Hippocrates' Modern Colleagues
|The Doctor as a Policeman or Inmate||
by Del Meyer
Doctor Phil Alper in his OpEd column in the WSJ has pointed out the shackles into which Medicare places doctors. Doctors have to be able to document the need for any test that is ordered. Gone are the days of a routine screening panel. Many patients have gotten use to coming in for a yearly physical examination. After Iíve taken a complete medical history and given them a complete physical examination, the laying of the hands on every part and orifice of the body, they look at me and say, "But I came in for my physical." But I just did a complete and total Mayo-type physical. "But I havenít been to the lab yet," is the response. "Oh, you mean a blood, and urine and chemical analysis." "Is that what you call it now?" After finding out what they think they want and what is justifiable on the basis of the medical history and physical examination, I proceed to write out a requisition for the tests medically warranted, usually less than that requested. Someone who has always had a normal cholesterol level does not justify a yearly cholesterol test. In fact, an abnormal cholesterol that has been treated and corrected, with the patient on a stable dose of a medication such as a statin or niacin, only requires being checked every three years, according to some published criteria, until the medication dose is changed.
Sometimes patients get unhappy if they canít get what they want when it is paid for by Medicare, an HMO or their insurance carrier. Some patients simply change doctors to find one that will "authorize" the test or service they deem appropriate. Alper points out that many times neither the "lenient" doctor nor the patient realizes that fraud has been committed.
At a recent Medicare training seminar, the leader stated that Medicare hired 400 ex-FBI men and gave them guns, a $400 million budget and a directive to go out and get all those doctors that are committing fraud. However, itís frequently the more honest physician who disgruntles the patient that gets placed in a higher profile and thus more likely to get arrested, than the quiet doctor who keeps his patients happy.
One congressman allegedly made a statement in confidence that he felt most doctors were probably doing fraudulent billing of Medicare. At one meeting I attended, an attorney stated that one of the investigative FBI men working for Medicare stated that he felt all doctors are crooks. As one attendee remarked (with tongue in cheek I hope) maybe we should have a higher goal to see how many doctors we can put into jail. Perhaps if we put badges and guns on 650,000 law men and station one in each doctorís office in this country, we should be able to arrest all 650,000 of them by the end of the first week. One FBI officer actually went into a doctorís office as a patient. After the examination was completed, he asked the doctor to sign a requisition so that his mother, who would be a patient the following week, could get an assistive device. After the doctor signed the request, the officer pulled out his gun and arrested the doctor for prescribing without performing a medical examination. Do we have enough prison cells to contain an extra two-thirds million physician felons? Werenít prisons with stone walls and steel gates designed for the violent? Why are we placing a nonviolent profession behind bars?
Sound far fetched? Not really. Every day the doctor has to police numerous requests for government services. A Medicare patient requests a cane. Instead of purchasing one for $5, he sees his doctor at Medicareís expense (about $50), requests a prescription verifying medical necessity, and goes to the medical supply house that has a medically approved cane for $100. (These figures may be a little dated.) For each doctor that authorizes a piece of medical equipment, I am sure that Medicare could find several doctors that would verify that it was "not medically indicated." Therefore, after an outside review of such a physician, the cop can quickly pounce on the doctor that did not police this patient well enough. Tear the license off the wall, handcuff the doctor, and paddy wagon him to jail.
A more common request today is for home care from a hospital that has a home care division, developed to replace the revenue the inpatient division has lost. I have counted up to 29 items requested for a patient. These include instructing the patient about his disease (which I have already done), to taking his temperature (the family shouldnít be bothered), to instructing the patient about his medications (which I have also done but find the patient more confused after the home care nurse goes through it in different fashion). Many doctors freely state that they have never been sure that the dozens of requests are really all that necessary. But to try to reduce it could take all morning, eliminating seeing patients. Others have stated they are concerned if they eliminate too many of the items, they invoke the wrath of the hospital by interfering with their revenue stream.
What is the answer? More Medicare regulations? We already have far more pages of rules and regulations that even attorneys can read, much less physicians who must take care of patients. Each law puts a further straight jacket on the doctor-patient relationship. Ultimately it is the patient that suffers. When doctors give up and are satisfied with being the pawns of Medicare, or the insurance company or an HMO, the patient will never partake of the modern advances in medicine we have come to enjoy in this country. Some feel that a high deductible health insurance policy is the answer. The patient pays cash for his annual exam, lab tests and x-rays. If he is hospitalized or has surgery, then the insurance is there for the catastrophe. In the long run, that will be a lot less expensive and more patient oriented than our current system.
