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Hospital payment systems(DRG paymentReinhard Busse, Prof. Dr. med. MPH FFPH)European Health Summit: DRG paymentWhy DRGs? Advantages and disadvantages of different forms of hospital payment

Reinhard Busse, Prof. Dr. med. MPH FFPHDepartment of Health Care Management, Berlin University of Technology (WHO Collaborating Centre for Health Systems Research and Management)&European Observatory on Health Systems and Policies

DRG paymentppt

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USA 1980sWhy DRGs? Advantages and disadvantages of different forms of hospital payment dumping (avoidance), creaming (selection) and skimping (undertreatment) up/wrong-coding, gaming

(DRG paymentReinhard Busse, Prof. Dr. med. MPH FFPH)European Health Summit: DRG paymentJAPANDPC2003COST)

DRG-based case payments, DRG-based budget allocation(possibly adjusted for outliers, quality etc.)Excluded costs (e.g. for infrastructure; in U.S. also physician services) Payments for non-patient care activities (e.g. teaching, research, emergency availability)Payments for patients not classified into DRG system (e.g. outpatients, day cases, psychiatry, rehabilitation)Other types of payments for DRG-classified patients(e.g. global budgets, fee-for-service)

Additional payments for specific activities for DRG-classified patients (e.g. expensive drugs, innovations),possibly listed in DRG cataloguesScope of DRGs within set of hospital activities

Patient classification systemData collectionPrice settingActual reimbursement

Diagnoses Procedures Severity Frequency of revisions

Demographic data Clinical data Cost data Sample size, regularity Cost weights Base rate(s) Prices/ tariffs Average vs. best

Volume limits Outliers High cost cases

Import

1234

Quality Innovations Negotiations(DRG paymentReinhard Busse, Prof. Dr. med. MPH FFPH)European Health Summit: DRG payment

Choosing a PCS: copied, further developed or self-developed?

Patient classification system Diagnoses Procedures Severity Frequency of revisions

The great-grandfatherThe grandfathersThe fathers

DRG3MHCFA-DRGAP-DRGAR-DRGDPCCCPEuropean Health Summit: DRG payment

AP-DRGAR-DRGG-DRGGHMNordDRGHRGJGPLKFDBC DRGs / DRG-like groups6796651,2002,2977941,38951897930,000MDCs / Chapters25242628282316--Partitions233422*2*2*-

Basic characteristics of DRG-like PCS in EuropePatient classification system Diagnoses Procedures Severity Frequency of revisions

European Health Summit: DRG paymentDPC2,309MDC18(DRG paymentReinhard Busse, Prof. Dr. med. MPH FFPH)

20 11 DPChttp://www.mhlw.go.jp/shingi/2009/02/s0223-8.html

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Basic characteristics of DRG-like PCS in EuropePatient classification system Diagnoses Procedures Severity Frequency of revisions

European Health Summit: DRG paymentDPC2,309MDC18(DRG paymentReinhard Busse, Prof. Dr. med. MPH FFPH)

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DRG-based case payments, DRG-based budget allocation(possibly adjusted for outliers, quality etc.)Excluded costs (e.g. for infrastructure; in U.S. also physician services) Payments for non-patient care activities (e.g. teaching, research, emergency availability)Payments for patients not classified into DRG system (e.g. outpatients, day cases, psychiatry, rehabilitation)Other types of payments for DRG-classified patients(e.g. global budgets, fee-for-service)

Additional payments for specific activities for DRG-classified patients (e.g. expensive drugs, innovations),possibly listed in DRG cataloguesScope of DRGs within set of hospital activities

Patient classification systemData collectionPrice settingActual reimbursement

Diagnoses Procedures Severity Frequency of revisions

Demographic data Clinical data Cost data Sample size, regularity Cost weights Base rate(s) Prices/ tariffs Average vs. best

Volume limits Outliers High cost cases

Import

1234

Quality Innovations Negotiations(DRG paymentReinhard Busse, Prof. Dr. med. MPH FFPH)European Health Summit: DRG payment

