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Forum on IOM: AMI's Richard Sarnat, MD, Leader in Integrative Business, Offers a Report and Musings PDF Print E-mail
Written by John Weeks   

Forum on the IOM: AMI's Richard Sarnat, MD, Leader in Integrative Business, Offers a Report and Musings

Summary: One sign of the IOM's good faith effort to bring the best people to the table for the Summit was the invitation the IOM extended to Richard Sarnat, MD, to participate in one of the Summit's influential working groups. Sarnat co-founded  Alternative Medicine Integration Group, the business that has brought us two of the most significant integrative care effectiveness experiments in the nation (HMO in Illinois, Medicaid in Florida). Sarnat takes the opportunity to summarize his perspectives on health reform, suggesting innovative polities, research models and business practices that came from discussions at the IOM. He lays out what he believes will support health-oriented, integrative practices that will break the cycle of of our degenerative addiction to disease-focused interventions. Sarnat calls on all of us to provide the grassroots backing that he believes such change will require.  

Image
Richard Sarnat, MD - on the IOM's economic-related assessment group
One action area at the IOM's Summit on Integrative Medicine and the Health of the Public was a set of invitational working "groups" or "assessment groups" that met privately during the Summit. By theme, the half-dozen groups roughly paralleled the themes of the IOM's keynotes and panels (vision, models, economic, etc.).
Each group had 12-20 participants. In moderated forums, the invitees considered the same series of 4 questions noted below. Their work was reported back to the larger gathering and is expected to figure into the report on the meeting from the Bravewell Collaborative which is to be published later this year.

That
Richard Sarnat, MD was invited to participate in the assessment group on "designing and building economic incentives" speaks well for the inclusiveness of the sponsors. I have marveled sometimes at how it is that Sarnat and his partner James Zechman, at Alternative Medicine Integration Group, have managed to produce two of the perhaps half-dozen most interesting sets of data on outcomes of integrative practices. The Imagechronic pain initiative of AMI, an Integrator sponsor, is generating data in Florida via a Medicaid waiver. I covered the structure and outcomes of this initiative in a 4-part Integrator series. The 7-year data of their primary care integrative independent practitioner association (IPA) model in Illinois was noted as one of the Integrator Top 10, for 2006. The outcomes of that model, published in the peer-reviewed media, are available via that link.

When I think of how it is that one firm can be operating 2 of the most important projects of the sort that we all need to being examining, I think back to a practice of Sarnat. Together with his business savvy and medical knowledge, Sarnat has for 30 years had a serious meditation practice. Did the combination allowed him to access some possibilities not available to most? Enjoy his report and musings.

________________________________

A SUMMIT REPORT AND INDIVIDUAL MUSINGS ON THE FUTURE OF HEALTH CARE:  (FOLLOWING MY ATTENDANCE AT) THE SUMMIT ON INTEGRATIVE MEDICINE AND THE HEALTH OF THE PUBLIC - HELD AT THE INSTITUTE OF MEDICINE, A BRANCH OF THE NATIONAL ACADEMY OF SCIENCES Feb. 25 – 27, 2009 

By Richard L. Sarnat M.D.
Co-founder and Chief Medical Officer,
Alternative Medicine Integration Group (AMI)


BACKGROUND

My invitation to the summit from the Institute of Medicine requested that I participate in the working group called “designing and building the economic incentives.”  All working group members were asked to answer the following questions: 
1) What are the three most important priorities in addressing the focus issue?
2) Who are the key actors for implementation and their roles?
3) What might be the achievable 3-year and 10-year goals?
4) What are the next steps? 
This editorial is an attempt to answer these questions more fully, while synthesizing the “highlights” presented at the summit

THE CASE FOR CHANGE

Real change and momentum exists within Washington, D.C. to promote actual health reform, as opposed to allocating more money for our current dysfunctional disease care system.  An historical window of opportunity exists, which must be seized now.  It is imperative for each of us to contact our Federal Congressional Representatives and Senators and make our passions on this issue known.  Grass roots activism is essential if we are to triumph against the prevailing forces of the “stagnant quo” who will rise to protect their economic interests.  All licensed health care providers have a place in this future model, where primary prevention and wellness strategies intersect with disease care.  But clearly, a new balance in the allocation of resources between these two disparate systems must be achieved.
A.  There is recognition that each person’s current and future state of health needs to be “spotlighted” as a national priority. Funds will be allocated to changing our current culture in order to make health a cradle to grave strategic priority for every person.

