Monthly Archives: September 2014

Global Competitiveness

“We all have a stake in improving the quality of care we receive while spending our dollars more wisely,”

“It’s good for businesses, for our middle class, and for our country’s global competitiveness.”

HHS Secretary Sylvia Burwell

For anyone who believes that I have been out of line in linking the national obsession by health care pundits, economists, and managed care apologists to destroy fee for service medicine in the name of enhancing America’s global competitiveness, you just have to read a recent observation linking the two by our current HHS Secretary.

The link was buried in a story reported by The Hill and others about savings from the nation’s Accountable Care Organizations (ACOs). http://thehill.com/policy/healthcare/217881-small-savings-reported-from-new-healthcare-models

Only about half of the ACOs that reported their financials had savings. See Jordan Rau’s excellent report on this complicated topic for Kaiser Heath

News:http://capsules.kaiserhealthnews.org/index.php/2014/09/one-quarter-of-acos-save-enough-money-to-earn-bonuses/

I am mystified about how ACOs enhance our “global competitiveness.” But that’s what happens when you just have medical and law degrees but not an MBA or a PhD in economics from a prestigious Ivy League University.

Does it mean we will use the savings to build more prisons? We already lead the world in the number of our citizens – now disenfranchised from voting – we have in prison. And the private prison owners/political donors are laughing all the way to the bank.  Or maybe we can pay for more re-cycling of closed prisons as immigration – er future voter – living quarters?  Isn’t it ironic that we put our citizens in prison and they lose the right to vote, but when immigrants are put in the re-cycled prisons, they are way stations on the path to vote?    Again, I don’t have a degree in criminal justice or political science so I can’t understand the process.

Will we have more money for higher salaries for professional athletes under indictment for domestic violence and child abuse? We already lead the world in that.  Young doctors should be proud that our average professional baseball player makes well over $1 million per year, and an unnecessary test ordering pediatrician gets an exorbitant $120k or so.

Will it increase the amount of money we have to spend on pets – who are considered members of the family? I think we lead the world on that, too.

Will it increase the amount of money we have to spend on golf? We have been pretty bad at Ryder Cup play in recent years and sure need a boost there?

Maybe it will help us wage better wars (err counter terrorism efforts) in foreign lands? We lead he world in that too, but never have enough money to spend on foreign adventures to prop up defense contractors and other big political donors. See owners of private prisons above.

Or maybe we can give some subsidies to GE so it can sell more CT scanner in China.  I hear doctors there like to use them to order unnecessary tests to enhance income – at least according to the Wall Street Journal.      

Maybe we can build more Chrysler and GM and Ford cars? After all, they deserve the same tax incentives that Tesla got in Nevada. And the “Big Three” auto makers are always interested in telling doctors how to compete even though they can’t figure out how to build cars that can compete with their South Korean, Japanese, and German rivals.

And I’ll pose the eternal Uwe Reinhardt question that never gets answered: “Why is it good when Americans buy cars, but bad when they buy health care?”

What’s very clear is that in the not –too- distant future ordering unnecessary care for some dying senior with heart failure will be viewed as a felony punishable by prison time because the doctor who ordered it placed that individual’s selfish will to live over promoting America’s global competitiveness –whatever that is.   He wasn’t a good team player and the taxpayers need to finance his prison stay to help preserve our country’s global competitiveness.

Here’s my last question: What happens when we get rid of fee-for-service medical payments and everyone is in managed care with fixed contribution payments?  How do we enhance our global competitiveness? Maybe start HMOs and walk in clinics on Mars?

VA cover up of deaths at Phoenix VA hospital

Watch today’s hearing of the House Committee on Veterans’ Affairs about whether the VA’s Inspector General (IG) was trying to cover up the VA’s responsibility for the many deaths it evaluated and reported on in its August 26, 2014 report.

http://www.va.gov/oig/pubs/VAOIG-14-02603-267.pdf

I totally agree with VA whistleblower, Dr. Sam Foote, who is testifying today that the report was a cover up.

Even a casual reading of that report raises considerable suspicions. There is negligence galore, but being lawyerly, the IG stopped short of finding causation.

Here’s the sentence on page ii of the report that all the national media reported:

“While the case reviews in this report document poor quality of care, we are unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.”  (my emphasis added)

Don’t believe that.

