On Wednesday, Bloomfield, CT-based Cigna announced a definitive agreement with Chicago, IL-based Health Care Service Corporation (HCSC), a large Blue Cross Blue Shield insurer, to sell its 600K-member MA business, as well as its Medicare prescription drug plan and Medigap offerings, for $3.3B.
The two insurers also agreed to a four-year services agreement where Cigna’s Evernorth Health Services subsidiary, which includes Express Scripts, will continue to provide pharmacy benefit services to the Medicare businesses.
While Cigna is exiting the MA market, other major payers—including UnitedHealth and Humana—are seeing their MA profits drop amid an increase in utilization, according to analysis from Moody’s Investors Service.
The Gist:While it initially appeared that Cigna’s divesture of its MA business would position it to combine more smoothly with Humana, this deal with HCSC makes sense even in the wake of that reportedly called off merger.
Cigna has been a bit player in MA for years, covering only two percent of MA lives in 2023, and the shrinking pie of MA profits will discourage all but the most successful or uniquely positioned payers.
But while increasing utilization rates are contributing to a declining outlook for payers, MA is still a solidly profitable business, covering over half of Medicare beneficiaries and still growing by millions of lives each year.
The MA payers that last are going to have to work harder at integrating their various care and data assets, and more carefully manage spend for an aging cohort of seniors with increasingly complex needs.
Baptist Health said reimbursements for the medications were determined by a payment model that was later invalidated, and the insurer continues to benefit from a “windfall” of underpayments due to the health system, according to the lawsuit.
The suit comes months after the CMS finalized a rule that aimed to fix years of illegal payment cuts in the 340B program. Hospitals had previously argued the solution didn’t consider how MA insurers would benefit financially from the remedy.
Dive Insight:
The 340B program requires pharmaceutical companies to give discounts — which can range from 25% to 50% of the medication’s cost — to providers who serve low-income communities.
The program aims to help safety-net providers better serve vulnerable groups, and it has grown significantly since 340B was created in 1992.
But in 2018, the CMS cut Medicare payments for certain drugs acquired under the 340B program, setting off a legal challenge that hospitals eventually won in front of the Supreme Court four years later.
To fix the underpayments, regulators decided to pay each hospital in 340B a lump sum that would total $9 billion overall. But the fix needed to be budget neutral, so the CMS would cut payments to all hospitals for non-drug items and services over 16 years.
In comments on the proposal, the American Hospital Association argued there was a “significant problem” with the plan, noting many MA insurers pay hospitals according to traditional Medicare rates.
Payers would benefit from reducing the non-drug payments to hospitals, and wouldn’t be required to repay 340B providers for the lower payments between 2018 and 2022, commenters argued on the rule, which was finalized in November.
In response, regulators said they appreciated the concerns, but that they were outside the scope of the rule and “CMS cannot interfere in the payment rates that MAOs [Medicare Advantage organizations] set in contracts with providers and facilities.”
In the Baptist lawsuit, the health system reported it contacted Humana multiple times about retroactive adjustments and remedy payments, but the insurer’s counsel disputed any obligation to make those payments.
“Humana’s refusal to act has worked a substantial windfall to Humana as it continues to hold funds provided by CMS for Humana’s Medicare Advantage plans without reimbursing Baptist Health for the amounts owed to it under the Agreement,” the system said in the lawsuit.
Humana said it does not comment on ongoing litigation.
The physician-led healthcare network formed to save hospitals from financial distress. Now, hospitals in its own portfolio need bailing out after years of alleged mismanagement.
Steward Health Care formed over a decade ago when a private equity firm and a CEO looking to disrupt a regional healthcare environment teamed up to save six Boston-based hospitals from the brink of financial collapse. Since that time, Steward has expanded from a handful of facilities to become the largest physician-led for-profit healthcare network in the country, operating 33 community hospitals in eight states, according to its own corporate site.
However, Steward has also found itself once again on the precipice of failure.
Steward’s ongoing issues in Massachusetts have played out in regional media outlets in recent weeks. Massachusetts Gov. Maura Healey warned there would be no bailout for Steward in an interview on WBUR’s Radio Boston.
The Massachusetts Department of Public Health said it is investigating concerns raised about Steward facilities and began conducting daily site inspections at some Steward sites to ensure patient safety beginning Jan. 31.
