with the provider to investigate the scope of the allegations, determine the loss, and facilitate its return. Though additional costs will be incurred, cooperative self-reporting providers avoid many of the complications of legal actions and exclusion.

III. Challenges

With the implementation of the Affordable Care Act, the number of Medicaid recipients has grown significantly. Currently there are over 600,000 Medicaid recipients in Nevada. That number was closer to 250,000 in 2010. With the rapid expansion of Medicaid, opportunities for fraudulent providers to prey on these recipients also expands. Fraudulent providers often take advantage of Medicaid recipients by appearing to treat them nicely while requesting they provide their Medicaid identification or provide an acknowledgement for services that were not actually provided. The MFCU combats these kind of issues by bringing the billings/claims to recipient interviews. Recipients are often shocked to see how much money was billed under their numbers.

Over the past few years, an additional challenge relates to how Medicaid recipients are covered for their services. Fee For Service (FFS) Medicaid refers to the ability for providers to contract with Medicaid and submit their claims directly to Nevada Medicaid for the services they provide to recipients. As Medicaid has grown and the number of recipients has grown, Medicaid has looked to other means to provide services to recipients, including managed care organizations (MCOs). MCOs are commercial insurance companies that are contracted with Medicaid to provide Medicaid services to recipients on a capitated basis. Currently, the three Nevada MCOs are Health Plan of Nevada (UnitedHealthcare), Amerigroup (Anthem), and SilverSummit Healthplan (Centene). MCOs have their own policies and procedures to cover the services they provide.

Medicaid MCO claims are documented in a different format than Medicaid FFS claims. The MFCU works with the MCOs to obtain information on inaccurate or fraudulent claims. Because the money paid to the MCOs consists of Medicaid funds, the MFCU has the jurisdiction to investigate and prosecute these cases. With the growing number of MCO recipients, it is important for the MFCU to establish strong and lasting relationships with the MCOs, ensuring that it is receiving information of fraud being perpetrated on the MCOs by contracted providers.

As the landscape of health care changes, the MFCU continues to change and seek proficient methods of detecting fraud, safeguarding our elderly and vulnerable, and protecting the provision of healthcare for Nevada. For more information about the Nevada MFCU see: http://ag.nv.gov/About/Criminal_Justice/Medicaid_Fraud/.

Andrew Schulke, Supervising Senior Deputy Attorney General, has been with the MFCU for 11 years and during that time has prosecuted a variety of fraudulent schemes.

Connie Akridge, the Administrative Partner of Holland & Hart, LLP’s Las Vegas office practices in the areas of health law and insurance regulation.


Mass Tort Litigation: A Necessary Deterrent to Profits Over Safety?

By Peter C. Wetherall, Esq.

A corporate mentality that ever-increasingly places profits on a higher plane of priority than consumer safety gives rise to all sorts of injuries. Recent examples include Takata airbag defects, Toyota’s unintended acceleration issues, and the Volkswagen diesel-emissions scandal. Here in Clark County, a tragic hepatitis epidemic was caused by unsafe, profit-motivated anesthesia practices by gastroenterologists and a drug manufacturer in 2008.

A “profits over safety” mentality exists in all industries, but people are more susceptible to injury from defective drugs and medical devices than other types of products because they often have little input into which medicines or devices they’re prescribed. Doctors and surgeons typically decide which stent, hernia mesh, or anti-coagulant product get prescribed and, for the most part, patients take what they’re given. In a world where large and powerful companies compete aggressively for every dollar spent on health care, the substantial financial risks imposed by “mass tort” lawsuits act as one of the few meaningful deterrents to the sale of dangerous drugs and devices.

Mass tort defined

A “mass tort” is simply a cluster of individual personal-injury lawsuits arising from a common cause, typically resulting in court coordination and consolidation of those cases. A “mass tort” differs from a “class action” in at least two key respects: (1) individual claimants in a mass tort are themselves plaintiffs in the litigation; whereas, in a class action, a few duly-appointed representatives act as the party-plaintiffs and (2) mass tort claimants can and do seek money damages for their own specific physical or mental harm, whereas class action cases typically do not enable the recoupment of “pain and suffering”-type damages.

