The ‘S’ Word in Health Care

Americans greatest fear in today’s debate on health care may be the spectre of the ‘S’ word – socialized medicine.

Socialized medicine is ‘code’ for the government takeover of healthcare (already 50% ‘taken over’ by Medicare).

Socialized medicine is a poorly-defined, alarmist and pejorative label that describes Americans’ fear that individual medical decisions made between doctor and patient will be replaced with decisions made in some far-off place, like Washington DC or, possibly, Bangalore, India.

I sure don’t want this possible future scenario for my doctor to be forced to do this to treat me:

1. pick up the phone to a call center in Bangalore to get approval for my flu shot
2. wait on hold for 15 minutes
3. describe my symptoms to ‘Steve’ from Bangalore
4. wait on hold for 15 more minutes
5. then get the rejection with a recommendation to try the generic, cheaper alternative.

Rationing Health Care

The other, common usage of the ‘S’ word is in context with rationing. Rationing is another politically charged word often used to describe denial of payment based on price. Rationing is not a question of ‘if’, but ‘how’ as this article from the New York time suggests.

Similarly, and seriously, decisions about needed surgeries, diagnostic testing, preventative testing and treatment options are best made locally between the doctor and the patient.

The Moral Imperative

No worthwhile physical therapist needs to be told the moral imperative in healthcare: Do what is best for the patient. The Oath of Maimonides said to originate from a 12th century Jewish physician-philosopher is perhaps most appropriate:

The Oath of Maimonides

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

May I never see in the patient anything but a fellow creature in pain.

Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.
Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

The Financial/Business Imperative

Health care delivery in America often contrasts with the moral imperative in health care. Medical businesses exist to do the following:

• make money
• provide professional autonomy
• ensure high standards of care
• allow physical therapists to practice in specialized settings

– however, the first imperative is money, without which further imperatives are irrelevant.

The American health care market, through fee-for-service, creates an incentive for physical therapists to provide higher volumes of care than is necessary.

Medicare fraud and abuse prevention efforts, in general, and the PT Cap Exceptions Process, specifically, encourage PT firms and private practices to limit necessary services to patients who need them.

The 'Black Hats'

In my town of 400,000 we have a 13-doctor practice that, in purely rational self-interest, automatically discharges patients when they hit the ‘PT cap’.

They've abdicated their moral imperative in favor of their financial/business imperative.

I use a POPTs example because, as a private practice physical therapist (PTPP), it’s fun to pick on POPTs. Based on purely rational self-interest, however, another PTPP might choose to make the same business decision and discharge patients who hit the arbitrary cap based on perceived audit risk.

Are they bad people? No. They work in a bad system.

POPT's are not evil, they’re not bad people and they’re not even bad medicine – some even do a pretty good job of post-surgical PT if anecdotal stories are to be trusted. Some of my friends work for POPTs.

But any policy that unnecessarily drives up costs and drives a financial divide between decisions made by the PT and the patient is bad health care policy. The same would be true for policies that distort with dollars decisions between physicians and patients.

How can physical therapists reconcile the two imperatives in private practice PT in America? Surely pushing decisions to far-off decision-makers is less efficient and, presumably, less effective than one-on-one decisions between doctor and patient.

Right?

The Future Price of Outpatient Physical Therapy

Will outpatient physical therapists face 'bundled episodes of care' from Medicare in August when the current administration brings it health financing reform package together?

Right now we are all speculating.

However, we can speculate based on evidence and perhaps gain some perspective. The sooner we know the sooner physical therapists can act.

I've posted some action points for physical therapists to prepare for bundled episodes of care here and here.

But, what recent evidence do we have that bundled episodes of care will be a part of the reform package?

This is a part of the speech President Obama gave to the American Medical Association (AMA) in Chicago on June 15, 2009. He specifically addresses the alternative to bundled episodes of care at 20:40 - just drag the cursor on the video.


(click here to start the video)

If you prefer to read I've posted the text below.

