I blog about free markets in medical care and transparent pricing.
A fellow physician told me recently that he had seen a worker’s compensation patient who had been treated and released by another surgeon for a wrist fracture. He was now in my friend’s office complaining about his hips, knees, spine and shoulders. The patient’s records indicated that he had recently seen an occupational medicine doctor who had ordered 12 MRI scans, all performed at a facility in which he had an ownership interest. He then recommended that the patient have both knees and both shoulders operated on by his business associate, a surgeon who also has an ownership interest in the same MRI facility and one not known for his ethical leadership skills.
Before you conclude that this is an argument against physicians owning and controlling medical facilities, consider the following.
An orthopedic surgeon employee of a local hospital was called on the carpet for not ordering enough MRI scans on his patients. The next month he ordered 77 of them to get the administration off of his back.
How are these two stories different? In the first instance, rogue and unethical physicians have positioned themselves to take complete and utter advantage of the third party system known as worker’s compensation, a notoriously corrupt system where many times unscrupulous lawyers team up with unscrupulous physicians to insure that the medical bills, and hence, the “settlement” amount is maximized. These physicians and their actions hurt the reputations of all physicians, not just those of us who own and control medical facilities. After all, physician ownership of a medical facility represents a situation which almost invariably benefits patients financially when compared to any alternative.
In the second instance we are witness to the institutionalization of corruption and fraud, rather than an exception. Unlike the first example, a regrettable and shocking exception, the second is just the way business is done…business as usual. Remember that the hospital administration leaned on the physician employee, just as they had leaned on many others, to act in this unethical way, this theft becoming standard operating procedure, company-wide policy.
Whenever I hear the hospital cronies complain about conflicts of interest for physician facility owners, I ask the rhetorical question, “If it’s wrong for physicians to own hospitals, why is it o.k. for hospitals to own physicians?” Those in the hospital business that would denigrate physician ownership in general while hoping no one will notice the magnitude of their established and unethical ways, is not unlike the federal government’s prosecution of Bernie Madoff, all the while conducting a little Ponzi scheme of their own known as social security. Bernie stole a billion. Social security has stolen trillions. Also keep in mind that the federal government, Obamacare, in particular, has pushed hard for the “physician-as-employee” model, directly attacking the institution of the private practice of medicine and insuring the predominance of the giant hospital brand of fraud.
Are there some bad physician actors out there? Of course there are. At a meeting in Austin, Texas several weeks ago, I listened to health policy folks go on and on about a particularly notorious and unethical physician-owned hospital in Texas, while they defended the predatory and bankrupting giant hospital “systems” in their state, whose criminal practices are widespread and institutionalized. I would further make the point that most of the unethical physician actors are unwelcome in physician-owned facilities such as mine as the mere association with doctors like this would affect the reputation of our facility and that of each of us as private practitioners. This phenomenon of shunning actually increases the concentration of the unethical actors that are hospital employees, I would argue, a condition that bodes well for the profits of the institution with which they are affiliated, but bodes poorly for patients ending up in their lair.
What is the real problem? The real problem is the absence of the free market. It is the presence of third parties and the absence of the sticker shock that introduces the moral hazard into medical economics. When someone else is paying, patients are not inclined to question these aggressive money-making schemes by the bad actors, whether the occasional rogue physician-owners, or routinely abusive hospitals and their employed doctors. The introduction of price transparency is the beginning of the end of these scams, as a hard look at the pricing begs questions of value. ”Is a tonsillectomy at this big hospital 10 times as good, because it costs ten times as much!?” ”Is it necessary for me to have all of this expensive lab work prior to surgery at the hospital when the physician-owned facilities usually require no lab work whatsoever, in accordance with national standards?” ”Do I really need all of these MRI’s and surgeries?” ”Is this doctor sending me to this MRI facility because his employer is pressuring him to keep his numbers up?”
Let’s not let a few bad apples in the physician-owner group cause us to take our eye off of the most unethical promoters of unnecessary care: the giant, corporate hospitals and the doctors that work for them. It is they who have created and manipulated a dysfunctional, largely “corporatist” system to their outrageous advantage, subjecting countless individuals to bankruptcy, and shoved this country to the brink of insolvency.
