Hpapyy Hlodiyas

ErodedMentalHealth_THUMBIf you have followed my blog over the past few years, you know by now that I am passionate, and write rather frequently, about mental and behavioral healthcare policy. So I first wanted to share with you an informative and powerful infographic (below) from the Best Social Work Programs website.

And secondly, I wanted to take just a moment to remind you this is an especially hard time of the year for someone you very likely know – and may even know very well. The absence of friends and family lost is felt more acutely. Pressure is greater to suppress feelings of anxiety and sadness. Failures of achievement must be reconciled with another year’s passing.

Try to remember that with few exceptions the person you know who may be struggling with mental and/or behavioral health issues finds very little joy in having a negative influence on your holidays. They did not choose to be saddled with their disease any more than those with Diabetes, Heart Disease or COPD chose their lots in life.

Here’s hoping that messages like the one below will continue to build public awareness and find their way into more proactive mental/behavioral health policy in 2015.



The Cleveland Clinic’s Big Gamble

When I first started speaking on the Affordable Care Act back in the fall of 2010 one of the observations I liked to make was about needing to change the cost trajectory resulting from chronic disease. I would say something to the effect that, “if we are somehow successful at becoming more efficient, expanding access and affordability – none of it is going to matter if we cannot become a healthier country.” I didn’t have any research or statistics to support my thinking – it just seemed axiomatic given a fundamental understanding of disease incidence, costs and demographics.

My good friend and colleague Dr. Toby Cosgrove, President and CEO of the Cleveland Clinic (okay, so we’ve said hello to one another on a few flights back and forth from Ft. Lauderdale) posted an article on his LinkedIn blog this morning: New Way to Fight Chronic Disease that puts some meat on the bone of my rudimentary understanding of public health. Dr. Cosgrove notes some very basic facts about chronic disease management in the United States.

  • The CDC estimates that 75% of all healthcare expenditures in the US are attributable to chronic disease ($2.85 trillion in 2013)
  • Almost one out of every two adults (117 million) is afflicted by chronic illness
  • More information on the impact chronic disease has on our healthcare system can be found on the CDC website.

Dr. Cosgrove’s article introduces the Cleveland Clinic’s recently opened Center for Functional Medicine, which is a collaboration with the Institute for Functional Medicine led by Dr. Mark Hyman. The thematic focus of the Center is to take a more holistic approach to individual health and wellness and driving at the underlying causes of chronic disease – whether related to genetics, environment or lifestyle.

Functional Medicine is not intended to be a replacement of traditional medicine. We aren’t talking about spiritual healing, wild berries and unproven treatment regimens. It is intended to recognize and address the underlying causes of chronic disease that, if effectively addressed, will reduce the need for traditional medicine. But it also should be able to compliment and enhance the effectiveness of traditional medicine.

Given the magnitude of the problem and the impending consequences on our country it is exciting news that a medical institution no less than the Cleveland Clinic has chosen to proactively attack this problem with pragmatism and innovation. That’s the good news. Now here’s the bad: human nature is an incredibly obstinate challenge that isn’t likely to bow in the face of the best efforts of worthy institutions such as the Cleveland Clinic.

Understanding the underlying causes that lead to chronic disease is one thing. Being able to change human behavior in a manner that addresses those causes is quite another altogether. And this tees up a host of moral policy conundrums where we start to look at responsibility of the individual versus society. Demographics will intensify these to a level that I suspect will lead to significant social unrest.

So while I applaud the Cleveland Clinic for taking the bull by the horns in seeking to address this immeasurable challenge facing us, I do hope they understand what happens if they let go.


Do Hospital Amenities = Value?

33ec2fbThere was an article in yesterday’s Dallas Morning News, Hospitals compete for patients with creature comforts, by Jim Landers that shares how hospitals are making huge capital expenditures in the name of patient satisfaction. The purported impetus behind this is in recognition of Medicare payments tied to patient-satisfaction scores under the Hospital Value-Based Purchasing Program. But there also has to be an element of competitive market positioning that is more to do with attracting a patient than satisfying a patient.

In either case, an obvious concern has to be to what extent, if any, more attractive aesthetics, better tasting food and higher speed Wi Fi access impact patient outcomes. Recall, Value = Outcomes / Cost. So what must be considered is how patient perceptions and experience factor into outcomes. Whereas one might  subscribe to a stricter definition of did the patient get well? others might want to consider is the patient happy?