"Despite what some have suggested, the reason we have these costs is not simply because we have an aging population. Demographics do account for part of rising costs because older, sicker societies pay more on health care than younger, healthier ones. But what accounts for the bulk of our costs is the nature of our health care system itself - a system where we spend vast amounts of money on things that aren’t making our people any healthier; a system that automatically equates more expensive care with better care.

A recent article in the New Yorker, for example, showed how McAllen, Texas is spending twice as much as El Paso County - not because people in McAllen are sicker and not because they are getting better care. They are simply using more treatments - treatments they don’t really need; treatments that, in some cases, can actually do people harm by raising the risk of infection or medical error. And the problem is, this pattern is repeating itself across America. One Dartmouth study showed that you’re no less likely to die from a heart attack and other ailments in a higher spending area than in a lower spending one.

There are two main reasons for this. The first is a system of incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I’m talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can’t spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it’s not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business.

That is not why you became doctors. That is not why you put in all those hours in the Anatomy Suite or the O.R. That is not what brings you back to a patient’s bedside to check in or makes you call a loved one to say it’ll be fine. You did not enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers - and that’s what our health care system should let you be."

The article about high-cost McAllen, Texas from the New Yorker magazine by Atul Gawande, MD can be found here - Dr. Gawande recommends bundled episodes of care administered by 'accountable care organizations' (ACO).

Obama references Gawande who strongly recommends episodes of care and rejects the current fee-for-service system.

Currently we've got some bundled episodes of care that we can look to for examples. This example is of Lower Back Pain. Most surgical procedures are bundled with the pre-op and post-op follow-up. Any other examples would be appreciated - just comment at the end of this blog.

I'd say the Obama-Gawande tandem is strong evidence to suggest what we may see in August.

Carol shows physical therapists how to change for Episodes of Care

Carol (same first name, different last name) was classified as a traction patient - she had all the traction predictor variables:

• non-centralizing leg pain
  
• pain made worse with extension, better with sitting
  
• altered reflex findings in the painful leg
  
• altered sensory findings in the painful leg
  

The problem?

Her neurosurgeon always ordered NO lumbar spinal traction because he had a bad experience with a chiropractor's Spinal Decompression unit last year.

The other problem?

Carol had commercial insurance that paid using the Episode of Care payment model which puts physical therapists at risk for the cost of care that exceeds a predetermined amount.

In Carol's case the predetermined cost of care was $375 for the whole episode.

Her clinical presentation, however, implied that her case needed to be 'risk adjusted' - based on the physician's orders to avoid the evidence-based, best treatment option. Instead, we had to use less-than-optimal treatments such as modalities and exercise.

The Episode of Care.

As part of the current administrations health care financing reform efforts Medicare is considering a 'bundled episode of care payment model' for all post-acute care providers such as doctors, physical therapists, ambulatory surgery centers and skilled nursing billing Medicare Part B.

The acute care hospital would be the 'banker' and would be responsible for distributing the episode payments (note: acute care hospitals usually bill Part A).

The episode of care is not quite like capitation (a single, annual fee for all care to a patient) and it is definitely not fee-for-service. It's a mix that is most appropriate for "isolated acute care episodes" (p.7). Usually, physical therapists treats acute episodes of ongoing, chronic conditions.

The Network for Regional Healthcare Improvement provides this useful graphic to explain the two types of risk providers and insurance companies 'trade off' under capitation and the episode of care model.

Capitation places all insurance and performance risk on the provider. The episode of care places some insurance risk on the provider - how much is uncertain.


So, what does an episode of care look like?

I recently analyzed the contract I have with a major, US commercial insurance company that switched me from fee-for-service to an episode of care model.

My analysis might give PTs some insight as to what a Medicare episode of care payment would look like for private practice physical therapy.

Patient	Fee Level	Fee	Visits	Co-pay	Total Fee	Per Visit Fee
Ronald Reagan	3	$225.00	1	$50.00	$275.00	$275.00
Bugs Bunny	3	$225.00	4	$50.00	$425.00	$106.25
Felix the Cat	3	$225.00	2	$50.00	$325.00	$162.50
Anakin Skywalker	2	$135.00	12	$25.00	$435.00	$36.25
Joe the Plumber	2	$135.00	2	$50.00	$235.00	$117.50
Shakira	2	$135.00	6	$50.00	$435.00	$72.50
Carol Burnett	2	$135.00	12	$20.00	$375.00	$31.25

Note that a Level 2 pays $135.00 and a Level 3 pays $225.00.