However, the tide may have begun to change. Steward executives said on Feb. 2 they had secured a deal to stabilize operations and keep Massachusetts hospitals open — for now. Steward will receive bridge financing under the deal and consider transferring ownership of one or more hospitals to other companies, a Steward spokesperson confirmed to Healthcare Dive on Feb. 7.
While politicians welcomed the news, some say Steward’s long term outlook in the state is uncertain. Other politicians sought answers for how a prominent system could seemingly implode overnight.
“I am cautiously optimistic at this point that [Steward] will be able to remain open, because it’s really critical they do,” said Brockton City Councilor Phil Griffin. “But they owe a lot of people a lot of money, so we’ll see.”
However, the business model wasn’t immediately a financial success. Steward didn’t turn a profit between 2011 and 2014, according to a 2015 monitoring report from the Massachusetts attorney general. Instead, Steward’s debt increased from $326 million in 2011 to $413 million at the end of the 2014 fiscal year, while total liabilities ballooned to $1.4 billion in the same period as Steward engaged in real estate sale and leaseback plays.
Under the 2010 deal, Steward agreed to assume Caritas’ debt and carry out $400 million in capital expenditures over four years to upgrade the hospitals’ infrastructure. However, that capital expenditure could come in part from financial engineering, such as monetizing Steward’s own assets, according to Zirui Song, associate professor of health care policy and medicine at the Harvard Medical School who has studied private equity’s impact on healthcare since 2019.
Cerberus did not contribute equity into Steward after making its initial investment of $245.9 million, according to the December 2015 monitoring report. Meanwhile, according to reporting at the time, de la Torre wanted to expand Steward. Steward was on its own to raise funds.
Such deals are typically short-sighted, Song explained. When hospitals sell their property, they voluntarily forfeit their most valuable assets and tend to be saddled with high rent payments.
Healthcare Dive spoke with four workers across Steward’s portfolio who said Steward’s emphasis on the bottom line negatively impacted the company’s operations for years.
Terra Ciurro worked in the emergency department at Steward Health Care-owned Odessa Regional Medical Center in January 2022 as a travel nurse. She recalled researching Steward and being attracted to the fact the company was physician owned.
“I remember thinking, ‘That’s all I need to know. Surely, doctors will have their heart in the right place,’” Ciurro said. “But yeah — that’s not the experience I had at all.”
The emergency department was “shabby, rundown and ill-equipped,” and management didn’t fix broken equipment that could have been hazardous, she said. Nine weeks into her 13-week contract and three hours before Ciurro was scheduled to work, Ciurro said her staffing agency called to cut her contract unceremoniously short. Steward hadn’t paid its bills in six months, and the agency was pulling its nurses, she said she was told.
In Massachusetts, Katie Murphy, president of the Massachusetts Nurses Association, which represents more than 3,000 registered nurses and healthcare professionals who work in eight Steward hospitals, said there were “signals” that Steward facilities had been on the brink of collapse for “well over a year.”
Steward hospitals are often “significantly” short staffed and lack supplies from the basics, like dressings, to advanced operating room equipment, said Murphy. While most hospitals in the region got a handle on staffing and supply shortages in the aftermath of the COVID pandemic, at Steward hospitals shortages “continued to accelerate,” Murphy said.
A review of Steward’s finances by BDO USA, a tax and advisory firm contracted last summer by the health system itself to demonstrate it was solvent enough to construct a new hospital in Massachusetts, showed Steward had a liquidity problem. The health system had few reserves on hand last year to pay down its debts owed to vendors, possibly contributing to the shortages. The operator carried only 10.2 days of cash on hand in 2023. In comparison, most healthy nonprofit hospital systems carried 150 days of cash on hand or more in 2022, according to KFF.
One former finance employee, who worked for Steward beginning around 2018, said that the books were routinely left unbalanced during her tenure. Each month, she made a list of outstanding bills to determine who must be paid and who “we can get away with holding off” and paying later.
Food, pharmaceuticals and staff were always paid, while all other vendors were placed on an “escalation list,” she said. Her team prioritized paying vendors that had placed Steward on a credit hold.
The worker permanently soured on Steward when she said operating room staff had to “make do” without a piece of a crash cart — which is used in the event of a heart attack, stroke or trauma.
She stopped referring friends to Steward facilities, telling them “Don’t go — if you can go anywhere else, don’t go [to Steward], because there’s no telling if they’ll have the supplies needed to treat you.”