   
 
 At the conclusion of this paper
is a website that lists all
federal congressmen and their
emails. We all have homework
to do, once you finish reading!
 
B.  Economically, our nation can no longer afford to pay the costs of treating the manifestation of disease in its late stages (current system).  We must intercept the disease process at the earliest possible stage.  Screening tests for the early detection of disease manifestations are not early enough (mammograms, rectal hemacult, etc).  We must launch a national awareness campaign to all stakeholders.  Our new national motto must recognize that lifestyle changes are more powerful than pharmaceuticals.  Hippocrates was correct: your foods must be your medicines and your medicines must be your foods.

C.  We now understand the social and behavioral determinants of disease, which create a disproportionate amount of disease and expense in the under-privileged, the lonely, isolated, depressed and abused.  Evidence reveals a 5-fold disparity in total medical cost over one’s lifetime between the lowest and highest socioeconomic strata (NHIS 2001 -2005
   
Our new national motto
must recognize that
lifestyle changes are more
powerful than
pharmaceuticals.

 
 
Overcoming Obstacles to Health). Additionally, people exhibiting loneliness, isolation and depression have a 3 -7 times increased mortality.  We must intervene and build a sense of community, well-being and support within all our social agencies: early education (K-12), community service centers, corporate environments and all governmental agencies.  We must change the national consciousness to make health a cradle to grave strategic priority for every citizen. 

D.  We must re-evaluate our food and water sources, exercise habits, options for stress management and overall community support services.  Obesity, tobacco usage, diabetes (metabolic syndrome), cardiovascular disease, depression, anxiety and other debilitating manifestations of stress can all be avoided with early intervention, if the support system and new culture for personal responsibility and proactive health initiatives are pervasive.

E.  Primary school initiatives, such as placing free fruits and vegetables within the classroom and halls have been documented to produce positive behavioral changes.  Further effort must be placed on the removal of harmful foodstuffs from our school’s cafeterias.  It is unrealistic to remove all vending machines from schools, as this is a source of revenue for extracurricular school activities.  But the quality of the food offerings within the vending machines must be closely monitored for their positive/negative effect on the health of our children.

F.  No discussion of prevention and wellness can be complete without considering it a national priority to refocus our attention on creating a healthy and sustainable environment in which to thrive.  Numerous toxins, known as endocrine disruptors, such as pesticides and industrial chemical byproducts now poison our environment and negatively affect the
   
  "It is important to remember
that while all models are
wrong; some are useful.”


population.  These same chemicals, known to create infertility in mice, are presumably responsible for the 11% of our population who now have fertility problems.  Similarly, the same gene for ovarian and breast cancer now carries a 3X times risk of expression in people born after 1940, when compared to the relatively “toxic-free” environment of the pre1940s.  It is instructive to look to Darwin and understand what allows for species longevity:  “It is not the strongest of the species that survives but the ones most adaptable to change.”  If awareness is truly the first step to healing, then let this be a call to action for our government - that an increased focus on wellness and prevention cannot take place without a comprehensive strategy that encompasses our family, our schools, our communities, our nation and our entire planet.

Our current disease care system was invented with economic incentives to reward an acute disease care model.  However, the various disease states and their cost burdens have shifted significantly over the last 50 years. In contrast to 50 years ago, 75% of our current total medical spend is now on chronic illness.  While conventional medical care excels at the treatment of acute disease, it neither prevents disease nor treats chronic illness effectively.  Our current reductionistic model of western science and our economic reimbursement model inadvertently have promoted the danger of falling in love with technological advancement for the sake of new advancement, in and of itself.  New is not always better.  Or, as I used to say in the operating room, “the enemy of good is better.”

   
"From my standpoint on the
first state technology
assessment committee
in the country here in
Washington State, I am
amazed to see the lack of
robust data to support
many of these technologies.”

- Michelle Simon, ND, PhD
  
 
To quote Michelle Simon N.D. PHD, who sits on the Washington State Technology Assessment Committee (the first state to scrutinize the evidence base of new or existing technologies before granting reimbursement by state funded health care plans.),  “I especially want to stress the evidence based evaluation of technology.  We spend a great portion of our healthcare dollar on technological interventions.  We need to make sure that those devices and/or interventions are indeed safe, effective and cost-effective.  From my standpoint on the first state technology assessment committee in the country here in Washington State, I am amazed to see the lack of robust data to support many of these technologies.” 

