I blog about free markets in medical care and transparent pricing.
One of my partners, an ear nose and throat surgeon resigned years ago from a particularly abusive HMO. He said, “never again,” as did all of the reputable ear nose and throat surgeons in the area, physicians whose practices were already solid and busy without having to deal with this outfit. Even though many of the HMO’s are long dead and gone from Oklahoma, this particular HMO has lingered on, only to crawl back to this partner of mine, telling him to make them an offer. They had, very simply, lost every single ear nose and throat surgeon from their “panel,”even the not-so-good ones.
He made them an offer he knew they would refuse, a ridiculous amount, one that would make this pathetic organization his best source of payment. They accepted.
His presence on their “panel” allowed the HMO to advertise….well…to advertise his presence on their “panel.” Having quality ear nose and throat coverage made their product easier to sell to reluctant employer groups, most of which know the HMO hunger games by now. Things seemed to be going well for about three months when he noticed a sudden change. The HMO had made it impossible to schedule a patient for surgery. Phone call after phone call. Extended phone consultations with remote nurse manager-gatekeepers to review the indications and justify the need for surgery. Lost, needing-to-be-refiled paperwork. Waiting on hold for 30 minutes while attempting to obtain pre-authorization for CT scans for patients needing sinus surgery. And more.
It dawned on my partner that what the “beneficiaries” of this HMO had as a benefit, was not unlike what the beneficiaries of the Canadian system have and what people in this country under “Obamacare” will have: a right to hope for care, or a right to a place in line. A health care card in your wallet may mean nothing. As Dr. Jane Orient has now famously said, “coverage doesn’t mean care.”
The poor child with gigantic tonsils and adenoids with sleep apnea and chronic ear infections who could be spared all of this misery with a 20 minute operation is left holding the bag. The parents, frustrated with this waiting game of insurance approval, are now very troubled to find out that my partner has resigned once again from this HMO. What will they do now?
If they follow the example of many patients that have been down this road, they will wind up at our facility, paying a fair price for their child’s surgery, a price that is within their budget and having their child’s surgery done immediately, and done by the surgeon they have rightly come to trust and respect. They will wonder afterwards why they have “insurance” at all. They will wonder if some “insurances” are really a black mark, that actually prevent them from receiving care. Finally and angrily they may conclude that this whole HMO idea must be good for someone, just not the patients covered by “the plan.”
I think this illustrates that while the central planners of HMO’s or ACO’s or government health care may boast that the reimbursement levels they have arbitrarily concocted are sound and fair, they will always retain the powerful tool of rationing-access-by-bureaucracy, an incredibly cruel way to balance a budget or book a profit.
G. Keith Smith, M.D.
You can see our prices here.
Imagine that you own a company with 100 employees. Your company has provided traditional health insurance to your employees at a cost of $45,000/month until about 3 years ago when you discovered that you could “self-insure.” You made this move because for many years in a row, the dollar amount of the health claims submitted by your employees didn’t amount to the dollar amount of your insurance premiums. You realized that had you paid for your employees’ health needs out of your operational revenue, you would have been financially better off. Very simply, you now pay this $45,000/month to a fund/trust you set up within your company, out of which health related expenses for your employees are paid. You back this “fund” up with insurance that kicks in for catastrophic claims.
This catastrophic claim deductible (called an attachment point) amounts to your liability or exposure for any given employee’s health needs. This catastrophic insurance is commonly referred to as “stop loss” insurance. As a result of your decision to do this, you now have $1,000,000 in this “fund” or “trust” that would have otherwise been paid to an insurance company. Rather than have an insurance company say what is or is not “covered” you can help your employees with their expenses more personally and more efficiently, having eliminated the insurance company middleman.
Let’s say that your attachment point is $30,000. This means that if an employee has $28,500 of health claims in a year, you pay every dime out of your “fund.” If they have $90,000 of claims, you pay $30,000, the stop loss insurance paying the rest. This is oversimplified, but you get the idea.
Actuaries make their living by applying mathematical models to help self-funded health plans “guess” what their loss experience will be. This information helps determine what the attachment point should be and also helps determine what sort of cash reserves a company should keep on hand. What is the statistical likelihood that one of your 100 employees will develop cancer? What is the statistical likelihood that 5 of your 100 employees will incur claims of over $30,000? These are the types of things that, although uncertain, are predictable within limits.