Away from regulatory review
Massachusetts officials maintain that it hasn’t been easy to see what was happening inside Steward.
Steward is legally required to submit financial data to the MA Center for Health Information and Analysis (CHIA) and to the Massachusetts Registration of Provider Organizations Program (MA-RPO Program), according to a spokesperson from the Health Policy Commission, which analyzes the reported data. Under the latter requirement, Steward is supposed to provide “a comprehensive financial statement, including information on parent entities and corporate affiliates as applicable.”
However, Steward fought the requirements. During Stuart Altman’s tenure as the chair of the Commission from 2012 to 2022, Altman told Healthcare Dive that the for-profit never submitted documents, despite CHIA levying fines against Steward for non-compliance. Steward even sued CHIA and HPC for relief against the reporting obligations.
Steward is currently appealing a superior court decision and order from June 2023 that required it to comply with the financial reporting requirements and produce audited financial reports that cover the full health system, Mickey O’Neill, communications director for the HPC told Healthcare Dive. As of Feb. 6, Steward’s non-compliance remained ongoing, O’Neill said.
Without direct insight into Steward’s finances, the state was operating at a disadvantage, said John McDonough, professor of the practice of public health at The Harvard T.H. Chan School of Public Health. He added that some regulators saw a crisis coming generally, “but the timing was hard to predict.”
Altman gives his team even more of a pass for not spotting the Steward problem.
“There was no indication while I was there that Steward was in deep trouble,” Altman said. Although Steward was the only hospital system that failed to report financial data to the HPC, that alone had not raised red flags for him. “[CEO] Ralph [de la Torre] was just a very contrarian guy. He didn’t do a lot of things.”
Song and his co-author, Sneha Kannan, a clinical research fellow at Harvard Medical School, are hopeful that in the future, regulatory agencies can make better use of the data they collect annually to track changes in healthcare performance over time. They can potentially identify problem operators before they become crises.
“State legislators, even national legislators, are not in the habit of comparing hospitals’ performances on [quality] measures to themselves over time — they compare to hospitals’ regional partners,” Kannan said. “Legislators, Medicare, [and] CMS has access to that information.”
However, although there’s interest from regulators in scrutinizing healthcare quality more closely — particularly when private equity gets involved — a streamlined approach to analyzing such data is still a “ways off,” according to the pair. For now, all parties interviewed for this piece agreed that the best way to avoid being caught off guard by a failing system was to know how such implosions could occur.
“If there’s a lesson from [Steward],” McDonough ventured, “it is that the entire state health system and state government need to be much more wary of all for-profits.”
Jayne Kleinman is bombarded with Medicare Advantage promotions every open enrollment period — even though she has no interest in leaving traditional Medicare, which allows seniors to choose their doctors and get the care they want without interference from multi-billion-dollar insurance companies.
“My biggest problem with being barraged is that so many of the ads were inaccurate,” Kleinman, a retired social services professional in New Haven County, Connecticut, told HEALTH CARE un-covered.
“They neglect to say that the amount of coverage you get is limited. They don’t talk about what you are losing by leaving traditional Medicare. It feels like insurance companies are manipulating us to get Medicare Advantage plans sold so that they can control the system, as opposed to treating us like human beings.”
Seniors face a torrent of Medicare Advantage advertising: an analysis by KFF found 9,500 daily TV ads during open enrollment in 2022. A recent survey by the Commonwealth Fund found that 30% of seniors received seven or more phone calls weekly from Medicare Advantage marketers during the most recent open enrollment (Oct. 15 to Dec. 7) for 2024 coverage.
In 2023, a critical milestone was passed: over half of seniors are now enrolled in privatized Medicare Advantage plans. The marketing for these plans nearly always fails to mention how hard it is to return to traditional Medicare once you are in Medicare Advantage, and that the MA plans have closed provider networks and require prior authorization for medical procedures. Instead, the marketing emphasizes the fringe benefits offered by Medicare Advantage plans like gym memberships.
U.S. Sen. Ron Wyden (D-Ore.), chairman of the Senate Finance Committee, criticized the widespread and predatory marketing of Medicare Advantage in a report in November 2022 and has continued to pressure the Biden administration to do more to address the problem.