From a policy perspective, to what extent should we be using tax dollars to make people happy versus making them well? From a holistic vantage point we want to consider those two objectives part and parcel of a singular goal. But again that old bugaboo raises its head: to the extent we measure achievement of a holistic goal by using objective criteria to assess subjective reality we risk wasting resources chasing an elusive butterfly.

Of course, the real irony here is that public policy designed to incent market-oriented provider behavior that improves value maybe doing more to increase the denominator than the numerator of the value equation. Makes you wonder whether we would be better off to just let the market develop solutions without artificial incentives – or whether it would make sense to stop pretending that healthcare is an industry that could ever provide value for a broad population left to its own devices.



How Images (And Hugs) Can Change the World

12-year-old Devonte Hart, Sgt. Bret Barnum share hug at Ferguson rallyIn 1604 Christopher Marlowe wrote these lines about Helen of Troy: “was this the face that launch’d a thousand ships and burnt the topless towers of Ilium?” The power of an image and its ability to evoke passion and emotion is ingrained in our history and social consciousness. This picture – and the story behind it – evoked so many personal feelings and emotions that I have had to sit quietly and alone for quite a while this Thanksgiving weekend determining what it was I wanted to share.

The photo above was caught by Johnny Nguyen at the start of a Ferguson rally being held in Portland, Oregon last Tuesday. Twelve-year-old Devonte Hart was holding a “Free Hugs” sign (more on that below) as he stood in front of a police barricade obviously upset.  Devonte’s mother, Jen Hart, is white, and she shared with reporters how her son has been struggling terribly to understand and reconcile his perceptions and understanding of what happened in Ferguson – and how race relations in his country will affect him as he grows into a man.

The officer pictured above, Sgt. Bret Barnum, works in the traffic division of the Portland police department and was at the site of the rally for crowd control. Standing about 10 feet from Devonte, officer Barnum noticed he was upset and called him over. They shook hands, chatted politely, Barnum expressing an interest in where Devonte went to school and what he had done this past summer. When asked why he was crying Devonte shared his concerns with the officer who empathized with those concerns. After they were done Barnum asked whether he might get one of the free hugs being offered. And thus be to infamy – maybe.

There was another time in our history when the camera captured an image that made a tremendous impact on the perception of race relations, but according to most accounts that image was not what it appeared to be. In his latest book, David & Goliath, Malcolm Gladwell relates the story behind this famous photograph of the civil rights movement in Birmingham, Alabama. The picture was taken by Bill Hudson of the Associated Press and shows 15-year-old Walter Gasden apparently being attacked by two police dogs during a May 3, 1963 protest in Birmingham.

But Walter Gasden was not a protester – he was a bystander who had been arrested by the officer in the photograph (Dick Middleton) for refusing an order to leave the street. It is believed that the police in the photograph are actually trying to hold the dogs back as Gasden strikes the dog with his left knee, causing it injury that required treatment by a veterinarian.

Diane McWhorter related this story in her book, Carry Me Home. Gladwell relied in part upon McWhoter’s account to relate how Wyatt Walker – an African American pastor and civil rights leader – had worked to confuse local authorities from being unable to distinguish protestors from bystanders in order to create chaos and a picture-perfect moment that had the purpose and effect Walker had hoped: it was printed in newspapers across the country with the understandable byline imagery of police using German Shepherds to attack a peaceful civil rights protestor.

Images can be incredibly powerful even when perception may not match reality (as in, perception is reality). A solitary image can profoundly impact a national cause just as a face can launch a thousand ships. Just as the image of a police officer accepting a free hug from a confused, scared and innocent youth can hopefully reset the dialogue we still desperately need to continue in this country on race relations, away from the hateful and destructive images of Ferguson that have perceptually hijacked that dialogue.

And what about those free hugs? The Free Hugs Campaign was started in 2004 by an Australian known under the pseudonym of Juan Mann (i.e., one man) in the Pitt Street Mall of Sydney.

imageI was first introduced to Free Hugs in 2010 when Sister Jill Bond of Catholic Health Service of Miami shared this 2006 video of the campaign shot in Hollywood, California (click on picture for link to the video). Set to the music of the late Israel Kamakawiwo’ole’s version of Over the Rainbow, it is one of the most captivating, inspiring and thought-provoking videos I have ever seen, and I have used it multiple times since in client workshops.