Go to page 17 and look at Case 30. First there is new pain diagnosed and treated over the phone. We aren’t told which pain medication was dispensed. Was it a narcotic painkiller?  For sure that was below the standard of care.

Then there is a two day delay before the patient goes to the Emergency Department complaining of 10/10 severe abdominal pain. This is spite of the new painkiller. The patient was hypothermic and had a fast pulse rate of 111 beats per minute. First diagnosis is sepsis and maybe septic shock. We aren’t told a blood pressure. Then there was a 2 hour delay getting a CT scan of the abdomen which showed a perforated bowel. Then a 4 hour delay getting a surgical consult. Then the patient was seen by a resident (doctor in training) not a senior staff physician. Then another 2 hour delay before being taken to surgery. Then we are told that the patient had to be maintained on blood pressure support and a ventilator until he died 2 days later.

And the VA’s IG wants us to believe that none of the poor quality care documented in this case report was a causal factor in this veteran’s death?

They sold it to the national media on August 26, 2014. The AP, NPR, the TV networks. All took the bait.

Where was ABC-TV’s Dr. Richard Besser – he of CDC and unfair hair fame? Did he bother to read the report? Did he get to Case 30?

I hope the doctor-Congresspersons on the House Committee grill the VA IG today about all the cases, but specifically about case 30.

Someone needs to ask the IG when the patient in Case 30 got antibiotics. For every hour of delay in getting antibiotics in a patient with sepsis there is a significant increase in the death rate.  Someone needs to ask the IG is sepsis was diagnosed prior to surgery.

And someone needs to demand that the VA release details of all the case reviews to the families. The report says the VA is thinking about doing this.

I am sure that their lawyers have determined what they think are applicable statutes of limitation and repose for all the cases and don’t want to give any family any details of negligence until a time when they think they are safe from a lawsuit.

Watch today’s hearing to see if the VA gets away with its cover up.

Book Review of “Doctored” by Sandeep Jauhar

The New York Times has outdone itself in doctor-bashing by publishing two reviews of the same book: Doctored. The Disillusionment of an American Physician by New York based cardiologist Sandeep Jauhar.  Both reviews are by journalists who obviously dislike doctors – probably until they need one.  Susannah Meadows wrote one review for the Book Review section of the Times. And Florence Williams – she, the author of Breasts described as having “double D talents as a reporter” – topped all the other reviewers in her attack on hapless physicians. The Times editors thought Doctored so important they published the second review — by Williams– in the Science Times section on September 09, 2014.

Dr. Sandeep Jauhar is who is a Long Island cardiologist who expert in heart failure, and a regular writing contributor to the Times. Ditto for reviewers Williams and Meadows.

Let me state at the outset that Jauhar is a stooge. One definition of a stooge is: “a person who serves merely to support or assist others, particularly in doing unpleasant work.”  Jauhar is a smart guy who has been used by the editors of the Times and the Wall Street Journal to further their political agenda of destroying fee-for-service medicine and private practice and deliver doctors into the hands of millionaire managed care executives and overpaid millionaire hospital administrators so that Americans can get high quality care, instant access to the best primary care doctors – but not specialists , and lower costs so as to preserve America’s global competitiveness – whatever that is.

Here is some of Williams’ “double D” doctor-bashing rhetoric:

“.. he finds himself underworked, underpaid, and pressured to cut corners in every direction.”

“to relieve money and stress, he does something he dreaded…He moonlights on weekends and  evenings for a private cardiology practice…”

“…an astute critic of the wasteful, mercenary, cronyistic and often corrupt practice of medicine today.”

“The fee-for-service model leads to overtesting, dis-organization and redundancy.”

“..wanton consultation..”

”Many of the doctors themselves are greedy, defensive, and untrustworthy – including, at times, himself.”

I just finished reading the book, complete with annotated sticky notes and underlining.  The first I saw of the book was in a long two page excerpt published in the Wall Street Journal’s Review section on August 30-31, 2014. The WSJ also published a review by a Harvard professor that was a lot more tempered than the reviews by Meadows and Williams.