My average reimbursement for this contract, according to this sample, is $64.23. Our average per-patient cost to provide PT is about $65.

We are keeping a very close eye on this one.

Also, our experience indicates that high co-pays ($50) tend to discourage patient visits. Patients ration their physical therapy - especially in these tough economic times.

Patients with low co-pays attend all of their prescribed treatments which, as you can see, leads to below-average-cost reimbursement.

Medicare Episodes of Care

Medicare co-pays tend to be the lowest out-of-pocket across the spectrum of private and public payers. I believe that any new Medicare payment system would most likely try to be sensitive to patient out-of-pocket costs, if only for political reasons.

This suggests that Medicare episode of care patients would tend to resemble Carol Burnett more than they resemble Ronald Reagan.

What is 'risk adjustment'?

Outpatient physical therapists are at risk for the number of visits beyond some expected average for a given condition, such as lower back pain.

Risk adjustment is usually needed for factors known to increase the number of visits such as...

• depression
  
• fear-avoidance beliefs
  
• anxiety
  
• coping strategies
  
• health locus of control
  
• previous surgeries
  
• obesity
  
• clinical complexities and co-morbidities (Carol's situation)
  
• social factors (eg: caregiver support, patient is a caregiver, etc.)

Baskets of Care

The Minnesota Health Reform Initiative created 'baskets of care' that describes suggested clinical scope and care components for an episode of care for lower back pain.

Baskets of care seek to...

"bundle payments for a set of health care services together in ways that will create incentives for health care providers to collaborate and develop innovative ways to deliver effective, high quality, and lower-cost health care services."

The Minnesota evidence-based approach gives us an idea how a Medicare episode of care might be structured from a clinical standpoint.

I hope Episodes of Care for outpatient physical therapy do not come to pass but the current administration has the 'bully pulpit' and is motivated to accomplish significant legislation in 2009.

Action points for physical therapists to prepare for Episodes of Care

1. Learn to measure baseline factors that increase 'risk' to physical therapists, like:


• Fear-Avoidance Beliefs
• Depression


2. Private practice PTs - know your costs to deliver care.


• Divide annual revenues by number of visits to get average cost per patient


3. Learn to treat Fear Avoidance using a 'cognitive behavioral approach utilizing graded exposure' to the fearful activities in order to reduce your risk for longer episodes of care.


4. Learn how to 'upgrade' Episode Levels based on valid predictor variables and risk factors

Private practice physical therapists are 'on the ropes' lately with POPTS, RACs, CMS, OIG, DOTPA, etc. Fortunately, there are many tools in our toolbox that we can use to manage the risk associated with the Episode of Care.

Hang in there with patience, persistence and the same caring attention to detail that originally made you successful in practice - change is in the air

Classifying Physical Therapy, Nuclear Submarines and Cardiac Care Beds

The United States Navy had a problem. It was the early 1970’s and the height of the Cold War.

US Navy submarines were playing cat-and-mouse submerged reconnaissance with Soviet submarines in every ocean around the world. Nuclear submarines ran quieter, faster and longer than older, diesel subs and could submerge to new, record-setting depths. US Navy submariners were among the best trained, most highly motivated military men in the world.

Submariners, however, still got chest pain at the same rate as ordinary civilians.

Navy doctors had to decide, based on clinical findings, if the submariner’s signs and symptoms were serious enough to consider aborting the mission and seeking a friendly port.(Blink - Malcolm Gladwell)

Underwater heart attacks didn’t fare well outside of a hospitals’ intensive care unit.

That’s where Dr. Lee Goldman came in. Dr. Goldman was studying statistical rules – algorithms – that predicted when people were having a heart attack. Dr. Goldman’s rules predicted the occurrence of a major cardiac event based on three predictor variables:

1. Is the patients’ pain unstable angina?
2. Do you hear rales above the base? (indicates fluid in the lungs)
3. Is the systolic blood pressure below 100mm Hg?

