More on patient responsibility

24

Category : Medical Rants

Very interesting comments on my previous post. Generally, some comments focused on the principle of responsibility, while others focused on the details. Most of the disagreement seems to occur with writers emphasizing different problems.

The idea of responsibility for ones health care is the philosophical and economic concept that I support. We can certainly debate the details (although we do not have the details, just a newspaper report). I believe that I could construct a program that is fair to patients, but rewards those who help themselves.

If we assume limited resources (a reasonable assumption I believe) then should we not invest more in those patients who help themselves. The West Virginia plan is an experiment of this philosophy. It may work; it may be a failure. Our current system is broken. Should we not try to influence patient behavior in a positive way?

What should be the priorities? I would offer smoking cessation, exercise program with weight loss (when indicated and possible), medication adherence (focusing on clearly indicated medications), and avoiding unnecesary ER use. We could debate the list, but I challenge everyone to debate the concept rather than the details. The concept of rewarding those who make the extra effort seems consistent with my beliefs.

As a physician I do my best to help all patients. I will admit that I probably work just a bit harder for those who make the effort to help themselves. I do not stop seeing the other patients, but I certainly do no agonize over their poor choices.

As a physician we see too many patients whose illnesses are avoidable. We see alcoholics with the ravages of too much alcohol; we see cigarette smokers with COPD, cancer and/or coronary artery disease; we see the obese develop type II diabetes mellitus. Those who do no drink excessively, do not smoke, and keep their exercise and diet reasonable are currently subsidizing the health care of the self abusing patients. Is that fair? What precentage of increasing health care premiums comes from smoking, drinking and obesity?

Should we not figure out how to reward those who care for themselves? Should we not reward those who reform (by stopping smoking or drinking or losing weight)?

I understand that considering this subject is very uncomfortable to many. Since I accept personal responsibility for my actions, I expect others to accept personal responsibility. And what is wrong with that?

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Comments (24)

I have said before that I believe in personal responsibility, and I certainly agree that people will maximize their life expectancy if they make sensible lifestyle choices, and, when they do develop diseases that can be effectively managed, are compliant with medical, diet and exercise recommendations. My fundamental question, however, is does it save money for the healthcare system over the long term?

In my own case, for example, I needed a CABG in 1999 despite cholesterol and weight in the normal range. Since then, I needed to have my gall bladder removed in 2000, prostate surgery in 2004, and a cardiac stent in 2005. I take five prescriptions plus aspirin to manage the heart disease and control blood pressure. I’m 100% compliant with the medical regimen, my BMI is 22.5, but I could probably do better on the exercise front, though I do walk a lot. My (superb) cardiologist recommends a stress echo every other year, and I see a urologist twice a year and get an annual physical as well. 20-30 years ago, I probably would have died of a heart attack in my early to mid-50’s (I’m 61 now). While I’m grateful to be alive thanks to excellent docs and the miracles of modern medicine, I seriously doubt that the system has saved money in my case vs what would have been spent if I were non-compliant with the medications, smoked, drank, and let my weight get out of control.

It might be useful if there could be a mechanism for tracking lifetime medical spending at the individual level in order to make more definitive judgments and conclusions as to whether healthy lifestyle choices and compliance with doctors’ orders and recommendations saves money or not. My sense is that, on average, the longer we live, the more healthcare we will consume. It would be nice if we could all stay largely healthy into our 90’s and then quietly die in our sleep one night, but life (and death) generally don’t work that way.

My main problem with Virginia’s plan is that it equates clear cases of irresponsible behavior such as going to the ER for every minor thing (or to get drugs) with one’s refusal of medical interventions. The ability of an individual to refuse the latter is a right as is getting the correct and honest information of benefits and risks. Your list is better in this respect.

I think, I might be more receptive of these plans if
a) they don’t interfere with our fundamental right to refuse medical intervention (except in cases where our choices pose a clear threat to public health).
b) there is absolutely clear and non-controversial evidence of benefit for others (and not just the person involved) and that the benefits clearly outweight the risks by a significant margin.

I think that it is OK to penalize people for missing appointments and overuse of the ER falls into this category. But only in clear cases – sometimes it is difficult for a layperson to know what is or isn’t an emergency. There are people who make mistakes either way, but the consequences for those who made the wrong choice in real emergency are worse. In case of missed appointments, the penalty should really be proportional – e.g. the cost of the appointment itself. This would be fair to people who had a valid reason for missing appointments as well as to doctors.