DPC

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MASTERCompliance / Risk ManegementChief Compliance OfficerVice President of Privacy and SecurityDirector of Risk ManagementEducation / communicationDepartment ChairProgram DirectorInformatics / Data AnalysisChief Clinical Informatics OffcerDirector of Clinical InformaticsIT / InfrastructureChief Technology OfficerVice President, Information TechnologyOperations Medical Records AdministrationChief Learning OffcerChief Knowledge OffcerDirector of HIMRegional Director of HIMConsultantRevenue Cycle Management Coding & BillingVice President of CodingDirector of CodingENTRYCompliance / Risk ManegementCredentialing SpecialistEducation / communicationInformatics / Data AnalysisIT / InfrastructureOperations Medical Records AdministrationHealth Information Management(HIM) ClerkPatient Care CoordinatorPatient RegistrarOperations Medical Records AdministrationCoding TrainerHIM ManagerREC/HIE Exchange DirectorE-MPI ManagerMeaningful Use SpecialistRevenue Cycle Management Coding & BillingRevenue Cycle ManagerCoding ManagerReimbursement And Insurance ManagerPractitioner ConsultantADVANCEDCompliance / Risk ManegementInformation Security ManagerCompliance OfficerPrivacy OfficerBusiness AnalystCompliance AuditorEducation / communicationProfessorICD-10 EducatorInformatics / Data AnalysisResearch and Development ScientistProject ManagerMapping SpecialistData Integrity AnalystInfomaticist ResearcherIT / InfrastructureData Quality ManagerData ArchitectHealth IT Sub-specialistMIDCompliance / Risk ManegementDRG ValidatorQuality Improvement AnalystEducation / communicationHealth Sciences Information LibrarianInformatics / Data AnalysisClinical Informatics CoordinatorClinical Data AnalystContent AnalystIT / InfrastructureHIM and Technology TrainerEHR implementation SpecialistData, Application or System Analystimplementation Support SpecialistPractice workflow and Implementation SpecialistOperations Medical Records AdministrationMedical Office AdministratorCancer RegistrarHealth Information TechnicianTranscriptionistRevenue Cycle Management Coding & BillingCoderDocumentation and Coding SpecialistHIM Revenue Cycle Auditor

http://www.nicovideo.jp/watch/sm18327001

AHIMA2016UPRevenue Cycle Management Coding & BillingBenefits CoordinatorCollections ClerkMedical BillerCustomer Service Representative: Medical BillingInsurance Claims ClerkAHIMA20162007HIMAHIMA79Reality 2016 Educators WebEx MeetingThe Council for Excellence in Education's Recommendations for HIM EducationJuly 9,2012https://newsletters.ahima.org/newsletters/Academic_Advisor/2012/Special_Edition/Special_Edition2016.htmlHIMAHIMAIFHIMA3M

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AHIMA has launched Code-Check, a subscription service assisting professionals in accurately assigning codes through person-to-person guidance and demonstration of the appropriate search pathways necessary for the most accurate code assignment. Code-Check provides users with the unique ability to ask ICD-10-CM, ICD-10-PCS, CPT, or HCPCS questions.102

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103

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DPCICD-106 250mg 500mg 250mgDravetG403010230010230xx97x00x010230xx97x01x010230xx99x00x010230xx99x01x010230xx99x10x7500mg94%E722100335100335xx97x0xx100335xx97x1xx100335xx99x00x 100335xx99x01x 100335xx99x1xx

8200mgC490

C491C492C493C494C495C49603001x03001xxx0103xx 03001xxx0104xx 03001xxx0113xx 03001xxx0114xx 03001xxx97x3xx 03001xxx97x4xx 03001xxx99x3xx 03001xxx99x4xx070041070041xx01x3xx

C6411001x11001xxx01x1xx11001xxx97x1xx11001xxx99x1xx9

60mg90mg120mgE220100260100260xx9711xx100260xx9911xx1050mg

DPCICD-1011300mgE84$100335100335xx97x0xx100335xx97x1xx100335xx99x00x 100335xx99x01x 100335xx99x1xx

