Maximizing value in high-performance networks

Healthcare Systems and Services Practice Maximizing value in high-performance networks David Knott, Tom Latkovic, David Nuzum, Jessica Ogden, and Shu...
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Healthcare Systems and Services Practice

Maximizing value in high-performance networks David Knott, Tom Latkovic, David Nuzum, Jessica Ogden, and Shubham Singhal


Maximizing value in high-performance networks Many payors now have experience developing value networks, but they may not yet have optimized their network configuration or approach. Over the long term, payors must be able to maximize the value these networks deliver.

With healthcare costs in America continuing

There are a number of reasons for doing

to rise and an increasing number of value-

this. For example, attitudes toward value

conscious employers and consumers making

networks are changing. Until recently, most

explicit choices about healthcare coverage,

employers and individual consumers have

the time is ripe for payors to focus on the

chosen broad networks as a way to maximize

development of lower-cost, high-perfor-

choice and minimize patient/provider disrup-

mance provider networks. Although these

tions. However, McKinsey’s market research

value networks can take a variety of forms,

(described in the appendix) has found that

they all give members access to only a

when consumers are exposed to a simulated

limited number of quality-credentialed pro-

exchange environment and then asked to

viders, in return for lower premiums, lower

select their own health benefits, up to 80

out-of-pocket costs, or both.

percent of them are willing to trade access for a lower premium. (The percentage varied

Over the past two years, most major payors

in different simulations, depending on the

have begun creating value networks or have

size of the premium reduction and the

expanded their portfolio of such networks.

specific providers involved.) Even many

These efforts were undertaken, in large part,

purchasers in the gold and platinum tiers

to ensure that payors could offer affordable

were willing to make this trade-off.

options to individuals who will be purchasing health insurance on the new state and federal

Furthermore, value networks could play

exchanges, especially those with lower in-

an important role outside the individual

come levels. In many cases, however, devel-

exchange market. These networks could,

opment of the new networks was accelerated

for example, help hold down premiums in

to meet the timelines specified in the Afford-

the growing (but potentially reimbursement-

able Care Act (ACA), resulting in some cases

rate-constrained) Medicare Advantage and

in network designs that address basic require­

managed Medicaid markets. They could also

ments but are but not necessarily optimal—

be an attractive option for employers looking

they are, in essence, version 1.0 value networks.

to control benefits costs to their employees.

Now that this deadline has been met, payors

Thus, as payors begin to design their net-

have the opportunity to think more carefully

works for 2015 and beyond, they should ask

about the optimal design of their value net-

themselves how they can maximize value

works and their overall portfolio of networks.

in high-performance networks. To address

David Knott, Tom Latkovic, David Nuzum, Jessica Ogden, and Shubham Singhal


McKinsey & Company Healthcare Systems and Services Practice

this issue effectively, payors must carefully

or because the penalties for using out-of-

appraise the dynamics of each local market

network providers are relatively modest

to determine which type (or types) of value

(often, less than a 20-percent difference in

network would work best in each region.

co-payments). Value networks, in contrast,

They must also decide on the approaches

restrict access either by not covering out-of-

they want to use with providers in the near

network services or by imposing significant

term to hold down premiums. In addition,

cost-sharing differentials (often, co-payment

they must contemplate the types of innova-

increases of 20 to 50 percent).

tions they are willing to adopt over the longer term to hold down overall healthcare spend-

The restrictions can be applied to some or

ing and improve care quality.

all categories of providers, including inpatient and outpatient facilities, primary care

We believe that, over the next few years,

physicians, specialists, pharmacies, and

there will be a dramatic increase in the

ancillary service providers, but not emer­

prev­alence, profile, and importance of

gency care. Typically, value networks limit

value networks. However, careful stake-

a member’s access to at least one major

holder communication and dialogue will

category of provider to between 30 and 70

be critical for payors that want to expand

percent of those in a local market (except

their use of these networks. High-perfor-

for emergency care, where all facilities

mance networks entail a substantial change

continue to be covered). However, the pro­

in the way payors interact with providers,

viders included in these narrower networks

and some providers (especially those not

are also quality-credentialed, given the

participating in these networks) may react

networks’ objective of maximizing value,

negatively. Furthermore, a range of other

not just minimizing costs.