As far as the rest of the items on the list in this post, I am not sure how cost-saving they are. BC already posted on it. I hate smoking and I’d love nothing better if everyone just stopped. But will it save money? Maybe to companies who only pay for insurance while the person is employed. But to medicaid? I am not sure since smokers tend to die sooner. As far as exercise is concerned, yes, it is good to exercise, but it may also increase the number of injuries. Would the cost be significantly lower than expenses of such a program? I am not sure.

The other thing is the cost of bureacracy to track all of it. Nobody seems to consider this. But it should be taken into account as well.

I think that before one tries to “experiment” and see how such a program would work, one should try to get a rough estimate and see if it really is cost-saving.

Diora,

It is West Virginia’s plan not Virginia’a plan. They are different states.

I think one of the key issues here is the medicaid culture. Personally, I would love to be able to say “if you aren’t complaint, you don’t get free care” but I don’t think that’s a culturally realistic expectation for this group.

You see, I was brought up with the idea that I could improve my circumstances by working hard and applying myself. This means education, being a good employee, taking responsiblity, sacrificing today for more tomorrow, etc…
In general, the poor are brought up with the idea that you have to take what you can get because that’s all you’ll get. Emphasis is not placed on education because the benefits are long term only. High risk behavior is modeled and consequences are not often discussed because benefits are more immediate. Also, most (and I emphasize the word most) people on the medicaid rolls will have a fatalistic worldview and will not believe they have control over their own lives.

My point:
Based on my studies and experience, it is my belief that the medicaid patient faced with either a) quitting smoking or b) losing benefits will simply accept the loss of benefits because he or she will not believe he or she is capable of quitting smoking. The same goes for weight loss. The dominant thinking in this group is 1) now is more important than later and 2) you can’t change anyway so why bother.

This is not a jab at the poor by any means. It’s an issue of socialization. Middle and upper class children are brought up being taught that they are empowered. Poor children are brought up in a survival environment where present is more important than future. This is why rent-to-own , check cashing, and title pawn stores are so popular in poor areas. The middle and upper classes would balk at the interest rates charged by these places, but the poor are more interested in right now.

Over all, I don’t think that this plan does not take into account the social factors involving the majority of those on medicaid.

Correction, that last line should read:
Over all, I think that this plan does not take into account the social factors involving the majority of those on medicaid.

A big problem is that many people refuse to consider how their lifestyle choices affect their health until their bodies begin to breakdown from those choices. Health is the result of a life time of choices AND a dose of good genes (or, more likely, good common sense).

Then, just consider how often the public is bombarded with ‘scientific information’ (from doctors as well as the media) about how to stay healthy that proves to be absolutely wrong! It’s confusing, and people begin to somewhat ignore medical advice — even those who are willing to put effort into good health.

In my opinion, it is reward enough, for staying healthy, simply to be able to avoid the expense and myriad difficulties of coping with doctors and hospitals. But I am so grateful we have them for those who through no fault of their own need a great deal of medical care.

As for the slackers-in-self-care and the abusers of the system, they’re always going to be around, and no bureaucracy will curb them.

I agree that “incentives” to those who help themselves by making positive choices WRT thier general health make sense – certainly fiscally and for general health, and more arguably from a moral standpoint (pt. responsibility etc.) but there are two points I would make:

1) It must be addressed that many of these behaviors have an addictive component – it is not so easy for everyone to lose weight, stop smoking or drinking exessively – especially for the disadvantaged and those from a background of addiction and substance abuse. If it were easy we would not have the national problems that we do with these behaviors. All I am saying is that there would have to be REAL effort made to *help* the patients control their problems.

2) Perhaps more problematically from a purely practical standpoint is how do you enforce such standards? How do you prove that the overweight man is not stuffing down cheesebugers at home? How do you prove that the smoker has quit? Random home raids? Surveillance? I know that for some substances there are tests but in general I can see these measures making the doctor-patient relationship (even more?) duplicictous and adversarial with some patients…..

I am not saying there are not good ideas here but there are also both philosophical and practical obstacles too.