G. Keith Smith, M.D.
Thanks to Todd Rice for this article. The timing of the implementation of the Unaffordable Care Act was carefully planned so that many of those who supported this “president,” those adversely affected by this “law,” wouldn’t face the consequences until after his “re-election.” Let’s call this “law-Ponzi”…making folks pay later for laws passed today.
I don’t think the massive and leftist teacher unions will forget this betrayal any time soon.
G. Keith Smith, M.D.
I have referred to states creating their own “insurance exchanges” consistent with Obamacare, as “constructing your own gallows.” States that are expanding Medicaid are doing further damage by helping to build a constituency. As George Bernard Shaw famously said, “the government that robs Peter to pay Paul will always have the support of Paul.” Beneficiaries of government loot aren’t likely to vote against someone whose campaign is based on taking those goodies away.
Creation of vast new numbers of Medicaid recipients virtually guarantees that they will only politically support those who maintain or even increase these benefits. I agree with Mencken who described elections as “an advance auction on another’s property.” It thus pains me to provide this political admonition to those supposed “conservatives” out there who are actually considering expanding Medicaid in their states.
Medicare beneficiaries shred anyone suggesting that this Ponzi scheme be curtailed or eliminated, paying little attention to the rational arguments, reacting many times like an entitled voter bloc. Same with Social Security. I’ve heard all the arguments. “I paid into that. That’s my money!” There is no point in pointing out to people who say this that they have probably long since consumed any money they paid in. It makes no difference to many of them that thieves in Washington made off with the money they did pay in long ago, the source of funds for the current beneficiaries being the future elderly, who will likewise victimize their young.
One of the cynical truths about American politics is that just as politicians can be bought and sold, so can the voters. What beneficiary of a government program is going to support the politician advocating for ending this handout? Every handout from Uncle Sam comes from someone’s wallet. Increasing the number of folks at the trough adds to the power of those willing to “redistibute” the wealth of taxpayers.
Justice Roberts interestingly gave the states an “out.” Why on earth wouldn’t the states seize this opportunity? Embracing Medicaid expansion will bring financial hardship to those states that take this road and for what it’s worth, wreck political devastation on any state “leaders” that decide to undo this later.
The big hospitals want this Medicaid expansion. Many of the big insurers want this Medicaid expansion as this will remove the liability of many of the sickest and poorist of patients from their roles. “Conservatives” who expand Medicaid in their states will be acting in the interests of the health cartel, giving little thought to future consequences. American politics. Everything’s for sale. Grant favors now, make others pay later. Current “conservatives” pulling the trigger on future “conservatives.” Yet another Ponzi scheme.
G. Keith Smith, M.D.
From our local paper, “The Oklahoman,” the most recent Saturday edition:
“Ray Walker took his job because he wanted to be better enabled to help his mother as she aged. Walker serves as the divisional director of the state’s Medicare Assistance Program. Walker’s job is to help people make health care decisions that are best for them. Part of that job includes helping older adults and their caregivers understand Medigap, the term used to describe supplemental insurance that covers what traditional Medicare doesn’t.”
I guess it’s not enough that your tax dollars fund the Medicare Ponzi scheme. You also get to pay a guy to explain to Medicare beneficiaries the ins and outs of buying policies that pay the bills the bankrupt scheme doesn’t cover! Think about it. What other insurance do you have that needs a back up insurance policy? Hmmm. Ahh, limited, constitutional government! But wait, there’s more!
Again from our local paper, “The Oklahoman,” the most recent Sunday edition:
At a recent news conference at our state Capitol: ”Changing health care is hard - changing behavior is even harder,” said Gregg Koehn, the Oklahoma Foundation for Medical Quality chief executive officer. “We certainly don’t have all the answers, but we can together make a difference.”
Continuing: ”The Oklahoma Foundation for Medical Quality hosted the news conference, which served as an announcement of ‘Oklahoma Healthcare Quality Week.” ”The foundation is a state-based ‘Quality Improvement Organization,’ a term that means it’s contracted through the Centers for Medicare and Medicaid Services to improve the effectiveness of services delivered to Medicare beneficiaries, according to the center’s website. Koehn said over the past few years, the organization has helped about 1000 primary care providers implement electronic medical records. About 200 providers have achieved Stage 1 Meaninful Use, he said. ’Meaningful Use’ is the set of standards defined by the Centers for Medicare and Medicaid Services Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria, according to the U.S. Department of Health and Human Services.”