Part of the problem that actuaries have with their calculations, however, is that one never knows what a cardiac surgery or a hip replacement or a gall bladder removal or a tonsillectomy will cost. There has been simply no way for actuaries to get this information in advance. You can see where this is going, can’t you?
The significance of transparent and upfront pricing that we have embraced and that more and more physicians and facilities are embracing is revolutionary for the self-funded plans, as employers taking this approach can now with much more certainty, ascertain the “risk” their plan must endure. Furthermore, as the costs of healthcare have skyrocketed over the last few years, smaller and smaller companies are venturing down the “self-funded” path, making this decision based on cost savings and partly to maintain some autonomy.
To quote Jim Epstein from Reason Magazine: “Enter Obamacare!” This central planner’s dream catcher has made the risk-benefit proposition of self-funding an even better decision, as self-funded plans are not subject to many of the provisions of this legislation. I have maintained all along that Obamacare was meant to fail, a Trojan horse meant to introduce chaos and even higher prices into the medical economy, just the nightmare the state needs to justify rescuing us with the sequel…single payer.
“That’s crazy,” many of you have said! The Unaffordable Care Act was meant to reduce costs and protect patients and make sure that everyone had “coverage!” Keep dreaming. Uncle Sam doesn’t want you to have “coverage.” Uncle Sam wants you to buy approved coverage, that is, coverage from their crony pals. That is the purpose of the exchanges. The price of insurance has already risen, with up to 100% increases in premiums expected (that’s right, doubling) for January renewals. Residents of states that have embraced Medicaid expansion will (an expansion pushed for hard by none other than the big hospitals) soon hear these same hospitals whining about all of the new Medicaid patients that are not covering the costs of the care they receive and using this as their excuse to continue to aggressively “cost-shift” to others. Translation? The charges and costs everyone will see at these big “not for profit” hospitals will escalate, particularly in the states where Medicaid expansion and exchanges are embraced!
Back to the self-funded bunch. The government can’t just let these businesses stay on the sidelines, refusing to wade into the price whirlpool, can they? 70% of private insurance claims are paid by these self-funded trusts. The government has made promises to their crony buds in the hospital and insurance industry. This self-funded bunch must be reigned in or the scheme to mandate the purchase of health insurance through exchanges that will operate under government oversight (rationing) will fail. As a bureaucrat, how would you devise a plan to stop the growth in the number of companies “seceding” from the system by self-funding and possibly even bring some that are already self-funded into the drowning pool?
The answer is here, here and here. If the National Association of Insurance Commissioners is successful in destroying the “stop loss” industry in each of the states, few-no companies will take the self-funded risk, as they have no effective “back-stop” for catastrophic losses. Bingo! Everyone is now drowning together! Crisis complete. There is no doubt whatsoever in my mind that this attempt to destroy or hamstring the stop-loss industry proves that a single payer system is the goal of the statists, a system that will allow the medical industrial complex to extract wealth even more directly from the taxpayers, rather than profit by providing a service to consumers/patients.
If the state insurance commissioners move (some are already doing this) to raise attachment points or otherwise hamstring this stop-loss industry, you will know that those state commissioners are playing on Uncle Sam’s team. This stop-loss industry represents the biggest obstacle in this country to a Soviet-style single payer system, in my opinion. The efforts to crush this industry are not something the “state” wants you to know about, as this will make their ultimate goal even more ridiculously obvious.
G. Keith Smith, M.D.
Joseph Stalin and Adolph Hitler weren’t exactly friends, but ideologically they were on the same page about many issues, the right to health care and the right to due process, amongst them. They were proponents of the former and obviously, not so much the latter. Sound familiar?
What they were actually in favor of was control of the healthcare their citizens received. Hitler and his National Socialist Democratic Party actually used this issue of the “right” to healthcare to politically destroy Otto von Bismarck, whose power was already tenuous given the economic devastation intentionally inflicted on the Germans after the First World War, a “crisis” economy that begged for a tyrant like Hitler.
Control over healthcare gave the statists control over the very lives of their citizens, arming the state with the authority to decide who got healthcare and who did not, for many, who lived and who did not. As all totalitarian regimes value individual citizens strictly as a function of their value to the state, and as the citizens began to believe the “we’re all in this together” sort of nationalistic chant, this grant of power over healthcare given to the state therefore had credibility and even seemed to be a necessity to many of the affected citizens.