It is West Virginia’s plan not Virginia’a plan. They are different states.
Sorry about it. I could claim “grew up in another country” card, but I’ve lived in the US long enough not to use it as an excuse. Thanks for correcting me.

“if you aren’t complaint, you don’t get free care”
I posted my problem with this statement in the previous thread. Being compliant means different things to different people. The way West Virginia plan in its current form interprets it this statement can be translated as “if you want to get better medical care, you have to sign away your right to refuse any kind of medical intervention even the one that can harm you. Guidelines are not really guidelines, they are requirements, you must follow them”. We may talk forever that these are “just details”, but these are fundamental parts of the plan in its current form. These are also the most dangerous parts of the plan in that they can harm some people.

it is my belief that the medicaid patient faced with either a) quitting smoking or b) losing benefits will simply accept the loss of benefits because he or she will not believe he or she is capable of quitting smoking. The same goes for weight loss
I think this statement can be applied to the the majority of people, not just poor people. How many doctors saw middle or even upper middle class smokers who failed to stop smoking even if their child was suffering from asthma? What is more important than the health of one’s child? Same with weight. If health implications and looks are not enough of an incentive, surely the reduced coverage will not be? By the way, I don’t see West Virginia plan as only a medicaid issue which is probably I have such strong feelings about some of its parts. I can easily see employers trying to adopt some parts of it – especially the parts that concern and scare me.

One other thing that West Virginia plan fails to consider is what people who get reduced benefits will do when they need medical care. It seems the obvious solution would be to go the the ER. So I wonder if there actually be an increase in ER visits because of the plan. And of course, the effect on public health: if the reduced plan doesn’t cover medications or office visits, what would a person with less coverage and active TB do? Go to a doctor right away or wait and see if the symptoms “go away” and infect everyone who has a misfortune to ride in the same subway car?

In otherwords…punish those who do not, or are not able to, comply with recommended medical treatment ?

What of the doctor or business executive who develops a stress related cardiovascular problem and refuses to reduce their working hours ? Should they be refused treatment ? What if someone is non-compliant because they are unable to afford the medication ? What of the impoverished who are only able to afford junk food to eat rather than a broad healthy diet ?

In terms of personal responsibility, what if you cause a car accident(eg from fatigue, inattention) and suffer serious injuries – should your insurance be entitled to refuse you treatment?

Where do you draw the line ?

By this line of reasoning, are the homeless and poor in dire straits purely due to laziness ??

Are not mental health disorders, including alcohol and drug addictions, by their very nature characterised by poor insight and hence difficulties with compliance ?

Wolves may cull the weak from the pack…but we are human beings.

DrDork makes *very* good points….

As I understand it, the underlying motivation for West Virginia’s personal responsibility initiative is to save money, while improving the health of beneficiaries would be a favorable byproduct. While I can appreciate a number of the concerns raised, I wonder if any of those who raised them have alternative ideas for saving money that they would like to pass on. For example, would mandatory living wills be a good idea? How about changing the default protocol to one that would allow doctors to apply common sense depending on circumstances in the absence of a living will instead of the current “do everything” without having to worry about being sued? Specialized health courts, anyone, as a replacement for the current jury based malpractice system in order to reduce defensive medicine? Robust price and quality transparency, maybe?

As a result of lots of experimentation among the states, combined with Medicare taking over the drug costs for dual eligibles, the cost of the Medicaid program actually declined on a nationwide basis in the most recent fiscal year for the first time in recent memory. Doctors are the people who know the most about healthcare and its delivery. They are also the people who drive virtually all healthcare costs through hospital admissions, ordering tests, prescribing drugs, doing procedures themselves and consulting with patients. With healthcare costs already soaking up 16% of GDP and rising faster than general inflation, where are the money saving ideas from the experts? Or, do you just shrug and say, that’s not my problem; I just practice medicine?

As for the Medicaid program specifically, my understanding is that half of its costs are for long term care. Perhaps something as basic as redefining what constitutes good and sound medical practice in treating very sick and frail elderly people might be in order. Should we be doing aggressive interventions just because technology makes it possible? Of course, saving money for the healthcare system also means less income for hospitals, doctors and other providers.

Absolutely agree that Dr Dork makes lots of great points.
As additional examples of non-compliance, we could include elite athletes who participate in competitions even if they are injured. Also, allergy sufferers who refuse to give up a beloved pet who is really a family member when the doctor tells to do it. (I’d imagine the furor that would happen if West Virginia tries to enforce this).