Apparently, we not only need a government program like Medicare - we need a government program to improve the effectiveness of Medicare! We are paying these clowns to have news conferences like this. Declaring this Oklahoma Healthcare Quality Week will make a big difference, don’t you think?
One of their greatest accomplishments? Bringing us more electronic medical records! And forcing the “meaningful use” garbage down the doctors’ throats. To say that incentive payments are available to those adopting “meaningful use” criteria, isn’t exactly true. What they mean is that for doctors who don’t adopt this set of criteria, the purpose of which is to provide the bureaucrats with patients’ confidential health information, those doctors will be paid less. That’s not exactly an incentive payment, is it? The’ve called the stick a carrot, I think.
I have called the electronic medical record scam, the KGB of medical intelligence. Patient’s private and confidential information will be transmitted via this technology to folks whose job will be to deny care to those believed to cost the system the most or those who are politically expendable. ”That can’t happen here,” you say!
Sorry. It has already begun and the henchmen like Mr. Walker and Koehn are with us and working hard for the boss man. Principiis obsta, finem respice ( Resist the beginnings, consider the ends).
G. Keith Smith, M.D.
Lew Rockwell described the General Motors bail out as follows. Imagine that you have saved enough money to by a car. After doing careful research you decide that you want a Toyota. Uncle Sam says, “NO!” ”You must buy a Chevrolet!” The funds are taken out of your account and deposited in the General Motors account. The catch? You don’t get a car!
I don’t like the use of “bail out” as a phrase that indicates a rescue of sorts. I prefer to think of “bail out” as ejecting from a burning airplane leaving everyone else on board to fend with the mess. Isn’t this what the GM bailout really was? ”What was seen” was GM continuing to operate. What was not seen was the robbery of the taxpayers and the ruin inflicted on those holding GM’s bonds.
“Bail out” can also mean scooping water out of a sinking ship or vessel. The key to understanding this use of the phrase is that the ship is sinking.
I think it would be more honest to start using the phrase “bail in.” This phrase would be more useful in that Uncle Sam’s role might be more clear as the distributor of money stolen from taxpayers to political or corporate favorites. Solyndra is a great example of a “bail in.” Your money and mine was “bailed in” to that poorly conceived black hole. We have involuntarily participated in countless “bail ins” for big banks over the years, institutions deemed “too big to fail.”
I have begun to think of Medicare as a “bail in” effort. Rather than declare this Ponzi scheme a disaster, voters over the years have tarred and feathered anyone suggesting even the slightest change in this program. ”Don’t touch MY Medicare!” ”I have paid in to this for many years and now I want my benefits!” The current Medicare beneficiaries receive their “benefits” not from money they paid in, but rather from money others currently pay and even money that future generations will pay. Medicare is being “bailed out” by bailing young people’s money in.
If a private company had Medicare’s balance sheet, it would be declared bankrupt, broken up and sold off and those that had put money into the organization would take their lumps, recognizing they had contributed to a failed enterprise and learned their lesson. However, as a government institution, Medicare has the power to bail the money of future generations in to this financial abscess, only to make the boil even larger. Cries from Medicare beneficiaries continue and the politicians respond just as you think they would, maintaining or increasing the benefits to this powerful voting bloc.
Some politicians paid a big price for voting for the various bailouts. I don’t see the difference between that and political promises to “save Medicare.” Placing Medicare in to receivership won’t be easy and can’t be accomplished quickly as too many folks have come to count on this program to provide funding for their health care. That said, I believe it is irresponsible and immoral to continue to present future generations with the current health care bills of today’s Medicare population. Is it possible to end the confiscatory “bail in?” Is it possible for a group of the elderly to endorse the end of the robbery of our young, and those struggling to make their own ends meet?
G. Keith Smith, M.D.
I’ve been asked how physicians and patients will be affected by the Court’s declaring the Unaffordable Care Act unconstitutional. My sources tell me that this is extremely likely. I am reminded of the comment of the brilliant Joe Sobran, who said, “…if Iraq needs a constitution let them have ours…we’re not using it.” Incredibly, this “brother-in-law” court appears poised to reject Obamacare based on “the constitution.” It is useful to review the reasons this legislation was passed in the first place to keep any specifics about the bill in proper context. The bill served at least two purposes, neither of which has anything to do with health care.