Ghosts vs Live Inmates
Speaking of inmates, do we really need live inmates? The WSJ reported that the two senators from Mississippi were dined by a lobbyist, Wayne Calabarese, to solve the prison empty bed crises. Mississippi built 15 prisons in seven years and then ran out of inmates. Mississippi lawmakers wrote legislation that, according to corrections commissioner Robert Johnson, set aside millions of dollars for empty prison bedsĖor ghost inmates. Although the number of live inmates behind bars has quadrupled in the past 20 years, it was not enough to fill the beds. The prisons won this favor even as budgets were cut for classroom supplies, community colleges, mental-health services and other programs. . . .
Almost sounds like the government spending huge sums of money in the 1970s after Medicare got into full swing to build hospital beds, which are now being closed at a great loss of capital cost and revenue stream. When will taxpayers say, "Enough is enough?"
|Medical Record Confidentiality vs Gridlock||
by Del Meyer
Medical record confidentiality is a serious concern of many patients. This is reflected in a lead, front page, headlined article titled: "Medical data private? No," which I recently came across while passing through Hawaii. A companion article on page 10 indicated that a judge ruled in favor of the Hawaii Medical Service Associationís request for 15 records from a physician. To obtain the single record the HMSA really wanted, they requested 15. The other 14 served as a smoke screen. They were willing to invade the privacy of 14, uninvolved patients to protect the confidentiality of one member. The purported reason was to check possible billing fraud. Privacy issues directly affect medical care, according to Dr Joseph Heyman, former president of the Massachusetts Medical Society. "Itís a terrible, terrible problem and something needs to be done about it," Heyman said.
The implication is that we need another law to protect patientsí privacy. California added nearly 1000 new laws in 1997, about the same as in each of the previous years and in the now subsequent years. LeRoy Green, who completed 35 years in the California State Legislature, admits that he personally introduced more than a thousand legislative proposals during these years with hundreds having become law. He states that the other 119 members do the same. In his final column, "The Greene Scene" titled "Gridlock," he points out that, except for a few laws which he termed beneficial, (e.g. seat belts, helmets on cyclists) virtually all limit our choices and increase bureaucracies and penalties. These are strong words from a party stalwart who is not normally concerned with enlarged bureaucracies. And laws get longer, from the few words in the ten commandments, to a few sentences in the constitution, to volumes today. At some point, he predicts, the entire system will grind to a halt because we never learned how to subtract. For every thousand words we add, he feels we may subtract a sentence or two. Sooner or later, we will have covered everything conceivable with legal requirements. When that day comes, we may have frozen ourselves into total immobility or gridlock.
If another law is proposed that in some way protects our medical privacy, we can rest assured that our HMOs, Managed Care Organizations (MCO), or other insurance carriers will also have plenty of laws to protect their rights. If it comes to a urinating contest, we may all become soiled - none of us would pay anotherís bills unless we knew for what we were paying. And the insurance company will have to, as a matter of business practice, verify that the services they are paying were indeed rendered.
So is there an alternative without restricting laws which may be a lose/lose proposition? There is. But it may be painful.
Insurers have relied on some sort of review process to verify claims. Usually a hospital system of quality management or chart review would satisfy. But with increased utilizations by patients whose medical care is free from additional costs after the employer pays the premium, healthcare costs have gone off the charts. Hence, managed care came into being to reduce costs demanded by businesses paying the premium, with the obvious decrease in quality, despite claims to the contrary. Thus HMOs and MCOs have started to review the charts themselves to verify that appropriate codes were used. These HMOs and MCOs have made numerous visits to my office to review 10 to 25 charts and never could find one error. Hence, they have reduced their frequency of visits. MediCal made two visits to my office over the past eight years, reviewing 300 codes on one occasion and 360 codes on another. They were unable to find one error. Certainly this is an invasion of privacy as these reviewers copy items as they please. They seemed to have copied entire visits that relate to any code. But it does give them the confidential information on any of these patients, which then goes into their briefcase with all the risks involved. Who knows if many patientsí confidential and personal/drug/venereal past may haunt them at sometime because a reviewer just happened to make another copy on the way to the state or HMO office?