Mass tort cases act as a restraint upon corporate greed by imposing foreseeable and calculable costs upon decisions that endanger consumers. Mass tort cases impose substantial costs of defense, substantial costs compensating consumers for their pain and suffering, and the potential for a punitive damages award in many jurisdictions, including Nevada.

In cases where injury is caused, “public policy demands that one who places upon the market a [product] in a condition dangerous for use must be held strictly liable to the ultimate user for injuries resulting from such use, although the seller has exercised all reasonable care, and the user has not entered into a contractual relation with him.” Shoshone Coca-Cola Bottling Co. v. Dolinski, 82 Nev. 439, 441, 420 P.2d 855, 857 (1966). “The purpose of such liability is to insure that the cost of injuries resulting from defective products are borne by the manufacturer that put such products on the market rather than by the injured persons who are powerless to protect themselves.” Id., 82 Nev. at 442, 420 P.2d at 857 (citing Greenman v. Yuba Power Products, Inc., 59 Cal.2d 57, 27 Cal.Rptr. 697, 377 P.2d 897 (1962)).

Constraints against health-care companies’ profit motive

There are other arguable constraints against the type of corporate greed that puts recipients of medicines and medical devices at risk of injury. There is self-policing by the industry itself, there’s a regulatory framework for the approval of medicines and devices through the Food and Drug Administration (FDA), there’s potential federal criminal prosecution for misbranding or over-promotion of a product, and, of course, there’s the natural forces of the marketplace that can potentially make harmful medicines and devices money losers and the safe and effective ones money-makers.

Unfortunately, these types of constraints have never really kept corporate greed in check by themselves. In fact, in a system where even the criminal prosecution of misbehaving companies merely results in fines (albeit often into the hundreds of millions and, more recently, into the billions of dollars, and no prison for the white-collar perpetrators), these companies manage to simply accept the consequences of their over-reaching as a cost of doing business. When caught, they’re covered by either passing on that cost to the consumer or by insurance coverage – a fact that has been tacitly acknowledged in support of strict products liability causes of action by the Supreme Court of Nevada:

The well-accepted principle supporting our products liability cases is expressed in comment c of section 402 A of the Restatement:

[P]ublic policy demands that the burden of accidental injuries caused by products intended for consumption be placed upon those who market them, and be treated as a cost of production against which liability insurance can be obtained; and that the consumer of such products is entitled to the maximum of protection at the hands of someone, and the proper persons to afford it are those who market the products.

Allison v. Merck and Co., Inc., 110 Nev. 762, 772, 878 P.2d 948, 955 (1994).

The role of the FDA

Are we sufficiently protected by the FDA? Hardly. The FDA neither conducts nor funds studies. The FDA merely reviews studies and data presented to it by the prescription drug or device applicants. Even worse, new drugs and devices are often piggy-backed onto the market by an abbreviated mechanism of review involving data submitted for predecessor or competing drugs, with little if any data on the effects of the new drug or device’s effect upon a broader swath of the population over a longer period of time than can be measured in a clinical trial. The budgetary and mission limitations of the FDA render it inconsistent at best at sniffing out dangerous drugs or devices, meaning consumers are frequently the unwitting recipients of unreasonably dangerous products, largely untested until prescribed or implanted in them.

When a consumer is injured by a medicine or medical device, there is no compensatory remedy to be found at the FDA, the U.S. Attorney’s Office, the Department of Health and Human Services, or anywhere else but the civil courtroom. Even in court, the fight for compensation is never easy, but is often aided in the mass tort context by the sophistication and combined resources of the plaintiffs’ lawyers and the strength in numbers of plaintiffs, which ratchets up the risk to a company whose drug or device has caused injury. Add to that the potential for substantial punitive damages, then the sale of a harmful medicine or device becomes something a responsible company will take greater pains to avoid in the absence of mass tort litigation consequences.