Our current disease care system is neither:  we are the only western developed nation not to have universal health care.  We spend twice as much as the next closest nation and the WHO ranks our outcomes overall at 37th worldwide.  As a medical doctor and compassionate human being I feel this is an embarrassment for our country, which is criminal at worst and shortsighted at best...

THE EVOLUTION OF A WHOLE PERSON HEALTH AND WELLNESS TREATMENT MODEL

Our current economic model, with its economic rewards for the over-utilization of technology, medical devices and pharmaceutical usage in our disease care system, must be changed to an outcomes-based reimbursement model.  Why not create economic incentives to reward our primary care physicians so that 50% of their income is derived from metrics, which measure the health status of those for whom they care?  Standard clinical benchmarks such as:  hospitalization days, hospital
   
 Our current economic model,
with its economic rewards for
the over-utilization of technology,
medical devices and pharmaceutical
usage in our disease care system,
must be changed to an outcomes-
based reimbursement model.

 
admissions, pharmaceutical utilization, pre/post HRA’s, Obesity percentage, tobacco cessation percentage, etc. can all be monetized to economically reward correct physician and patient behavior.The IOM estimates that 50% of all conventional medical expenses are not evidenced based, are unnecessary and are potentially harmful.  Thus, the savings created from proper utilization of our current disease care system will net more than enough funds to create a health and wellness system, which should exist as the primary portal to the disease care system.  While attending the summit, one of the nation’s most respected cardiologists testified before the Congress that 100 billion dollars per year is spent unnecessarily on both cardiac stents and angioplasties.  In a study of over 30,000 patients, cardiovascular diseases were deemed preventable for almost 95% of the population at risk, just by changing diet and lifestyle (Yusuf S et al, Lancet 2004).  This is a perfect example of the cost offsets that can be utilized to pay for a health and wellness initiative.

A.   Our current disparity in reimbursement, between primary and specialty care medical doctors, has created a situation where less than 5% of all medical school graduates now choose primary care as their future occupation.  This shift in choice of future practice patterns will, in the near future, create a large shortage of primary care MDs and DOs.  It is estimated that by 2025 we will have 200,000 too few conventional medical physicians to serve the needs of the public (Cooper and Getzen, Health Affairs 2002).  Is this a bad thing?  Primary care MDs/DOs are not well trained in prevention and wellness interventions when compared to other primary care provider options:  doctors of chiropractic (DCs), naturopathic doctors (NDs), doctors of oriental medicine practicing traditional Chinese medicine (DOM/TCM) and holistic nurse practitioners (NPs), who should prove to be more effective as a primary car portal to wellness and
   
  A loan forgiveness program,
such as the model existing
in Washington State, would
further economically reward
health care providers to
choose primary care and help
meet the predicted workforce
needs of our future.
  

prevention strategies.  A loan forgiveness program, such as the model existing in Washington State, would further economically reward health care providers to choose primary care and help meet the predicted workforce needs of our future.  While currently this loan forgiveness program only covers naturopathic physicians, licensed midwives, nurse midwives, doctors of pharmacy and dental hygienists, I think it would be more efficacious if it included holistic primary care providers of all licensures, as suggested above.

B.   Many other licensed wellness and prevention health care providers exist and would be capable of making large contributions:  acupuncturists, massage therapists, nutritionists, mental health specialists, fitness and exercise specialists, stress management specialists, dentists and dental hygienists.  As non-licensed practitioners pose regulatory problems and must be under the direct supervision of a licensed provider in the clinical setting, all health care providers are encouraged to form professional boards for licensure and accreditation.

   
I would recommend that Federal
and State Agencies restrict
educational grants to those
institutions willing to cross train
all primary care providers
as a cohort, e.g. ideally MDs,
DOs, DC’s, NDs, NPs and DOM/TCM
should be doing hospital rounds
as a cohort. 

Those who train together
will practice together.