That it serves as an underpinning of the story behind the image of Devonte and Officer Barnum is emotionally compelling to me on multiple levels. In a time when technology has done so much to keep us connected it truly amazes – and depresses – me to realize just how disconnected we have become. And how way too often it seems our preference is to remain that way unless someone – like an innocent 12-year-old boy whose heart is full of love and wonder – has the courage to help us understand how simply powerful one hug can be – especially when it’s captured as an image that can be shared with others.


150-to-1 Reasons To Be THANKFUL

Sometimes the stars align. Sometimes your best efforts can make a difference. Sometimes you’re just in the right place at the right time. Tomorrow is Thanksgiving and this is the 150th post I have written for Sparky’s Policy Pub.

I had thought, for a brief moment mind you, of coming up with 150 different healthcare policy oriented reasons for being thankful and sharing them. But if there is one thing I have learned too well over the past 149 posts it’s that in a world of electronic media expanding at an accelerated rate it is extremely difficult to attract the attention of anyone interested in reading a paragraph – let alone a boring list – on public policy issues.

So I settled upon one policy-oriented reason to be thankful that is both timely and in keeping with the American heritage and tradition of Thanksgiving: I am thankful the Tea Party has gone into hiding, at least for now.

Writing this morning in Politico, Kyle Cheney asks the question: Is the tea party ready to chill out? Cheney posits that at least some portion of the Republican Party’s success is owing to their being able to smartly steer clear of TP challengers that historically have split the party against itself. And rather than swinging for the fences on every issue at least some TP strategists appear to be taking a more pragmatic approach, accepting that getting something – anything – is a lot better than getting nothing.

The Democratic Party is going to face its own fringe albatross dividing its constituency in the years ahead, particularly leading into the 2016 election. And their situation may be even worse because of some recent success the far left has had in influencing legislation. They have come to taste an unsustainable success that the Tea Party by and large has not. That will, of course, change, as Chuck Schumer and others have already begun signaling as they start to distance themselves from the party’s far left.

Politics in America can often best be characterized as a pendulum of public opinion: as the public comes to realize their lives are not better under one party they begin to have hope in the other. Of course, overall voter turnout earlier this month – at 36.4% – was the lowest it has been since 1942, perhaps an indication that 6 or 7 out of every 10 Americans have lost hope in either or any party, or could really care less about public policy until it is in some fashion proven to affect them directly.

That lack of interest in public policy is in good part because it has been overwrought by the rancor smell of partisan politics in an age of media-driven elections. The media’s complicity is our own: we like to be entertained, as I have written here before. Just ask ad agents at Fox News or MSNBC what type of programming advertisers will pay the highest rates to underwrite. Entertainment is found on the fringes of both parties because their behavior is usually characterized as aggressive, controversial and uncompromising.

But it’s the very lack of compromise that has thrown this country into a political tailspin. Without wanting to find myself disappointed to the point of joining the 7 out of 10 who don’t care what happens in public policy I hope the Republican Party’s ability to gain control of Congress is a harbinger of future hard fought debates on the floors of both chambers that will result in legislation that neither party loves but both can live with in the interest of knowing that doing something is better than doing nothing.

It will be interesting to see whether the likes of Ted Cruz, whose star for better or worse is at least for now firmly affixed to the Tea Party, will choose personal political ambition over progress and seek to make the 114th Congress as dysfunctional as the few before. Who wants to bet he’ll choose the road of constructive compromise? I’ll give you 150-to-1.

Happy Thanksgiving!


Ferguson and the Politics of Healthcare

f01_59546488On August 9th, when campaigns across the country were beginning to ramp up for the 60-day sprint to the November elections Michael Brown was fatally shot during an altercation with a Ferguson, Missouri policeman, Darren Wilson. The circumstances of the incident – primarily that Mr. Brown had been unarmed – set off a firestorm of protests in the hot summer nights of this St. Louis suburb.

Those flames were reignited late yesterday afternoon when it was announced that the grand jury reviewing the case would not indict Officer Wilson on any charges stemming from the incident. From relief to acceptance to disappointment to outrage and insolence to rioting and looting, the decision has placed the nation’s issues of inequality front and center again ironically enough just before the Thanksgiving holiday.