I am afraid, it is difficult for me to see past these features of West Virginia plan that I feel are a gross violation of the principle if not the letter of informed consent and everyone’s right to refuse a potentially harmful medical procedure. I’d love to give some of West Virginia residents an idea to contact ACLU and see what they make of the plan. Because I see the plan as it is described in NY Times as something to be feared, it is virtually impossible for me to think of these issues as “details”.

I think encoraging people to have living wills may be a good thing. Explanations how it can benefit them and some assistance in creating them – lawyers cost money – would help. Reducing the number of unnecessary tests would be good as well. Instead of forcing people to submit to more tests (recommended or not) without truly understanding benefits and risks, the plan should try to educate people. Very few people understand that more tests is not the same as better care and that tests have risks. A little understanding of risks may reduce enthusiasm for new and unproven tests, unnecessary MRIs and cat scans. It may even reduce the number of lawsuits or at least lead to more sympathetic jurors.
As far as missed visits and ER overuse is concerned, charging people for missed visits would reduce the former while charging extra cash for clearly (!) non-emergent problems and not honest mistakes may help with the latter.

As far as smoking is concerned, as much as I hate it, I don’t see what can be done. And if you reduce benefits to smokers, you’ll just treat them in free clinics or, even worse, the ER.

Same with really bad examples of non-compliance – however harmful somebody’s decision might be, everyone still has a right to refuse treatment.

I never thought about how frustrating it must be for doctors who have patients who don’t listen and don’t take care of themselves. I know so many people who don’t take their health seriously and make stupid decisions for no reason other than stupidity or laziness.
As a non-smoker, non-drinker, normal weight, and celibate person, I also hate being judged or treated differently by doctors who seldom encounter my “type” and just assume I’m irresponsible and not telling them. So sometimes I think there is as much a problem with doctors as there is with patients. (I’ve had several doctors try to force pregnancy tests and other procedures on me just because they assume I’m lying.)
But I don’t blame doctors at all for putting less effort into the health care of those who are non-compliant or obviously don’t care much about their long term health. And I’m not sure it’s even practical to try to change them, since they represent the majority. YES, they do. The majority of people are overweight and don’t take good care of themselves, and are just waiting for their bodies to break down under the abuse and then for medical science to rush in and save them. Then we have people who mean well but actually have no clue what is important or what they are doing. Look at all these dumb women who are rushing to have pelvic exams every year and they actually think they are preventing cancer. Talk about a waste, and meanwhile a lot of them are overweight or smoking. Maybe the better approach would be better patient education. I agree with the positive reinforcement that will offer some sort of benefits to those who are compliant, but I don’t think the “punishment” is a good idea, as much as it does agree with my general views about society. It seems unfair that the people who have insurance get to abuse their bodies and milk the system, while those of us who can’t afford insurance have to stay healthy on our own or potentially die. I do have a great doctor, but everything comes out of my pocket, and if I ever needed a serious operation or something, I don’t know what would happen. (I recently had to go to ER and now I’m out $3000.) It is like you are always just one leap ahead of doom.

I was thinking about this again and reading Dr. Dork’s comments. I realized that there are plenty of *doctors* who don’t take care of themselves, mainly because they are under so much stress and (I guess) don’t have time to exercise and worry about their health, and surely they can afford insurance. But if even doctors are basically non-compliant, what is a patient to think ?
My doctor is a gem and I would never go to anyone else, but it’s obvious that he doesn’t exercise or eat right. He has the teddy bear physique and everything.
It seems like this is an aspect of medicine that people (and doctors) don’t want to talk about, that even some doctors set a bad example. It doesn’t bother me personally, but other people are very suggestible.

I have philosophical issues with a proposal that holds the poor to a higher standard and demands more of them than we do for everyone else.

You can argue all you want that Medicaid patients are on the taxpayer’s dime and we therefore have a right to make demands of them. I submit that we don’t.

Anyone who’s in a health plan of any kind, whether it’s publicly funded or not, is in a sense paying for everyone else’s “bad choices.” If we’re going to penalize the poor, then let’s penalize everyone else.