 
C.   A new patient/relationship-centric paradigm of medical school education with core competencies across all primary care providers needs to be developed.  In my opinion, National University of Health Sciences (Lombard, Illinois) is, perhaps, the most well developed model of a university setting where DCs, NDs, TCM practitioners, massage therapists and other health care providers and students share a patient/relationship-centric core curriculum.  I would recommend that Federal and State Agencies restrict educational grants to only those institutions willing to cross train all primary care providers as a cohort, e.g. ideally MDs, DOs, DC’s, NDs, NPs and DOM/TCM should be doing hospital rounds as a cohort.  Those who train together will practice together.

D)   A profound evidence base exists and is ever expanding for mind/body therapies:  new research showing neuroplasticity in the brain from visualization (yes, objectively on scans we can grow dendrites) as well as the ability to alter one’s existing genes (altering the growth and repair of telomeres via the regulation of telomerase) show the enormous potential within the various interventions in this sector (Conrad, Behav Cogn Neurosci, 2006); (Ornish D et al, Proc Nat Acad Sci 2008).  The historic debate as to the relative weight and predictive modeling of our nature (genetic basis) versus nurture (our environmental influences) is anything but straightforward.  It has now been demonstrated that our gene expression in over 500 genes can be modulated beneficially by interventions with nutrition and lifestyle changes alone (Ornish D et al, Proc Nat Acad Sci 2008).  The strength of this association is further substantiated by the fact that the degree of successful lifestyle changes was also positively correlated with significant measurable decrease in the growth of prostate tumor cells, as evidenced by the concentration of LNCap (Ornish D et al, J of Urology 2005).  By contrast, there is not a single pharmaceutical which can accomplish the up-regulation of gene expression, yet we remain ever fascinated with the utilization and high cost of the pharmaceutical model.  Such are the dangers of economically rewarding patented R&D, while naturally occurring biologics and life style changes are difficult to monopolize and thus economically reward

Another example of the evidence base for mind/body interventions is the existing research on Transcendental Meditation (TM).  A long-term grant from NCCAM, conducted over 9 years with 1500 subjects for the treatment of essential hypertension, has illustrated that from both a clinical and cost effective standpoint (TM) should be considered as a first line treatment instead of pharmaceuticals. (Schneider, R., et al, Am. J. Cardiol 2005)  The usefulness of TM is further substantiated by additional recent meta-analysis (Anderson, J. et al, Am J Hypertension 2008) and (Maxwell, R. et al, Cur Hypertension Reports 2007).

E.  The corporate, private sector has been an excellent testing ground for the evaluation of prevention and wellness interventions:  A meta-analysis of all evidence based wellness and prevention programs currently offered in the workplace shows a 3.5 ROI within a 3 – 4 year period.  (Pelletier, K. – IOM presentation)

FUTURE RESEARCH MODEL


Our current research model, the double-blinded randomized controlled trial (DBRCT), was developed as a methodology for the study of pharmaceutical interventions.  It is best at measuring a single variable direct comparison.  Integrative medicine/health is not practiced as a single variable.  It is a model which is patient/relationship-centric and uses many modalities, thus creating a multitude of variables in a non-controlled environment.  As such, DBRCT is not a viable methodology to measure the evidence
   
  It is imperative that the
research communities,
especially those at the
NCCAM, recognize that
a practice based research
methodology must be
developed, refined and
adopted for the future
study of integrative
medicine/health. 

Dr Pelletier, in his
presentation, suggested
that we incorporate a cost
benefit analysis (CBA)
model into all “effectiveness”
trials throughout the health
care continuum.
 

base for integrative medicine/health.  It is imperative that the research communities, especially those at the NCCAM, recognize that a practice based research methodology must be developed, refined and adopted for the future study of integrative medicine/health.  Dr Pelletier, in his presentation, suggested that we incorporate a cost benefit analysis (CBA) model into all “effectiveness” trials throughout the health care continuum.  This way the real-world impact of the integrative medical model can be quantified by monetizing such variables as pharmacy offset, patient and provider satisfaction, changes in HRAs or SF-12s, as well as overall employee performance and productivity measurements (which are of interest to the corporate sector).

NCCAM should look to partner with existing population and practice based models and coordinate both the refinement of research methodology and the effectiveness of the practice based model (when possible) to strive for the best possible evidence based outcomes.  Despite the lack of a demonstration-ready integrative medical/health model, much can be learned from the examination of already existing models, which have in some cases been around for decades.  As opposed to the study of individual CAM modalities, there are a variety of settings and models, which are population-based approaches to the delivery of integrative medicine/health.

