Who is Donald Berwick?

Posted by on Monday, Mar 29, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Obama to nominate Berwick to head CMS

By the Associated Press
March 28, 2010

An administration official says President Barack Obama will nominate healthcare scholar Donald Berwick to be CMS administrator.

Berwick, a pediatrician and noted health policy expert, is president and CEO of the not-for-profit Institute for Healthcare Improvement in Cambridge, Mass.

Berwick is also a professor of pediatrics and healthcare policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health.

An elected member of the Institute of Medicine of the National Academy of Sciences, Berwick served as a member of the IOM’s Committee on Quality of Health Care in America, which launched the slowly building revolution in healthcare quality improvement. The committee published in November 1999 To Err is Human: Building a Safer Health System, which gave the healthcare industry one of its most totemic phrases: “At least 44,000, and perhaps as many as 98,000 Americans, die in hospitals each year as the result of medical errors.”



Donald Berwick speaks up

Quote of the Day
November 18, 2005

‘A Deficiency Of Will And Ambition': A Conversation With Donald Berwick

By Robert Galvin
Health Affairs
January 12, 2005

Donald Berwick is president and chief executive officer of the Institute for Healthcare Improvement (IHI) in Boston, Massachusetts. Bob Galvin is director, Global Health Care, at the General Electric Company in Fairfield, Connecticut.


Galvin: I’m interested in your thoughts on the impact of the Leapfrog Group, an effort organized by the purchasers of health care, both private-sector employers and public purchasers. The Leapfrog agenda has focused on… benefit incentives that engage consumers and patients in the quality and cost of care…

Berwick: The one part of the (Leapfrog) plan that I am absolutely against at the moment is the shifting of burden to individual patients. I do not believe that making the individual American patient more “cost-sensitive” has any rationale in science, ethics, or evidence. It will fail, and it will fail miserably. It will result in a shifting of care away from the people who need it the most. It is a displacement of responsibility for changing the system. You know, if CalPERS or Xerox or GE can’t change care through using its purchasing power, then I absolutely promise you that Mrs. Jones can’t. The idea that she will now be more sensitive because she pays an extra ten bucks out of pocket is, to me, nearly stupid. So I really disagree with that element of the agenda.

Internationally, when one looks at high-performing systems around the world – and ours is nowhere near the highest-performing one – it is almost a routine characteristic of the best systems that they have first-dollar coverage, and there is no attempt to make patients pay more when they’re sick, which is a stupid thing to do.


Galvin: The conceptual basis of this is – as unsettling as it may be to “dangle money” to increase motivation-grounded in personality and motivation theory. In private industry, we would simply call it understanding what makes people tick. People respond to incentives. So part of the pay-for-performance movement is based on this idea that clinicians are really no different than other people and that they’ll respond to incentives.

Berwick: At the individual level, I don’t trust incentives at all. I do not think it’s true that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses. I think that’s a fundamental misunderstanding of human motivation. I think people respond to joy and work and love and achievement and learning and appreciation and gratitude-and a sense of a job well done. I think that it feels good to be a good doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and to individual pay, we are playing with fire. The first and most important effect of that may be to begin to dissociate people from their work. That’s really where we’ve come to, and we’ve done it by pay-for-performance in terms of throughput measurements and manipulating payment schemes.


Galvin: Let me move to another issue, and that is the explosion that’s about to play out in biomedical innovation. If you talk to patients… they are also interested in innovations that can cure them or their loved ones. They speak about it with pride and passion…

Berwick: I do think this: We have a learning disability in this country with respect to the difference between technologies that really do help and technologies that are only adding money to the margins of the companies that make them, without essentially paying their way in value. One of the drivers of low value in health care today is the continuous entrance of new technologies, devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know the difference, and I would more fully support what I think you’re correctly proposing, which is an innovations value. We need to help the public know the difference. There’s a big agenda here, possibly for government, to help create a public awareness that more is not necessarily better. Frequently it’s worse. So we can be smart about what we buy and what we choose not to buy.