In fact I would argue that the poor are probably the least in control of their environment and the least able to make the “choices” we are demanding of them. There are social factors at play here – lack of education, low literacy, substandard housing, lack of access to reliable transportation, and possibly addiction and mental health issues, to name just a few. And let’s not forget that when you are poor, your lack of money means you have fewer options in life, period. This doesn’t mean you can’t rise above it, but it takes a tremendous amount of determination and often support from a mentor or counselor to get past the rough patches.

I would echo the commenter above about the proportion of Medicaid dollars spent on the elderly. Most of the stats I’ve seen indicate that more than half of Medicaid dollars are spent on the elderly and long-term care.

As far as the younger Medicaid recipients are concerned: Do you know the average length of time someone is on Medicaid in your state? I’d venture to guess that the majority of folks are not on Medicaid lifelong. I’d also be interested in knowing how many of them are children.

It’s ironic how we preach about choice and getting the government off our backs. Then we turn around and start mandating personal behavior for certain segments of the population. Deep down I suspect this isn’t at all about noble issues such as saving money or encouraging personal responsibility. It’s class warfare, pure and simple.

I would echo the commenter above about the proportion of Medicaid dollars spent on the elderly. Most of the stats I’ve seen indicate that more than half of Medicaid dollars are spent on the elderly and long-term care.
This is interesting because it underlines exactly what some of us are trying to say. West Virginia hopes to obtain savings from “prevention” of chronic deseases. But chronic deseases are not like smallpox, science doesn’t know how to eradicate them completely. Everyone dies – some quickly some not. An obese smoker may die younger than a slim non-smoker, but it is not at all clear that the latter will simply die quickly in his sleep without requiring a lot of money for end of life care.

Turkoise, you realize of course that when they say non-compliant they don’t just mean those who refuse to stop smoking or loose weight. You mentioned that you refuse some tests because you are celibate. Under West Virginia’s plan the way it stands now (based on NY Times description), you would be penalized for doing just that – refusing recommended screenings or not following doctor’s advice.

“that you refuse some tests because you are celibate. Under West Virginia’s plan the way it stands now, you would be penalized for doing just that – refusing recommended screenings or not following doctor’s advice. ”
I follow my doctor’s advice, but he is a good doctor and knows I don’t need those things, so he does not recommend them. I have been put in the opposite situation by ER doctors, though, who in my experience are not half as knowledgeable as Family Practice docs.

So that is another issue, that not all doctors are competent or really know what is important to recommend. Plus, they assume I’m a liar, and then try to make recommendations based on that, so there is NO quality care possible when the doctor does not believe what the patient is saying. Again, that means money is going to be wasted on unnecessary tests, because some doctors are retarded. If even doctors can’t agree on what to recommend, the situation seems hopeless. Particularly the green ones will naturally over-recommend.

In conclusion I’m thinking that if some people with insurance choose not to have certain screenings or tests that are recommended, that is their right and they may just have to pay a little extra to “skip it” ? Maybe this is a fair solution, as the right to refuse treatment is still respected.

I suspect that what some may see as over testing or unnecessary care may be, in large part, attributable to the culture of defensive medicine which is, in turn, a defense mechanism against a litigious society. This is likely to be especially true in an ER setting where the doctor probably does not know the patient or his or her medical history which makes it more difficult to zero in on an accurate diagnosis that would be the case if the doctor and patient had a long and ongoing relationship.

I get impatient with the view that poor people were just dealt a bad hand in life, and nothing is their fault, and they can’t do anything to improve their lot and we should not expect them to even try. Why should poor people be allowed to impose their healthcare costs on society without limit and without requiring any proactive participation on their part to help themselves? We routinely charge smokers more for life insurance, for example. I say again that personal responsibility should count for something (within reason). Separately, if someone lives in an area with little or no economic opportunity, perhaps they should consider moving to a location with more promise, especially if taxpayers are prepared to help with relocation assistance.

In conclusion I’m thinking that if some people with insurance choose not to have certain screenings or tests that are recommended, that is their right and they may just have to pay a little extra to “skip it” ? Maybe this is a fair solution, as the right to refuse treatment is still respected.