Both the conservative WSJ and the liberal NY Times have long agreed in their news sections that doctors are greedy and incompetent and have to be reined in by managed care. They obviously love a guy like Dr. Jauhar who is a doctor-bashing doctor.  It takes Dr. Jauhar exactly 9 pages in the introduction to his book to conclude that doctors are responsible for their own woes because they were corrupted by Medicare into performing millions of unnecessary surgeries and were “bilking” and “mismanaging” their patients. Jauhar trumpets HMOs as the cure for doctors’ greed and claims the HMO was invented in the 1970s when in fact they first appeared on the West Coast in the 1940s. And Jauhar could have easily found the House Subcommittee on Oversight and Investigations report on “unnecessary surgery” from 1975 which he cites and read the testimony of the chief of surgery at Johns Hopkins who pointed out that “unnecessary” surgery was hard to define and for doctors to agree on.

But Jauhar only needed some evidence and I’m certain his editors at his book publisher and the editors at the Times and the WSJ could care less whether the evidence for unnecessary   surgery or “inappropriate” care was valid or not as long as it had been the conventional wisdom of those eager to take over medical decisions from doctors  – like the various business groups on health, to name a few.

What is ironic and more than a little inconsistent, is that Jauhar goes from bemoaning too many surgeries on page 10 of his introduction to on page 11 bemoaning the fact that doctors are not doing enough preventive and screening procedures because of the time constraints of managed care. Either way, I guess doctors are at fault and the doctor-bashing editors were pleased.

Jauhar’s book is a great read, don’t get me wrong. I loved the sections describing a corrupt subculture of South Asian physicians who (or through their assistants) order unnecessary echocardiograms and nuclear stress tests. That struck a chord of recognition of the same kinds behaviors in the same kinds of knaves – of all ethnic and WASP persuasions –right here in San Antonio. But Jauhar gives a false impression that all doctors in private practice are like that – corrupt and looking to do unnecessary testing or engage in fraudulent activities to bilk patients and insurance companies – as opposed to “academics” like him.  And the fact that he occasionally writes a disclaimer that not all doctors are corrupt makes me wonder how much his initial drafts were influenced by the three book editors he thanks for helping him.  Let’s face it: if he were not a critic of private practice doctors and fee-for-service medicine he never would get even one column inch in the NY Times.

I was charmed by his lyrical and amusing writing about the way many unnecessary echocardiograms were being ordered, until I was jolted back to the reality of my own experience of needing a third opinion at the Mayo Clinic in Rochester to get a transesophageal echocardiogram not ordered by my two prior nationally recognized consultants to diagnose a ruptured support structure of my mitral valve needing urgent surgical repair. And how the emergency repair itself was not supported by a randomized trial and the kind of evidence that insurance companies are demanding so they can bring the “knaves” in private practice – who Dr. Jauhar so well describes – under control.  Had my surgery been denied by my insurance company, I would today probably be a candidate for Dr. Jauhar’s services in his chronic heart failure clinic, if I were even alive today.

Reviewer Williams admits that “insurance companies have taken away doctors’ autonomy.”  And she does get one thing right: doctors can’t be trusted anymore. But for the wrong reasons. Neither she nor Jauhar understand that it’s not doctors’ inherent dishonest selves that patients can’t trust. It’s what insurance companies and hospital administrators make them do when the young doctors enter practice beset with debt and trying to balance family life and the often-oppressive demands of sick patients and anxious family members.   That’s what Jauhar’s book is about, but somehow he blames doctors for the mess they and he are in. He thinks they brought it on themselves.  And he has done a lot to undermine patients’ trust in their overworked and underpaid physicians – except for those few like him.

While he admits certain flaws and at least one case with a bad outcome, it is clear that he thinks he is better than most doctors and the media have anointed him as such to use his credentials and moderate sounding voice to levy all sorts of criticism on doctors trying to do a good job.

I see the same problems that Jauhar sees, but not that much knavery. And I have long written about how HMOs and managed care executives in concert with bought off politicians have destroyed the doctor-patient relationship. I chose to say no to HMOs from the very beginning when I was offered the medical directorship of the first HMO in San Antonio. But I was still was able to care for sick people, but not get rich. Jauhar wants to get rich to satisfy an expensive Long Island lifestyle. He should learn to say no and get his colleagues to say no to managed care.   I am not better than Jauhar, just different. He will be proven to be right because the Times and the Wall Street Journal have anointed him right. That’s what their corporate advertisers want and they will deliver the written history to fit their advertisers’ needs.

It is true that most young doctors are too weak and scared to stand up to managed care medical directors and hospital administrators who own their contracts. And who can really blame them? They don’t know any better. They haven’t been taught to be courageous. Their Machiavillain medical school professors never taught them that saving lives should take precedence over saving dollars. Please tell me the number of medical school professors and medical journal editors who have spoken out against the depredatory practices of managed care.  The answer: very few.