Combinations of these predictor variables indicated different treatment options:

1. surface and give away your submarine’s position to the enemy but save your submariner’s life
2. sit tight and monitor your submariner’s vital signs or
3. send your submariner back to work with a bottle of Pepto-Bismol.

Navy doctors studied these treatment algorithms and used them in the care of their sick submariners. At one point, military physical therapists led their civilian cousins using evidence-based medicine in decision making, ordering radiographs and making referrals to other health care professionals.

While the US military lead the way in the early 1970’s in using clinical prediction rules the American health care community responded to Dr. Goldman’s work with deafening silence. (Gladwell)

American Doctors Make a Decision

It wasn’t until 1995 that American doctors began to use decision rules to inform the care of their patients. The best example on record comes from Cook County Hospital in Chicago. (Gladwell)

This 700-bed urban teaching hospital is a century-old, publicly-funded institution that was seeing thirty new chest pain patients per day in its emergency room and 79% of them were getting a full work-up for chest pain.

Patients were admitted to one of two wards for hospitalized chest pain patients:
• eight coronary intensive care beds or
• twelve telemetry-monitored coronary beds.
The coronary intensive beds cost $2,000 per bed per day and the telemetry-monitored beds cost $1,000 per bed per day.

Ironically, only 5-10% of the patients admitted to the hospital suspected of having a heart attack progressed to a full-blown heart attack. The hospital’s problem was that they were spending expensive resources on patients who were not having a heart attack.

The hospital’s chairman of the Department of Medicine, Dr. Brendan Reilly, wasn’t worried about the quality of care – the quality was good. Dr. Reilly was worried about the cost of providing cardiac care to patients who weren’t having a heart attack. He began studying the decision-making processes used by the emergency room doctors caring for patients with chest pain.

Ironically, the initial response from the ER doctors was reluctance and resistance – how can Dr. Goldman’s algorithm allocate intensive care bed space better than ER doctors’ decisions? What about family history? What about weight, sex, race, smoking history, stress and many other factors considered important at the time in the diagnosis of heart attack?

What Dr. Reilly found out was that race, gender and lifestyle factors were less important than whether or not the doctors followed the algorithm. Not that these factors were unimportant in the overall care of the patient – just that the initial decision to allocate the expensive, intensive care bed was better made by adhering to the algorithm, not to the host of factors that, while important, were incidental to the initial decision.

Dr. Reilly studied the impact of using the Dr. Goldman’s CPR in the Cook County ER. He found that the efficiency, the rate at which patients not having a heart attack were sent to inexpensive observation or sent home, went from 21% to 36%. Dr. Reilly also found that safety, the rate at which patients having a heart attack were triaged to coronary intensive care, went from 89% to 94%.

Just as the submariner’s doctor had to make a quick, initial decision that balanced the risk of giving away the submarine’s position with the risk that the submariner would progress into a full-blown heart attack so too did the Cook County ER doctor have to make a decision that balanced the risk that Cook County would spend $2,000 per night for up to three nights on a patient with acid indigestion versus the risk that the patient was having a heart attack.

Classifying submariners was a clinical 'shortcut' that enabled the submarine to stay submerged in those cases that were not clearly a major event. Classifying chest pain patients in Cook County was a clinical 'shortcut' that prevented spending thousands of dollars on people with tummy gas.

Classification as a Resource Allocation Tool

Both the submarine and the cardiac beds examples treat classification as the solution to a resource allocation problem. Both scenarios were prompted by crises of scarcity. Dr. Reilly at Cook County finding fewer public funds to pay for critical care cardiac beds as emergency room admissions rose and the US Navy facing a trade-off between dying submariners and national security.

American health care is facing its own crisis of scarcity as rising rates of per-capita health care consumption, the tidal wave of aging baby boomers and budget constraints on increased health care spending impose resource allocation challenges on increasingly scarce physical therapy resources, like time and money.