A tax increase: Taxes are sent to the government with the hope that some of them will be returned for roads and bridges, that kind of thing. Politicians make more money, however, by doling taxpayer loot out to those who bribe them. We all remain hopeful that some of the bribers will be road and bridge builders, I suppose. Insurance works the same way. We pay premiums, hoping that when the day comes and we need to make a claim, some of our premiums will be returned. Insurance companies are prevented from becoming too abusive (refusing to pay claims) through competition. If one insurer is too abusive, another will gladly accept a disgruntled customer. With the government acting as the only “collector of premiums,” customers (patients) are disarmed, unable to retaliate against poor service. To the extent that claims are denied or delayed this amounts to a simple tax increase. The federal budget will look improved at first with loot from this new robbery rolling in and rationing of care in full swing. Later, as demand outstrips supply, the program will become bankrupt, the bankruptcy assuming the form of long lines for care. The political hacks that dumped this on us won’t care a flip, as they will be long gone, leaving future politicians to deal with the politically impossible chore of dismantling a federal program, or alternatively will be smeared as mismanagers of the earlier politicians’ great idea. FDR understood this. To this day he is considered one of the great ones because he introduced the Ponzi scheme of old age pensions, a program that threatens to bankrupt us today.
“Return on Investment”: Health information technology companies, big pharma, big hospitals and big insurance companies either have already received huge benefit from this law and/or stand to in the future. This quid pro quo of political bribery was very successful. HIT companies were successful in getting Uncle Sam to declare the purchase of their products mandatory. Incredibly, 20 billion dollars in taxpayer subsidies were doled out to buy this product. I like to refer to this as a “bail in,” as opposed to a “bail out.” Close negotiations with the big pharma lobbyists in connection with the health care law insured maintenance of their profits. Big hospitals were granted the upper hand in hostile takeovers of physician practices and smaller hospitals due to the intentionally expensive mandates that the little guys couldn’t handle. The big insurance companies supported this effort in anticipation of the country being carved up into regions over which these big boys will have complete control. The medical loss ratio provision of the bill insured that their smaller rivals would be destroyed, a political gift, the deception of which can not be overstated.
The players haven’t changed. Bankruptcy due to cancer is the fault of the government-created cartel of big hospitals, big pharma and big insurance companies. Death from rationing (the favorite budget-balancing tool in the universal health care bag) will likewise be inexcusable, but will be implemented by the same cast. The free market, one characterized by real competition and transparent prices, has brought a standard of living to the world that no other economic system could have produced. Why do most continue to believe that the application of this mutually beneficial system of exchange does not apply to medical care?
After this law is overturned, lawmakers will be in a heat to “fill in the gaps.” My advice: take some deep breaths. A real opportunity to return to healthcare sanity is upon us and the solution (a transition to a free market) will not come from Washington, short of repealing countless past laws bought with bribery. Application of the libertarian principle of non-aggression is indicated. By this I mean that no individual’s health needs should be the involuntary responsibility of any one else. Short of this, the feds should turf as much of this as possible to the states for them to figure out on a local level, as local politicians are more accountable to their electorate. Washington politics has made millionaires too numerous to count already, as a result of this fiasco. That is what politicians do: make already rich folks (who agree to kick back bribes) richer. To paraphrase the great libertarian Harry Brown, “..this is much too important to leave to the incompetent, inefficient and corrupt officials in the federal government.”
G. Keith Smith, M.D.
Thanks to the goons in D.C., health insurance is basically witheld from most folks’ paycheck just like the Ponzi schemes social security and Medicare. That the purchase of health insurance is a deductible expense for employers and not for employees creates the most perverse consequences, one of which is that insured employees feel like their health care is essentially “free.” This creates an artificially high demand, employers try to check with all manner of obstacles. Employers as the providers of this insurance are also inclined to provide this product in name only, to the extent many can get away with it. HMO’s are essentially this “insurance in name only” product. Barriers to real care (not the ridiculous and cheap “wellness” insanity) prevent patients from gaining access in a timely fashion or getting the care at all. This is achieved by granting bonuses to the gatekeepers to the extent to which their denial of real care has been effective. Patients enrolled in HMO’s have health cards they carry around authorizing them to see a doctor whose job it is to deny them care.