125mg2.5mg2mg3mgD432

010010010010xx01x50x 010010xx01x51x 010010xx97x4xx 010010xx9904xxD177180060 180060xx97xxxx180060xx99xxxx

C50$, D05$090010090010xx01x3xx090010xx01x4xx090010xx01x6xx090010xx02x3xx090010xx03x2xx090010xx03x3xx090010xx97x2xx090010xx97x30x090010xx97x31x090010xx97x5xx090010xx99x2xx090010xx99x30x090010xx99x31x090010xx99x40x090010xx99x41x13()100mgC76003001x03001xxx0103xx03001xxx0104xx03001xxx0113xx03001xxx0114xx03001xxx97x3xx03001xxx97x4xx03001xxx97x5xx03001xxx99x3xx03001xxx99x4xx03001xxx99x5xx

DPCICD-1014()10mg/mL(100mg/10mL)10mg/mL(500mg/50mL)M300M313070560 070560xx97x0xx070560xx97x1xx070560xx99x0xx 070560xx99x1xx 070560xx99x4xxCD20BD477130140130140xxxxxxxxN04$110260110260xx97x0xx110260xx97x1xx110260xx99x0xx110260xx99x1xx110260xx99x3xx15B2500G243010180010180xx97x0xx 010180xx99x0xx1630mg100mg100mgC34$040040040040xx97x3xx040040xx97x4xx 040040xx9903xx 040040xx9904xx 040040xx9913xx 040040xx9914xxC25$06007x06007xxx0104xx06007xxx0114xx06007xxx97x3xx06007xxx97x40x06007xxx97x41x06007xxx99x3xx06007xxx99x40x06007xxx99x41xC16$060020060020xx01x4xx 060020xx03x4xx060020xx97x4xx060020xx99x40x060020xx99x41x

DPCICD-101740mgC182C183C184C185C186C187060035()060035xx0105xx 060035xx0115xxC15$

C16$

C17$C268

C182C183C184C185C186C187

C19,C20 060010 060010xx01x3xx 060010xx01x4xx 060010xx02x3xx 060010xx02x40x 060010xx02x41x 060010xx97x3xx 060010xx97x40x 060010xx97x41x 060010xx99x30x 060010xx99x31x 060010xx99x40x 060010xx99x41x

060020 060020xx01x3xx 060020xx02x3xx 060020xx03x3xx 060020xx04x3xx 060020xx97x3xx 060020xx99x30x 060020xx99x31x

060030 060030xx01x3xx 060030xx97x3xx

060035)060035xx0105xx 060035xx0115xx 060040S 060040xx02x6xx1811.25mgE881100335100335xx97x0xx100335xx97x1xx100335xx99x00x 100335xx99x01x 100335xx99x1xx

19100mg1000mg C911130050130050xx97x2xx130050xx99x2xx

DPCICD-102040mg0.8ml K51$

K803K804K830

K65$060185060185xx01x0xx060185xx01x1xx060185xx97x0xx060185xx97x1xx060185xx99x0xx060185xx99x1xx060185xx99x2xx060185xx99x3xx

21 100mg/4mL 400mg/16mLC71$010010 010010xx01x4xx010010xx01x50x 010010xx01x51x010010xx01x7xx010010xx01x8xx010010xx97x4xx010010xx97x5xx010010xx97x6xx010010xx97x7xx 010010xx9904xx010010xx99050x010010xx99051x 010010xx9907xxC56120010 120010xx01x4xx120010xx01x50x120010xx01x51x120010xx97x40x120010xx97x41x120010xx97x50x120010xx97x51x120010xx99x40x120010xx99x41x120010xx99x50x120010xx99x51x221.5g1.5g C71$ 010010 010010xx01x00x010010xx97x00x23420mg/14ml HER2C50$090010090010xx01x6xx090010xx99x6xx

2450mg100mg50mg100mg

Q90$150110 150110xxxxxxxx

DPCICD-10252.3mg/0.23mL H34$020210020210xx01xxxx020210xx97xxxx 020210xx99xxxx H358