While I am admittedly biased as the medical director of this IPA, I believe that from an integrative medicine/health model, the largest population treated over the longest timeframe is the AMI IPA- model contracted with BCBS’s HMO-Illinois.  This population which averages 1000 members per month has been under study for 11 years and has been documented to have exceptional clinical and cost effective results, literally reducing the total medical spend on an age/sex adjusted risk pool population by over 50% annually (Sarnat JMPT 2007).  The HMO is a classical gatekeeper model where the AMI Primary Care Physicians (PCPs) uniquely have been MDs using natural medicine interventions or chiropractors (DCs) who specialize in the practice of broad scope chiropractic.  It is my educated guess that any naturally-based broad scope primary care provider who meets the state regulatory PCP licensure requirements would be effective in this role:  MDs, DOs, DCs, NDs, DOM/TCM and holistic NPs.  I would suggest that as a matter of national security (our immanent bankruptcy if we get this wrong) that the federal government mandates that all of the above primary providers be licensed in every state, after meeting the newly proposed core competency primary care curriculum.  This will alleviate the impending shortage of primary care MDs/DOs and provide a more holistic and patient/relationship centered portal of entry into the health/wellness/disease care system. 

   
  AMI’s experience in this
model has shown that a
capitated economic model,
that shares its cost offsets
for the reduction in total
medical expenses, is a fair
and sustainable model
for the delivery of integrative
medicine/health.
  

AMI’s experience in this model has shown that a capitated economic model, that shares its cost offsets for the reduction in total medical expenses, is a fair and sustainable model for the delivery of integrative medicine/health.  The current contract between HMO-Illinois and AMI, however, is not ideal in that the managed care organization (MCO) fails to share with the IPA the reduction of expenses gained through the decreased utilization of pharmaceuticals.  As this is a major component of the total medical spend, it threatens the sustainability of this model.  There is no reason that future private or governmental economic models could not correct this deficiency, which would increase the overall revenues to the IPA by an estimated 30%.   The improved IPA-model would have the following components:
1.   Government agencies, self funded ERISA plans and MCOs would provide an age/sex actuarial risk pool calculation of total medical expenses for a given population prior to taking their margins; in other words the total premium paid.

2.   The integrative medical/health IPA would then contract with the large MCOs to utilize the leverage of their existing contracts for networks, hospitals, reinsurance, PBM’s and all other exotic carve outs (transplant centers, addiction programs, durable medical equipment, etc.).

3.   The IPA would pay capitation to all of its PCPs for primary prevention/wellness outpatient care.  Aside from the few holistic natural medicine MDs and DOs acting as PCP’s, all other MDs and DOs would practice as secondary and tertiary specialists and would be paid negotiated fee-for-service or per member per month (PMPM) carve outs, as the IPA desires.  In our experience, once proper wellness and prevention measures are emphasized at the PCP’s portal of entry, the utilization of secondary and tertiary conventional medical specialists is so small that this expense represents a small percentage in the total medical spend. The resultant savings from the previous over-utilization of procedures, pharmaceuticals and surgery is reallocated to the many CAM modalities, which are more low cost, low technology and have a higher patient satisfaction than conventional medicine.  Outcomes savings can then be shared back to the PCPs on a percentage basis, as they have created the transformation to health/wellness, which has reduced the downstream costs of the disease care system.  In other words, outcomes based reimbursement model.

4.   As the IPA, not the MCO or governmental agency, now assumes the primary financial risk, it is at the discretion of the medical director for the IPA as to define the benefit coverage for CAM and conventional medicine.  This puts the benefit decision back within the sphere of the implicit trust between the health care provider/team and the patient who chose the team, without interference from the government (CMS) or the MCO.  Historically, legal actions against CAM and IM providers is very low; thus I do not feel this will be a barrier to the acceptance of this model. 

5.   A process already in place in Washington State is the formation of a consensus panel of clinicians to screen the evidence base for clinical and cost outcomes before any new or existing treatment or procedure is allowed upon the population’s members.  This helps negate the immense industry pressure (both CAM and conventional) to utilize new treatment modalities, when they may have no actual clinical and cost effective advantage over the current best treatment options.
There are other sub-models that the IPA can use within its population, such as TM for all hypertensive patients meeting a set criterion, AMI’s integrative chronic pain management program (as previously reported in the integrator blog), preoperative visualization techniques, stress management techniques or health coaches, etc. for defined populations at risk.  Obviously, the primary focus even in disease management should be away from the current model of pharmaceutical compliance and towards the whole person-healing model of root cause analysis.