In the final days leading up to the November 4th election Democratic Senate candidates in the South sought to use racial tensions as a tactic to encourage support and voter turnout of the African American population. As we know now that effort didn’t work out so well as Republican David Perdue defeated Democratic candidate Michelle Nunn in an open Georgia race while Republicans Thom Tillis and Tom Cotton defeated Democrats Kay Hagan and Mark Pryor in North Carolina and Arkansas, respectively.

If Bill Cassidy, the Republican candidate facing Democrat Mary Landrieu in Louisiana’s December 6th runoff election, wins (polls currently show he has a substantial lead), Republicans will have secured a 54 to 46 advantage in the Senate – a pickup of 9 seats and control of the United States Congress. And thus, if you were to believe the more optimistic sort in the Republican Party, they have secured a mandate to dismantle the Affordable Care Act, whether in total or piece by piece.

That was I believe, until yesterday. What is happening – what has happened – in Ferguson is community self-destruction on a par with some of the worst cases this nation has ever seen. The unsupportable actions of those rioting and looting belie and disguise the very real and troubling root causes of community and individual impoverishment that are at the heart of the anger and frustration playing out in Ferguson and across the country.

There are very real income and wealth disparities in this country, and they continue to get worse. I have maintained this is, in part, a byproduct of foundational and structural changes occurring in the US economy resulting from deindustrialization that could take several generations to play out.  It is clearly also the result of a failed welfare state that has irreparably influenced the social and individual psyche of what value means in a market economy.

Regardless of what got us here, with the chasm of inequity growing daily how can it be a politically practical reality that Congress should rescind the efforts to provide access to an affordable, minimum level of quality healthcare in this country? And with the aforementioned structural obstacles facing our economy how can we not seek to proactively reign in the runaway healthcare costs that are putting such a tremendous drag on economic growth?

Look deeper into what is happening in Ferguson and cities across the country. Recognize that under the foolish, destructive and misguided actions of the violent few is a growing population of impoverished from every race, creed and nationality in this country. How can we go backwards on healthcare now?

  ~ Sparky

Medicine’s Tragedy of OR

Thanks to Dr. Paul Wiseman for sharing the NY Times op-ed article,  How Medical Care Is Being Corrupted, via LinkedIn this afternoon. Article authors Pamela Hartzband and Jerome Groopmannov are on the faculty of Harvard Medical School and co-authors of Your Medical Mind: How to Decide What is Right for You.

    The article deals with an old nemesis in healthcare policy: individual incentives. More particularly, how the misalignment of individual incentives can often be the Trojan horse befalling well-intended policy initiatives.

    Idealistically, as patients we we want our doctors to have our best interests in mind at every touch point of our experience with them. And fortunately, I believe that continues to by and large hold true. But the forces pushing against physicians to maintain that altruistic objectivity and autonomy on our behalves is being vehemently tested by what the authors describe as, “financial forces largely hidden from the public [that] are beginning to corrupt care and undermine the bond of trust between doctors and patients.”

    Though coming from different sources the common thread is the push toward value-based payments. I have written here in the past on value and value-based healthcare. The theory is market-based sound logic: value = outcomes/cost. The challenge, as I have written before, starts within a few nanoseconds after you start to contemplate how to objectively assess outcomes and whose value are we talking about?

    As Hartzband and Groopmannov importantly note, there is a challenging conflict between what is perceived as valuable for population health (i.e., in the aggregate) versus what is valuable for individual health. Physician payment incentives are increasingly being created based upon broad public health metrics (e.g., incidence of hypertension and hyperlipidemia, which are both often treated with medications that can be very effective – but also have significant side effects that can vary significantly from one individual to the next).

    So it doesn’t take too many connected dots to imagine the potential conflict of interest between wanting to hit the metrics versus doing what’s in the best interest of the patient. And the challenges are compounded when it’s not just the rewards that are in play – but the potential punishment for not following prescribed protocols from third parties – e.g., poor ratings publications and/or loss of base payments. That’s what is known in the non-scientific world as getting it coming and going.

    So what the authors propose is the establishment of legislation that would make public information available on, “the hidden coercive forces” that could be at the root of physician-patient incentive misalignment due to the aforementioned consequences of well-intended policies. That may not be enough, but it’s an important recognition that the policies may not work as intended. I note, however, that they do not recommend going backwards to the past era of, “paternalism, where doctors imposed their views on the patient.”

