Re: ACO's --> end of solo? --> Re: Anyone Following This?

December 29, 2009

I had a patient ask me yesterday if the Health Care Bill would

lead to the end of solo practices. I knew about the ACO discussion, but I didn’t

know it had been flushed out like this. We really need to start working to

prove our worth and really begin to market our good results or we will be run

over. This piece of the legislation is written specifically for hospitals and

large organizations, but as written does not seem to affect small offices

(except we will never get another pay raise). There has been a discussion for a

while as to whether bigger is better with many of the proponents of this idea

looking at data from the 90s which did indeed show solo independent docs were

less likely to engage in quality initiatives. We have changed the paradigm, but

we are still generally unknown. Perhaps we need to let Sec. Sebelius and others

know of our existence.

From:

[mailto: ] On Behalf Of Locke

Sent: Tuesday, December 29, 2009 3:51 AM

To: Practice Management Issues; practiceimprovement1

Subject: ACO's --> end of solo? --> Re:

Anyone Following This?

Some wondered if the new health bill would be the end of

solo practices.

===============================

I think the concern is that the bill may favor larger

practices - at least in the sharing of cost savings w/ Medicare.

It would seem to exclude solo practices since ACO's appear

to be large practices and systems -- although there is the interesting option

for " networks of practices "

I suppose IMPs or solo docs could come together somehow to

meet the criteria for an ACO - although it sounds like it would be complicated.

Also, you would have to have at least 5,000 Medicare fee-for-service beneficiaries in the overall networks of practices.

I'm not even sure we have 5,000 Medicare patients in the

valley we live in.

http://stabenow.senate.gov/healthcare/100209_Americas_Healthy_Future_Act_AMENDED.pdf

Page 110

PART III—ENCOURAGING DEVELOPMENT OF THE NEW PATIENT CARE MODELS

Accountable Care Organizations

Chairman’s Mark

The Medicare program would allow groups of

providers who voluntarily meet certain statutory criteria, including quality

measurements, to be recognized as ACOs and be eligible to share in the

cost-savings they achieve for the Medicare program.

Beginning on Jan. 1, 2012,

eligible ACOs would have the opportunity to qualify for an incentive bonus.

Eligible ACOs would

be defined as groups of providers and suppliers who have an established mechanism for joint decision

making, such as for capital purchases.

The following groups of

providers and suppliers would be eligible for participation:

practitioners

in group practice arrangements;

networks of practices;

partnerships or joint-venture

arrangements between hospitals and practitioners;

hospitals employing practitioners;

and

such other groups of providers of

services and suppliers as the Secretary determines appropriate.

Practitioners would be

defined as

physicians, regardless of specialty,

nurse practitioners,

physician assistants,

clinical nurse specialists, and

other practitioners or suppliers as the Secretary determines appropriate.

To qualify as an ACO, an organization would

have to meet at least the following criteria:

(1) agree to become accountable for

the overall care of their Medicare fee-for-service beneficiaries;

(2) agree to a minimum three-year

participation;

(3) have a formal legal structure that

would allow the organization to receive and distribute bonuses to participating

providers;

(4)

include the primary care physicians for at least 5,000 Medicare fee-for-service

beneficiaries;

(5) provide CMS with information

regarding primary care and specialist physicians participating in the ACO as

the Secretary deems appropriate;

(6) have arrangements in place with

a core group of specialist physicians;

(7) have in place a leadership and

management structure, including with regard to clinical and administrative

systems;

(8) define processes to promote

evidence-based medicine, report on quality and costs measure, and coordinate

care such as through the use of telehealth, remote patient monitoring, and

other such enabling technologies; and

(9) demonstrate to the Secretary

that it meets patient-centeredness criteria determined by the Secretary, such

as use of patient and caregiver assessments or the use of individualized care

plans.

To earn the incentive payment the organization would have to meet certain

quality thresholds.

In determining the quality of care furnished by an ACO,

the Secretary would be required to use measures such as:

(1) clinical processes and

outcomes;

(2) patient and caregiver perspectives

on care; and

(3) utilization and costs (such as

rates of ambulatory-sensitive admissions and readmissions).

ACOs would be required to submit data, at the group and

individual provider level, on measures the Secretary determines necessary to

evaluate the quality of care furnished by the ACO.

The Secretary would be required to establish performance

standards for measures of the quality of care furnished by ACOs.