People are on to HMO’s. They suck and everyone knows it. It has become very difficult to peddle this fraud. Even employers have soured to this scam as they tend to lose their best employees once this product is implemented.
The legislative session just ended here in OKlahoma featured two of the biggest insurance companies in the country proposing a bill that was essentially a fraud. Since HMO’s suck and everybody knows it, they assigned it three different letters of the alphabet. HMO became EPO, or exclusive provider organization, a product that provided for no out of network benefits. The usual political suspects aligned with those in the insurance industry, pushed hard for this with the help of the largest lobbying firm in the state. Incredibly, this legislation failed. House Bill 2447 got nowhere, thanks to the efforts of my friends Patrick Gaines and Tonya Lee, two people who have worked hard to protect medical practice in Oklahoma from attacks on the free market, like this bill. They have never met a free market-threatening bill they have not been able to kill. Their record of success and ability to build political coalitions is truly remarkable.
Much of what we have been able to accomplish at our facility has been due to the efforts of these two, working hard on the political front, keeping the looters and cronies (who would hamstring our efforts to offer quality care at low prices) from having the success they experience regularly in other states.
Hats off to their success. Their success has translated into ours. Many thanks to you two.
G. Keith Smith, M.D.
I’ve thought for some time that no real “reform” or serious change in the Medicare system will ever occur until the elderly are visibly and palpably shut out or harmed by this very system they currently want preserved at all costs. The elderly scare the politicians to death. That’s why there’s no chance of any “top-down” change to the system. Only when this politically powerful group demands that Medicare be abolished or relegated to the states for dismantling will this have a chance. Ironically, failure to dismantle this and other entitlement programs guarantee the continuing bankruptcy of all those left living who will pick up the tab.
Imagine for a moment you are given the task of addressing a large group of Medicare beneficiaries, the purpose of which is to persuade them to advocate for the dismantling of Medicare. Assume that everyone in the crowd you are addressing is wearing a t-shirt that says, “Don’t Touch My Medicare.” What would you say? How would you go about this?
You could go on about how the money is running out and eventually there won’t be any care for them at all. This would get you nowhere. You could say that as the money runs out, the doctors will be paid so poorly that they won’t see Medicare patients. This would get you nowhere. You could say that as the money runs out, that the government will set up death panels and those over, say age 67, with cancer or kidney disease will just be left to die. This, too, will get you nowhere. How do I know this? All of this and more has been said/tried with no results. Why? Time preference. The older we get, the less days we perceive we have remaining in our lives, the higher our time preference becomes. I mean by this that little thought is given to future planning, a “live for the here and now” sort of mentality prevails. This is no criticism, just a fact of human nature.
So what could you say that would make a difference? I don’t really know. But here is something that occurred to me. If you could get the crowd to understand that Medicare is like a monthly fruit delivery company and that the company delivering the fruit has gone bankrupt. The executives of the Ponzi fruit company have left with all of the money and are hiding on the beach in the Cayman Islands somewhere. Political pressure to continue the fruit deliveries is so intense that a judge orders another fruit delivery company to take up the slack….without compensation. It just so happens that the owners of this conscripted and soon-to-be-bankrupt fruit delivery company are the children of those receiving the deliveries. The parents, undeterred, continue to press for their fruit deliveries, all the while knowing that they are financially ruining their kids.
I know what you’re thinking. This wouldn’t do any good either. Is this logic sound? I’m thinking it is.
G. Keith Smith, M.D.
What would the health care world look like if everyone knew that our facility (www.surgerycenterok.com) charged 1/5-1/10th of what the “not for profit” hospitals in town charged for the same thing? What if everyone further understood that our prices are profitable, as well? What if they understood that the care rendered here is second to none, not just priced better?
What would be the reaction of those paying for the care? Would employers or individuals with policies be angry about all of the years that they have been ripped off by the scamming hospitals? Would those who have mortgaged their homes or those who have been financially ruined feel wronged?
What would be the reaction of the average person toward the big hospitals once they realized that the real problem with health care in this country isn’t the lack of insurance, but the cost of the care? What would be their reaction once they realized that the high cost of care was primarily due to the unholy cartels created by the hospitals with certain insurance companies? What would be their reaction once they became aware that our own government was culpable in this endeavor and that the birth and continuation of this insanity actually have had their champions in Congress?