The report said that consumer complaints about Medicare Advantage marketing more than doubled from 2020 to 2021 to 41,000. It cites cases such as that of an Oregon man whose switch to Medicare Advantage meant he could no longer afford his prescription drugs, as well as a 94-year-old woman with dementia in a rural area who bought a Medicare Advantage plan that required her to obtain care miles further from her residence than she had to travel before.
When open enrollment began last fall, it was “the start of a marketing barrage as marketing middlemen look to collect seniors’ information in order to bombard them with direct mail, emails, and phone calls to get them to enroll,” Wyden stated in a letter to the Centers for Medicare and Medicaid Services (CMS), which was signed by the other Democrats on the Senate Finance Committee.
Just three weeks after Wyden sent the letter, CMS released a proposed rule reforming Medicare Advantage practices that the main lobby group for Medicare Advantage plans, the Better Medicare Alliance, endorsed.
But key recommendations by Wyden were missing, including a ban on list acquisition by Medicare Advantage third-party marketing organizations, which includes brokers, and banning brokers that call beneficiaries multiple times a day for days in a row.
Among the prominent third-party marketing organizations is TogetherHealth, a subsidiary of Benefytt Technologies, which runs ads featuring former football star Joe Namath.
In August 2022, the Federal Trade Commission forced Benefytt to repay $100 million for fraudulent activities. The month before, the Securities and Exchange Commission levied more than $12 million in fines against Benefytt.
But CMS continues to allow Benefytt to work as a broker. Benefytt is owned by Madison Dearborn Partners, a Chicago-based private equity firm with ties to former Chicago mayor and current Ambassador to Japan Rahm Emanuel. Benefytt collects leads on potential customers, which they then sell to brokers and insurers to aggressively target seniors. CMS did not provide comment as to why they had not blocked Benefytt’s continuing work as a third-party marketing organization for Medicare.
Two different rounds of rule-making on Medicare Advantage marketing in 2023 instead focused on such reforms as reining in exaggerated claims and excessive broker compensation.
The enormous profits generated by Medicare Advantage plans — costing the federal government as much as $140 billion annually in overpayments to private companies — explains what drives the aggressive and often unethical marketing practices, said David Lipschutz, an associate director at the Center for Medicare Advocacy.
“The fact is, there is an increasingly imbalanced playing field between Medicare Advantage and traditional Medicare,” he said. “Medicare Advantage is being favored in many ways. Medicare Advantage plans are paid more than what traditional Medicare spends on a given beneficiary.
Those factors combined with the fact that they generate such profits for insurance companies, leads to those companies doing everything they can to maximize enrollment.”
Adding to the problem, Lipschutz argued, was the enormous influence of the health insurance industry in Washington. Health insurers spent more than $33 million lobbying Washington in just the first three quarters of 2023 alone.
“There is no real organized lobby for traditional Medicare, or organized advertising efforts,” he said. “During open enrollment, 80% of Medicare-related ads have to do with Medicare Advantage. We regularly encounter very well-educated and savvy folks who are tripped up by advertising and lured in by the bells and whistles. The deck is stacked against the consumer.”
Private equity firms have made a large investment in the Medicare Advantage brokerage and marketing sector, in addition to Madison Dearborn’s acquisition of Benefytt. Bain Capital, which Sen. Mitt Romney (R-Utah) co-founded, invested $150 million in Enhance Health, a Medicare Advantage broker, in 2021.
The CEO of EasyHealth, another private equity-backed brokerage, toldModern Healthcare in 2021 that “Insurance distribution is our Trojan horse into healthcare services.”
As federal law requires truth in advertising, a group of advocacy organizations–led by the Center for Medicare Advocacy, Disability Rights Connecticut, and the National Health Law Project–cited what they considered blatantly deceptive marketing by UnitedHealthcare to people who are eligible for both Medicare and Medicaid, in a complaint to CMS.
UnitedHealthcare had purchased ads in the Hartford Courant asking seniors in large bold-faced type: “Eligible for Medicare and Medicaid? You could get more with UnitedHealthcare.”
People who are eligible for both Medicare and Medicaid due to their income level are better off in traditional Medicare than Medicare Advantage given that Medicaid covers their out-of-pocket costs, meaning that they have wide latitude to choose their doctors, hospitals and medical procedures.
Sheldon Toubman, an attorney with Disability Rights Connecticut who worked to draft the complaint, framed the ad in the broader context of poor marketing practices by the Medicare Advantage industry.