I think back over my numerous attempts to speak about the realities of managed care in San Antonio at our local medical school – the University of Texas Health Science Center at San Antonio.  Dr. Steve Cohen and I got to give one after hours lecture at night to students who wanted to attend. That talk was not part of any formal course. It was poorly attended. And I was allowed to give one noon brown bag lunch talk on the topic which was pretty well attended but still not part of any formal endorsement by the medical powers. It was sponsored by a drug company with ZERO editorial content control. Most of the students came to get the free lunch the company handed out. And I was not paid an honorarium. It was strictly a volunteer effort.

But, local medical students during the 1990s when national reporters regularly trooped to San Antonio to do then- popular stories on abusive practices of managed care entities –including a one year undercover investigation of the HMO industry — never heard any of their professors speak out about managed care. Medical politicians were and are too smart to poke big money in the eye. They are astute at playing politics to advance their careers. And the local media in San Antonio didn’t care to hear any of this either. They were too busy selling ads to the managed care companies and to car dealers who suppressed critical stories on managed care – according to one still working newspaper reporter here.

The editors of national papers like the WSJ and NY Times ( and the TV network producers who read their work to get their story ideas)  -as opposed to some few reporters in the news divisions –  use stooges like Dr. Jauhar to advance their political agendas – to break the back of fee-for-service medicine and deliver the medical profession into the hands of big corporations who call the shots in America and are big advertisers in their papers. These national papers just want to make money and if they can lower health care bills for themselves, their advertisers, and their poorly paid reporters and contributors like Ms. Meadows and Ms. Williams, so much the better.

You would think that if Dr. Jauhar were so upset by the control of managed care, one of the reviewers would see fit to talk about how managed care ( big insurance companies) have to be reined in. But no such idea is seen anywhere in the two Times’ reviews. Instead, there is bitter attack after bitter attack on doctors – and specifically doctors in private practice. The reviewers don’t criticize hospitals or hospital administrators that are buying up doctors’ practices and telling their doctor employees how to practice, as if they knew the right way to practice medicine – which they don’t – and in the process increasing the costs of medical care to medical consumers according to a recent court filing by 16 state attorney generals.

Are the reviewers are so naïve and ill-informed that they think that the “knaves” ( to use Dr. Jauhar’s metaphor borrowed from a top official of the American Board of Internal Medicine and buried in that doctor bashing medical journal, the Journal of the American Medical Association) in private practice – when they become hospital employed physicians – suddenly become “knights”?   Don’t the reviewers realize that the” knaves” in hospital administration seek out the biggest “knaves” in private practice to combine their talents to synergistically produce even bigger knavery?  If not, they should read the amicus brief filed by the state AGs in the Idaho case now before the Ninth Circuit Court of Appeals. See my previous blog on this subject.

Below are two unpublished letters to the editor I sent about reviews of Dr. Jauhar’s book. Both were written before I had read the entire book and were responses to the published reviews or book excerpt.

One letter was to the San Antonio Express News after they published an excerpt of Meadows’ review in the Sunday paper on August 31, 2014 Page F4.

RE: “Book examines dysfunctional medical system”

Susannah Meadows’ book review of Dr. Sandeep Jauhar’s memoir, “Doctored: The Disillusionment of an American Physician” correctly points out that Dr. Jauhar finds fee-for-service payment for medical services “poisonous” – as do many policy makers these days. First, it should be noted that Ms. Meadows is a veteran journalist who has covered politics not medicine or health policy. Second, neither she nor Dr. Jauhar answer the obvious question about changing to a payment system featuring salaried doctors with bundled and capitated payments going to their employers: If the greedy incompetent doctors can’t be trusted in a fee-for-service model where every charge and payment are explicitly listed, how can those same suspect practitioners be trusted to not under prescribe needed care and cut corners when their salaries and bonuses depend on not exceeding the fixed payment per patient? What suddenly makes these villains trustworthy? If you think that monitoring death rates in sick elderly patients will easily show up rationed care, think again. By the time the statistics become evident – if ever – it will be too late. Both Meadows and Jauhar conveniently ignore the medical mayhem chronicled by the media in the 1990s when patients were harmed by capitation –induced cost cutting. Many large medical groups that took on financial risk through capitation went bankrupt. There is no evidence presented that such risk shifting to doctors, hospitals and patients won’t result in the very same undesirable outcomes this time around. Jauhar’s book tells politicians and the media elite what they want to hear and fosters magical thinking about easy solutions to the high cost of health care.