stakeholders, including regulators, legis­ lators, advocacy groups, and the general

Exhibit 1 describes the most common

public, will be following the development

types of value networks: tiered networks,

of these networks closely. Payors that pro­

best-of-breed networks, hospital-centric

actively communicate to all stakeholders

networks, physician-centry networks,

the benefits a new value network can deliver

and virtually integrated networks.

to the community will likely increase the chances of successful implementation

Transparent networks are closely related

significantly. The message should be clear:

to value networks, but they do not formally

value networks help give patients access

limit members’ access to providers. Instead,

to more affordable, high-quality care.

they use provider performance report cards

Types of value networks

and/or consumer decision support tools to encourage members to obtain care only from high-performing providers. They often

The majority of payors’ networks today,

also offer incentives to members, providers,

including those considered to be health

or both to achieve this aim. As more and

maintenance organizations, give members

more data about healthcare quality and

broad access, either as an explicit choice

costs become available, value networks


Maximizing value in high-performance networks

White Paper - Payor Value Networks — July 2013 Maximizing value in high-performance networks Exhibit 1 of 4

EXHIBIT 1 Common types of value networks


Broad network

Tiered network

Narrow network

Sole provider

Inpatient facility



Outpatient facility Primary care Specialists

Majority of networks today – including those dubbed “HMO”





Pharmacies Ancillary services1

1 Tiered networks use very high cost-sharing differentials to discourage members from going outside an exclusive set of preferred, high-performing providers in all major categories.

2 Best-of-breed networks include only high-performing providers in each category, without regard to existing relationships (e.g., referral patterns) among the providers.

3 Physician-centric networks limit members’ access to physicians to a small panel of primary care providers, specialists, groups, or clinics; these providers are given strong referral/gatekeeper discretion.

4 Hospital-centric networks restrict members to a single hospital system and its affiliated physicians. 5 Virtually integrated networks restrict members to a single hospital system and physician group, which are “virtually integrated” through shared incentives and clinical information systems.


radiology, lab, durable medical equipment, chiropractic, etc.

may increasingly use transparency as a way to further encourage members to seek only

Understanding local market dynamics

high-quality, lower-cost care. For a payor, the first step in creating a strong There is no simple formula a payor can use

value network is to understand the dynamics

to determine which one (or ones) of these

of each local market in which it operates,

network types to focus on. The answer

because healthcare delivery remains a local

depends on a range of variables specific to

concern and the healthcare landscape—

each market, as well as the approaches the

including reimbursement pressures—varies

payor thinks are best for reducing the cost

significantly from region to region. The

of care while improving its quality.

primary factors that must be understood on


McKinsey & Company Healthcare Systems and Services Practice

White Paper - Payor Value Networks — July 2013 Maximizing value in high-performance networks Exhibit 2 of 4

EXHIBIT 2 Growth in individual market may vary significantly by market US population by coverage type

Increase in share of individual coverage

Millions of members, 2010 and 2019

Percentage points, 2010–2019












+70% – 150%




+30% – 40%



14 45 44










Scenario 1




_< 0

Scenario 3










–30% – 40%

2019 Scenarios2 1Approximately

75% of future enrollment in the individual market nationally is likely to be through the exchanges (25% off the exchanges). 1: lower employer opt-out, weaker consumer uptake; scenario 2: lower opt-out, stronger uptake; scenario 3: higher opt-out, stronger uptake.


Source: MPACT version 5.0; McKinsey analysis


To estimate growth in the individual exchange population in local markets, we often use the McKinsey Predictive Agent-based Coverage Toolkit (MPACT). This analysis enables us to develop a range of scena­r ios at the county level, based on varying employer optout and consumer-uptake assumptions. See the appendix for more infor­mation about MPACT.

a market-by-market level are the charac­

are likely to be. Initially, a significant

teristics of the consumer population, the

portion of the demand for value networks

provider landscape, and the regulatory

will come from consumers in the individual

and legislative environment.

market. However, some regions may see much stronger growth in that market than

Characteristics of the consumer population

others (Exhibit 2).1 Among the factors that

The payor must be able to estimate how

the current number of uninsured people

quickly, in each market, the population

in each region, income dis­tribution levels,

of consumers with control over their

state regulations affecting individual insur-

health plan selection will increase and

ance premiums, and the current industry

how price-sensitive those consumers

and employment mix.