Since the patient only pays a $5, $10 or $25 copay, there is no interest, concern or knowledge of the total charge the hospital, pharmacy, laboratory or physician renders to the carrier. However, if the patient paid a 10%, 20% or 30% copay, the patient would have an interest in the total bill, since that would affect the amount paid out of his or her own pocket.
Last December I read a letter from the family of a hospital patient requesting the patient be kept in over the four-day holiday weekend, about five or six extra days. The daughter had too much to do preparing for guests and Christmas dinner. Since Medicare pays the entire bill, there was no incentive to accept the discharge of the patient, since the $2,000 per day hospital charge would not be paid by the patient or the family? But isnít an extra $12,000 for the additional six days an unnecessary charge to the taxpayers? I can assure you, if Medicare only paid 90% of the hospital bill and the patient had to pay 10% without MediGap insurance, the family would not have objected to their mother being released to a convalescent hospital on December 23 rather than on December 29. The simple additional 10% copay would then assure Medicare, or any other insurance company, that there is someone out there more effective than a reviewer to make sure the lowest possible bill is rendered.
May I also suggest that a 20% copay on outpatient surgical center charges would have the same effect to assure the cheapest possible treatment rendered. And for the sake of completeness, a 30% copay on all other outpatient physician visits, laboratory and pharmacy charges would make every beneficiary vitally interested in controlling healthcare costs.
How do we do this without more restricting laws? It could easily be accomplished by a simple change in the tax code. If all health insurance that followed this 10/20/30% copay were made tax deductible to either the employer or the individual (if MediGap were purchased, one would lose this tax deduction), managed care and HMOs would not have been required to reduce costs. And then we would not have to worry about the need to review our medical privacy matters.
But we donít really have to worry about something so simple and beneficial ever happening. Otherwise, lawyers, our legislatures, and congress wouldnít have all that fun in pushing us into total immobility--into MEDICAL GRIDLOCK.
|Coronary Artery Bypasses||
by Del Meyer
Part of my responsibilities at University of California, Davis Medical School, include teaching physical diagnosis. This means teaching and observing second-year medical students as they obtain a medical history and perform a physical examination. Sometimes I observe and instruct them in my office and other times in the hospital. Recently I had a patient in the cardiac unit who was a willing volunteer in this learning process.
While recording the students' skills, I was able to observe the patient in the next bed who had a coronary artery bypass. She was lying still in her bed, looking at the ceiling, surrounded by her family talking amongst themselves as if she weren't there. When the student physicians had completed their examination of my patient, we stopped at the nursing station to talk with the nurse who was taking care of the patient in the adjacent bed.
The nurse told us that the patient had Alzheimer's Disease and had not recognized her husband or children in several years. The nurses had a hard time understanding why the heart was being rejuvenated to last years longer, when the brain had ceased its cognitive function. Most of us feel that when the brain goes, hopefully another organ will fail so that the body can die along with the brain that has essentially "died."
This reminded me of a conversation I had with a member of my parish. He stated that his mother, who was 91 years old and had lived alone a few blocks from them, had some mild chest pain. Her personal physician was treating it with the usual nitrates. He referred her to a cardiologist "since there are a lot of new medications on the market and perhaps she could benefit from one of them."
The cardiologist immediately did a cardiac catheterization and found some vessels that were nearly blocked. He had a cardiac surgeon see the patient and he immediately scheduled her for a coronary artery bypass graft (CABG). The operation took place the following morning and was accomplished by taking some veins from her legs and grafting them to either side of the coronary artery blockage. After five days, the family was told that she, being old, was unable to be discharged home, and should go to a nursing facility for a month or so. She spent over three years and died there.
My friend said that his mother's chest pain had not been all that severe or disabling and did not interfere with her usual minimal activity. But after she was referred to the cardiologist, the family lost control. In hindsight they felt it would have been preferable if she had remained in her own house near them, even if it meant that she might have lived for only six months to a year before her coronary caught up with her. It had been difficult to visit her in a convalescent home for over three years. The cost of $3,000 per month for 40 months was covered by selling her house. And of course, Medicare paid for the $120,000 hospital bill with taxpayer revenue. The surgeon's fee of $6000 was almost inconsequential in relation to the quarter million that was spent on the last three years of a life which was devoid of quality. The family felt that there would have been greater quality of life without that quarter million-dollar expense.