While the Allied nations worked hard to publicly paint Hitler as the monster he was, these same nations quietly and privately embraced his economic fascism. Frederick Hayek’s “Road to Serfdom,” an unintentional best-selling blockbuster in the United States, was written as a warning for the British people, a warning that the fascist corporate state so decried by the British government, had in fact, been embraced by the British government! The proud British paid no attention and quickly adopted what we now know as the National Health Service, a system that is actively and admittedly euthanizing patients in these modern times to make bed space for those in the waiting room.
This could never happen in the United States could it? Only the most naive wouldn’t recognize that we are on the same path as these failed and murderous states. One very sinister activity that is escaping most people’s attention is the move by the federal government designed to promote the hospital employment of physicians. This arrangement erodes the patient-doctor relationship and therefore disenfranchises the patient, as the doctor’s boss is the hospital, not his patient. Physician employees are much easier for tyrants to control. Hospital administrators controlling large groups of doctors and the government controlling a small group of hospital administrators-that is the goal. Private practitioners, those with their patients’ best interest at heart, never mind what the state has to say, must be marginalized if not eliminated completely, for the complete takeover of medicine by the state to succeed. This effort is well on its way.
This article in the Wall Street Journal provides a glimpse into how the productivity of hospital-employed physicians falls, but doesn’t go far enough to show the true devastating effects of this employment arrangement, I think. While patients can appeal to their personal physician for help, their appeals to their employed doctors are more likely to fall on deaf ears, as these employed doctors must follow the old proverb, “whose bread I eat, his song I sing.” These doctors must ultimately advocate for their boss, not their patient in the event their interests are not aligned.
Here are some examples of how the current system is rigged in favor of the physician-as-employee arrangement. Medicare pays hospital-employed doctors 40% more for the same service as non-employees. Physicians must buy prohibitively expensive electronic medical record systems (promoted in the name of “safety”) or face even lower payments from Medicare. Physicians who do not demonstrate “meaningful use” of their electronic medical record systems (if they can afford them at all) will face further cuts from Medicare. “Meaningful use” includes transmission of confidential patient information to Uncle Sam, by the way, without the patient’s consent. One part of Obamacare calls for bundled Medicare payments to hospitals, which then divvy up the money to the doctors, as they see fit. One part of Obamacare prohibits the construction or expansion of physician-owned hospitals, institutions demonstrating better outcomes and lower prices consistently. Recently, the federal government issued regulations providing for profitable administration of chemotherapy only to hospital-based oncology units, not the non-hospital private practitioners, who can only charge a price less than their cost for these drugs. I could go on.
If your doctor isn’t working for you, he or she is working for someone else. It is only a matter of time before this represents a conflict, your interests as a patient suffering as a result. This is a necessary part of the national health care plan, where rationing from the central planners will be used to balance health care budgets.
The response to shortages (invariably the result of state intervention) by the free market and its entrepreneurs, is to look for new and more efficient ways of providing the service, activities that lower prices and improve access for everyone. Entrepreneurs see shortages as opportunities, while central planners, not only cause these shortages, but respond with the usual rationing and price controls. The Independent Payment Advisory Board (IPAB), an integral part of Obamacare will be the price control mechanism, the mission for which will be to price services below their actual market price, ensuring that little supply of these services is available and therefore balancing health budgets with this subtle, behind-the-veil rationing.
This is the compassion of the state, where central planners decide who gets what from a shrinking supply, whereas market players deliver more supply at lower prices. Employed doctors will be much more easily controlled than independent ones when this system is fully operational. Hitler and Stalin understood this. The current regime in the United States does, as well.
G. Keith Smith, M.D.
What if I were to tell you that those hospitals which were “outed” as charge abusers by Steven Brill in his massively boring TIME Magazine article will ultimately be the biggest beneficiaries of this diabolical piece of journalism?
Stay with me and we’ll go through it. Looking back at my initial reaction to this piece by Brill, I was excited that he revealed how obscenely wealthy these poor-mouthing hospitals really were. I was troubled, however, by what he didn’t mention (the uncompensated care scam and PPO cartels and repricing schemes) and even more troubled that he embraced the efficiency of Medicare. I am now convinced that the reason this piece appeared in TIME (no bastion of libertarianism) at this time is to fuel the movement for a single payer system. Here’s how I came to this conclusion.