Galvin: Many of us on the purchaser side see radically improving the efficiency of the system as a way to free up capital to cover the uninsured and to fund innovation. How do you think efficiency fits into the quality agenda?

Berwick: Let’s define efficiency as making sure that every dollar you spend gets a dollar of value back, so that efficiency is the opposite of waste. Right from the start, it has been one of the great illusions in the reign of quality that quality and cost go in opposite directions. There remains very little evidence of that. There may be some innovations that raise cost while raising quality, but many, many improvements reduce costs.

What puzzles me is how to access efficiency as a social agenda in health care. There are couple of problems. The first is that a lot of people make a lot of money on inefficiency – on production of things that have no value. So the minute you try to become truly efficient, you’re going to run into stakeholders who are going to tell you that you’re harming care, and the knee-jerk reactions of doctors and others will be to reinforce that idea. And they include you. I mean, GE pays out of one pocket and then makes money on products and services that do not add real value.


Galvin: There’s a threshold issue with most purchasers when you talk about getting a patient financially engaged. That is that no one ends up paying more because they’re sick. The only option would be to pay less. Let me give you an example: Many employer-sponsored benefit plans across the country have hospital copays as part of their cost sharing. This means that there is a fee of a hundred or several hundred dollars when one is admitted to a hospital. In these benefit designs, while most people have pretty free choice of what hospital they go to, going to the one that objective data demonstrate is of superior quality and efficiency would result in a waiver of the copay.

Berwick: Well, I can be an empiricist about it. Go ahead and try it. I shudder to think about what may happen, because in the end, that sick patient arriving at that hospital is in the absolutely weakest position at that particular point to decide, “Aha, I’m going to save a hundred dollars and go elsewhere.” That person is more likely to be poor, more likely to be black, more likely to be a low-wage earner. I think it’s regressive social policy, and I predict that it won’t work. It’s a displacement of responsibility from the stewards who actually have the job of crafting systems to meet the needs of the people who come to them for help. I think it’s a bad, bad policy, and I don’t see it playing out productively in other countries, either.

Full interview:



Checking in with Donald Berwick, President and CEO, Institute for Healthcare Improvement

Kaiser Health News
November 12, 2009

An interview of Donald Berwick (video 8:39)



Video Segments of Dr. Donald Berwick from the Documentary “Money Driven Medicine”

Health Beat by Maggie Mahar
The Century Foundation
March 26, 2010

Nine video clips (total 9:38)


Soon everyone will know what Donald Berwick is – a Harvard professor and head of the Institute for Healthcare Improvement, about to become the administrator of CMS (Centers for Medicare and Medicaid Services), assuming that he survives the acrimonious vetting process in our highly politicized Congress.

More importantly than what, today’s message tries to show who he is by repeating a prior Quote of the Day extracted from an interview of him published in Health Affairs five years ago. Also included are links to more recent video interviews of him (total less than 20 minutes).

From Alice Faryna M.D.
Columbus, OH

After hearing someone say that health care reform is the civil rights issue of this decade, I retrieved the 1966 speech on civil disobedience by Dr. Martin Luther King. The two strategies described were marches and boycotts. His marches were successful because large target populations could be found in cities like Chicago and Atlanta , and quickly reached through churches. The single-payer movement has not been able to find such concentrated populations. Our rallies in D.C. and the Mad Docs tour in 2009 did not produce numbers of sufficient size to command attention. Let’s consider boycotts.

Dr. King said, “There is nothing quite so effective as refusal to cooperate economically with the forces and institutions which perpetuate evil in our communities.” Under the leadership of SCLC, refusing to buy products from companies which do not hire Negroes (sic), resulted in an increase of income in that community by more than $2 million annually.

Another example is the boycott organized by the Committee of African Organizations (CAO) with support from South Africa ’s Liberal Party in 1959. Additional support grew in British organizations and international labor movements. South African products came off the shelves. Eventually apartheid ended.

Paul Krugman recently commented on the sharp increase in premiums announced by WellPoint in their California individual market. WellPoint is not the villain. The current system invites a death spiral for the insurance industry which relies on large a large pool containing healthy clients to keep costs down. In the current economy, cash-strapped workers drop coverage resulting in a smaller, sicker pool. Legislation which bans discriminatory practices will further increase premiums and hasten the death spiral.