020350020350xx97xxxx020350xx99xxxx

H360

E103

E113

E143020180020180xx97x0x0020180xx97x0x1020180xx97x1x0020180xx97x1x1020180xx99xxxx

100060100060xxxxxxxx

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100080100080xxxxxx0x100080xxxxxx1x26100mg C71$010010010010xx01x00x010010xx01x01x010010xx01x10x010010xx01x2xx010010xx01x3xx010010xx97x00x010010xx97x01x010010xx97x1xx010010xx97x3xx

C15$D001060010060010xx01x3xx060010xx01x4xx060010xx02x3xx060010xx02x40x060010xx02x41x060010xx97x3xx060010xx97x40x060010xx97x41x060010xx99x30x060010xx99x31x060010xx99x40x060010xx99x41x

DPCICD-102715mg30mg Q780140500140500xx97xxxx2820mgG63$

E851010111010111xxxxx0xx

100370100370xx97xxxx100370xx99xxxx29100mg1a1b(1)(2)B182060295060295xx97x1xx060295xx99x1xx30123F02801021x01021xxxxx0x0x

3140mg/mL40mg/mLH348

H358020210020210xx01xxxx020210xx97xxxx020210xx99xxxx020350020350xx97xxxx020350xx99xxxxH353H31$020350020350xx97xxxx020350xx99xxxxH360

E103

E113

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DPCICD-103250mg100mg200mgC25$06007x06007xxx0104xx06007xxx0114xx06007xxx97x3xx06007xxx97x40x06007xxx97x41x06007xxx99x3xx06007xxx99x40x06007xxx99x41xC16$060020060020xx01x3xx060020xx02x3xx060020xx03x3xx060020xx04x3xx060020xx99x30x3340mg100mg40mg100mgC25$06007x06007xxx0104xx06007xxx0114xx06007xxx97x3xx06007xxx97x40x06007xxx97x41x06007xxx99x3xx06007xxx99x40x06007xxx99x41x3425mg100mgC25$06007x06007xxx0104xx06007xxx0114xx06007xxx97x3xx06007xxx97x40x06007xxx97x41x06007xxx99x3xx06007xxx99x40x06007xxx99x41x35250mg1000mgC25$06007x06007xxx0104xx06007xxx0114xx06007xxx97x3xx06007xxx97x40x06007xxx97x41x06007xxx99x3xx06007xxx99x40x06007xxx99x41x360.25g0.5g0.5gG042010080010080xx99x00x

37500mg3850mgC81$

C836130020130020xx97x3xx130020xx99x3xx130030130030xx97x3xx130030xx99x30x130030xx99x31x39100mg160mgC50$090010090010xx01x3xx090010xx02x3xx090010xx03x3xx090010xx97x30x090010xx97x31x090010xx99x30x090010xx99x31x

DPCICD-104025mg75mgC750, E210100220100220xx03xxxx41LA10.8mgC50$, D05$090010090010xx01x3xx090010xx02x3xx090010xx03x2xx090010xx03x3xx090010xx99x2xx427.5mg15mg30mgQ612140550140550xx97xxxx140550xx99xxxx4340mgC61110080110080xx01x1xx110080xx02x1xx110080xx97x1xx110080xx97x20x110080xx97x21x110080xx9901xx110080xx9902xx110080xx9903xx44T15T20C18$, C19, C20060035060035xx0103xx060035xx0113xx060035xx99x2xx

060040S060040xx9713xx060040xx99x3xx45300mgG35010090010090xxxxx0xx46a50100C840C841130030130030xx99x2xx47120mgD161, D162070010070010xx010x0x070010xx010x1x070010xx011xxx070010xx970xxx070010xx971xxx070010xx99xxxx4852mgN920120250120250xx97xxxx120250xx99xxxxN946120250120250xx97xxxx120250xx99xxxx