I have maintained all along that Obamacare was meant to fail, designed to fail. The purpose of this legislation was to introduce such chaos into the medical marketplace, eliminating what little was left of the free market in medicine, that prices for care would soar, prices for “insurance” would soar and that access to medical care would be restricted. The creation of this “crisis” will lead to a crying out for the government to ride in to rescue us with their final solution, the sequel to Obamacare: single payer. Watch this 37 second youtube video of Barney Frank where he carelessly reveals the ultimate goal.
Nothing in Brill’s article is new. Charge-master price gouging by these big hospitals has been going on for years and many articles have been written about it. The full effect of Obamacare’s “high price crisis” haven’t yet been felt or realized by the public, so corporate healthcare must tell everyone how expensive health care is at these out of control hospitals….with a megaphone. Brill’s article pours gasoline on the “crisis,” a crisis the most gigantic beneficiary of which are the big hospitals!
Jim Epstein of Reason Magazine encouraged me while filming his mini-documentary about our facility to look for industry consolidation in all its forms. This, he maintained, was the smoking gun of government corruption and bribery. The primary purpose of Obamacare is just this, fewer players in the hospital and insurance industry, with all health care dollars going to them. Can you imagine the money flowing into the D.C. cesspool when discussions begin about carving the country into regions, each region provided “insurance” by a single company or care provided by a single hospital health “system?” The intention of Brill’s piece, I believe, was the creation of the outrage, a necessary precursor of “crying out for a solution.”
Karl Denninger devastates the Wall Street Journal’s pathetic response to Brill’s article here. Denninger gets it. One thing Denninger left out, however, was the Hill-Burton legislation and the devastation that followed that piece of crony-benefitting legislation. He is right to call the WSJ out for their silence on how we got into this mess.
Corporate healthcare and their Wall Street chums are licking their chops right now, as Brill’s article brings the crisis from which they will all profit from so obscenely, closer and closer. I’ve decided that Brill is a shill. I’d bet that Brill’s stock portfolio is full of corporate health care stocks, too.
G. Keith Smith, M.D.
Here’s a Forbes review of a WSJ article that gives us a heads up about what exchange insurance products will look like and how they will work. Dr. Scott Gottlieb points out that the design of Obamacare is identical to Medicaid, in that increased demand will be managed with less access.
This will be accomplished in two ways. Patients will be funneled to networks that are already extremely overworked, creating the waiting lines we know all to well in countries like Great Britain and Canada. An additional rationing tool will be the physician reimbursement at rates lower than the market-clearing-price, a payment amount that will lead many physicians to limit their exposure to this population or quit participation altogether.
“Yet the higher costs of taking care of the Medicaid population hasn’t been made up with more funding, but fewer services that these patients are able to get access to.”
Actually he’s wrong here. In many states Medicaid funding has gone up while access has suffered, just what you would expect from a Postal Service business model. Read more here. Gottlieb’s description is rosy, it turns out.
Later in the article, Gottlieb writes:
“The Medicaid benefit is great on paper, but often stingy when you try to use it.”
Remember “coverage doesn’t mean care,” from Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons? And what is Obamacare’s solution? Expand Medicaid!
Dr. Todd Rice sent me the following quote recently which applies to this perfectly:
“If you think the problems that government creates are bad, wait until you see its solutions.”
G. Keith Smith, M.D.
“Socialism, like the ancient ideas from which it springs, confuses the distinction between government and society. As a result of this, every time we object to a thing being done by government, the socialists conclude that we object to its being done at all.”
More wisdom from Bastiat. I think when muddy-headed folks say that health care is a “right” they are making the mistake of blurring the distinction between government and society. A desire to make health care available to the most vulnerable and poor is, after all, distinctly different from inviting government corruption to the task.
The socialist would say,” charity won’t adequately provide for the poor!” This is the primary justification and argument of the socialist for the compassion of collectivism, the barbarity of entitlements and the widespread violation of property rights. Here are three ways to respond to this argument.
First, “I don’t care what you do with money stolen from me. All I care about is that I’ve been mugged.” After all, the government doesn’t have any money to pass out that it didn’t first take from someone at gunpoint. This argument is sufficient in itself. Nothing more really needs to be said. That someone else should claim a “right” to your property, means it was never your property to begin with, as no right can exist, the exercise of which violates another’s rights, property or otherwise.