The role of punitive damages

In Wyeth v. Rowatt, 126 Nev. 446, 244 P.3d 765, 780 (2010), the Supreme Court of Nevada specifically rejected an attempt by a drug manufacturer to premise an immunity from punitive damages upon its alleged compliance with the FDA, stating: “Wyeth’s conduct was fraught with reprehension and deception, and if this court adopts the policy that Wyeth seeks, potentially every company that complied with federal regulations would be absolved of punitive damages, regardless of the manner in which those requirements were allegedly satisfied (citations omitted) . . . Therefore, we reject Wyeth’s contention that compliance with FDA standards negates its liability for punitive damages, as Wyeth should not be able to benefit from its malicious and deceptive practices.”

A drug or medical device company’s risk assessments are far different in a world with mass-tort remedies available to consumers than in a world without them. Particularly under circumstances where no drug company executives ever seem to go to prison when unrestrained corporate greed causes an epidemic of cancers, kidney failures, strokes, heart attacks, birth defects, loss of sexual function, hepatitis, or death, it’s important to have in place a substantial risk to a company’s bottom line as a deterrent to profiting at the expense of consumer safety.

Peter C. Wetherall, Esq. has practiced throughout Nevada for over 25 years. He has tried over 50 cases to a jury and argued numerous appeals before the Supreme Court of Nevada and the Ninth Circuit Court of Appeals. Mr. Wetherall’s primary practice areas include pharmaceutical mass torts and serious injury cases.


Nevada’s Corporate Practice of Medicine Doctrine: How AGO, NRS & NBME Work Together to Create the Silver State’s Legal Framework for Professional Medical Practice

By Glenn H. Truitt, Esq. and Malvika Rawal, Ph.D., J.D.

Malvika Rawal, Ph.D., J.D.
Glenn H. Truitt, Esq.

The Corporate Practice of Medicine (“CPOM”), or more appropriately, the prohibition thereof, was developed from the public policy arguments which feared the potential for interference of a corporation’s profit motive into physicians’ independent medical judgment. State courts and legislatures around the country were concerned about “commercialization of medical practice, exploitation of the public, and quackery”, if corporations could practice medicine. Alanson W. Willcox, “Hospitals and the Corporate Practice of Medicine,” Cornell Law Review 45 (1960): 432-487, 434.

However, with the shift in the structure and delivery of healthcare, more physicians prefer to be employed by larger organizations rather than conduct their solo practices. Sara D. Mars, “The Corporate Practice of Medicine: A Call for Action,” Health Matrix 7 (1997) 241-300, 244. This change forced legislatures to reevaluate the CPOM laws, as the impracticality of the doctrine grew more apparent in the late 1990s. Id. This led to the doctrine’s modification so that only licensed medical professionals could own medical entities. Physicians, however, are still prohibited from employment by for-profit entities owned by non-licensed individuals or laypersons. Id. These aforementioned measures ensure that the physician’s medical judgment is not divided between their employer and their patients.

The practice of medicine in Nevada

Different states have codified various iterations of the CPOM doctrine. Although, the State of Nevada does not have a codified CPOM law, the Nevada Attorney General has addressed the doctrine in Nevada as it applies to hospitals:

In the two prior Attorney General opinions, the corporate practice of medicine doctrine was described to prohibit a corporation from employing physicians because, as its employees, the acts of the physicians are attributable to the corporation, which itself cannot be licensed. See also Berlin v. Sarah Bush Lincoln Health Center, 688 N.E.2d 106, 110 (Ill. 1997).

The justifications for the doctrine center on three public policy concerns: (1) the possibility of lay control over the physician’s judgment; (2) the division of the physician’s loyalties between his patient and his employer; and (3) the commercialization of the medical profession. Op. Nev. Att’y Gen. No. 2010-01 (Apr. 8, 2010).

Several regulations in the Nevada Revised Statutes (“NRS”) govern the practice of medicine in the State. NRS Chapter 630 defines the ‘practice of medicine’ in the State of Nevada, and governs those involved in the practice of medicine. NRS 630.020 defines the ‘practice of medicine’ as

‘To diagnose, treat, correct, prevent or prescribe for any human disease, ailment, injury, infirmity, deformity or other condition, physical or mental, by any means or instrumentality ( . . . )’.