    Progress often means a couple of steps forward and a few back. Trying, learning and adjusting. This is a fundamental difference in  thinking among healthcare policy types that believe we just have to give Adam Smith’s invisible hand wider breadth. Way back in 1995, Jim Collins (Good to Great) wrote an article, (Building Companies to Last), in which among other areas of recognition – that even back then noting that relying on lessons of the past would not suit us well in a world of transformational change – he discusses embracing the genius of the “and.” This is a theme that has pervaded much of his work since.

    Too often those critical of policy initiatives jump for self-satisfactory joy whenever they come across fair and objective criticism of those initiatives. But such criticism, if you can get by the politics (yeah, I know), doesn’t have to be viewed through the prism of the Tranny of Or. It can be viewed as an opportunity to learn and work toward the Genius of And.

      ~ Sparky

Photo Credit: Alex Merto

Stupid Is As Stupid Does

If you haven’t heard or read about the recent uncovering of remarks made by Jonathan Gruber in relation to the crafting and passage of the Affordable Care Act (i.e., ObamaCare: pub patrons will note I rarely use that term even though I have largely supported it), then it is most likely because you are stupid. Yes, sorry, but that’s the sad reality of affairs according to intelligentsia types like Professor Gruber.

Aaron Blake writing in the Washington Post yesterday argued effectively that Gruber’s remarks will likely have little effect on any legislative initiatives to fully repeal the ACA. And as Kevin Drum pointed out in MotherJones, while Gruber’s choice of wording may have been very poor, he is right in noting that most of the electorate knows very little about public healthcare policy – if that’s what Gruber indeed meant. To me, stupid implies the inability to learn. I think Gruber may have accurately depicted an electorate that is disinterested in and/or unwilling to learn. Even still, I question how someone supposedly so smart could be so stupid.

Whatever term might best describe the initial benchmark of the electorate’s understanding of healthcare delivery, policy and regulations back in 2010, it has certainly advanced substantially from then. I’d like to think I’ve contributed a smidgeon since I started this blog in May of 2012. Whether the ACA is repealed, amended or dismantled one line at a time (parish the thought – I read the whole damn thing) healthcare public policy debate between January 2015 and the November elections of 2016 promises to be as energized, contentious and fraught with misinformation and misunderstanding as ever.

And knowing that, I am hoping to take the PolicyPub to a higher level next year. I am hoping to invite guest bloggers representing differing perspectives and backgrounds. Through my firm’s recent strategic alliance with Healthcare Lighthouse we are exploring ways to collaborate on sharing of healthcare public policy knowledge and information in ways that bring real value to organizations involved in healthcare. I am hoping to reenergize our free private discussion group where healthcare public policy is debated based on the merits of ideas and beliefs, and not sound bytes and news clippings.

To accomplish this I am going to need help. I am going to need to find others who share my passion for wanting to learn, understand and share their knowledge on the inner workings of healthcare public policy – and more importantly, the impact of that policy on patients and provider organizations. If you know of anyone who would be interested in adding to the discussion, please have them contact me.

I would like to commit myself in 2015 to proving how wrong Mr. Gruber is: not only is our electorate not stupid – but neither by implication are they willing to allow college professors to determine the future of our healthcare delivery system while they sit back and accept what’s given to them.

  ~ Sparky

Effective Communication: A Shared Illusion

Shaw_George-001I wrote last week in my post, Mental Illness Is A Community Disease that I was planning to participate in today’s public listening session held in connection with the development of new criteria that will impact Certified Community Behavioral Health Clinics (CCBHC). Mandated under Section 223 of the Protecting Access to Medicare Act of 2014, the intent is to strengthen community mental health systems by establishing higher standards of care and better coordination and communication across individuals, organizations and agencies that provide assistance and care to individuals in their communities.

Among the five topic areas discussed today (see previous post), not surprisingly I found Care Coordination to be the most interesting because of the parallels I recognized between mental/behavioral health and post-acute/long-term care. These include:

both groups of individuals typically require help from both community-based services and supports, as well as healthcare providers, and the lack of sharing of timely information across those entities in both instances is a challenging obstacle to managing care;

both groups rely heavily on Medicaid to fund needed services and care – and so both are likely to increasingly have to navigate the world of managed care – which doesn’t bode well in light of the point above;

both groups have evidentially achieved significant benefit from taking a holistic approach to care;

there is a need with both groups to understand and address the impact that varying levels of cognitive awareness can have on patient activation; and

the ability to achieve sustainable wellness in both groups is often primarily dependent upon the ability to maintain meaningful, long-term connectivity with care providers (in particular where medication management is concerned).