The Secretary would be required to seek to improve the

quality of care furnished by ACOs over time by specifying higher standards for

purposes of assessing quality of care.

The Secretary would be authorized to incorporate reporting requirements and

incentive payments and penalties related to the physician quality reporting

initiative (PQRI), electronic prescribing, electronic health records, and other

similar initiatives into the reporting requirements for ACOs.

CMS would assign Medicare fee-for-service beneficiaries to ACOs based on their

use of Medicare items and services in preceding periods.

The achievement thresholds and rewards for the ACO would be

as follows.

The spending baseline would be

determined on an organizational level by using the most recent three years of

total per beneficiary spending for those beneficiaries assigned to the ACO.

The target would be set by the

baseline amount plus a flat-dollar amount that is equal to the risk-adjusted

average expenditure growth per beneficiary nationally.

Baselines would be re-set at

end of the three-year period.

ACOs with three-year average Medicare expenditures that are determined by CMS

to be below their benchmark for the corresponding period would be eligible for

shared savings at a rate determined appropriate by the Secretary.

The Secretary would be required to set a minimum threshold

of savings that would need to be achieved by an ACO before savings would be

shared.

The Secretary would have the authority to adjust the savings

thresholds to account for the varying sizes of participating ACOs.

If the Secretary determines that an ACO has taken steps to

avoid at-risk patients in order to reduce the likelihood of increasing costs,

the Secretary would be authorized to impose an appropriate sanction, including

terminating agreements with participating ACOs.

Locke, MD

> Which parts suggest that solo will phased out? I can't

follow all of the details enough to see what is really being said.

>

> Lowell Kleinman, MD

> Family Practice of San Clemente

> 1300 Avenida Vista Hermosa

> Suite 150

> San Clemente, CA 92673

> (949) - 361-6623 office

> (949) - 361-8163 fax

> www.DrKleinman.com

>

> Re: [practicemgt] Anyone Following This?

>

> Once again Glenn, you've expressed my thoughts better

than I could.

>

> As an independent small group owner, I don't

think that AAFP supports

> us in this fight.

>

> R. Pierce MD

> Rockport, Maine

> www.midcoastmedicine.com

>

>> But my AAFP leadership assured me that this

legislation was good

>> overall, though admittedly imperfect! How could it

be so flawed?

>>

>> The truth is, for various reasons, I suspect our

leadership would have

>> swallowed ANY bill, as long as it had healthcare

reform in the title.

>> Honestly, it seemed that no matter what got crammed

into this bill, no

>> matter how much good stuff got taken out, we kept

modifying our degree

>> of support, but never withdrew it. Our Board

of Directors sees some

>> significant difference between saying

" support " and " endorse " , but in

>> the end, laws either pass or fail, regardless of

whether the legislators

>> can claim 100%, 90%, or 65% support from the

doctors.

>>

>> Guaranteed, all they heard in Congress was that the

AAFP was on board.

>> Qualifying our support is of what meaninful

consequence after this bill

>> is signed into law?

>>

>> Will we be allowed to obey only 80% of its

provisions because the AAFP

>> was only 80% satisfied with it?

>>

>> As to the provisions that effectively aim for the

extinction of

>> solo/small groups, it is clear that our leadership

sold us out.

>> When confronted with this, I can already tell you

what we will hear:

>> 1) Silence. Hope the questioner goes away.

>> 2) " Oh, no. " " You're reading this

all wrong. It won't be that bad. "

>> 3) " This was a necessary compromise to ensure

the overall position of

>> primary care in HCR. Better to have large groups of

primary care than

>> multiple solo specialists as the future of

healthcare in the U.S. "

>>

>> I've refused to give a dime to our PAC as I feel it

is advancing the

>> cause of Corporate, Top-heavy Family Medicine (at

best), and Corporate,

>> Top-heavy Primary Care (with the FP gradually being

phased out to the

>> NP/PA model) at worst. I've listened to Board

members within our own

>> specialty say that they think this is the future of

primary care and

>> that we should be preparing to be managers rather

than face-to-face

>> clinicians. They may be right (I pray not),

but I'm not going to fund a

>> lobbyist to facilitate that process. My money will

go to oppose such

>> trends.

>>

>> The AAFP claims to be strong medicine for America.

Our support for this

>> so-called HCR looks more like a placebo with

nauseating side-effects.

