View Full Version : High Hearing Aid Prices? Is it Just Me??
Donald Manuel
10-17-2006, 03:10 PM
Greetings,
My wife is the hearing aid wearer in our home. She wears two aids. When one started to have problems a few weeks ago she took it into the audiologist to have it checked. He told her he would check with the manufacturer to see if it could be repaired.
He checked with the manufacturer and they said they don't supply the parts anymore. To make a long story short he guided us to the decision that buying new aids would solve our problem. Each costing between $1200 and $3100. Well that's about a $6000 solution. Well dang.
I didn't mention the name of the company ..... I am new to this forum and didn't know if you could do that in here.
I asked him if I could buy two computers, about 20 cell phones, or maybe almost a plasma screen tv for about the same price?
When I asked him what is so expensive about the technology, micro circuitry in a hearing aid is so expensive ........ he really couldn't logically explain himself.
Can someone in here help me out with why they are so expensive and maybe offer some cost effective solutions??
thanks
donald manuel
aprsl
10-18-2006, 10:20 AM
Try this link for hearing aid repairs:
http://repair-your-hearing-aid.com/index.html
You may also want check out myhearpod.com for lower cost aids.
Scott
Admin
10-18-2006, 04:53 PM
Prices are generally high because your wife's audi and most other hearing aid offices sell very few units per month.
Thus, they need to take a larger margin to cover their operating costs, such as rent, utilities, labor costs, etc, thus raising the original cost of the goods 3-4 times.
Only high volume stores/locations and or internet providers can offer much lower prices, due the high volume of sales.
Our earlier reply pointed to hearpod as a solution, as they reportedly sell hundreds of hearing aids every month versus a typical office selling just 20-30 per month.
Maybe your audi can offer lower priced yet high quality hearing aids, such as the Sonic Innovations Natura Pro or the phonak Extra, which should run around $3,800 for 2 or about 1/3 less than you were quoted.
Donald Manuel
10-21-2006, 06:55 PM
Thanks for the info.
I've done a little research since my last post. I have been to a few more vendors and from what I gather that commisioned sales is one of the incenstives for the salesman to offer you the higher priced aids.
It seems like a conflict of interest for him to try to help you, and help himself at the same time. So I guess part of it is finding a salaried sales person in stead of a commissioned sales person who will give you the business, then give you the business. :)
thanks
don manuel
Admin
10-25-2006, 04:04 PM
One thing to keep in mind...just because someone is salaried doesn't mean that they have absolutely no incentive to have you purchase the more costly hearing aid. Many salaried audi's/dispensers often work on a salary plus bonus, so they may just tell you they are salaried, yet you still can run into the same problem.
Thus, it is always best to work with a reputable company and audi/dispenser who is well recommended in the community. You can also check with the local licensing board (state) and the BBB to find out if there are any complaints.
Don,
Hearing aids are very expensive, and there is a lot of mark up in hearing aids. Not many professionals will tell you that. But then when you go and buy a prescription from the pharmacy and they charge $10 per pill before insurance, it is not because those pills cost $10 to make, it is because the pharmaceutical company may have spent several millions dollars inventing that pill.
Hearing aid companies spend millions of dollars working on the next generation of hearing aid technology. The latest advancement in the company I work for cost around $40,000,000 and four years to invent. They want their money back!
In addition there is a fairly unique business model with how hearing aids are sold. I run two offices in my community. We have to pay rent on each, all the usual office expenses, a secretary, advertising (which is never cheap), and then we provide lifetime free service for all our clients. The only money they ever give us is the purchase price of the aids and then the tiny profit we make on battery sales and offering extended warranties and out of warranty repairs.
So from each sale the factory has to make their money. The instrument produced is often custom built for the patient's ear, and thus useless should it be returned. By state law we have to offer a 30 day trial, and returned aids are pretty much useless to us, so that costs money. We may only sell one hearing aid system to one patient every ten years or so.
Unlike the other items you mentioned such as plasma TV and cellphones we are not selling millions of units, or offering lucrative service contracts. We need to make one big profit from a sale that can cover all of our expenses associated with that patient for years to come. The insurance industry puts a nice little exclusion clause in their contracts for hearing aids, usually offering no help to people that need the help.