appear to be driving this variability are


Maximizing value in high-performance networks

However, the number of individuals who

Value networks can succeed, however,

will be choosing their own healthcare

only if consumers are willing accept them.

coverage is likely to grow significantly in

As discussed earlier, we found that up to 80

other markets as well. For example, popu­

percent of participants in simulated exchanges

lation aging makes it highly probable that

appeared willing to accept restrictions in their

the number of people with Medicare Ad­

plan design in return for lower premiums.

vantage plans will increase substantially

However, the participants’ willingness to

in many regions. The managed Medicaid

accept restrictions was strongly influenced

market is also poised for significant expan-

by a number of factors, including the size of

sion. Furthermore, many people who retain

the discount offered, the types of insurance

employer-sponsored coverage may find

coverage they currently have, and the provi­

themselves selecting their own health in­

ders included in each network. For example,

surance products if their companies shift

when we ran repeated simulations in one

to defined-contribution benefit plans and White Paper - Payor Value Networks — July 2013 state, we discovered that the proportion private exchange models. Even some em-

of participants who said they would either

ployers that value opt not make this shift may Maximizing into high-performance networks

change insurance plans or pay extra to go out

come to view value networks as an attrac-

of network if their insurer removed their hospi­

tive way3toofhold Exhibit 4 down benefit costs.

tal from the network varied widely (Exhibit 3).

EXHIBIT 3 Consumers place varying levels of importance on whether certain

hospitals are included in their network (disguised state example) Importance that a specific hospital or health system1 is within a plan’s network (%) Unimportant


















34 18

Provider 1 1May

Provider 2

Provider 3

Provider 4

or may not be the “preferred hospital” to which a participant was affiliated.

Source: McKinsey Consumer Exchange Simulation 2012-2013 (state-level data)

Provider 5

Provider 6



McKinsey & Company Healthcare Systems and Services Practice

Hospitals that have a highly respected brand

oncology services) would be difficult to

within their community may inspire more

exclude from a value network.

consumer loyalty than other facilities. Thus, the extent to which pricing outweighs con-

Hospitals using only a small amount of their

sumer loyalty could differ from health system

available capacity are likely to be eager to

to health system and locality to locality, as

capture additional volume (or defend against

well as by product tier within a given locality.

erosion of existing volume) so that they can spread their fixed costs over more patients.

Provider landscape

These facilities may be willing to offer deep

The payor must also have a deep under-

discounts in exchange for more volume.

standing of the providers within each market.

By contrast, hospitals with more balanced

Obtaining standard market-composition

capacity utilization may see less value in

information (e.g., who the players are, what

trading price for volume.

relationships exist among them, and how much market share each has) is only the first

Each market is unique. No hard rules govern

step. The payor must also develop detailed

the way specific providers will respond.

insights into the level of consolidation among ership of those hospitals (since such owner-

Regulatory and legislative environment

ship influences referral patterns), and each

State regulations on health-system pricing will

hospital’s capacity utilization. Ideally, the

also shape the payor’s pricing strategy, since

payor should also develop detailed insights

they influence both what the payor can do and

into the relative total-cost-of-care perfor-

how providers will respond. Among the issues

mance of each provider (and the level of

that must be considered: Does the state cur-

disparity in that performance within each

rently have balance billing limitations? What are

market). This information will enable the

the usual and customary restrictions on billable

payor to determine whether the market

charges? Based on the above, what level of

composition can support the creation of

reimbursement are providers likely to receive

a value network (and if so, what type) and

for patients who seek care out of their networks?

local hospitals, the extent of physician own-

also to estimate how much of a discount the providers must offer to retain patients

Improving the value delivered

or capture additional volume. To date, most payors have focused primarily For example, a rural health system with

on three approaches to improve the value de-

no major competitors would be difficult

livered through their value networks:

to exclude from a value network, especially

reducing reimbursements to providers,

if smaller, nearby hospitals have capacity

taking advantage of existing variations in

restrictions. Such a health system is also

provider efficiency, and increasing perfor-

not likely to offer a payor significant dis-

mance-based competition for providers.

counts. Similarly, a health system with

The most successful value networks we

unique clinical offerings (e.g., the only facil­-

have seen capture value from all three

ity in a region that can provide advanced

sources, wherever possible.