I don’t think it is fair at all for the following reasons:
a) There is no cost savings in most of the popular screenings. The cost of testing many, false positives, overdiagnosis is several times higher than any savings for less treatment for very few. Why should refusers pay more when they are more likely to save money than to use more of it?

b) It sends the wrong message and misleads the public. Screening has benefits, but they also has risks. Some people benefit greatly from it, but some are harmed. Penalties and incentives turn screening from personal choice made based on evidence and personal preferences into “a responsible thing to do”. It is already happening in today’s climate, and it is wrong, IMHO.
c) This emphasis on testing as a risk-free activity and something “responsible people do” increases public expectation of tests. This in turn leads to huge payments in “not found early enough” lawsuits. The doctors respond with the increase in false positives, biopsies and cost. It may even lead to doctors not willing to do some tests and decreased availability for those who want them. It’s already happening with mammograms. Here is an interesting article on the subject from a professor of radiology.

You mentioned that your doctor trusts that you are celibate . But the insurance company or plans like West Virginia’s wouldn’t – they would just follow the common guidellines. So you’d still have to pay this penalty under the plan in its current form. By the way, don’t judge doctors who don’t believe you – there are plenty of women who lie and then sue doctors later. I don’t understand why they lie, but there were precedents and lawsuits when a “virgin” turned out to be pregnant.

I suspect that what some may see as over testing or unnecessary care may be, in large part, attributable to the culture of defensive medicine which is, in turn, a defense mechanism against a litigious society.
This is exactly why people should be able to refuse them without penalties. I understand why doctors do them, but some warning that a particular test is ordered for defensive reasons (with a release form for refusers) would reduce both the number of these tests and the cost. I just think that public education on the risks associated with extra testing and the fact that “incidental finding” is not a good thing, may reduce at least some of the lawsuits or at least lead to more understanding juries.

I don’t think of West Virginia plan as specifically a plan for the poor. I see it as a dangerous precedent that some employers may decide to follow. Some already have small incentives for what they consider “healthy behavior”. Why I don’t mind such incentives with respect to things like smoking or exercise, I strongly object to incentives for screenings, taking preventive drugs and the like. By the way, employers are more likely to save money on encoraging people to stop smoking than medicaid since they don’t pay insurance for lifetime only until retirement.

He who pays the piper, calls the tune. If you let government pay for health care you will eventually give them the power to enforce healthy behavior. See NYC’s trans fat ban for another example. Either your health is your own business or it’s public business. Period.

Workers Could Control Their Own Medical Records Under New Plan:

http://www.healthdecisions.org/News/default.aspx?doc_id=96071&source=rss

If you let government pay for health care you will eventually give them the power to enforce healthy behavior.
There is a difference between “enforcing healthy behavior” and “forcing medical intervention”. The former might infringe on our liberties but the latter endager our lives.

“By the way, don’t judge doctors who don’t believe you – there are plenty of women who lie and then sue doctors later. I don’t understand why they lie, but there were precedents and lawsuits when a “virgin” turned out to be pregnant”

Irrelevant. Doctors are supposed to treat based on the information you provide, NOT what they “surmise” about you based on race, age, or gender stereotypes.

Any doctor who assumes
you are a liar is NOT a good doctor, and this has no connection to medical sense or good judgement. When you fill out insurance info, they ask you if you are a smoker. Well, if you
say “no,” they don’t then investigate you on the matter or assume you’re lying, even though you could be
lying to benefit yourself. The same goes for when you go to the doctor and need a new prescription.
If he asks, “Is there any chance you could be pregnant,” and you say “No,” he doesn’t then give you a
pregnancy test, even if the medication could kill a fetus.
With doctors, it has entirely to do with whether the doctor has respect for the patient. Some believe you and some don’t; there is no consistency to it. Even when the situation is an emergency or the potential consequences of a lie would be serious.
Particularly in an emergency, it is a BAD idea to assume a patient is lying, as the doctor may
waste valuable time on tests that the patient knows are not necessary. As with my case, I was taken by
ambulance and in a very bad way, and the doctor was wasting time asking further sexual questions instead of
diagnosing me and treating me properly. His narrowminded view and prejudiced attitude *hindered* his
ability to give me good treatment, as he diagnosed me incorrectly (twice), and did not even listen to what I was
saying. THAT would be a greater concern for litigation: when a doctor is so convinced
that the patient is lying that he cannot correctly diagnose, and discriminates against patients just because they don’t fit his stereotypical views. The patient is the one who suffers for that, and would seem to be in an ideal position to litigate based on it.

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