A variation of that scenario was being replayed in the next bed my student physicians were observing. The critical item that would control such unnecessary costs is usually missed. Neither the patient nor the family had any financial consequences from that decision and may not have had the fortitude to go against the tide of surgical opinion. However, if there were a 5% or 10% copay that the hospital would have told the family to pay, they immediately would have had a family council or discussion on "Do we really want this for our wife and mother?" We see that in healthcare cost projections; it is generally considered that healthcare needs are fixed. As these two examples show, it is very elastic. From my own personal, clinical, nonscientific observations, there is at least an excessive 30% utilization that could be avoided with the appropriate incentives.
While elements of our society are debating end-of-life decisions, physician-assisted suicide and euthanasia, the impetus for this direction is heightened because we don't allow people to die when the next stage in their illness is to die with some dignity. But the push for this allowance has to come not only from primary care physicians, but also from patients and their families who must remain involved in every decision that concerns their loved ones. Otherwise, in our illness or in our desperation, we may not recognize whether our doctors are adding to future misery by prolonging dying, or really giving us improved or even acceptable quality of life.
by Del Meyer
KEEP THE GOVERNMENT OUT OF THE MEDICINE CABINET
Chris Ward, an independent consultant to the pharmaceutical industry, spoke at the annual meeting of the Association of American Physicians and Surgeons (AAPS) this past month on the topic of prescription drugs. His specialty is Market Access & Health Policy Issues. He was formerly in charge of Canadaís pharmaceutical research and development program. He also was the Minister of Education in 1987 and the House Leader in 1990. He described himself as a recovering politician.
Until 1985, he believed that medical care was a right - that there was a free ride. With no background in medicine, healthcare or medical policy, he is now surprised as to how much he thought he knew about these issues. He finally came to his senses and realized these issues are too complicated to plan for the masses. He is now on a crusade in keeping government out of the medicine cabinet.
WHY ARE DRUGS SO EXPENSIVE?
Ward feels that drugs are actually the best bargain in healthcare. Because of diseases treated with pharmaceuticals, the death rate in the US has dropped from 19,000 to less than 9,000. Hospitalization rates have decreased by 31% in the decade of the 1980s. Because peptic ulcers can now be more effectively treated, hospitalizations from 1980 to 1998 have decreased from three million days to one million days per year, saving huge health resources. The value of a new drug is found in the benefits it provides in meeting the needs of patients. Medical research and innovations are leading to new therapies replacing more costly and invasive medical procedures.
As the average age of the population increases, so does the consumption of medicines necessary for the treatment of many diseases and conditions. However, price increases contribute only a fraction of the annual growth in drug expenditures. Drug development is a long and costly process. Only one in 5,000 molecules that are tested makes it to market as a new therapeutic drug. In the last decade, 1000 new medical entities were approved, but only 100 made it to market. Only three of 10 that make it to a market develop sales exceeding cost of development. The process is highly competitive, assuring us of the lowest possible costs. The estimated cost of bringing a new drug to market from1976 to1996 increased from $54 million to $500 million. Forty-five per cent of pharmaceutical research in the world is done in the US. Industry-funded research has increased from one-third to one-half, and government-funded research has decreased from one-half to one-third.
WHY ARE PHARMACEUTICALS CHEAPER IN OTHER COUNTRIES?
Pharmaceuticals have a higher value in the US in terms of costs of other health services that they replace. If we compare drug expenditures among developed countries with their total expenditures, the US has the lowest ratio. Drug costs in Italy is19.4% of their total healthcare expenditures, France 17.2%, UK 16.7%, Canada 13.8%, and the US 10%. Thus drugs in our country have the lowest proportion of total healthcare costs of anywhere, although there was a 40% increase in cost of pharmaceuticals.
HEALTH CARE SPENDING GROWTH
Healthcare spending growth in 2000 has not shown any preference for increased drug costs. In fact, physician costs have increased 1.8%, drug costs have increased 1.9%, and hospital costs have increased 3.4%. Per person health expenditure in the US & Canada have not shown any disproportionate costs. The average cost per person for hospitalization is $1700 in the US vs $760 in Canada, cost of physician fees is $761 vs $300, and cost of pharmaceuticals is $320 vs $264.