This unpublished letter to the Wall Street Journal dealt with the excessive number of column inches they devoted to Dr. Jauhar’s book excerpt:

To the Editor:

Re: “Our Ailing Medical System” Page C1, August 30, 2014

“Here goes another letter that won’t be published. Just consider it occupational therapy but work for my forthcoming memoir that will tell it like it is and was – not the way Dr. Jauhar sees it.

The reason Dr. Jauhar gets so many column inches in both the “liberal” New York Times and the “conservative” Wall Street Journal is that he is a first string member of the doctor bashing team. I have reported for many years that doctor-bashing is a national media team sport. Both liberal and conservative papers bash doctors to satisfy their corporate advertisers who have decimated the profession of medicine over the last 40 years, while improving their bottom lines.

Jauhar gets media darling status – like your other favorite, Zeke Emanuel – because he recites the usual problems ailing American medicine: high health care costs, unnecessary testing, waste and fraud, “bilking the system” — and blames doctors for these problems. Therefore, his rising fame promoted by the national media. He then goes on to propose the usual solutions: end fee for service payments, go to bundled payments and capitation, and promote professionalism by medical school professors. Good luck.

Jauhar completely ignores the reality that doctors have become distressed because the profession has been subjected to a hostile takeover by insurance companies, overpaid hospital administrators, hospital community boards run by home builders, car dealers, and Junior Leaguers, and HMOs in the name of corporate greed. He should have said what doctors really need to do: strike. Let the Junior League do gooders and car dealers get their care from nurses at CVS walk in clinics while real doctors go to teach-ins to learn about how to practice in a truly professional way in which HMO medical directors don’t have the ultimate say on what is medically necessary. Don’t expect any medical school professors to be at such meetings. And don’t expect many doctors. Too many are the “excellent sheep” that William Deresiewicz has just written about and which you reviewed on these pages.

The thing that you all at the national papers don’t realize is that you can’t “get” the doctors without getting yourselves. You have brought down the medical profession – as Dr. Jauhar chronicles – but you have also brought on a form of medical holocaust in which the sickest will be allowed to die sooner than necessary because it’s more “cost effective” and a better use of resources for “population health” and promoting the RWJF’s “culture of health.”  You can file that under “unintended consequences.”

Coming soon to an urgent care center or hospital or primary care office near you might be the kind of care you have promoted all these years with articles like this but which fails you when you really need it.  You will then be like Charles Ornstein of ProPublica who just wrote about his using the “I am a reporter” trump card when dealing with his managed care insurer’s incomprehensible charges for a drug for his sick child. Maybe your “I am a reporter for the Wall Street Journal” or “I am an Editor with the Wall Street Journal” will save you or your aged sick parent. But don’t count on it. The system you have brought on features doctors whose primary allegiance is to some corporate bottom line. After all, they have big student loans to pay off, house payments to make, and wives who want to drive Mercedes and Jaguars.  In other words, you can’t trust doctors to do what’s best for you and your loved ones any more. They’re going to please the hospital administrators who own them.

In July, 1986, I was having dinner with the late journalist Harry Schwartz – who wrote for the NY Times for 29 years, had a PhD in economics, and was a long-time critic of managed care. He was helping me prepare for an appearance on “Good Morning America” debating the head of a state Medicaid managed care program. I asked Harry for a good, terse soundbite to respond to a question like, “Why can’t HMO doctors take good care of sick patients?” He threw back his head and laughed and roared, “They won’t let “em.”

Dr. Jauhar either hasn’t learned that lesson or won’t come clean with the American public. And you are complicit in not exposing that reality. “

The practice of medicine today is all about money, as in large amounts of capital, not doctors driving a new Mercedes. Those with large amounts of capital control the practice of medicine and I’m referring to big employers, big insurance companies, HMOs, big hospital corporations, places like Harvard – and not the much maligned doctors in private practice.

Doctors and patients were reduced to profit and loss centers a long time ago.

Dr. Jauhar, and the two Times’ book reviewers, don’t seem to understand that the same forces that bought off Congress a long time ago used that influence to induce Congress to  pass laws, rules and regulations and re-shape the courts to destroy the ability of doctors and patients to freely make decisions about medical care.