DPCICD-1049200mgC73100020100020xx97x1xx100020xx99x1xx50500mg2500mg5000mgL511080105080105xxxxx0xx5150mg150mgE720100335100335xx97x0xx100335xx99x00x100335xx99x01x100335xx99x1xx5220mg40mgALKC34$040040040040xx97x5xx040040xx9905xx 040040xx9915xx53250mgC61110080110080xx01x1xx110080xx02x1xx110080xx97x1xx110080xx97x20x110080xx97x21x110080xx9901xx110080xx9902xx110080xx9903xx545mgC945

D471130010130010xx97x2xx

130050130050xx97x2xx130050xx99x2xx55mgD143

D219

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070010070010xx010x0x070010xx010x1x070010xx011xxx070010xx970xxx070010xx971xxx070010xx99xxxx

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DPCICD-105820mg50mg100mg200mgWHOI27004026x04026xxx01x0xx04026xxx01x3xx04026xxx97x0xx04026xxx9900xx04026xxx9901xx04026xxx9902xx04026xxx9903xx04026xxx9910xx04026xxx9912xx04026xxx9913xx5960mgC61110080110080xx01x1xx110080xx02x1xx110080xx97x1xx110080xx97x20x110080xx97x21x110080xx9901xx110080xx9902xx110080xx9903xx6020mg100mg6150mg200mg B440B441B442B447B448B377B378B371B451B450040080040080x097x0xx040080x099x0xx040080x1xxx0xx040080x1xxx1xx180010180010x0xxx0xx200mg B440B441B442B447B448B377B378B371B451B450040080040080x097x0xx040080x099x0xx040080x099x1xx040080x1xxx0xx040080x1xxx1xx

040150040150xx97x0xx040150xx99x0xx040150xx99x1xx

180010180010x0xxx0xx2800mg B440B441B442B447B448B377B378B371B451B450040080040080x097x0xx040080x099x0xx040080x099x1xx040080x1xxx0xx040080x1xxx1xx

040150040150xx97x0xx040150xx99x0xx040150xx99x1xx

180010180010x0xxx0xx

DPCICD-1062100mgC921C947130050130050xx99x4xx63150mg1((1a)(1b))(1) (2)B182060295060295xx97x1xx060295xx99x1xx640.1%G41$010230010230xx99x00x653.6mg661.5gT509T511T518T523T528161070161070xxxxx00x161070xxxxx01x161070xxxxx10x161070xxxxx11x161070xxxxx3xx671g6830mgC911130050130050xx97x2xx130050xx99x2xx6950mg70mgB371B376B377B447040080040080x1xxx0xx040080x1xxx1xx

180010180010x1xxx0xx70g10g15g20g30g40g60g120g180gD46$130060130060xx97x00x130060xx97x01x130060xx97x1xx130060xx99x0xx

DPCICD-1071mgmg10mgE702100335100335xx97x0xx100335xx97x1xx100335xx99x00x100335xx99x01x100335xx99x1xx72240mgBRAF7350mgD748T37$T41$T46$T50$T52$T55T60$T62$T65$T887130120130120xxxxx0xx130120xxxxx1xx

161070161070xxxxx00x161070xxxxx01x161070xxxxx10x161070xxxxx11x161070xxxxx3xx74200mg22C C B182060295060295xx97x0xx060295xx97x1xx060295xx99x0xx060295xx99x1xx75100mgE752100335100335xx97x0xx100335xx97x1xx100335xx99x00x100335xx99x01x100335xx99x1xx76mg10mgC73100020100020xx97x1xx100020xx99x1xx77mgmgmgmgC900130040130040xx97x5xx130040xx99x50x130040xx99x51x

DPCICD-1078400mg22C C B182060295060295xx97x0xx060295xx97x1xx060295xx99x0xx060295xx99x1xx79100mg500C16$060020 060020xx01x3xx060020xx01x4xx060020xx02x3xx060020xx03x3xx 060020xx03x4xx060020xx04x3xx060020xx97x2xx060020xx97x3xx060020xx97x4xx060020xx99x2xx060020xx99x30x060020xx99x31x060020xx99x40x060020xx99x41x80150mg8125008250/0.5mL100/0.5mL150/0.5mL83C831130030 130030xx97x2xx 130030xx97x3xx 130030xx97x40x 130030xx97x41x 130030xx99x2xx 130030xx99x30x 130030xx99x31x 130030xx99x40x 130030xx99x41x