Second, government handouts consist of the value of the handout plus the overhead of administering the bureaucracy in charge of theft and distribution of the loot. This is very inefficient and is not what any economist would call an ideal or maximal utilization of resources.
Third, we will never know if charity would have sufficiently provided for the poor, as denied the use of money through confiscatory taxation, many are denied their opportunity to be charitable. The great libertarian Leonard Read wrote angrily about this, seeing this denial of the “right to be charitable” as an incredibly destructive influence on communities and society, distancing and depersonalizing the plight of the unfortunate in need of help.
Expand Medicaid? Government health care for all? Just because liberty-minded folks are opposed to government involvement in health care, doesn’t mean that they are opposed to the poor having access to health care. In fact, it is the innovation of individuals in a free market that brings prices down to levels that more and more people can reach, levels that in other industries like cell phones and computers would have been unimaginable 20 years ago. It is the involvement of government that guarantees limited access, skyrocketing prices, fraud, corruption and death.
How much more of the carnage of socialism must we endure before we abandon this way of thinking? Free markets in health care will help us to avoid the rationing and death that has characterized government health systems all over the world. Our model is a free market one. There are many others in the works dedicated to price transparent, high quality, reasonably priced health care. No economic system known to man makes better use of scarce resources than a free market. To maintain otherwise, particularly with a service as important as heath care, is either ignorant or duplicitous.
G. Keith Smith, M.D.
After giving a talk to a group of students recently, during which the long waiting lines for surgery and medical care in Canada were discussed, one of the students defended the Canadian system, saying that Canadians received the same care as we did here- just after longer waits. I encouraged her to rethink her discounting of the time during which much pain and suffering occurs during these “waits.” I told her how eye-opening it has been to meet many of these Canadian patients who have been told that they or their children must wait 2-3 years for life-changing, pain-eliminating procedures. What the student then said is the genesis of this blog: ”These individual cases should be considered in the aggregate, though.”
In medical school I was taught that a certain number of unnecessary appendectomies, for instance, was a good thing, as the surgeon who was never taking out a normal appendix was missing some of the diseased appendices that presented more subtly. This made sense to me then and now, as the risk for missing a needed appendectomy far outweighed the risk of undergoing this procedure unnecessarily. Each and every one of these patients presents themselves differently and the decision to operate or not is an individual one, one which includes the patient’s assessment and acceptance of the risk/benefit picture.
As my dad once told me, “whatever the percentage of folks in the population get cancer, it’s 100% for those who do.” His insight makes things clear, doesn’t it? Neglecting individual suffering for the aggregate, greater good, doesn’t feel statistically justified by the victims of this type of thinking. Which brings me to my point.
Thousands of people are wearing the pink ribbons these days to raise awareness of breast cancer, many of them women, many of these women supporters of the man in the white house and his health care plan. Part of Pharaohbamacare is an emphasis on “wellness,” with mandatory suspension of copays and deductibles for many preventative health procedures like colonoscopies and mammograms. Sounds great, doesn’t it? Maybe- until you realize that “scientists” employed by the government are declaring in their “studies” that too many mammograms are being done, resulting in unnecessary breast biopsies. Just as with appendectomies, some normal breast tissue should be removed to insure that the fewest number of cancers are missed. The recent recommendation by “The U.S. Preventive Services Task Force” and “The National Cancer Institute” (both federally funded) serves to undermine Obamacare’s wellness promise. To believe that there isn’t intense pressure on these “scientists” to find what their boss wants them to find, is naive.
“Official” discounting of the importance of mammograms also demonstrates the true intent of “evidence-based medicine:” a rationing tool. After all, if “studies show” that mammograms should be done less often, government and other third party payers will balk at payment for these “unnecessary” diagnostic studies. More cancer for you, but less strain on the budget! Still thrilled that the government is getting more involved with health care?
Female supporters of Obamacare should be protesting this obvious attempt to ration care for breast cancer. I’m surprised that women aren’t burning their bras in mass riots, insisting that any of these government “scientists” and those in the political machine who control them be barred from wearing the pink ribbons on their lapels.