NRS 630.020.

NRS Chapter 630 also establishes The Nevada Board of Medical Examiners (“NBME”). The NBME also derives its power to enforce the provisions of NRS Chapter 630 on medical practitioners from this chapter, including but not limited to, governing licensure for those practitioners. NRS 630.130, NRS 630.160.

Professional medical corporations and entities

NRS Chapter 89 and opinions from the Nevada Attorney General provide the CPOM framework for the State of Nevada. NRS Chapter 89 governs professional entities and associations, including medical practices. However, it states that all professional corporations and other entities will also be governed by the respective provisions of NRS chapter 78 and 86, which govern limited liability companies and corporations in the State as well. NRS 89.030.

The difference between professional and non-professional entities was created by NRS 89.040-050. NRS 89.040 states that

“[E]ach person organizing the professional entity must (…) be authorized to perform the professional service for which the professional entity is organized.”

This provision, therefore, implies that a professional entity practicing medicine must be comprised only of licensed medical professionals. In addition, the articles of organization for professional medical entities must include the profession practiced by the entity as well. NRS 89.040. The professional requirement is further clarified in NRS 89.050. Professional medical entities must be composed of medical professionals licensed in accordance with the requirements of NRS 630. NRS 89.050.2(b). This requirement for both the equity holders (i.e. owners) and employees of professional medical entities to be licensed by the NBME was reemphasized by Op. Nev. Att’y Gen. No. 77-219 (Oct. 3, 1977).

Conclusion

Both the NRS and the various Attorney General opinions have always emphasized the licensure and accountability of medical practices to the State. It is critical for both the medical practitioners and the legal counsel assisting them to understand the black-letter law and the public policy associated with the CPOM to ensure their own compliance and the compliance of the entities and structures in which they are involved.

Glenn H. Truitt, Esq. is the Managing Partner at Ideal Business Partners (www.idealbusinesspartners.com), a multidisciplinary professional services firm serving healthcare professionals with state-of-the-art legal, financial, compliance and strategic advice, working together to lift up their practices.

Malvika Rawal, Ph.D., J.D. is a Law Clerk at Ideal Business Partners. She received her Ph.D. in Free Radical and Radiation Biology, and her J.D. at the University of Iowa.


Critical Health Care Legislation That Impacts Your Retirement

By Mark Cordner

Mark Cordner

One of the most exciting changes in health care legislation quietly occurred within the Pension Protection Act of 2006 (PPA). In that act and later modifications, tax-benefits for non-medical assistance‒aka long-term care (or LTC)‒expanded significantly. Americans can now use never-before-taxed money to pay for LTC.

Before we consider the tax and legislative benefits, let’s provide context. Most of us have personal experience with family members or loved ones who have needed extensive assistance due to a decline in their physical or cognitive abilities incidental to accident, illness, or age. As life spans have increased, so has Alzheimers and other conditions that require assistance. especially among women, who typically outlive men by 6.7 years. Scientific American (www.scientificamerican.com/article/why-is-life-expectancy-lo/). Studies suggest “three out of four” Americans will require some form of assistance during their lifetime – though our individual odds are obviously 50:50. (You either will or won’t need LTC!)

Unfortunately, with LTC, you may be sick but it’s your loved ones who suffer. The consequences to their physical, emotional, social, and financial well-being can be enormously painful and disrupting. So, in short, the question isn’t if you or I will need care but rather, “If it does happen, who will be impacted, what will it cost, how will it be paid, and who will pay for it?”

The impact of LTC can’t be overstated, particularly to adult-children sandwiched between their needy parents and own underage children. The stress can be so bad that an older adult caring for another with Alzheimers “has a 60 percent chance of dying before the person they’re taking care of.” Alzheimers Association, The Grand Rapids Press, March 15, 2011.