>>

>> Glenn Wheet, MD

>> South Bend, MD

>>

>> On Thu, 24 Dec 2009 16:04:19 -0500, " Pennie

Marchetti "

>>

said:

>>

>>> Just to scare you some more, here are some

details about the bill that

>>> just

>>> passed that make me want to weep.

>>>

>>> From the Wall Street Journal

>>> http://online.wsj.com/article/SB10001424052748704254604574613992408387548.html

>>> :

>>>

>>> Primary-care doctors who refer patients to

specialists will face

>>> financial

>>> penalties under the plan. Doctors will see 5%

of their Medicare pay cut

>>> when their " aggregated " use of

resources is " at or above the 90th

>>> percentile of national utilization, "

according to the chairman's mark of

>>> Section 3003 of the bill. Doctors will feel

financial pressure to limit

>>> referrals to costly specialists like surgeons,

since these penalties will

>>> put the referring physician on the hook for the

cost of the referral and

>>> perhaps any resulting procedures.

>>>

>>> Next, the plan creates financial incentives for

doctors to consolidate

>>> their practices. The idea here is that Medicare

can more easily apply its

>>> regulations to institutions that manage large

groups of doctors than it

>>> can

>>> to individual physicians. So the Obama plan

imposes new costs on doctors

>>> who remain solo, mostly by increasing their

overhead requirementssuch as

>>> requiring three years of medical records every

time a doctor orders

>>> routine

>>> medical equipment like wheelchairs.

>>>

>>> The plan also offers doctors financial carrots

if they give up their

>>> small

>>> practices and consolidate into larger medical

groups, or become salaried

>>> employees of large institutions such as

hospitals or " staff model "

>>> medical

>>> plans like Kaiser Permanente. One provision,

laid out in Section 3022,

>>> allows doctors to share with the government any

savings to the government

>>> they achieve by delivering less carebut only if

physicians are part of

>>> groups caring for more than 5,000 Medicare

patients and " have in place a

>>> leadership and management structure, including

with regard to clinical

>>> and

>>> administrative systems. "

>>>

>>> While these payment reforms are structured as

pilot programs in the

>>> legislation, this distinction has little

practical meaning. Medicare is

>>> being given broad authority, for the first

time, to roll these

>>> demonstration programs out nationally without

the need for a second

>>> authorization by Congress.

>>>

>>> And then there's this proof of what we've all

felt intuitively - that

>>> government intrusion in our business is already

unbearable:

>>>

>>> http://healthcare.nationalreview.com/post/?q=NjZhZGE1ODZhOGJlMDY0OTU3ZDBjYjdjZmRlYWJlZmM=

>>>

>>> The Public Welfare Code contains 109 pages of

rules governing providers.

>>> This includes rules governing the National

Practitioners Database, HIPAA,

>>> as well as other administrative regulations. A

mere ten years earlier,

>>> the

>>> number of pages was only seven!

>>>

>>> That's an increase of 1,457% over ten

years. Ouch! Don't expect that to

>>> go down.

>>>

>>> Merry Christmas, here's hoping we all survive

the New Year.

>>>

>>> Pennie Marchetti, MD

>>> Stow, Ohio

>>> solo practice

>>>

>>> At 10:27 PM 12/22/2009, you wrote:

>>>

>>>> " Why else would they pursue healthcare

bills that their own party's left

>>>> wing detests, unless they are doing so with

a wink and a nod indicating

>>>> that the liberals will eventually get

everything they want & #8211; a

>>>> single-payer system? "

>>>>

>>> ---

>>> You are currently subscribed to practicemgt

as: gswheet@...

>>> To unsubscribe or to manage your settings,

please go to

>>> http://members.aafp.org/members/cgi-bin/myaafp.pl?op=subscriptions & type=lists

>>>

>

> ---

> You are currently subscribed to practicemgt as: drk@...

> To unsubscribe or to manage your settings, please go to

http://members.aafp.org/members/cgi-bin/myaafp.pl?op=subscriptions & type=lists

>

> ---

> You are currently subscribed to practicemgt as: lockecolorado@...

> To unsubscribe or to manage your settings, please go to

http://members.aafp.org/members/cgi-bin/myaafp.pl?op=subscriptions & type=lists

>

December 29, 2009

,

I believe it depends what you consider a solo practitioner, a

person reinventing the wheel every day or can it be one clog in a bigger gear.

In my neck of The Barrio we have an IPA that is actively transforming itself

into a ACO, with the aim of keeping all practices independent and striving.