I suggest that PNHP and other organizations support disinvestment in companies which are on an unsustainable path. A precedent exists for pension fund managers to do this: In 2002, CALPERS embarked on a series of “socially responsible” investment boycotts starting with Asian companies which violated guidelines on human rights and labor standards. Also targeted were companies like Disney, Safeway, the New York Stock Exchange, and health maintenance organizations.

We could begin with encouraging PNHP members to purge their personal portfolios of health insurance companies; I have already done so. I intend to approach the STRS board with a request to divest from companies likely to see a sharp stock price reduction. Money talks.

India’s outsourcers outsource to U.S.

Posted by on Friday, Mar 26, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

US healthcare reform is boon for India outsourcing companies

By Taylor Barnes
The Christian Science Monitor
March 25, 2010

President Obama signed into existence not just a historic healthcare reform law but also monumental piles of paperwork: New member registration forms. More claims. Ever-expanding databases.

The bulge in administrative work may look like a nightmare to American insurance firms and government employees. But to outsourcing executives here in India, it’s heaven-sent.

The addition of 32 million insured Americans is “very significant” for Indian outsourcers, says Ananda Mukerji, chief executive officer of Firstsource Solutions in Mumbai. Companies like his will see “increased opportunities” as US health insurers and hospitals scramble to reorganize to comply with the new law.

This extra work will include processing new enrollments, organizing bigger member databases, processing more claims, providing more support services, and managing more revenue, he says.

The US healthcare reform offers a “natural extension” of the back-office outsourcing that Indian companies already specialize in, says Tu Packard, a senior economist with Moody’s Economy.com.

But some services in the US healthcare industry cannot be outsourced beyond America’s borders due to regulations. That’s one reason major Indian outsourcing firms have set up shop in the United States. In a twist, America’s outsourcers are now outsourcing back to America.


President Obama and Congress rejected the administratively efficient model of single payer, and have now enacted into law the most expensive and most administratively complex model of reform. In the ultimate of ironies, India is now outsourcing to the United States the profusion of health care administrative services outsourced to them. It reminds you of why Willie Sutton robbed banks.

Middle and high income levels experience largest increases in financial burden

Posted by on Thursday, Mar 25, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Growing Financial Burden Of Health Care: National And State Trends, 2001–2006

By Peter J. Cunningham
Health Affairs
March 25, 2010

The financial burden of health care — the ratio of total out-of-pocket spending for health care services and premiums to total family income — continues to increase nationally.

Although attention has been focused on rising health care costs, the fact that real median household income remained largely unchanged between 2000 and 2007 — hovering at about $50,000 — was an equally important contributor to increasing financial burden.

Among the total nonelderly U.S. population during 2004–6, 15.7 percent were insured people with high out-of-pocket expenses, and 14.2 percent were uninsured for the entire year. Thus, almost 30 percent of the U.S. population either had high financial burden or were uninsured.

Among those with employment-sponsored private insurance, the percentage with high financial burden increased from 15.1 percent in 2004 to 18.4 percent in 2006 — an increase that was very similar to that seen in the 2001–4 period.

Nationally, middle- and higher-income people with private insurance experienced the largest increases in financial burden.

Between 2001 and 2006, high burdens among the privately insured increased 17 percent for those below poverty, 56 percent among middle-income people, and 98 percent among higher-income people. An additional eleven million people with private insurance had high burdens in 2006 than in 2001; of these, 39 percent were high-income and 48 percent were middle-income.

(In the legislation just signed into law by President Obama) there are no subsidies for families with incomes greater than 400 percent of poverty, a group that has been experiencing the greatest percentage increase in high financial burden in recent years.

Thus, subsidizing private coverage and expanding public coverage for lower- and moderate-income families alone is not sufficient to stem the increase in high financial burden or to reduce the variation in financial burden across states. To stem the increase in financial burden among families at higher income levels — and to sustain proposed subsidies to lower-income people — it will be essential to combine cost containment efforts in health care along with achieving real gains in family income.