DPCICD-10843030ALSG122010155 010155xxxxx00x 010155xxxxx01x 010155xxxxx10x85100mg150mgJ841040110 040110xxxxx0xx 040110xxxxx1xx8610mg15mgC900130040 130040xx97x5xx 130040xx99x50x 130040xx99x51x8711C C B182060295060295xx97x0xx060295xx97x1xx060295xx99x0xx060295xx99x1xx8850mg89 600DICD688D65130100130100xxxxx0xx130100xxxxx1xx130100xxxxx2xx130100xxxxx4xx

130130130130xxxxx0xx130130xxxxx1xx

Graph16877.359997195754004588.7466448914346.19227721354126.4850216073880.668680543732.11535244473254.62147556392994.16324519632859.46476075322768.25369323362702.15317223452643.75392296722585.53521278892027.12128883771939.44224256871926.82891891891905.08688097311901.50773993811907.68232181251899.63663877521901.7000572411860.99855818741859.68854258121888.19694477091869.79994973611858.81468624831898.11834654591858.38810027181858.85760940561661.49965253651654.67421991091653.3388822831654.64531183711656.32231779091693.14334140441649.21957534961661.64178272981651.61342042751659.5585642317

DPCDPC5DPC25010060x099x3xx16,8774730142643913010060x099x3xx25,4004730142393913010060x099x3xx34,5894730140833913010060x099x3xx44,3464730138813913010060x099x3xx54,1264730136533913010060x099x3xx63,8812892134073913010060x099x3xx73,7322892131513913010060x099x3xx83,2552892127683913010060x099x3xx92,9942892121783913010060x099x3xx102,8592892115782892010060x099x3xx112,7682892109662892010060x099x3xx122,7022892103872892010060x099x3xx132,644289298142892010060x099x3xx142,586289292582892010060x099x3xx152,027289286902892010060x099x3xx161,939289279732892010060x099x3xx171,927289274002892010060x099x3xx181,905289269062892010060x099x3xx191,902245864602458010060x099x3xx201,908245860472458010060x099x3xx211,900245856172458010060x099x3xx221,902245852412458010060x099x3xx231,861245848552458010060x099x3xx241,860245845562458010060x099x3xx251,888245842552458010060x099x3xx261,870245839792458010060x099x3xx271,859245837452458010060x099x3xx281,898245835322458010060x099x3xx291,858245833112458010060x099x3xx301,859245830622458010060x099x3xx311,661245828782458010060x099x3xx321,655245826922458010060x099x3xx331,653245825232458010060x099x3xx341,655245823572458010060x099x3xx351,656245822092458010060x099x3xx361,693245820652458010060x099x3xx371,649245819312458010060x099x3xx381,662245817952458010060x099x3xx391,652245816842458010060x099x3xx401,660245815882458