While the task of health reform as discussed above may seem daunting, it is instructive to examine the footsteps of those who have gone before us on a similar quest.  This is best illustrated by examining the steps taken by Oregon’s legislators. In 1987, the Oregon Legislature realized that it had no method for allocating resources for health care that was both effective and accountable. Over the next two years, policy objectives were developed to guide the drafting of legislation to address this problem. These policy objectives included:

  • Acknowledgment that the goal is health rather than health services or health insurance
  • Commitment to a public process with structured public input
  • Commitment to meet budget constraints by reducing benefits rather than cutting people from coverage or reducing payments to levels below the cost of care
  • Commitment to use available resources to fund clinically effective treatments of conditions important to Oregonians
  • Development of explicit health service priorities to guide resource allocation decisions

A complete review of Oregon’s methodology in prioritizing care can be found through this link and  in the document:Oregon Health Services Commission. Prioritization of Health Services: A Report to the Governor and the 74th Oregon Legislative Assembly. Salem, OR: 2009. DiPrete, Bob and Darren Coffman. A Brief History of Health Services Prioritization in Oregon. Mar. 2007. Health Services Commission. 4 Mar. 2009
 

 

IN CONCLUSION

   
 
While imperfect, I do feel
that the direction given by
this summary of ideas
generated by so many leaders
 in the health care sector
gives us a workable road map
for our immediate and long
term future. 

May the arrow find its target
and allow us to become the
society and planet worthy
of our heritage.
 
This document is a synthesis of the ideas presented at the integrative medicine Summit and my personal editorial bias, which reflects the distillation of the many conversations and presentations that I was privileged to have over the course of this historic event.  I intend to submit this document to Senators Kennedy and Harkin, who will chair the committee for health care reform, as well as to make it available by Internet and peer review journal.  It is my sincere hope that it will act as a call to action for all of us who feel passionate about creating true health care reform.  While imperfect, I do feel that the direction given by this summary of ideas generated by so many leaders in the health care sector gives us a workable road map for our immediate and long term future.  May the arrow find its target and allow us to become the society and planet worthy of our heritage.

IT IS NOW TIME TO CALL AND EMAIL YOUR CONGRESSMEN, YOUR FRIENDS AND MAKE SURE THAT THOSE ENGAGED IN THE POLITICAL PROCESS UNDERSTAND THAT THERE IS A NATIONAL CONSENSUS FOR WHOLE PERSON HEALING; THAT IT IS NOT ENOUGH TO INCREASE OUR FUNDING AND FOCUS ON ACUTE, CRISIS DISEASE CARE, WHILE IGNORING THE ROOT CAUSE OF ALL DISEASE.   WE MUST MAKE SURE THAT OUR VOICES ARE HEARD LOUD ENOUGH, THAT THE WELL-HEELED VESTED INTERESTS WITHIN THE “STAGNANT QUO” WILL NOT BE SUCCESSFUL IN DERAILING TRUE HEALTH CARE REFORM.  GOD BLESS

http://www.congress.org/congressorg/home/
Right there on the left side of the home page you will see:

My Elected Officials
Find and contact your federal, state, and local officials.
Enter ZIP Code     

Gives you everything you would want to know about your own personal elected officials!
 

Comment
: I have been a fan of Sarnat's work since I first heard of it, via reporting his unique IPA model in Illinois a decade ago. Happily, the feeling has been mutual. Those of you who value the Integrator have Sarnat and his colleagues at Alternative Medicine Integration Group to thank for their steady, 3 years of Integrator sponsorship.

Sarnat and I have always shared a kind of dumb-foundedness that so few of our colleagues have developed business models based on actual clinical and cost outcomes. I cannot count on more than one hand those that have. And thus, here we remain, a decade down the pike, with woefully little effectiveness evidence to go along with our claims that this care we providee is more effective and cost effective that conventional treatment. Yes, contact your federal officials. But, for you who are part of healthcare operations, let's also contact our own experience to ask the right questions and mine the data!


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