But from all I know of the industry, and I've worked on two continents since 1994, I don't believe that the bottom line of any hearing aid center is any more lucrative than any other similar business such as an optician, dentist, chiropractor etc.
As to your issue of how a specialist is paid, this is par for the course in America. Almost everything you buy from shoes in a shoe store, to suits in a suit store, to your meal out, your automobile, your mortgage, even your electronic goods. At almost every point that you buy something, someone somewhere makes a bonus of some kind. To imply that the hearing aid industry is unique in employing greedy little con men desperate to sell you something at any cost, is a little unfair.
dougsan
04-12-2007, 09:59 AM
ZCT:
Can you justify a hearing aid sales and maintenance person earning the same income per year as a dentist? Where I live (Massachusetts) dentists are degreed. Hearing aid sales people are salespeople who may or may not have a knowledge of hearing.
Also, your choice to supply free service to your customers is a cost you choose to absorb.
Chasing technology is expensive but the technology in hearing aids does not appear to be very cutting edge or bug free. And, as to the cost of research -- 40 million dollars in your note -- it appears the money is not earning very good results.
I have no idea how much hearing aids cost outside the U.S. but somehow I doubt countries with national health plans pay the equivalent of US$3000. for the hearing aids they supply to the general public.
The economics lesson offered about the capatalist system at work in the U.S. leaves out a bit. Yes, everytime a product changes hands on the way to the final consumer some cost is added but in most instances there is free trade - I can add whatever mark-up I choose and you, the next consumer in the line, can choose to pay my price or shop elsewhere. In most instances I am not the only supplier of the product I sell. I tend to think this is not true in the medical field, especially the supplies end.
And, yes, the pharmacutical companies have a high overhead they must pass on to the consumers but they also receive a great deal of federal funding and most have reported exceptional profits year in and year out.
brucel
04-12-2007, 08:13 PM
High local prices may be why more and more Americans are buying hearing aids directly from the manufacturers, such as HearPod and other online providers.
ZCT:
Can you justify a hearing aid sales and maintenance person earning the same income per year as a dentist? Where I live (Massachusetts) dentists are degreed. Hearing aid sales people are salespeople who may or may not have a knowledge of hearing.
Calling a person who tests hearing, and fits hearing aids a sales person is a little harsh. These people usually spend well over a year getting trained, and licensed. They are usually closely monitored for the following year. So generally it takes two years to be a completely autonomous well qualified hearing instrument specialist. Audiologists have a master’s degree that takes two years, and some have a doctorate that takes three years (both post graduate). So for the most part a full audiologist has spent 6-8 years in college.
There are no ‘hearing aid sales people’ out there who have no knowledge of hearing. Getting licensed in the US requires extensive knowledge of the subject. You cannot simply sell a hearing aid without understanding the fundamentals of how hearing works, how to accurately test loss, and how to fit that patient with a working solution.
It is ridiculous to suggest that a person’s income potential should be directly proportional to the length of time they spent in college. People earn what the market will pay them. It's not 'fair' that Paris Hilton earns more money than me, but it is one of life's facts. There are plenty of business people out there who never went to college, and now they are millionaires.
Also, your choice to supply free service to your customers is a cost you choose to absorb.
It's just a business model. Just like BMW offers free service for the warranty period. Our research has shown that people don't want to be nickel and dimed after the fitting. I happen to agree with that. I don't want my patients to feel they cannot come back to see me because they don't want to waste the money. I want them to come back any time they feel like they need some help. It's not like insurance provides any kind of help for most of them.
Chasing technology is expensive but the technology in hearing aids does not appear to be very cutting edge or bug free. And, as to the cost of research -- 40 million dollars in your note -- it appears the money is not earning very good results.
I qualified in 1994. Since that time, I have seen some incredible advances in technology. I can do things to help patients, that simply did not exist even a decade ago. Some of the latest advances are using nanotechnology and a functional computer system on a chip, right inside the hearing aid. This technology allows people to hear in situations they never could have heard in a few years ago.
But I think your misunderstanding of the situation may stem from the fact that probably 75% of patients do not wear this cutting edge technology. Many people have older hearing aids, or purchased cheaper aids initially, that don’t feature this kind of technology.
I’d like to know what research paper you are reading to support your claim that hearing aids in general are not cutting edge or bug free. How are you making the determination that hearing aid technology has not improved over the last decade? Are you just making baseless claims based on your feelings or do you have some scientific evidence or research to back up your opinion?