Those individuals with good incomes and who have employer-sponsored health plans should not be complacent, but should be very concerned for the following reasons:

* The largest increases in the financial burden of health care have been occurring amongst middle- and higher-income people

* Among those with employer-sponsored private insurance, 18.4 percent face a high financial burden (spending over 10 percent of income on health care)

* In the reform legislation just passed, there are no subsidies for families with incomes greater than 400 percent of poverty ($88,000 for a family of four)

* Subsidizing private coverage and expanding public coverage for lower- and moderate-income families alone (the reforms in the legislation) are not sufficient to stem the increases in high financial burden

The insurance reform legislation is now law, but the measures “are not sufficient to stem the increases in high financial burden.” There is no law against passing a new law. Do we live with the increasing financial burdens of this law, or do we eliminate the financial burdens by enacting an improved Medicare for all?

News from Columbus, OH

Posted by on Thursday, Mar 25, 2010

PUSH Private Insurance Over the Cliff!

From Alice Faryna M.D.

At a presentation to Concerned Ohio Retired Educators on March 17th, I used Paul Krugman’s recent article on the “death spiral” of for profit insurance industry to call on pension plans to divest from this industry. This is the latest financial bubble and is unsustainable. Private insurance is headed for the cliff. We should give it a push. We will take this proposal to State Teachers Retirement Board next.

Reconciliation Act includes wealth transfer

Posted by on Wednesday, Mar 24, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Health Care and Education Reconciliation Act of 2010

The Library of Congress


(a) Investment Income-
(1) IN GENERAL- Subtitle A of the Internal Revenue Code of 1986 is amended by inserting after chapter 2 the following new chapter:

Sec. 1411. Imposition of tax.

(a) In General- Except as provided in subsection (e)–
(1) APPLICATION TO INDIVIDUALS- In the case of an individual, there is hereby imposed (in addition to any other tax imposed by this subtitle) for each taxable year a tax equal to 3.8 percent of the lesser of–
(A) net investment income for such taxable year, or
(B) the excess (if any) of–
(i) the modified adjusted gross income for such taxable year, over
(ii) the threshold amount.
(2) APPLICATION TO ESTATES AND TRUSTS- In the case of an estate or trust, there is hereby imposed (in addition to any other tax imposed by this subtitle) for each taxable year a tax of 3.8 percent of the lesser of–
(A) the undistributed net investment income for such taxable year, or
(B) the excess (if any) of–
(i) the adjusted gross income (as defined in section 67(e)) for such taxable year, over
(ii) the dollar amount at which the highest tax bracket in section 1(e) begins for such taxable year.
(b) Threshold Amount- For purposes of this chapter, the term `threshold amount’ means–
(1) in the case of a taxpayer making a joint return under section 6013 or a surviving spouse (as defined in section 2(a)), $250,000,
(2) in the case of a married taxpayer (as defined in section 7703) filing a separate return, 1/2 of the dollar amount determined under paragraph (1), and
(3) in any other case, $200,000.



(a) In General- Section 7701 of the Internal Revenue Code of 1986 is amended by redesignating subsection (o) as subsection (p) and by inserting after subsection (n) the following new subsection:
(o) Clarification of Economic Substance Doctrine-
(1) APPLICATION OF DOCTRINE- In the case of any transaction to which the economic substance doctrine is relevant, such transaction shall be treated as having economic substance only if–
(A) the transaction changes in a meaningful way (apart from Federal income tax effects) the taxpayer’s economic position, and
(B) the taxpayer has a substantial purpose (apart from Federal income tax effects) for entering into such transaction.



Is Single-Payer Health Care The Best Option?

By Don McCanne
The New Republic
July 16, 2008

Because of our very high costs, we must accept the fact that the insurance function is no longer simply a transfer from the many who are healthy to the fewer with health care needs, but it now must also include a partial transfer from the wealthy to middle- and lower-income individuals with needs. There is no alternative to this wealth transfer.