“I have been aware for a long time of basically fraudulent advertising in the MA insurance industry,” Toubman told HEALTH CARE un-covered. “There’s an overriding misrepresentation — they tell you how great Medicare Advantage is, and never the downsides.
“There are two big downsides of going out of traditional Medicare:
They don’t tell you that you give up the broad Medicare provider network, which has nearly every doctor. And should you need expensive medical care in Medicare Advantage, you will learn there are prior authorization requirements. Traditional Medicare does almost no prior authorization, so you don’t have that obstacle. They don’t ever tell you any of that,” he said.
But it is marketing to dual-eligible individuals that is arguably the most problematic, Toubman argued. “They have Medicare and they are also low income. Because they are low-income, they also have Medicaid.
“Medicaid is a broader program — it covers a lot of things that Medicare doesn’t cover.
In Connecticut, 92,000 dual-eligible seniors have been ‘persuaded’ to sign up for Medicare Advantage. What’s outrageous about the marketing is they get you to sign up by offering extra services. … If you look at the ad in the Hartford Courant, it says you could get more, with the only real benefit being $130 per month toward food. But you now have this problem of a more limited provider network and prior authorization. UnitedHealth is doing false advertising.”
It’s a nationwide problem, Toubman said. “All insurers are doing this everywhere. We’re asking CMS and the Federal Trade Commission to conduct a nationwide investigation of this kind of problem. The failure to tell people that they give up their broader Medicare network — they don’t tell anybody that.”
For Jayne Kleinman, the unending ads are about one thing only: insurance industry profits. “Medicare Advantage has been strictly based on the people who make millions of dollars at the top of the company making more,” she said. “It’s all about money, not about you as an individual. Every time I saw an ad I’d get angry every single time — because I felt they were misleading people. The Medicare Advantage insurers are trying to scam people out of an interest of making money.”
Day one of the healthcare strategy course I teach in the Stanford Graduate School of Business begins with this question: “Who here receives excellent medical care?”
Most of the students raise their hands confidently. I look around the room at some of the most brilliant young minds in business, finance and investing—all of them accustomed to making quick yet informed decisions. They can calculate billion-dollar deals to the second decimal point in their heads. They pride themselves on being data driven and discerning.
Then I ask, “How do you know you receive excellent care?”
The hands slowly come down and room falls silent. In that moment, it’s clear these future business leaders have reached a conclusion without a shred of reliable data or evidence.
Not one of them knows how often their doctors make diagnostic or technical errors. They can’t say whether their health system’s rate of infection or medical error is high, average or low.
What’s happening is that they’re conflating service with clinical quality. They assume a doctor’s bedside manner correlates with excellent outcomes.
These often false assumptions are part of a multi-millennia-long relationship wherein patients are reluctant to ask doctors uncomfortable but important questions: “How many times have you performed this procedure over the past year and how many patients experienced complications?” “What’s the worst outcome a patient of yours had during and after surgery?”
The answers are objective predictors of clinical excellence. Without them, patients are likely to become a victim of the halo effect—a cognitive bias where positive traits in one area (like friendliness) are assumed to carry over to another (medical expertise).
This is just one example of the many subconscious biases that distort our perceptions and decision-making.
From the waiting room to the operating table, these biases impact both patients and healthcare professionals with negative consequences. Acknowledging these biases isn’t just an academic exercise. It’s a crucial step toward improving healthcare outcomes.
Here are four more cognitive errors that cause harm in healthcare today, along with my thoughts on what can be done to mitigate their effects:
Availability bias
You’ve probably heard of the “hot hand” in Vegas—a lucky streak at the craps table that draws big cheers from onlookers. But luck is an illusion, a product of our natural tendency to see patterns where none exist. Nothing about the dice changes based on the last throw or the individual shaking them.
This mental error, first described as “availability bias” by psychologists Amos Tversky and Daniel Kahneman, was part of groundbreaking research in the 1970s and ‘80s in the field of behavioral economics and cognitive psychology. The duo challenged the prevailing assumption that humans make rational choices.
Availability bias, despite being identified nearly 50 years ago, still plagues human decision making today, even in what should be the most scientific of places: the doctor’s office.