G. Keith Smith, M.D.
It turns out the the Oklahoma Highway Patrol, in spite of years denying this, are paid on commission. In a crisis of conscience, a trooper, worried about the public’s perception of him and his fellow “officers” has anonymously revealed that “pay-for-performance” is at work within this group, a policy handed down from management who refused to be interviewed for the “Tulsa World” newspaper article revealing this. In some areas of the state, 30 arrests for driving under the influence must be made by each officer to reach the “bonus” level. In addition, 40% of traffic stops or more should result in fines or tickets, not warnings, in order to reach the next level of pay.
Local attorney, John Hunsucker is quoted: ”When their paycheck depends on and their raises depend on the numbers of stops they do, then at that point are they really enforcing the law or are they seeing stuff? You see some exaggeration.”
Quoting from the article: “Hunsucker said the patrol has other motives besides safety to enact such policies. He noted that court costs and fees generated by arrests and citations add money to the agency’s coffers in tight budget times.”
“You are going to see more situations where you are going to be pulled over for doing nothing more than driving at 2 o’clock in the morning,” Hunsucker said.
I would maintain that it is just as crazy to pay physicians for performance as to give incentives to the police to write us tickets or arrest us. ”Pay for performance”, just as it will result in bizarre results in law enforcement will do the same or worse in medical practice. First, surgeons will more likely operate on normal people. What? If nothing is wrong with someone to begin with, they will more likely have a great outcome. On the flip side, people who are sick and high risk will have more trouble getting care as the increased likelihood that they will end up with a bad result, will “foul” the doctor’s performance statistics and lower his reimbursement. ”Pay for performance” will ultimately act as a rationing tool for the sicker more complicated patients, as taking these folks on will expose the physician to the risk of a lowered paycheck should the patient not do well.
“Pay for performance.” A bad idea for the police and a bad idea for physicians and their patients. What sort of arrogant lunatics come up with this stuff?
G. Keith Smith, M.D.
Check out Jim Epstein’s newest video on medical tourism for Reason.TV. I told Jim in an email that “The Surgery Center of Oklahoma won’t be so easy to compete with!”
As we transition from “health care is too expensive” to “good health care is extremely hard to find” to “I’ll take what I can get,” a plane ride to escape cartel-dominated health markets in the U.S. will be more palatable and less scary for patients victimized by Obamacare’s wrath.
You should note that the centerpiece of the business plan of these foreign hospitals is price transparency. Never believe anyone who says this is not possible. As the world gets smaller, more of corporate healthcare will realize that they are in a competitive market, whether they like it or not.
G. Keith Smith, M.D.
Aetna has announced that it is no longer issuing policies with a 12 month rate guarantee. I want to be perfectly clear here. This means that you will not know from month to month what your health insurance premium will be if you are enrolled in one of their plans. Guess when this takes effect? If you guessed January 15, 2014, you go to the head of the class, as this coincides with the date of the full Obamacare implementation.
As Ralph Weber, founder of Medibid said in his email to me: “..this is about to get ugly.” People in this country are about to discover how Orwellian the name “Affordable Care Act” really is. What? You don’t think that Aetna made this move so they could lower their charge for premiums each and every month, did you?!
To not know the future cost of insurance is to not know within limits the risk/benefit of the decision to buy insurance, or what type of insurance to buy. This move will introduce the chaos so anticipated and desired by the central planners itching for a single payer plan. I hate to tell you I told you so…but I did. This health care bill was meant to fail from the beginning, was meant to drive costs and care completely through the roof, meant to bring its victims to beg the government (which has caused all of this) for the sequel: single payer. This will allow the government to better line the pockets of those who bribed their way to the table, those who helped craft this bill.
This move by Aetna is soon, no doubt to be followed by others. I think, however, the statists will be frustrated in their attempts to completely take over by some “out of the box” thinking entrepreneurs, ourselves included. More and more companies will pursue “self-funding” options, reject the old cartel’s “PPO” model (which has done nothing but drive even more money to the cartel) and seek direct contracts and relationships with physicians and facilities that are willing to be transparent in their practices and pricing.
As lines form for individuals seeking health care (even those with “coverage”) more will begin to seek affordable ways to obtain healthcare and a new market will boom, one that paradoxically will thrive in spite of the best efforts of the statists and their cronies in health care. This is already happening! Check out Medibid, Pokitdok and Snaphealth to name just a few.
G. Keith Smith, M.D.