The traditional role of health insurance has been to transfer funds from the many who are healthy to the few who are sick. But now health care costs in the United States are so high that if we expect everyone to have the health care that they need, a transfer of funds from the wealthy down would be absolutely mandatory if we are to be able to finance that care.

The easiest way to accomplish that transfer would be to establish a single national risk pool that covered everyone, and fund that pool through progressive taxes. Unfortunately, Congress and the President selected a much more complex financing scheme for their health reform program. Nevertheless, there was no way that they could escape the necessity of including a wealth transfer mechanism. So what did they do?

The most obvious transfers are contained in the bill signed yesterday that is now law. Individuals purchasing their health plans from the state exchanges will receive federal subsidies in an amount inversely related to their incomes. Individuals with very low incomes will be enrolled in Medicaid and will not have to contribute any premium. Since the taxes collected to support these programs are progressive, the wealth transfer is automatic.

The Reconciliation Act that is still under consideration in the Senate provides additional measures that acknowledge the need for a wealth transfer, including the unearned income Medicare contribution, and the codification of the economic substance doctrine.

Our current tax policies extract both income taxes and payroll taxes from hard-earned wages, but passive unearned income such as interest, dividends and capital gains may receive favorable treatment for income taxes, and totally escape payroll taxes. It seems unfair to tax individuals who are contributing to society by their personal work effort at a higher level than wealthy individuals who contribute little more than conversation at the nineteenth hole of the golf course. The common argument that those funds shouldn’t be taxed so that they can be invested in the economy holds little water when you consider that increased productivity comes from the workforce and not from passive investors.

In recognition of this imperative of wealth transfer, the Reconciliation Act includes a Medicare tax of 3.8 percent on passive income over $200,000 for individuals or $250,000 for couples. Although that is a relatively modest tax for wealthy individuals, it is a giant step forward in solidifying the principle of wealth transfer.

The codification of the economic substance doctrine is simply locking into law the principle that wealthy individuals can no longer establish sham transactions that have the sole function of reducing income tax liability. Although this is not a wealth transfer in the same sense as the Medicare tax on passive income, it does ensure that the rightful transfer can no longer be avoided by these devious transactions, subject to an extra 40 percent penalty if attempted.

Although the decision of Congress and the President to continue to use private health insurers to finance health care was a terrible decision that we will continue to attempt to upend by pushing for a single payer system, nevertheless we can celebrate some of the beneficial features of the legislation such as the expansion of community health centers and the reinforcement of primary care.

One of the most important beneficial features of all is the firm establishment of the principle that the transfer will not come only from the healthy but must also come from the wealthy. That is a policy bridge that we will have already crossed on our march to an improved Medicare for all.

Campaign for SB 810 – Single Payer Universal Health Care

Posted by on Tuesday, Mar 23, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

California OneCare

Lily Tomlin as Ernestine

30 second video:


We have been saturated with commentary since the passage and signing of the trillion dollar Private Insurance Industry Stimulus legislation. Lily Tomlin provides us with a much needed break as she reminds us, in her own incomparable style, of the industry that Congress and the President have so richly rewarded.

Private insurer nightmare

Posted by on Monday, Mar 22, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Effects of health overhaul will take time to become clear

By Duke Helfand
Los Angeles Times
March 22, 2010

(The industry’s Washington lobbying arm, America’s Health Insurance Plans) ran ads in national newspapers last week criticizing the overhaul for failing to adequately contain costs. Without bolder action, it warned in its “Open Letter to the American People,” the country could face a healthcare cost “crisis similar to the financial crisis that has rocked our economy.”

“Virtually everyone believes that we have a huge number of issues that remain to be addressed,” said Jay Gellert, chief executive of Woodland Hills-based Health Net Inc. “If anyone thinks that just by passing this we’re going to solve the problems, they are seriously mistaken.”


I had a nightmare last night. I dreamed that we reformed the financing of health care in America, but that we left the private insurance industry in charge. Oh, wait… Oh, no!

If this bill were a step forward, we would support it
by Margaret Flowers, MD

If this bill were a step forward, we would support it.