Most importantly however, germane to – yet beyond just – the importance of care coordination, a key take away from today’s sharing of thoughts, insights and the occasional organizational promotion and positioning was the shared impact that ineffective communication has in mental/behavioral health as it does in post-acute/long-term care. And really, across all of healthcare as has been discussed here before.

Effective communication is an art form, but it’s an art that can be taught and learned among willing participants. All too often, however, that willingness comes from a desire to be heard rather than to be understood – and to understand. George Bernard Shaw (pictured above) once wrote that, “the single biggest problem in communication is the illusion that it has taken place.”

Despite, or perhaps in good measure because of, all the technological advancements that have achieved miraculous achievements in healthcare we still fall well short of our potential to reduce human suffering because of a basic inability to communicate effectively.

I would like to see more sharing of experiences and best practices in care integration between mental and behavioral health and post-acute/long-term care: each probably could learn a lot from the other. But that would involve effective communication . . .


Does Legislative Negligence Trump Legislative Intent?

The Supreme Court today agreed to hear the King v. Burwell case, which – similar to Halbig v. Burwell, wherein the DC Circuit Court ruled against Burwell (i.e., the Affordable Care Act) in July – challenges the legality of tax subsidies used to offset the cost to individuals buying health insurance through federally administered exchanges. As the ACA was written subsidies were to be available through state run exchanges, but since most states opted out of creating and running their own exchanges more than two-thirds of everyone who signed up for health insurance did so through federal exchanges. Of those, approximately 85% – or 5 million people – received subsidies at an average value of approximately $3,200 per year.

Those folks stand to lose that benefit – and in many cases likely health insurance –if SCOTUS determines that the letter of the law should supersede legislative intent. Beyond that, given the actuarial models supporting expansion of individual health insurance under the ACA the prospective financial viability of that expansion would likely becomes untenable.

Congressional staffers had already been discussing ideas of how to work around the loss of tax subsidies – but that was before this Tuesday. The new sheriff in town won’t be very anxious to support legislative efforts that seek to save Obamacare in any fashion. What can be done through regulations? My guess is not much, so a ruling in favor of King would likely be the devastating blow detractors have been chasing since March of 2010.

From a retrospective standpoint this is just another serious distraction in a long line of legal and administrative obstacles that have become part and parcel of legislative implementation. It reflects the urgent and manipulative manner in which the Affordable Care Act was rammed through passage in March 2010 following a string of made-for-TV political events that played out beginning with the death of Senator Ted Kennedy in August 2009.

Ever since then Republicans have argued that a policy initiative of the breadth and scope of the Affordable Care Act necessarily should have been subject to broader bipartisan support, such as what would have been required through a normal reconciliation process of the two House and Senate bills. While at the same time Democrats have argued Republicans’ expressed concern has largely been a case of “protesting too much” and only really being concerned with stopping any legislative initiative of the President, regardless of its policy merits.

In any event, what SCOTUS will have to wrestle with is attempting to understand the contextual purpose of the health insurance subsidies and whether legislative intent is a sufficient enough consideration to disregard the stated restriction of those subsidies to only state run exchanges. As someone who has supported the ACA I don’t share this from the perspective of looking for any opportunity to blow it up. But I think it has to be taken into consideration by the Court that the law’s contorted framework and structure is a theoretical obstacle for accepting the legislative intent argument.

How can you accept legislative intent as a theoretically understood precept for a provision of an act that in several significant instances (i.e., CLASS, the employer mandate, renewal of noncompliant plans, special enrollment and hardship exemptions), has not been implemented as intended? Are the justices required to not consider legislative enactment and just look at the Act independently of the apparent disconnect? I’m not a lawyer, so maybe I am just thinking of this like a four year old – but then someone is going to have to explain to me what’s wrong with my logic.

Cheers and enjoy the weekend,
  ~ Sparky

Policy Prescriptions ®

The Evidence-Based Health Policy™ Experts


By Dr. Bill Thomas


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