Physicians frequently recommend a treatment plan based on the last patient they saw, rather than considering the overall probability that it will work. If a medication has a 10% complication rate, it means that 1 in 10 people will experience an adverse event. Yet, if a doctor’s most recent patient had a negative reaction, the physician is less likely to prescribe that medication to the next patient, even when it is the best option, statistically.
Confirmation bias
Have you ever had a “gut feeling” and stuck with it, even when confronted with evidence it was wrong? That’s confirmation bias. It skews our perceptions and interpretations, leading us to embrace information that aligns with our initial beliefs—and causing us to discount all indications to the contrary.
This tendency is heightened in a medical system where physicians face intense time pressures. Studies indicate that doctors, on average, interrupt patients within the first 11 seconds of being asked “What brings you here today?” With scant information to go on, doctors quickly form a hypothesis, using additional questions, diagnostic testing and medical-record information to support their first impression.
Doctors are well trained, and their assumptions prove more accurate than incorrect overall. Nevertheless, hasty decisions can be dangerous. Each year in the United States, an estimated 371,000 patients die from misdiagnoses.
Patients aren’t immune to confirmation bias, either. People with a serious medical problem commonly seek a benign explanation and find evidence to justify it. When this happens, heart attacks are dismissed as indigestion, leading to delays in diagnosis and treatment.
Framing effect
In 1981, Tversky and Kahneman asked subjects to help the nation prepare for a hypothetical viral outbreak. They explained that if the disease was left untreated, it would kill 600 people. Participants in one group were told that an available treatment, although risky, would save 200 lives. The other group was told that, despite the treatment, 400 people would die. Although both descriptions lead to the same outcome—200 people surviving and 400 dying—the first group favored the treatment, whereas the second group largely opposed it.
The study illustrates how differently people can react to identical scenarios based on how the information is framed. Researchers have discovered that the human mind magnifies and experiences loss far more powerfully than positive gains. So, patients will consent to a chemotherapy regiment that has a 20% chance of cure but decline the same treatment when told it has 80% likelihood of failure.
Self-serving bias
The best parts about being a doctor are saving and improving lives. But there are other perks, as well.
Pharmaceutical and medical-device companies aggressively reward physicians who prescribe and recommend their products. Whether it’s a sponsored dinner at a Michelin restaurant or even a pizza delivered to the office staff, the intention of the reward is always the same: to sway the decisions of doctors.
And yet, physicians swear that no meal or gift will influence their prescribing habits. And they believe it because of “self-serving bias.”
In the end, it’s patients who pay the price. Rather than receiving a generic prescription for a fraction of the cost, patients end up paying more for a brand-name drug because their doctor—at a subconscious level—doesn’t want to lose out on the perks.
Thanks to the “Sunshine Act,” patients can check sites like ProPublica’s Dollars for Docs to find out whether their healthcare professional is receiving drug- or device-company money (and how much).
Reducing subconscious bias
These cognitive biases may not be the reason U.S. life expectancy has stagnated for the past 20 years, but they stand in the way of positive change. And they contribute to the medical errors that harm patients.
A study published this month in JAMA Internal Medicine found that 1 in 4 hospital patients who either died or were transferred to the ICU had been affected by a diagnostic mistake. Knowing this, you might think cognitive biases would be a leading subject at annual medical conferences and a topic of grave concern among healthcare professionals. You’d be wrong. Inside the culture of medicine, these failures are commonly ignored.
The recent story of an economics professor offers one possible solution. Upon experiencing abdominal pain, he went to a highly respected university hospital. After laboratory testing and observation, his attending doctor concluded the problem wasn’t serious—a gallstone at worst. He told the patient to go home and return for outpatient workup.
The professor wasn’t convinced. Fearing that the medical problem was severe, the professor logged onto ChatGPT (a generative AI technology) and entered his symptoms. The application concluded that there was a 40% chance of a ruptured appendix. The doctor reluctantly ordered an MRI, which confirmed ChatGPT’s diagnosis.
Future generations of generative AI, pretrained with data from people’s electronic health records and fed with information about cognitive biases, will be able to spot these types of errors when they occur.
Deviation from standard practice will result in alerts, bringing cognitive errors to consciousness, thus reducing the likelihood of misdiagnosis and medical error. Rather than resisting this kind of objective second opinion, I hope clinicians will embrace it. The opportunity to prevent harm would constitute a major advance in medical care.
HENRY KOTULA 