Unfortunately, the problem is worse for women. Almost 70% of women over age 65 live alone, and are often without support systems or financial resources after having cared for a spouse or parent of their own. Family Caregivers Alliance, Women & Caregiving: Facts & Figures, Feb. 2015)

Medicare and health insurance were not designed to pay for the custodial services LTC requires. Consequently, Americans are left with only four ways to pay for this critical care: government programs, friends & family, personal savings, or insurance (i.e. leverage).

Government LTC programs are limited, insufficiently funded, and only provide basic care for the destitute – and at a cost of $30,000 – $100,000+ per year, personal savings can quickly disappear. Friends and family can’t be guaranteed – and that leaves insurance-based strategies as the final option. Insurance leverages money, literally multiplying a limited supply of dollars into a larger (and sometimes unlimited) pool of tax-free funds.

And so we come back to the PPA. Congress recognizes the problem of aging Americans and created tax-incentives to help people prepare. In addition to allowing tax-deductibility of some LTC insurance premiums, Congress now allows the tax-free transfer of appreciated life insurance and annuity values from old contracts into newer contracts that offer LTC benefits – thus permitting never-before–taxed earnings to purchase contracts that produce tax-free LTC benefits. Furthermore, unused funds may then pass on to beneficiaries in a tax-advantaged and even tax-free manner. It’s literally a tax-free trifecta. Once understood, these funding strategies can be powerful tools in retirement, divorce, and executive-benefit planning. More importantly, they allow loved ones to coordinate professional caregivers rather than provide hands-on care themselves.

The probability of LTC is high and the implications potentially catastrophic. Insurance isn’t the only solution. Planning is — and government is willing to help.

Rosalynn Carter said, “There are only four types of people in the world . . . Those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers.”

Don’t leave your future to chance. Create a plan that maximizes the tax benefits allowed by government. Can you even say “Tax free” without smiling?

Mark Cordner is a Chartered Retirement Planning Counselor, Certified in Long-Term Care. An insurance and financial advisor since 1992, he owns Golden Years Financial, a Las Vegas-based Registered Investment Advisory firm. Mark Cordner and Golden Years Financial do not provide legal or tax advice. Please consult your legal or tax professional for personal assistance.


Disasters Don’t Plan Ahead. You Can.

By Heather Anderson-Fintak, Esq.

Heather Anderson-Fintak

September was National Preparedness Month. This year’s theme was “Disasters Don’t Plan Ahead. You Can.” It’s never too late to prepare your home. Here are some items that are suggestions for your emergency kits:

  • Bottled/purified water and water storage bags;
  • Emergency food, such as cans, bulk, freeze dried;
  • Full first aid kit;
  • Extra prescription medication;
  • Generators, batteries & propane;
  • Walkie talkies, radios, and other low tech communication devises;
  • Axes, hatches, and knives;
  • Tents and other camping equipment;
  • Survival gear, such as fire starters, water filters; and
  • Portable toilets.

In case of a Zombie Apocalypse, there are a few more items you may want to consider, such as:

  • Shotgun, compound bow, and throwing knives;
  • Compass;
  • BlackHawk SOLAG Gloves (for punching zombies without injuring your hands);
  • Thermal vision and night vision scope;
  • Light scope for shotgun;
  • Tactical vest to store all your attachments; and
  • Dark or camo clothes in order to confuse brain eaters

If you are interested in learning more about Emergency Preparedness, please visit SNHD’s website at http://www.southernnevadahealthdistrict.org/php/index.php

Heather Anderson-Fintak is the 2017-2018 Editor-in-Chief of the COMMUNIQUÉ. She is also the Associate General Counsel for the Southern Nevada Health District and has been protecting public health since 2012. Previously, Heather spent 10 years advocating for low income individuals as a legal services attorney in Maryland and Nevada.


About COMMUNIQUÉ

COMMUNIQUÉ is published eleven times per year with an issue published monthly except for July by the Clark County Bar Association, P.O. Box 657, Las Vegas, NV 89125-0657. Phone: (702) 387-6011.

© 2017 Clark County Bar Association (CCBA). All rights reserved. No reproduction of any portion of this issue is allowed without written permission from the publisher. Editorial policy available upon request.

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