Classification, however, is not the appropriate tool for every clinical decision faced by physical therapists. As noted, classification is probably appropriate only for the initial treatment assignment and may not describe the exact treatment to be used. For example, the spinal traction classification is useful in cases of non-centralizing leg pain of radicular origin but the decision rule does not give information as to the parameters of spinal traction: force, total time, ramp time, or patient position.

Classification is probably most useful when one or more discrete alternative treatment possibilities exist, eg: lumbar manipulation or stabilization. Presumably, not both. Classification is probably not helpful in straightforward PT decision-making such as an uncomplicated ankle sprain. There needs to be some risk that making the wrong choice will produce worse outcomes or a less efficient clinical process.

For example, if the Navy doctor incorrectly diagnoses a heart attack and the submarine captain decides to surface en route to a friendly seaport it reveals its position to enemy radar and US national security could be compromised.

The submarine and cardiac beds examples offer illustrations of risk that are far more clear-cut than physical therapists would typically encounter in the clinic. It seems obvious that clinical prediction rules developed by Dr. Goldman and others were utilized earlier in these environments because of increased risk and greater costs involved.

Classification as Diagnosis

The physical therapy profession is currently shifting towards Treatment Based Classification (TBC) using clinical prediction rules (CPR) for diagnostic and treatment decision-making.

Unlike the physician profession, the physical therapy community seems almost uniform in its acceptance and embrace of classification measures as an aid to clinical decision-making. (Gladwell, Groopman in How Doctors Think)

An understanding of probability is required to fully understand the use of statistically-derived predictor variables. For example, the Fear-Avoidance Beliefs Questionnaire (FABQ) is a predictor variable for the manipulation classification while plausible findings like pelvic landmarks and sacroiliac region pain are not predictor variables. How can this be?

The derivation studies that identified the original predictor variables tossed out biologically plausible tests and measures instead showing us the true predictors of patients likely to respond to lumbar spinal manipulation.

Not leg length inequality, not mechanism of onset, not MRI or x-ray findings, not pelvic landmarks or pelvic movement tests. Instead, some surprising findings turned out to show physical therapists who should be manipulated:
1. Time since onset (> 2 weeks)
2. Extent of distal leg pain (not past the knee)
3. Lumbar hypomobility
4. FABQ work sub-scale >19 points
5. No hip ROM asymmetry

If, on average, manipulating your patients is a coin flip (about 50% get better, 50% don’t get better), then application of the CPR improves your chances to 68% for patient who have any 3/5 of the predictor variables. Your chances improve to 95% if the patient has just one more of the predictor variables.

Classification as Probability

Probabilistic decision-making is consistent with the hypothetico-deductive model that is associated with physician decision-making, prescriptive medicine and the patient’s role emphasizing ‘compliance’ over ‘collaboration’. As such, classification seems to shift traditional physical therapist decision making way from its ‘collaborative’ roots.

Will this shift threaten the intimacy that physical therapists have come to treasure with our patients?

Is intimacy sacrificed when decisions are made quickly?

Will physical therapists continue to consider patient-centered factors such as culture, social class, age, experiences and goals when applying clinical prediction rules? Just like the Cook County ER doctors who felt that the chest pain CPR ignored too many important factors in the ongoing care of their patients so too can TBC ignore important aspects that impact the ultimate physical therapy outcome.

Will CPRs allow therapists to quickly deliver routine aspects of care that are best made by statistics, like initial group allocation? Then physical therapists can focus on face-to-face interactions that engage patients’ emotional involvement in their own care.

Classification Success

Nothing succeeds like success and classification has succeeded in capturing the imaginations of educators, researchers and clinicians within physical therapy because of clinical successes and because of several well-designed studies published in prestigious medical journals.

Classification of spinal pain patients has crystallized an incoherent field of data into five or fewer examination findings per group. Classification has revolutionized physical therapy education and empowered students and experienced clinicians to become better decision-makers.

Questions remain:
1. Can classification change physical therapist behavior?
2. Can classification change physical therapy outcomes?
3. Are classification groups mutually exclusive and exhaustive? 75
4. Are some manipulation patients also candidates for stabilization?
5. Can some findings be treated that are not measured by classification predictor variables?
6. Can one patient fit the criteria for more than one diagnostic label?

Is classification good for documentation?