Maximizing value in high-performance networks

Reducing reimbursement to providers

after we accounted for each MSA’s capacity

How payors approach contracting with

of volume that could be shifted to the

providers for reduced reimbursement can

highest-efficiency providers) and level

heavily influence the level of discounts

of fragmentation (the less fragmented

achieved. Our experience suggests that

a provider base is, the more difficult it

achieving significant reductions through

is to create a value network). Our calcu-

traditional negotiations is likely to be diffi-

lations also suggested that if capacity

cult. However, alternative approaches that

constraints were relaxed over time, the

reset the context for the negotiations (e.g.,

savings achieved through value networks

by using a request-for-proposal, or RFP,

could be as much as $36 billion annually

approach or by sending an opt-in letter)

in the top 50 MSAs alone.

constraints (which would limit the amount

can help achieve more substantial savings. Sending an RFP to hospitals, for example,

We have worked with several payors that

could allow the payor to include all hospitals

have successfully introduced value-network

in the process (avoiding the need to selec-

products in select MSAs; many of those

tively choose up front which ones to work

payors were able to reduce premiums by

with) and develop a better sense of how

10 to 20 percent in the network’s first year

willing each hospital is to accept lower

simply by taking advantage of existing

reimbursements before negotiations begin.

vari­ations in provider efficiency. Any payor that wants to adopt a similar approach

Taking advantage of existing variations in provider efficiency

must begin by fully analyzing the efficiency

In most markets, payors can capture signi­

cost-of-care basis. One provider category

ficant value by analyzing, understanding,

should be analyzed at a time to ensure that

and taking advantage of existing variations

the comparisons among the providers’

in provider total-cost-of-care performance.

performance are fair. The payor should

This source of value is the one we observe

then include in its value network only the

to be most often overlooked by payors,

most efficient providers in each category.

of each provider on a risk-adjusted, total-

perhaps because it is harder to implement than simply reducing reimbursement levels.

Although efficiency on a total-cost-of-care basis can be substantially more difficult to

Considerable evidence suggests that there

measure and analyze than unit costs (or other

are significant variations in the total cost of

common metrics, such unit costs multiplied

care among all provider categories. After

by length of stay), we have found that select-

analyzing hospital costs in the top 50 metro-

ing the most efficient providers is the most

politan statistical areas (MSAs), we estimated

effective way to ensure the delivery of lower

that simply by directing patient volume to

premiums (Exhibit 4). This approach can be

hospitals that are more efficient on a total

the difference between developing a truly

cost of care basis, savings of $18 billion

affordable value network and discovering

to $24 billion could be achieved annually.

that the expected savings erode following

Savings of this magnitude remained even



McKinsey & Company Healthcare Systems and Services Practice

White Paper - Payor Value Networks — July 2013 Maximizing value in high-performance networks Exhibit 4 of 4

EXHIBIT 4 Inpatient risk-adjusted cost and total capacity by hospital (example) Risk-adjusted cost per discharge ($ thousands) Excluding the three most expensive hospitals in this sample saves ~17% on total medical costs2

Excluding the single most expensive hospital in this sample saves ~3% on total medical costs2 16.0 14.0 13.0

12.5 10.4 8.4 7.0


Hospital 2

Hospital 3


Hospital 5

Hospital 6


Capacity (potential discharges per year1) 1Assumes

average length of stay remains unchanged and a capacity limit of 80% occupancy rate. average plan has utilization patterns that reflect the market overall, and shifted volume is allocated proportionate to excess capacity; only accounts for differences in unit cost, not utilization.


Source: McKinsey analysis; AHD data. Does not include unit-price reduction or performance improvement

Increasing performance-based competition among providers

networks can change provider performance.

Greater use of value networks could foster

system was initially excluded from the new

greater competition among providers. As a

networks that payors were developing in

result, the networks could accelerate growth

Massachusetts. Less than one year later, it

in the number of high-performing providers

announced a major cost-cutting initiative as

(by rewarding them with increased market

a way to improve its overall level of efficiency.

share and thus increasing their ability to

The health system cited concerns about the

expand) and create stronger incentives

number of patients enrolled in tiered net-

for lower-performing providers to improve.

works who were going to other hospitals

Indeed, evidence already exists that value

as one of the reasons for this effort.