Would most people realize that the high price of health care wasn’t a failure of the market, as much as it was a successful political campaign for those who would rob us? Would most people realize that price transparency (like you can see here) would bring the cost of health care down to a level where for a great number of individuals, health insurance would perhaps not even be necessary?
What if people began to understand that duped into being champions of “health care reform” they were actually serving a role not unlike Lenin’s “useful idiots?” What if they finally understood that the play for “universal care,” “single payor system,” whatever it winds up being called, is simply a new stream of tax revenue for the government and a gold mine for the select few crony capitalists that will pony up sufficient political bribes to belly up to the trough?
What if people realized that the tax code allowing for the deductibility of health insurance payments for businesses but not for individuals was likely in the top ten most corrupt and evil acts ever to come out of Washington? Would people then demand that this be changed?
What if people realized that Medicare really was a Ponzi scheme, a vote-buying tool? What if they realized that our children and grandchildren have been bankrupted by this handout? What if they realized that whatever money they have paid in to this black hole is long gone? Would they demand that it be reformed or abolished?
What if people realized that the new “Obamacare” is really a rationing tool, one meant to keep secure the new “premiums” paid in to the system, one meant to minimize payments for care? What if people knew that their child would likely on a waiting list for surgery like they do in Canada? What if they knew that this medical utopia of “health care for all” was doomed to failure just as in other countries where this has been tried?
Now ask yourself: if all of the above is true, would you even want to know?
G. Keith Smith, M.D.
More and more articles are surfacing about the bankruptcy of the British National Health Service. As a government organization, they will never go bankrupt, of course, they will just stop offering certain services. This is called rationing. Ah…the advantages of a monopoly. The NHS is looking for 20 billion in cuts. This is not something they want to phase in. They are looking for it now. This outfit is in trouble and the Brits, long accustomed to paying nothing, are very angry about the possibility that some services will be eliminated or privatized. One of the most popular tweets circulating now is that the Brits “earned our health care in a war.” This Ponzi scheme did, in fact, start in 1947 shortly after WWII. I’m not sure I understand the connection with free health care as some sort of reward for having endured a war, but the popularity of this quote gives you some idea of the entitlement mentality of the Brits.
The bankruptcy of the Canadian Health System has been looming for over a decade. Were it not for their monopoly and control of access, they would have disappeared long ago. There is little to no difference in not paying your bills and simply denying or delaying care to people. I have written at length on this blog about the Canadians that travel to our facility to avoid a wait of 2 years or more for the most routine surgical procedures. This rationing by delay would translate to bankruptcy in the private sector. Not surprisingly, more and more articles about partial to complete privatization of the Canadian system are surfacing from think tanks and journalists not known for their love of the free market.
That said, I think it is rational to think of Medicare as our National Health Service. I have thought this for some time. Medicare has no competitors and in the effort to create a “health care is free for anyone enrolled” has brought bankruptcy within sight. As P.J. O’Rourke has written, “if you think health care is expensive now, wait until it’s free.” Consistent with the national schemes in Britain and Canada, the Medicare bureaucrats are dealing out their brand of rationing here in the U.S. This has initially taken the form of payments to physicians so low that fewer and fewer doctors are willing to see patients enrolled in Medicare. This, of course, works beautifully for the rationers as it makes the physician look like the bad guy. This is the game of government, it seems. Engage in Draconian control and make sure someone else takes the fall for the consequences. Simultaneously, the consequences to physicians who run afoul of the incomprehensible Medicare codes and regulations are subject to fines and imprisonment. This coupled with the low payment makes the cost/benefit ratio even more problematic for the physician contemplating seeing Medicare patients.
Here’s a new one, though. A friend of mine told me recently that Medicare is conducting “audits” of payments to a facility where he does orthopedic surgery. This audit procedure is delaying payment for total joint replacements for up to two years. This is actually worse than the rationing activities in Canada. At least in Canada when they run out of money, the doctors stop working. With our national health service, the physicians and facilities are providing a line of credit to Medicare, who should be paying their bills. Once again, this would be declared bankruptcy in the private sector. Once again, the physicians will look like the rationers, the bad guys, and the Ponzi scheme will continue and those running it will get off scott-free.
What makes anyone think that Obamacare will be any different? Someone famously said years ago, “the only thing that’s new to you is the history you don’t know.”
G. Keith Smith, M.D.