I have no idea how much hearing aids cost outside the U.S. but somehow I doubt countries with national health plans pay the equivalent of US$3000. for the hearing aids they supply to the general public.
I used to live in the UK, a country that has socialized medicine. You can purchase hearing aids privately, as in the US or you can get a ‘free’ one from the National Health Service. The current wait time for a free one is 12-18 months.
http://news.bbc.co.uk/2/hi/health/4228846.stm
When I lived there the average cost to the tax payer was $1,500 per patient, and they would only fit one ear with an analog aid. This has no doubt changed since I left, but the cost was still up there.
In speaking to colleagues back in the UK, I can tell you that the cost of hearing aids in the private sector is markedly higher than in the US. The prices I charge in the US today are less than what I was charging in the UK seven years ago.
But even with all that said, America is the land of expensive health care. We spend something like $5,200 per capita on health care in the US. More than double what most other countries do. Yet we have a far less inclusive system than countries spending half as much. You can thank the insurance industry for that.
The economics lesson offered about the capatalist system at work in the U.S. leaves out a bit. Yes, everytime a product changes hands on the way to the final consumer some cost is added but in most instances there is free trade - I can add whatever mark-up I choose and you, the next consumer in the line, can choose to pay my price or shop elsewhere. In most instances I am not the only supplier of the product I sell. I tend to think this is not true in the medical field, especially the supplies end.
I agree that the medical field is outrageously expensive in the US. But this has nothing really to do with hearing aids. When it comes to hearing aids, my boss owns the franchise I work for. He purchases the hearing aids I dispense from the factory and sets the price at a level that allows us to stay in business. Our patients can buy from us, or shop elsewhere. In the community I serve, there are around 250,000 people. There are dozens of places they can purchase hearing aids. If our prices were not competitive for the level of service we offer, why would people buy from us? There are other brands, independent dispensers, chains, online sales, even our local ENT clinic that houses 5/6ths of all ENTs in this area has it’s own hearing aid center. Competition is fierce, but people still pay our prices.
And, yes, the pharmacutical companies have a high overhead they must pass on to the consumers but they also receive a great deal of federal funding and most have reported exceptional profits year in and year out.
Well that might be because the pharmaceutical industry has one of the most powerful lobby groups in America. But we are getting off topic again.
I am not privy to the exact profit margins of the owner of my company. But I can tell you, it is no more excessive than any other similar business. We don’t make any more profit than say a dentist office, an optician, or a small doctor’s office. We have significant overheads, and in essence we sell a product that no one wants to buy. Nobody wants a hearing aid. Even glasses are cooler. The average person waits seven years to address a hearing problem. We have to work hard to convince people to address this problem, this takes time and costs money.
If this industry were making the kinds of money that you suggest, I’d be driving a Porsche and I’d long since have opened my own office.
charliewideout
02-19-2009, 07:59 AM
I was at a dispenser's office and he took a call from a sales representive. They talked about their outing from 2 nights before - the dispenser thanked the rep for buying drinks and dinner, and told him that the last scotch put him over but yes, he did get home safely that night.
I think that type of deal has something to do with the high prices of hearing aids!
I was at a dispenser's office and he took a call from a sales representive. They talked about their outing from 2 nights before - the dispenser thanked the rep for buying drinks and dinner, and told him that the last scotch put him over but yes, he did get home safely that night.
I think that type of deal has something to do with the high prices of hearing aids!
I am sure you are correct. Maybe if it turns out like one of the key new admin guys said yesterday and it is 2012 before the employment numbers start to turn around this will drive out some of the excess margins in all industries.
GadgetsRme
02-19-2009, 01:07 PM
I was at a dispenser's office and he took a call from a sales representive. They talked about their outing from 2 nights before - the dispenser thanked the rep for buying drinks and dinner, and told him that the last scotch put him over but yes, he did get home safely that night.
I think that type of deal has something to do with the high prices of hearing aids!