For example, a major northeast health


Maximizing value in high-performance networks

Maximizing value beyond premium price

accuracy. Having a smaller, more efficient

The approaches just described can help

also give the participating providers direct,

payors reduce premium prices—obviously

positive incentives. (If the increases in the

an important goal, especially now that the

star ratings resulted in increased network

exchanges are about to be launched. Over

enrollment, for example, the providers would

the long term, however, payors may be able

gain more patients.)

network would not only make it easier for the payor to launch such an initiative, but could

to partner in other ways with the providers in their networks to create additional value.

Sharing data to better coordinate care. A

The options include:

smaller network could also make sharing clinical data and coordinating care easier.

Moving to value-based reimbursement. Value

As a result, payors and providers could work

networks can be a good way to introduce

together to identify new ways to improve

new value-based reimbursement models

care quality and make it more cost-efficient.

(e.g., bundled payments, gain sharing, risk sharing) in the commercial market. In turn,

Co-branding products. In some markets,

the value-based reimbursement models

value networks could be constructed around

can reinforce the value network’s goal of

one or two core health systems, which would

providing more affordable options to those

give all stakeholders the opportunity to

who most need or desire them.

co-brand products. Our research has shown that brand familiarity is likely to play a key

Scaling new care delivery models. Because

role in consumer choice on the exchanges.

new care delivery models, such as account-

A co-branded product would enable a

able care organizations and patient-centered

provider to get more market exposure for

medical homes, require time to ramp up to

its name and, simultaneously, offer the payor

their full savings potential, combining them

the positive association of the provider’s

with a value network can help marry near-

brand name.

term and longer-term savings, especially when efficiency is the primary criterion for

Partnering to improve access. In exchange for

network inclusion. A smaller network of more

inclusion in a value network (and the increase

efficient providers can be a more manage-

in volume that such inclusion would presum-

able forum than a broad population of pro­

ably bring), some health systems may be

viders when payors are introducing new

willing to offer the network’s members pre­

care delivery models as a way to ensure

ferential access or other special services

more affordable products.

(e.g., shuttles, dedicated private rooms, same-day appointments).

Developing additional quality initiatives with providers. A smaller network of more efficient providers may also lend itself to the intro­


duction of other win-win initiatives, such as

Many payors now have experience develop-

efforts to increase star ratings or coding

ing value networks. However, in the rush to


McKinsey & Company Healthcare Systems and Services Practice

meet external timelines, some payors may not have optimized their network configur­ ation or approach. As they refine their valuenetwork strategies moving forward, these payors would benefit from having a deeper understanding of local market dynamics, as well as stronger analytic tools to calculate each provider’s total cost of care (probably the best way to capture value). In addition, payors must consider how they can work more closely with the providers in their networks to create additional value. For all

David Knott ([email protected]), a director in McKinsey’s New York office, is co-leader of the Center for US Health Reform. Tom Latkovic ([email protected]), a director in its Cleveland office, leads its healthcare value work in the Americas. David Nuzum ([email protected]), is a partner in the Washington, DC, office. Jessica Ogden (jessica_ [email protected]), is an associate principal in the New Jersey office. Shubham Singhal ([email protected]), a director in the Detroit office, is head of the Health Systems and Services Practice in the Americas.

partners in the networks, the goal should be


to improve the efficiency of care delivery and

The authors would like to thank Noam Bauman, Manish Chopra, Jenny Cordina, Amy Fahrenkopf, Jennifer Meyer, Saumya Sutaria, and Frances Wilson for their help in developing the framework for thinking about value networks described in this paper. That team has written a companion article on the implications of value networks for providers (“Winning strategies for participating in narrownetwork exchange offerings”).

enable affordable, high-quality care.


Maximizing value in high-performance networks

Appendix: About the research and analysis This article leverages proprietary research

points, network designs, and availability of

and analysis that McKinsey has conducted

dental care or other additional services) on

over the past 18 months. This appendix

consumer buying preferences and choices

describes the major tools and data sources we used.