CHOICES FOR MANAGING THE IMPACT OF PHARMACEUTICAL INNOVATION
One can restrict the supply of medications by restricting formularies as they do in Canada and thus restrict patient access to new medicines. Canada cannot advertise the drug and the disease in the same ad. However, 80% of the magazines in Canada are from the US. One can also restrict access to pharmaceuticals by using prior authorization and thus putting more drag in the system. One can impose price controls which usually have been counter productive. Witness the recent news release that some generic medications are more expensive than proprietary medications because of governmental involvement in a selective discount and pricing web.
So, when one says very glibly that he can get the same medicine in Canada or some country with universal coverage, just remember that real costs are still better in this country.
|Medicare and Healthcare Costs||
by Del Meyer
In our continuing debate on having the government take over healthcare, the current debate on Medicare is germane. Medicare, a government healthcare program for senior citizens over 65 and those that have been disabled for over two years, has outstripped all projections in costs. When President Johnson stated in 1965 that Seniors should be able to assure their healthcare for a dollar a month or $12 per year, he missed the actual premium by thousands of percents and projected costs by hundreds of percents. As incomes and expenses soar, those in the healthcare field are being asked to continue to reduce their expectations because reimbursements are decreasing. The legislative branch of government continues to buy votes by increasing benefits without regard for the governmentís ability to take that much money away from citizens to pay for these benefits.
When I was in medical school, the physiciansí part of the healthcare dollar was nineteen cents. Today it is about fourteen cents and decreasing. Medicare reimbursement is expected to drop another 17% from 2002 to 2005. Many physicians are closing their practice to new Medicare patients. The director of the family medicine residency programs at the University of Colorado at Fort Collins states that many Medicare patients call the university clinic because, after 15 to 18 calls, they were unsuccessful in finding a physician.
The answer according to Ralph Nader in his recent book, CRASHING THE PARTY - How to Tell the Truth and Still Run for President, is universal healthcare coverage. The politicians say that is the answer to providing healthcare to all. However, in most countries with universal coverage, the waiting lists are so long that about the same percentage as our uninsured are not getting optimal health coverage. In one instance, the government set up a new program, got rid of the previous five year waiting list (which made the politicians feel better) and started a new waiting list. How can an integrated mind accept such duplicity? Nader feels that except for Russ Feingold, Jesse Jackson and Paul Wellstone, the Democratic Party has shifted far to the right.
Maybe we should just socialized the whole healthcare system, place doctors on a salary with government benefits, vie for the 10-hour, four-day week or 12-hour, three-day week like everyone else, and let the politicians take care of the sick people after hours and on weekends. That would probably cover about as many patients as the British National Health Service is doing at the present time.
* * * * *
Doctors are not innocent in hiking up healthcare costs. This past weekend, I received a call from a patient that I couldnít recall seeing recently. When I returned the call from my exchange, I asked him what his Saturday emergency was. We get a lot of inconsiderate patients these days whoíve been sick for a week or longer and wait until the weekend to obtain their healthcare. They are shielded from the market place and the laws of economics which cannot be avoided any more than the law of gravity. Why should one take time off from work when it doesnít cost any more to be seen on Saturday? However, the average free standing "Doc in a Box" charges about one and one-half to two times what an office call for an established patient costs. The average emergency room charges between 10 and 20 times what an established patient costs in a doctorís office. This additional money has to come out of increased taxes if we have universal healthcare coverage or out of increased premiums if itís private health insurance. Either way itís a waste of money. As Milton Friedman stated, no one spends someone elseís money as carefully as their own money.
However, in this case, the patient stated that although his cough began on Wednesday, it did not raise green sputum until last night. He had already called his doctor, who was signed out to another doctor, who told him to go to a "Doc in the Box." So he called the "Doc in the Box" and was told that he best go to the emergency room. Since he did not feel bad, and has had bronchitis previously, he thought this would be excessive cost. He then remembered that his family physician had sent him to me for a pulmonary consultation about a year ago and thought I might be willing to stand in. So I called in a prescription for Keflex, an antibiotic with which he previously had success.
What are the cost implications? This patient was judicious in his use of the healthcare dollar. It was reasonable for him to try to shake his upper respiratory infection. When it became a roaring bronchitis with green pussy phlegm, treatment shouldnít have to wait another two or three days. Thatís why my chronic bronchitis patients have one treatment of antibiotics at home for just such emergencies. He did not trade a $75 office call for a $900 emergency room visit as the on-call doctor suggested. As physicians, we must be cautious with spending healthcare funds.