And if you don't think that goes on in every industry then you're missing the clue.;)
dirtold
02-19-2009, 02:54 PM
And how about the $2000/night hookers bailout bank execs charged to their company credit cards.
like2hearbetter
02-19-2009, 05:59 PM
I suggest if you're where there's a COSTCO that even if you pay a membership fee (which you can get refunded by saying that you are unhappy if things don't work out) that their 90 day free trial with NO upfront charges for a hearing TEST or services means that it's something to investigate. You can get ALL your money back within the 90 days if you aren't happy with them and then try a different aid if you wish. You can't get the actual Siemens aids or others but may find something close that will do the job. The Rextons that they sell are supposedly from a company owned by Siemens.
Their audiologists are NOT ON COMMISSION as best I can figure and from what I was told. Thee is NO pressure to buy.
A friend in Southern California with a very severe hearing loss had become very well acquainted with his hearing aid provider from whom he has always had high end Siemens aids for 15 or more years. He says that he was told that the markup is at least 400% and his provider agreed that for him, a good customer, he was given them for 1/3 of the list price and the provider said he still made enough money at that price.
Your mileage may vary.
jay_man2
02-19-2009, 07:11 PM
... You can't get the actual Siemens aids or others but may find something close that will do the job. ...I don't know what they do now with regard to Siemens, but several years ago I bought a pair of Siemens Triano BTEs at Costco (for about half the price from my local audie). I hated those Trianos, and returned them in the then 60-day return period.
I understand they also sell Bernafon and Interton. The Costco in my city doesn't have an audiology department, but I'm seriously considering a trip to the nearest one that does, especially if I can save significantly on the price.
jay_man2
02-19-2009, 09:28 PM
I understand they also sell Bernafon and Interton. The Costco in my city doesn't have an audiology department, but I'm seriously considering a trip to the nearest one that does, especially if I can save significantly on the price.My grandmother wore a pair of Bernafon Smile in the ear full shell aids from Costco in the last years of her life. Interton is a GN ReSound brand. I believe that the first aids that Costco branded as Kirkland were Interton open fit aids.
And how about the $2000/night hookers bailout bank execs charged to their company credit cards.
Now that was what my set of AH LOF's cost and they keep giving and giving. :)
HI!
im new to forum but have been hearing badly since 1997 - usual stuff too many infections as a child and too many tubes to fix adult ear issues. In any case ive gotten much worse in last two years and cant hear myself say s's and t's and i desperatley need closed captioning on TV and in theatres if i could get it rofl. Very frustrating, but i do love my solitude and the quiet now.
I just happened upon the latest augiologist as they came into our building offering free testing.
What 'iirks' me now is my insurance will pay $500 and OHIP pays $500 per ear - so 'whoever' will gain $2000. for the sale right? Well, wouldnt you guess, they want another $125 over and above the $2000.
My IPOD doesn't cost that much:eek: - not that i can hear it in my right ear :p - but what on earth is so darned expensive about the mechanisms?
now i will have to forgoe having aids on both ears and just have one - which is all i have been using in past yrs - but after being told how safe and how much better having two is - i am IRKED to say very least.:mad:
AND i need to know if i showed get another ITC as i have now or one that fits on back of ear - as i wear glasses - usually around my neck - but i do need them for reading so im putting em on and off all the time??????
HELP PLS!!!:D
And yes i am totally aware of all the scamming - any wonder we are in a global recession??? maybe this industry need someone to check it all out? In my mind, if u can make an ipod do everything but help u with hygeine - why cant they make aids cheaper???
Shi-Ku Chishiki
02-20-2009, 01:03 AM
ZCT said in part..
Don,
There is a lot of mark up in hearing aids. Not many professionals will tell you that.
Of course there is.. so why doesn't the HA industry be up front and just admit it? It sure would make the whole thing a lot easier for prospective HA wearers.
The instrument produced is often custom built for the patient's ear, and thus useless should it be returned. By state law we have to offer a 30 day trial, and returned aids are pretty much useless to us, so that costs money.
Here we go with the excuses. The fact of the matter is.. and depending upon what's being sold, they aren't custom built.. and the returned HA's aren't useless.
Let me prove my point.
I wear a set of Starkey J13 Cierra BTE's. The factory grinds out ?-number of thousands per year. Each and every one is the same when it leaves the factory. The only thing that's different about them is.. NOTHING, that is until you attach the ear molds.. and even then the actual BTE's themselves are the same.
Now we'll program each one for the particular hearing problem that the wearer has, but wait!.. "They're Still Both Physically The Same!" Every nut, bolt, wire, chip, case, switch, contact, etc., etc. is absolutely 100 percent the same! Take off the ear molds, switch the actual HA's and re-program to the ear it's now on.....[/QUOTE]
We may only sell one hearing aid system to one patient every ten years or so.