Aside from the risk that classification will change the interaction of patient and physical therapist to a less intimate relationship that is more typical to that of patient and physician I have concerns that classification will be used as a panacea for documentation; the clinical ‘shortcut’ will become a note-writing shortcut that leaves the physical therapist exposed to a Medicare audit because she has not adequately expressed her skilled decision in writing at every follow-up visit.

Finish this thought in six words or less, if possible.

Hemingway once said his greatest story was only six words long:

For sale: baby shoes, never worn.

Constraints on words sharpen the wit and focus the mind. Can we tell a story about physical therapy in six words or less?

I'll provide a lead-in... (feel free to use it, or not)

Physical therapists are the first, best choice for musculoskeletal pain patients because...

Physical therapists prepare for Medicare RACs

It's a shame that our Federal government now sees health care providers as a revenue source - (tongue-planted-firmly-in-cheek) - this may be our contribution to balancing the federal budget!

Holland and Knight attorneys have penned this helpful 25-point list for providers to consider when you consider Recovery Audit Contractors (RACs). Note that most of the audit protection measures are aimed at inpatient hospitals - that's because most of the money is in inpatient hospitals not in small, private practice physical therapy clinics.

Nevertheless, PTs may want to familiarize themselves with audit risk in general and with small practice compliance specifically. Get the small practice compliance template here.

This blog has previously commented on our experience with the RAC demonstration project in Florida (2005-2008) and the amount of the adverse impact on PTPP, on average.

We have included a chart that describes the average repayment amount from physicians (PTs are lumped in with physicians).

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80/year	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

Note, I have revealed my own clinics' individual repayment experience.

Nationally, over the three-year demonstration period private practice physicians and physical therapists groups have repaid only $19 million from a total over- and under-payment determination of over $1 billion dollars.

Consider the circumstances in the demonstration project - if an overpayment determination reached the third level of the appeals process (Administrative Law Judge) then the RAC was not paid for the overpayment.

Now, in the permanent RAC (2009 going forward), if an overpayment is appealed at any level (1st, 2nd or 3rd) then the RAC will not be paid - this is a HUGE incentive for the RAC to avoid cases which seem likely to appeal, at any level.

Many hospitals have pledged to appeal every overpayment determination based on this rationale. Holland and Knight attorney/blogger Greg Piche' advises against 'knee jerk' audit appeals - only appeal those findings that seem unwarranted and excessive.

Small PT practices may have limited resources (time and money) to automatically appeal every time but with "skin in the game" an owner is personally incentivized to appeal large overpayments based on "medical necessity" (the most prevalent audit finding).

Medically unneccesary physical therapy speaks to the "home court advantage" of small private practices - how well do you know your patient and how well do you document your evaluation findings?

Most practice owners do a very good job with the face-to-face interaction. It should be a simple matter to go one step further to use a standard documentation format to show medical necessity.

The OPTIMAL is one such format to create baseline self-report data that shows medical necessity (need) for physical therapy.

Other baseline formats include the following:

• performance measures (like TUG test, Single Leg Stance time, etc.)
• impairment measures (like Straight Leg Raise, hip internal/external rotation ROM, etc.)
• treatment-based classification measures (like traction, manipulation, stabilization, etc.

Standard baseline formats that are evidence-based are recognizable to Medicare RAC 'audit police' - especially those that are also physical therapists! If, upon reviewing your charts the auditor finds standard tests and measures they are likely to recommend 'moving on' to the next case - your case will be too likely to win on appeal.

RAC audits are an unlikely but persistent threat for small practice physical therapists. The federal governement's current budget difficulties have only increased the need for 'self-funding' programs like the RACs.

Therefore, RACs seem unlikely to go away in the near term.

Medicare Quiz

Hey PT students and lifelong learners!

Do you have time for one more final exam?

Check out the Medicare Quiz at MyPhysicalTherapySpace.com.

Larry Benz, PT puts our knowledge and assumptions to the test with a humerous take-down of all things Medicare.

Full disclosure:  I've suggested some ways to effect health care change that are closer to revolution than evolution in Larry's comments section.

Enjoy.