Dr. Jauhar’s simplistic advice to doctors to concentrate on helping people in need will be a lot more difficult to follow after the effects of his book further erode the public’s confidence in their doctors.

Health Care Competition Drives Prices Up Not Down

“Competition” in health care is supposed to drive prices down. That’s the way the media-anointed economists have been explaining it for the past 30 years or so. That’s part of the reason we have Obamacare, with its Accountable Care Organizations and hospitals now gobbling up doctors practices all over the country.

San Antonio has always been at the forefront of “free market reform. “ This is where Humana Chairman and former CEO Mike McCallister cut his teeth teaching doctors how managed care worked.

And this is where Physicians Who Care was founded to try to educate patients about how corporate health care worked.

So, it was with interest that I read two things this week that are related, but maybe not obviously so.

One was an article in San Antonio’s only newspaper, the Express News, a long time doctor bashing screed, unless it’s the University Health Science Center and its physicians, who can do no wrong.

Their brand of “competition” is financed by tax dollars, but that’s another story.

The page 1 article Wednesday, September 3, 2014 was about “Small firms feel pinch in Bexar.” Bexar (pronounced BEAR) is the county where San Antonio is located. The article told how small businesses in the San Antonio area have been “closing their doors at a higher rate than their peers in Texas and the nation – especially medical doctors…”

The Express News goes on to speculate that the Affordable Care Act, otherwise known as Obamacare, has caused doctors to go to larger medical groups. And hospitals in San Antonio have acquired many medical solo practices and medical groups, especially in high revenue generating specialties like cardiology.

Now here is where “competition” comes in. As all media must do, the Express News trots out an expert, in this case, the interim dean of the business school of Trinity University. He explains that doctors in private practice are finding it harder to survive. So far so good. Then, the Express News trots out “Federal Reserve economic policy advisor Keith Phillips to opine that “As new businesses are established, increased competition drives some businesses into the ground.”

While not directly referring to medical offices, Phillips’ and Butler’s comments taken together provide an interesting insight into the kind of competition in health care that is actually driving up prices to patients – er medical consumers – rather than lower such prices.

You get that insight from another public document filed in what many would call an obscure legal case in Idaho pertaining to the Federal Trade Commission’s attempt to stop a large hospital system from acquiring a large medical group. A trial in federal court led to a ruling that the hospital could not acquire the medical group because it would be anti-competitive. It would give the hospital and medical group a near monopoly in that section of Idaho and eastern Oregon.  The hospital has appealed the trial court ruling to the Ninth Federal Circuit Court of Appeals.

In response to that appeal, attorneys general from 16 states – Texas is not one of them – filed a truly remarkable legal brief. On page 4 of that brief, the 16 AGs state:

“Even among not-for-profit health care providers, the growth in economic power through acquisitions leads to price increases – sued to fund salary increases for the board or management, or yet more acquisitions – rather than more affordable patient care or an expansion of the charitable reach of that care.”            

Wow! There is the best explanation yet of how all these high falutin’ theories of health care “competition” actually work in the real world of overpaid hospital administrators with their boards of car dealers, home builders, and Junior Leaguers.

I don’t have a PhD in economics or a title from a fancy Ivy League college, but I do know much about history – especially the history of predatory practices of hospitals here in San Antonio and the corporate greed of managed care entities.

This kind of “competition” by owned doctors is leading more procedures at higher prices. Hospital owned doctors bill with added facility charges. And the doctors are expected to earn their high guaranteed salaries.

Dr. Steve Cohen and I have been trying to tell the media about what was coming since 1985. But the Express News and their colleagues in other forms of media didn’t want to hear about it. We were just rich greedy doctors who feared competition.

So, now I say to the reporters and editors at the Express News: Don’t take it from me. Read it in a brief filed in federal court by the attorneys general of California, Washington, Pennsylvania, Connecticut, Delaware, Illinois, Iowa, Kentucky, Maine, Maryland, Mississippi, Montana, Nevada, New Mexico, Oregon, and Tennessee.

We’ve got competition right here in River City, but it’s fixin’ to have the opposite effect of what the gurus have predicted. Who would have thunk that?

So, the Express News got their way: doctors abandoning private practice and going under the control of hospital administrators. But prices will go up. Is that an intended or unintended result?