If you're only selling "one" HA (system) to "one" patient in a ten year period.. then you're in the wrong business. It's no wonder you're NOT making any money! My question would be: "What are you doing the other nine years and 364 days?"
Unlike the other items you mentioned such as plasma TV and cellphones we are not selling millions of units, or offering lucrative service contracts. We need to make one big profit from a sale that can cover all of our expenses associated with that patient for years to come.
There's a reason you're NOT selling millions of units per year.. it's called "Over Charging Your Customer!" There are what..? Millions and Millions of hard-of-hearing people who could use the help of HA's. When asked, polls have shown the number "ONE" reason why people shy away from getting HA's is.... (drum roll and a quick tah-dah, please), PRICE/COST!
Here's a link you might want to read.
Joe Girard.. The Worlds Greatest Salesman! (http://www.joegirard.com/joegirardbio.html)
Do you know why "America Hears" and "CostCo" gets such a big play on this web site..? Lower PRICE/COST !
Place a ad in the newspaper offering your HA's for $100 ?.. $200 ?.. above cost. Charge a reasonable price for your services and the HOH population will be banging your door down. Do I know if this works?
My BC-HIS had a ad in the paper just last week offering Starkey Destiny 200's for $999, Destiny 1200's were buy one regular price and get the second FREE (which means they're offering them at half price).. and Zon 3, 5, & 7's were $400 each off regular price. He said the had over 60 booked in a three day period. Out of the 60 only one (1) didn't show up.
Like I said before.. "give people what they want at a fair price and they'll be knocking down your door!"
Shi-Ky Chishiki ShiKu.Chishiki@Gmail.com
jbobp
02-20-2009, 06:51 AM
Here we go with the excuses. The fact of the matter is.. and depending upon what's being sold, they aren't custom built.. and the returned HA's aren't useless.
Let me prove my point.
I wear a set of Starkey J13 Cierra BTE's. The factory grinds out ?-number of thousands per year. Each and every one is the same when it leaves the factory. The only thing that's different about them is.. NOTHING, that is until you attach the ear molds.. and even then the actual BTE's themselves are the same.
Now we'll program each one for the particular hearing problem that the wearer has, but wait!.. "They're Still Both Physically The Same!" Every nut, bolt, wire, chip, case, switch, contact, etc., etc. is absolutely 100 percent the same! Take off the ear molds, switch the actual HA's and re-program to the ear it's now on.....
HAs are considered medical instruments and if they are returned they cannot be re-sold.
HAs are considered medical instruments and if they are returned they cannot be re-sold.
Do you understand your blanket statement may be incorrect.
jbobp
02-20-2009, 09:12 AM
Do you understand your blanket statement may be incorrect.
No, but I will qualify. In the State of Georgia in the USA hearing aids are labeled medical instruments and as such cannot be re-sold by a medical professional (Doctor, audiologist, etc.) and I was informed by GN ReSound my Dot 10s could not be upgraded for that very reason.
jem16
02-20-2009, 10:02 AM
There's a reason you're NOT selling millions of units per year.. it's called "Over Charging Your Customer!" There are what..? Millions and Millions of hard-of-hearing people who could use the help of HA's. When asked, polls have shown the number "ONE" reason why people shy away from getting HA's is.... (drum roll and a quick tah-dah, please), PRICE/COST!
Best post I've read in ages. Totally agree. Set the aids at a proper price and you will sell more.
Best post I've read in ages. Totally agree. Set the aids at a proper price and you will sell more.
Some are starting to do this but the old marketing plan of high margins die hard. Great post.
I am seeing some things in a new light in the few days I have been here. I am in the market for new hearing aids because the expensive Siemens ones I have are unacceptable. I can't say if they were junk from the gitgo, or the provider is a hack that can neither make them work nor identify that they are defective. No matter how many times I make the hour drive each way to have them adjusted, they quickly drift out of adjustment. So we are paying through the nose for lousy service?
RLENG
02-20-2009, 09:23 PM
Yes, but prices are dropping every week because of online sellers, like eBay.