The only impact to my practice is for the good, for example

better insurance contracts, EMR support (for the practices using eClinical so

far), billing support, visiting nurse support and other services. So far the

IPA as helped several practices stay in business because several hundred physicians

become a force that needs to be listen to and these practices had considerable

increase in reimbursement.

Health Affairs had an article (October) where they showed that practices

that behaved this way had better outcomes and were more cost effective than

traditional ones.

Personally I believe that ACO’s are the way to go in a

version that allows several independent, small, efficient and high quality

practices interact with each other and provide better care. For example refer

to a cardiologist that would only do what is needed for the patient and send

the patient back to the PCP, a gastroenterologist that would only scope send

the patient back to continue management of PPI also comes to mind. Use one

radiologist that you can believe in and talk to, and other services, sharing a visiting

nurse and dietitian is another example. Personally I can’t afford to

have someone come in to provide these services for my patients but if we share cost

between a group it can happen. Right now I am streamlining communications with

several partners to make information exchange and scheduling a breeze, that way

there is less duplicity and patients get the care they need quickly.

From that point of view it may benefit us. If they try to come

and recreate inefficient hospital structures for outpatient care, well, we have

been down that path and would not work.

Just a thought,

José from The Barrio.

From:

[mailto: ] On Behalf Of Locke

Sent: Tuesday, December 29, 2009 3:51 AM

To: Practice Management Issues; practiceimprovement1

Subject: ACO's --> end of solo? --> Re:

Anyone Following This?

Some wondered if the new health bill would be the end of

solo practices.

===============================

I think the concern is that the bill may favor larger

practices - at least in the sharing of cost savings w/ Medicare.

It would seem to exclude solo practices since ACO's appear

to be large practices and systems -- although there is the interesting option

for " networks of practices "

I suppose IMPs or solo docs could come together somehow to

meet the criteria for an ACO - although it sounds like it would be complicated.

Also, you would have to have at least 5,000 Medicare fee-for-service beneficiaries in the overall networks of practices.

I'm not even sure we have 5,000 Medicare patients in the

valley we live in.

http://stabenow.senate.gov/healthcare/100209_Americas_Healthy_Future_Act_AMENDED.pdf

Page 110

PART III—ENCOURAGING DEVELOPMENT OF THE NEW PATIENT CARE MODELS

Accountable Care Organizations

Chairman’s Mark

The Medicare program would allow groups of

providers who voluntarily meet certain statutory criteria, including quality

measurements, to be recognized as ACOs and be eligible to share in the

cost-savings they achieve for the Medicare program.

Beginning on Jan. 1, 2012,

eligible ACOs would have the opportunity to qualify for an incentive bonus.

Eligible ACOs would

be defined as groups of providers and suppliers who have an established mechanism for joint decision

making, such as for capital purchases.

The following groups of

providers and suppliers would be eligible for participation:

practitioners

in group practice arrangements;

networks of practices;

partnerships or joint-venture

arrangements between hospitals and practitioners;

hospitals employing practitioners;

and

such other groups of providers of

services and suppliers as the Secretary determines appropriate.

Practitioners would be

defined as

physicians, regardless of specialty,

nurse practitioners,

physician assistants,

clinical nurse specialists, and

other practitioners or suppliers as the Secretary determines appropriate.

To qualify as an ACO, an organization would

have to meet at least the following criteria:

(1) agree to become accountable for

the overall care of their Medicare fee-for-service beneficiaries;

(2) agree to a minimum three-year

participation;

(3) have a formal legal structure

that would allow the organization to receive and distribute bonuses to

participating providers;

(4)

include the primary care physicians for at least 5,000 Medicare fee-for-service

beneficiaries;

(5) provide CMS with information

regarding primary care and specialist physicians participating in the ACO as

the Secretary deems appropriate;

(6) have arrangements in place with

a core group of specialist physicians;

(7) have in place a leadership and

management structure, including with regard to clinical and administrative

systems;

(8) define processes to promote

evidence-based medicine, report on quality and costs measure, and coordinate

care such as through the use of telehealth, remote patient monitoring, and

other such enabling technologies; and

(9) demonstrate to the Secretary

that it meets patient-centeredness criteria determined by the Secretary, such

as use of patient and caregiver assessments or the use of individualized care

plans.

To earn the incentive payment the organization would have to meet certain

quality thresholds.

In determining the quality of care furnished by an ACO,

the Secretary would be required to use measures such as:

(1) clinical processes and

outcomes;

(2) patient and caregiver

perspectives on care; and

(3) utilization and costs (such as

rates of ambulatory-sensitive admissions and readmissions).