Graph12438.50596024342262.54680247952763.893615052478.45580742172461.362957722143.51651869132302.70984529472273.43646926582121.00336077612297.0513531742023.57991373851880.05079569643006.87321048392125.99559643092529.05157546582500.65423072182201.30650735022200.74596556672320.69195684062456.8374324292106.868778872628.81159323642377.14934911092306.9452281272557.47868840762456.06257356172283.38838087472227.87712918912271.32615881432667.44793089442539.06271517552281.32865710942228.04581283352405.68213918362313.79812454752415.55377013712059.69532903332534.30903952412306.45213981192574.5221242092527.37446219822504.42074230982204.1548331182476.41824755982377.92188049331726.42843235512305.64804657032116.32463744912295.77361625582370.18247911872181.11380749082209.60646560532300.85877526272204.47312234722582.74194047142450.31580135562709.19615282682189.64614481282258.31829158672415.78311911412145.91127330082560.83679904592338.56969796322464.10490093212449.73476798652328.2010704682458.25892540912189.34702217382561.30780907652023.42492387152300.79931858332336.05065810152441.36266600252361.0163745782517.02824345772089.84469989992588.89263534372283.96879438522603.19854116282424.68486013782245.96850479862578.12287171292698.46695615682344.30252125442600.70717328472521.89745838522393.18815405442187.60737632792727.26282771822406.09435196342842.34134206962355.4077536552348.4211538831970.19639695952070.04700445632305.18610661092402.13549437512459.0669748312628.40519661662185.3958672232682.02596656192524.01705589121813.29512343832679.43150384782427.27321212512029.95760654772751.18814362972196.89459750892499.90492396032288.70079275632553.12933188392767.91286317222466.3984277742628.79397508922792.74831072752373.82654529482301.61010819292527.70376033872632.54756776712230.16536834452628.43604261072179.73199452352404.64523043912330.07515741512337.85105090612581.33804656512707.30486001682534.01784324562894.66746840882676.43334327672400.16302892682329.04361733392183.39095553522559.45484100512415.810211912648.84603170372387.4576154542884.95979038342619.39640156272130.94346007722133.09170733152411.46411150922502.77047325842296.73223018992349.26198898162460.20453911962461.84744922792545.06110156662259.7226430042215.04772921322647.22082953552266.66296848662417.96742548492353.70746079762263.18749458782534.62442931022215.41763393041994.85620761012273.88802815082171.99826557882416.73894600562550.80280573882761.14706419542320.33506595992364.68801431632598.90688775712068.78171395892296.02696918362438.25666406762284.0839583042243.06013223922211.86763550432467.96731666172246.20755582842592.86634501832099.88428036542232.47319453262381.59330790072579.42362159392306.13822218361913.70823641412420.68943729922154.87179679242486.25855872062638.92406776512243.14616431462252.80906457672187.00110208232175.69369024152065.95110231142178.88529547132833.63859409322299.74117239342619.24892186752032.51661622552616.4583545832598.70802556112418.47816231652408.54249721092230.25472023442538.1386534322668.33027876552721.17707803072526.63036638242461.69027330312546.77421991812263.91951417792194.50735572962516.38696145452646.05340563282583.02438856442400.63387332632205.76903960922596.78147089142185.04234140552058.68386788261896.06645852062487.17416147152440.37834655362544.99572629312327.79328446532454.23806965992347.35417745162293.15882128332539.64875372932689.83110509562396.1888548632251.03317597212766.04857968842150.99953733142154.96972859732150.64129459322593.59733166032499.79111762532207.16394608532741.37845988462346.91359027062603.73176853922551.68891738982441.45775045772207.38524312992358.07376566262520.90050649182240.14314512252278.55209142532580.57673726272392.22950995632500.70752023062499.50870281542397.64975847372656.98492891592391.25513611662349.45671075362546.51296795442016.34923857582446.92673498852346.29076785112384.0676812572443.23968111742187.74358134692570.46336024142333.07598532682017.91444980362200.39154253442186.00348463392676.37228278182471.45314586612679.66886134722828.59693815242650.90105347172243.10697055962297.39508671332456.45462685192298.17426593042046.70754089132213.64110862892762.99494837522212.47449229942221.69507077412460.16651231552426.48058234472033.72720076821739.35427429192369.89987322012189.21477748642238.02620676782486.8872480022235.02878478472644.29484642532561.92473412192326.70583604862255.62454259492417.45462493552858.86713425582525.15191464982629.62204950192092.88537949092433.95065853132265.88721746622778.86162287782211.0050519112377.37782463562385.32134310732219.49608234562228.90850162552563.84279577372364.0397470672594.5705676392506.89243603472663.47079586712213.23262125272651.4582098572639.57460667822301.54849972842655.61370044262476.70114036912236.83971632942209.41771817352372.00534221472374.43258860262618.00787997912451.60470218252965.48087649542536.85941533572992.14119393382420.66904949792517.77388533792162.57570737212507.49141099662098.02925187062464.79039703752258.42648605362674.24251150182344.05090890112322.64322641342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