• See what types of consumers purchased their products, as well as the types that

McKinsey’s Consumer Exchange Simulation With this tool, users (typically, payors) design

preferred competitors’ products • Estimate how their product offerings would

a suite of insurance products that can then

fare in terms of revenue, margin, medical

be sold on a simulated online exchange.

loss ratio, and market share in a real market

Consumers browse the exchange, which high­ lights information on premiums, deductibles,

• Understand local market dynamics, compe­

coverage tiers, and other key product attri-

titive issues, and the effect of subsidies on

butes, before making a selection. As of the

insurance choices

end of 2012, nearly 150,000 consumers across the United States had participated in simu­

The “real” consumer feedback gives users

lations. On average, each consumer needs

unique insights into consumer preferences

about 25 minutes to complete the process.

and what their behavior on the exchanges is likely to be, information that is not available

The first round of simulation requires about

through any other source.

five weeks and typically involves some 4,000 local consumers between the ages of 18 and

Several payors have already used the

64, who have incomes above 133 percent of

McKinsey Consumer Exchange Simulation

the federal poverty level. An additional round

to support product design, off-exchange

can be conducted for users that want to test

strategies, and strategies for handling the

detailed product configurations and trade-offs.

transition of existing members from employer-sponsored insurance to individual plans.

The exchange simulation collects a wide cipating consumers, as well as information

McKinsey’s annual Consumer Health Insights (CHI) survey

on their current coverage, health status, and

This unique survey provides information

prior purchase behavior. Thus, the simulation

on the opinions, preferences, and behaviors

allows users to:

of more than 14,500 consumers, as well

range of demographic data about the parti­

as the environmental factors that influence • Assess the impact of different product attributes (including brand name, price

their healthcare choices. The survey also enables insights into the current market


Payor Value Networks July 2013

environment and can be used to make

tegies, consumer segmentation, consumer

predictions about the choices and trade-

targeting, network configuration design, and

offs consumers are likely to make in the

assessment of new channel opportunities.

post-reform environment. The CHI collects descriptive information

McKinsey Predictive Agent-based Coverage Tool (MPACT)

on all individuals who participate in the

MPACT is a micro-simulation model that uses

survey and their households. It also asses­s-

a comprehensive set of inputs and a distinc-

­es shopping behaviors; attitudes regarding

tive approach to modeling consumer and

health, healthcare, and the purchase and

employer behavior to project how health

use of healthcare services; awareness of

insurance coverage may change post-reform.

health reform; opinions about shopping

MPACT contains 300 million “agents” repre-

for individual health insurance and using

senting all residents of the United States.

an insurance exchange; preferences for

Each agent is characterized by his or her

specific plan designs (including trade-offs

county of residence, type of insurance

among coverage features, such as benefits,

coverage, and eight demographic variables.

network, ancillaries, service options, cost

Over the course of the micro-simulation,

sharing, brand, and price); employee per­

agents in each geo-demographic segment

ceptions of the employer’s role in healthcare

make health insurance purchasing decisions

coverage; attitudes about a broad range

depending on their eligibility, prior purchasing

of related supplemental insurance products;

behavior, demographics (including health

opinions, use, and loyalty levels regarding

risk status), subsidy eligibility, penalty impact,

healthcare providers; and attitudes and

and other factors.

behaviors regarding pharmaceuticals and pharmacies.

Provider Reform Impact and Stress-test Model (PRISM)

We supplement the information from the

McKinsey’s PRISM analytic takes hospital

CHI with data from other sources, such

financials, MPACT county-level covered

as infor­mation on a consumer’s estimated

lives projections, the Firm’s national hospital

lifetime value to a payor, consumer behavior,

operational benchmarking database, and

and marketplace conditions. This combina-

legislated changes to project hospital perfor-

tion provides a holistic view of healthcare

mance market-by-market. “Add-on” modules

consumers that is not available through

include projections of financial impact and

other sources.

utilization of services at the level of clinical service lines (e.g., cardiology, orthopedics),

We have used CHI data in a range of cus­

a bad-debt modeler, and a rapid outside-in

tomized analyses that address both current

module, that takes outside-in data to project

and post-reform healthcare issues. We

the impact of reform on hospital economics.

expect that payors and others will use the

PRISM has built-in flexibility to model a

information primarily in applications that

range of scenarios, based on reform- and

assist with product design, marketing stra­

non-reform-related factors.

Contact for distribution: Karen Hardin Phone: +1 (212) 497-5660. Email: [email protected] Copyright © 2013 McKinsey & Company CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of McKinsey & Company is strictly prohibited.

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