Once you take the mystery out of a ha purchase, prices will drop. As I understand it, all hearing aids have three common components; microphone, speaker and amplifier. Prices will increase with miniaturization and the quality and refinement of those three components.
I bought my first ha's a few months ago. I would not be wearing them today, if it were not for ebay ha sellers!
Bob
Yes, but prices are dropping every week because of online sellers, like eBay.
Once you take the mystery out of a ha purchase, prices will drop. As I understand it, all hearing aids have three common components; microphone, speaker and amplifier. Prices will increase with miniaturization and the quality and refinement of those three components.
I bought my first ha's a few months ago. I would not be wearing them today, if it were not for ebay ha sellers!
Bob
As noted on more than one occasion America Hears hit price point for digital hearing aids that opened the door to hearing aid ownership. Wal-Mart can be a big help in get aids to the masses.
like2hearbetter
02-21-2009, 02:39 PM
Having been in the "electronics related industry" either as an engineer or as a college teacher for the past 40 years, it seems to me that it's time that the manufacturer made SURE that the "electronics" or "guts" of the hearing aid are treated separately from the fabricated ready to wear hearing aid.
As somebody pointed out the GUTS ARE ALL THE SAME for a particular model and in spite of electronic customization of the GUTS that can be erased which then returns the guts of the device to the same as when it was fabricated.
Thus it is NOT a MEDICAL DEVICE, which the shell that is customized for a particular person might be considered, but a package of electronics. Behind the ear devices are IDENTICAL for every user with the exception of the ERASABLE programming and receiver and tube that enter the ear.
I would wonder that like so many professions, if there are pressures that have been brought to bear on the legislators by contributions perhaps that make sure that it's a MEDICAL DEVICE and therefore justify the high costs and the "non return-ablity" of the device.
Of course, the bottom line is really that once the development costs are retrieved the actual hearing aid likely costs very very very little to manufacture so a majority of the price is profit to somebody or entity.
hobbydog
02-22-2009, 08:42 PM
With the baby boomer entering the prime HA age the market will likely change in several ways. The demand for HAs will be high but there will also be pressure to change and adapt as retailers such as Cosco start to compete. One way to help drive that change is to make sure you shop different sources and let them know you have other options at a much lower price. The consumer will need to drive the change to lower price.
coppertop
02-23-2009, 05:34 PM
ZCT is dead on right.
The hearing aids ARE classified as medical devices by the FDA. As such, special rules apply. They are classified as medical devices because they deal with a medical condition--your hearing loss!
Numerous studies have been done related to pricing and hearing loss, and they show that pricing is not related to acceptance or purchase of hearing aids. In fact, one study in particular showed that 30% of those who are HA candidates wouldn't take free ones! There are many ads that offer half off, buy one get one free, etc, and those professionals who offer those are no richer than the others that don't subscribe to salesy gimmicks. Audiologists go to school for 6-8 years to learn about conditions of the ear, counseling for hearing loss, psychology of hearing, and programming hearing aids. Hearing itself is a very complex sense, and hearing loss is not any simpler. Bypassing the professional to get hearing aids cheaper is doing yourself a disservice.
Ultimately, you are going to put a value on your hearing, and determine what it is worth. Please don't sell it or yourself short.
EnglishDispenser
02-28-2009, 11:05 AM
I have no idea how much hearing aids cost outside the U.S. but somehow I doubt countries with national health plans pay the equivalent of US$3000. for the hearing aids they supply to the general public.
The NHS in the UK pays around £65 ($100?) in the UK for a Tego Pro I believe. Mind you , they must buy 250,000+ digital units per year ... and the NHS offers only 2 or 3 hearing aid models, mostly BTEs.
I believe they expect any sub-contracted private dispenser to fit these aids for around £150 ($300?) but with minimal aftercare.
As a low volume private dispenser I pay MANY MANY times more than this for decent hearing aids ... but that is only to be expected.
With the baby boomer entering the prime HA age the market will likely change in several ways. The demand for HAs will be high but there will also be pressure to change and adapt as retailers such as Cosco start to compete. One way to help drive that change is to make sure you shop different sources and let them know you have other options at a much lower price. The consumer will need to drive the change to lower price.
Great point. Some do not realize when getting a Rx filled they have options on source and cost. Cosco/Wal-Mart/etc and the current president will help lower prices since he as already spoken that this is one problem area driving up the cost of medical care in the US.
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