ACOs would be required to submit data, at the group and

individual provider level, on measures the Secretary determines necessary to

evaluate the quality of care furnished by the ACO.

The Secretary would be required to establish performance

standards for measures of the quality of care furnished by ACOs.

The Secretary would be required to seek to improve the

quality of care furnished by ACOs over time by specifying higher standards for

purposes of assessing quality of care.

The Secretary would be authorized to incorporate reporting requirements and

incentive payments and penalties related to the physician quality reporting

initiative (PQRI), electronic prescribing, electronic health records, and other

similar initiatives into the reporting requirements for ACOs.

CMS would assign Medicare fee-for-service beneficiaries to ACOs based on their

use of Medicare items and services in preceding periods.

The achievement thresholds and rewards for the ACO would be

as follows.

The spending baseline would be

determined on an organizational level by using the most recent three years of

total per beneficiary spending for those beneficiaries assigned to the ACO.

The target would be set by the

baseline amount plus a flat-dollar amount that is equal to the risk-adjusted

average expenditure growth per beneficiary nationally.

Baselines would be re-set at

end of the three-year period.

ACOs with three-year average Medicare expenditures that are determined by CMS

to be below their benchmark for the corresponding period would be eligible for

shared savings at a rate determined appropriate by the Secretary.

The Secretary would be required to set a minimum threshold

of savings that would need to be achieved by an ACO before savings would be

shared.

The Secretary would have the authority to adjust the savings

thresholds to account for the varying sizes of participating ACOs.

If the Secretary determines that an ACO has taken steps to

avoid at-risk patients in order to reduce the likelihood of increasing costs,

the Secretary would be authorized to impose an appropriate sanction, including

terminating agreements with participating ACOs.

Locke, MD

> Which parts suggest that solo will phased out? I can't

follow all of the details enough to see what is really being said.

>

> Lowell Kleinman, MD

> Family Practice of San Clemente

> 1300 Avenida Vista Hermosa

> Suite 150

> San Clemente, CA 92673

> (949) - 361-6623 office

> (949) - 361-8163 fax

> www.DrKleinman.com

>

> Re: [practicemgt] Anyone Following This?

>

> Once again Glenn, you've expressed my thoughts better

than I could.

>

> As an independent small group owner, I don't

think that AAFP supports

> us in this fight.

>

> R. Pierce MD

> Rockport, Maine

> www.midcoastmedicine.com

>

>> But my AAFP leadership assured me that this

legislation was good

>> overall, though admittedly imperfect! How could it

be so flawed?

>>

>> The truth is, for various reasons, I suspect our

leadership would have

>> swallowed ANY bill, as long as it had healthcare

reform in the title.

>> Honestly, it seemed that no matter what got crammed

into this bill, no

>> matter how much good stuff got taken out, we kept

modifying our degree

>> of support, but never withdrew it. Our Board

of Directors sees some

>> significant difference between saying

" support " and " endorse " , but in

>> the end, laws either pass or fail, regardless of

whether the legislators

>> can claim 100%, 90%, or 65% support from the

doctors.

>>

>> Guaranteed, all they heard in Congress was that the

AAFP was on board.

>> Qualifying our support is of what meaninful

consequence after this bill

>> is signed into law?

>>

>> Will we be allowed to obey only 80% of its

provisions because the AAFP

>> was only 80% satisfied with it?

>>

>> As to the provisions that effectively aim for the

extinction of

>> solo/small groups, it is clear that our leadership

sold us out.

>> When confronted with this, I can already tell you

what we will hear:

>> 1) Silence. Hope the questioner goes away.

>> 2) " Oh, no. " " You're reading this

all wrong. It won't be that bad. "

>> 3) " This was a necessary compromise to ensure

the overall position of

>> primary care in HCR. Better to have large groups of

primary care than

>> multiple solo specialists as the future of

healthcare in the U.S. "

>>

>> I've refused to give a dime to our PAC as I feel it

is advancing the

>> cause of Corporate, Top-heavy Family Medicine (at

best), and Corporate,

>> Top-heavy Primary Care (with the FP gradually being

phased out to the

>> NP/PA model) at worst. I've listened to Board

members within our own

>> specialty say that they think this is the future of

primary care and

>> that we should be preparing to be managers rather

than face-to-face

>> clinicians. They may be right (I pray not),

but I'm not going to fund a

>> lobbyist to facilitate that process. My money will

go to oppose such

>> trends.