If we believed and evidence indicated that this bill could be “tweaked” into something better, we would support it.

But this bill is a step backwards, a step away from single payer. This bill further cements the privatization of health care, further enriches the industries that are the problem.

We are seeing the same scenario play out at the national level that has played out at the state level for decades. People see the suffering because it is very real. They are told that we must do something and that this all they can get. So the people accept this believing it is an incremental step towards reform. And guess what – it is not a step in the right direction. This type of reform has failed every time. This is why we continue to be in a health care crisis.

As this passes, the public will be told it is a solution. They will be told to wait and see how it works when it is implemented in 2014. In the meantime, people will continue to suffer, go bankrupt or die of preventable causes. This is unacceptable.

We want health CARE reform. Health insurance reform makes no sense. Health insurance is very regulated but they are rich enough and clever enough to evade regulation. We will not support health insurance reform: it is a waste of time, money and human life.

If we want real reform, it isn’t going to be pretty. It can’t be brought in through the back door or by tweaking. We will have to take on a very powerful industry that currently owns the White House, Congress and the media. But work for anything less is a waste of time. The smallest increment of change that will be effective is to change to publicly funded health care.

It is not going to be another 10 years or 50 years before we get real reform if this bill fails. The single payer movement is growing. We can organize and push for real reform. But we must stand strong and united on our principles. We must put single payer on the table. It won’t happen any other way.

Dr. Margaret Flowers, a Maryland pediatrician, is PNHP’s Congressional Fellow.

Arizona shuts down CHIP, slashes Medicaid

Posted by on Friday, Mar 19, 2010

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Governor signs Ariz. budget-balancing bills

By Casey Newton
The Arizona Republic
March 18, 2010

Gov. Jan Brewer signed the fiscal 2011 budget on Thursday, enacting $1.1 billion in spending cuts and program eliminations.

The budget, passed last week by the Republican-led Legislature on largely party-line votes, drew criticism from opponents for what they called a disproportionate impact on the poor.

“I’m not sure how cutting three-quarters of a billion dollars from public education and kicking 300,000 people off of health care puts our state on the back on the road to recovery,” said Rep. Kyrsten Sinema, D-Phoenix. “In fact, it dismantles what we have been working for years to build in Arizona — a vibrant, healthy state where people want to live and work.”

One aspect of the budget expected to be challenged is a cut of $385 million to the state’s Medicaid program, the Arizona Health Care Cost Containment System.

The budget bills also eliminate KidsCare, which provided health care to 38,599 children of low-income parents.

Hours after she signed the budget, Brewer appeared at a news conference to urge opposition to federal health-care reform. Asked by reporters what the hundreds of thousands of Arizonans set to lose coverage this year should do, Brewer said they should use community health clinics and emergency rooms.


Programs benefiting low income individuals and families, such as Medicaid and CHIP, are politically vulnerable to the whims of conservatives wielding budget cleavers. Gov. Jan Brewer of Arizona has just provided us with a prime example of that.  Yet popular programs benefiting everyone, such as Medicare, are relatively impenetrable to the weapons of the conservatives.

The reform proposal likely to be enacted by Congress is heavily dependent on the expansion of Medicaid. Since it is a federal/state program, it requires the support of the government on both levels. In spite of the proposed increases in federal support, Gov. Brewer continues to urge opposition to the reform proposal. Low income families will remain vulnerable in her state as long as she and her Republican colleagues remain in charge.

Suppose Congress had included single payer in their deliberations and eventually decided that the benefits were too great to pass up ,and so enacted an improved Medicare program that covered everyone. Gov. Brewer and her ilk on the state level would be powerless to stop it. It would be so popular that conservatives who managed to take over the federal government would never be able to shut the program down.

Whether or not the current bill passes, we need to make every effort to replace our expensive, fragmented, often cruel, and relatively ineffectual system of health care financing with one that works for all of us – a single payer national health program – an improved Medicare for everyone.

Or failing that, as Gov. Brewer says, we could all just go to the emergency room when we can’t get into the clinic.

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Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.

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