The caveat you must not miss. This patient did not have an HMO where he was shielded from all financial risks. He had a PPO and shared risk of healthcare expenses. Hence, he was a partner in trying to reduce healthcare costs.
If we had all patients share some small risk of their healthcare costs, like 20% in this case, the costs of medical care would again become reasonable.
by Del Meyer
Last week a patient came in and told me that since his last visit, two years earlier, he had a gallbladder operation. He thought I would be interested in the bill his insurance company received, of which he brought a copy. He was in the hospital for about 23 hours, and the bill was $14,000. That calculate to about $600 an hour, even while asleep.
That struck me as rather strange since the Medicare fee for a five-day hospital stay for a gallbladder operation was $8700 several years ago. How can a one-day stay be nearly twice as high as a five-day stay?
Medicare controls inpatient hospital charges but not outpatient charges. Hence, hospitals have tried to gain the money lost on inpatients by doing as much outpatient work as possible. "Inpatient" stays of less than 24 hours are treated as outpatient by Medicare, and their restrictions, therefore, don't apply.
The possibility of having a gallbladder or other organ removed without a large incision (requiring a week's stay in the hospital) came about because surgeons developed a laparoscopic procedure performing the removal through a small tube inserted through a puncture in the abdominal wall. They naively thought they could reduce healthcare costs by reducing the hospital stay from five days to one day. The surgeons tell me that it takes greater skill to remove an organ through a small tube, but their charges didn't change significantly for this advanced procedure that allows patients to return to work weeks earlier. Hospitals, however, used it as a means of recapturing twice the cost of a five-day bed stay in just one day.
This reminded me of when I was a new medical director of a respiratory care department in the 1970s, and my chief technician noted that the price of oxygen had increased from 75Ę an hour to $3 an hour. He determined the cost to the hospital was about 25Ę an hour. His technicians only recorded the hours the patient was on oxygen. The hospital computer calculated the oxygen charge.
We went to the administrator in charge of our department and he was totally taken aback as to why we were even concerned. Looking at me with a stern eye, he asked "Isn't getting the money 'in' the name of the game?" He then told us that Medicare, Medicaid, Blue Cross and Blue Shield were all paying the $3 an hour and he had already authorized a further increase to $3.50 an hour! He said, "We haven't even found the ceiling that these carriers will pay."
Hospitals don't see this as an unethical problem. They see no problem in charging whatever the traffic will bear. They don't see costs as the determining basis for the charge. And there is no competition to keep everyone honest.
The name of the game really is "Get the Money In," or at least as much as possible. A colleague from India told me that her father had a coronary artery bypass surgery at a hospital in Sacramento. He got the hospital bill for $120,000. Being a corporate executive in his country who could easily pay the charge, he consulted his daughter who told him that hospital charges are very inflated in this country and he should offer to pay one-half. So he walked into the hospital business office with his check book, showed them the statement, and said he'd settle the account for $60,000. They accepted the check and marked the bill paid.
In this case, the surgeon who did the operation and managed the life-threatening care received his $6,000, which is about 10% of the cost (or 5% of the original hospital statement). Even a manager of a piece of real estate may get 10% of the revenue. Isnít managing oneís life/death challenges more valuable than managing an apartment house?
Years ago I was managing the tragic result of a boy who broke his neck in a diving accident. His spinal cord was transected at the third cervical vertebrae. He would never breath again on his own. The internist who was managing the overall care, while I was managing the life support system, told me one day after a month of ventilator support, that it was unreasonable for two doctors to submit a bill to the insurance company. He suggested that he submit a charge one day and I submit a charge the alternate day. In those days, the management of a critical patient, as I recall, was about $40 a day which included the bedside evaluation once or twice a day, plus availability by phone to the nursing staff 24 hours a day. We each continued to see the patient daily and manage our respective care but submitted our $40 every other day. The hospital charge in those days was about $800 a day. Knowing the hospital's position on trying to reduce oxygen charges, we knew the only way to save money was our own charge.
Healthcare costs have gone out of sight. But many of us are still working at cross purposes. It was managed care, unfortunately, that was required to reduce hospital charges. This was a double-edged sword. It also managed the captain of the ship, causing an exodus from medicine. What a waste of a quarter million dollar education.