>>

>> The AAFP claims to be strong medicine for America.

Our support for this

>> so-called HCR looks more like a placebo with

nauseating side-effects.

>>

>> Glenn Wheet, MD

>> South Bend, MD

>>

>> On Thu, 24 Dec 2009 16:04:19 -0500, " Pennie

Marchetti "

>>

said:

>>

>>> Just to scare you some more, here are some

details about the bill that

>>> just

>>> passed that make me want to weep.

>>>

>>> From the Wall Street Journal

>>> http://online.wsj.com/article/SB10001424052748704254604574613992408387548.html

>>> :

>>>

>>> Primary-care doctors who refer patients to

specialists will face

>>> financial

>>> penalties under the plan. Doctors will see 5%

of their Medicare pay cut

>>> when their " aggregated " use of

resources is " at or above the 90th

>>> percentile of national utilization, "

according to the chairman's mark of

>>> Section 3003 of the bill. Doctors will feel

financial pressure to limit

>>> referrals to costly specialists like surgeons,

since these penalties will

>>> put the referring physician on the hook for the

cost of the referral and

>>> perhaps any resulting procedures.

>>>

>>> Next, the plan creates financial incentives for

doctors to consolidate

>>> their practices. The idea here is that Medicare

can more easily apply its

>>> regulations to institutions that manage large

groups of doctors than it

>>> can

>>> to individual physicians. So the Obama plan

imposes new costs on doctors

>>> who remain solo, mostly by increasing their

overhead requirementssuch as

>>> requiring three years of medical records every

time a doctor orders

>>> routine

>>> medical equipment like wheelchairs.

>>>

>>> The plan also offers doctors financial carrots

if they give up their

>>> small

>>> practices and consolidate into larger medical

groups, or become salaried

>>> employees of large institutions such as

hospitals or " staff model "

>>> medical

>>> plans like Kaiser Permanente. One provision,

laid out in Section 3022,

>>> allows doctors to share with the government any

savings to the government

>>> they achieve by delivering less carebut only if

physicians are part of

>>> groups caring for more than 5,000 Medicare

patients and " have in place a

>>> leadership and management structure, including

with regard to clinical

>>> and

>>> administrative systems. "

>>>

>>> While these payment reforms are structured as

pilot programs in the

>>> legislation, this distinction has little

practical meaning. Medicare is

>>> being given broad authority, for the first

time, to roll these

>>> demonstration programs out nationally without

the need for a second

>>> authorization by Congress.

>>>

>>> And then there's this proof of what we've all

felt intuitively - that

>>> government intrusion in our business is already

unbearable:

>>>

>>> http://healthcare.nationalreview.com/post/?q=NjZhZGE1ODZhOGJlMDY0OTU3ZDBjYjdjZmRlYWJlZmM=

>>>

>>> The Public Welfare Code contains 109 pages of

rules governing providers.

>>> This includes rules governing the National

Practitioners Database, HIPAA,

>>> as well as other administrative regulations. A

mere ten years earlier,

>>> the

>>> number of pages was only seven!

>>>

>>> That's an increase of 1,457% over ten

years. Ouch! Don't expect that to

>>> go down.

>>>

>>> Merry Christmas, here's hoping we all survive

the New Year.

>>>

>>> Pennie Marchetti, MD

>>> Stow, Ohio

>>> solo practice

>>>

>>> At 10:27 PM 12/22/2009, you wrote:

>>>

>>>> " Why else would they pursue healthcare

bills that their own party's left

>>>> wing detests, unless they are doing so with

a wink and a nod indicating

>>>> that the liberals will eventually get

everything they want & #8211; a

>>>> single-payer system? "

>>>>

>>> ---

>>> You are currently subscribed to practicemgt

as: gswheet@...

>>> To unsubscribe or to manage your settings,

please go to

>>> http://members.aafp.org/members/cgi-bin/myaafp.pl?op=subscriptions & type=lists

>>>

>

> ---

> You are currently subscribed to practicemgt as: drk@...

> To unsubscribe or to manage your settings, please go to

http://members.aafp.org/members/cgi-bin/myaafp.pl?op=subscriptions & type=lists

>

> ---

> You are currently subscribed to practicemgt as: lockecolorado@...

> To unsubscribe or to manage your settings, please go to

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>

December 29, 2009