Monthly Review & Commentary On Health Issues From A Rural Perspective - September 1st, 1997

The Price of Greed
Our country's most aggressive for-profit health care giant has run into the brick wall of a system-wide Medicare fraud investigation and its consequent indictments. A small, stealth group of large urban hospitals almost succeeded in capturing a major Medicare capital payment exemption until exposure by Modern Healthcare set off a firestorm of opposition. The former action is likely criminal while the latter's not, but both represent a growing threat to each of us­the increasing seepage of greed into health care.
With a limited pot of Medicare dollars, every time a fraudulent claim is paid or when a subset of hospitals lobby secretly to rip off a billion dollars, all other providers lose. But these are the small potatoes. Where we lose big is with our patients and with our customers as they grow to believe that today's health care providers are motivated more by greed than by anything else. All the marketing campaign jingles in the world won't get this genie back into the bottle once it's out.
Our communities have believed that as health care providers we were primarily motivated to care for them as individuals, whatever it took and "to above all, do no harm." In exchange, we have benefited from major public and private philanthropy, multiple tax exemptions and a political base that has tended, all things considered, to be supportive. All of these benefits are being whittled away with the mounting evidence of the excessive pursuit of profit, by "tax-paying" and "tax-exempt" alike.
A popular rejoinder for non-profit administrators in an increasingly competitive, profit oriented market has been, "no margin, no mission." It's about time that we recognize the unique dual focus of our industry requires us to equally often chant "no mission, no market."
Americans remain decidedly uneasy about the use of the market place to allocate health care resources and more so, how their access to care may be limited. If public attitudes shift away from trusting health providers to be above all, patient driven, it will also shift away from accepting the current experiment with the competitive model.
We don't manufacture widgets or flip burgers; we are in the business of being entrusted with the life and well-being of parents, children and friends. If in our attempt to adapt health care to competitive markets we lose this trust, the public will return to government as a last resort. Its ours to lose, but we seem to be at risk of doing just that.
Governors Given Medicare Hot Potato
Wisconsin and all other states have the opportunity to eliminate rural-urban payment differentials for Medicare HMO premiums and medical savings accounts. "All that it takes" is a brief note from the Governor to Secretary Donna Shalala.
Buried in The Balanced Budget Act of 1997 (Section 1851(d)(3)(A)(i)) is an unpublicized provision worth noting. "Upon written request of the chief executive officer of a State for a contract year... the Secretary shall make a geographic adjustment to a Medicare+Choice payment area... to a single statewide Medicare+Choice payment area." This should make for some interesting discussions around many state capitals.
Employee Health Insurance Varieties Grow
From "Workers Getting Greater Freedom in Health Plans" by Peter T. Kilborn in The New York Times, 8/17/97:
"In response to public fears of restrictions on access to doctors and hospitals, employers have been offering their insured workers and retirees much wider varieties of health care, though sometimes at a higher cost to the workers."
"In the basic form of a health maintenance organization, participants must choose a primary care doctor from the group's network to act as a gatekeeper and steer the patient to specialists who are in the network. Now, most workers can choose other forms of managed care that offer more freedom, though they often must pay extra for the privilege."
"Point-of-service plans, which allow workers to choose where they go for care, also use gatekeepers. But the plans permit participants to bypass them and the plan's stable of doctors, again for an extra fee."
"Preferred-provider plans eliminate gatekeepers and let the patient choose any doctor -- primary care or specialist -- within the network, paying a set co-payment. If the patient selects a doctor outside the network, the cost would be higher, typically, 10 percent or 20 percent of the doctor's fee."
"The most expensive care is the traditional fee-for-service, or indemnity plan, under which employees can choose any doctor or health service, but generally pay a portion of the expense and a higher premium."
"Analysts say employers can offer more flexible coverage than they could even a few years ago because the overall cost of health care has stabilized. Employers also enjoy rising profits in the surging economy, permitting them to treat health plans more generously."
"Some analysts warn that as medical technology devises costly new cures for the ailments of the aging baby-boom population, today's climate of stable costs and wider choice will fade soon after 2000. 'I think it's great,' Meyer of the Economic and Social Research Institute said of the latest trends. But with more workers seeking more costly services, he said, 'My prognosis is that health care is going to have to be rationed.' "
[The data for the above graph is from Peat Marwick's Center for Survey Research, which this year looked into 1,502 randomly selected companies with more than 200 employees.]
Federal Funding for Children's Health
As a result of the recently passed federal budget, Wisconsin will receive $191 million in a new Children's Health block grant over the next five years. The following summary is from the "Overview of The New Child Health Block Grant" by Cindy Mann and Jocelyn Guyer at The Center on Budget and Policy Priorities. The Center analyzes a broad range of budget and policy issues, with an emphasis on those affecting low and moderate income Americans. The full text can be found at:
"The Balanced Budget Act of 1997 includes a child health block grant that offers states $20.3 billion in new federal funding over the next five years to provide "child health assistance to uninsured, low-income children in an effective and efficient manner that is coordinated with other sources of health benefits coverage for children."
"The law allows states to use these funds to expand coverage for children under the Medicaid program or to create or expand separate child health insurance programs. States that opt to spend their funds in separate child health insurance programs will have wide latitude in determining eligibility criteria but must comply with federal standards relating to the benefits offered and the cost-sharing requirements imposed. Under either the Medicaid or the separate state program option, states must spend some of their own funds as a condition of receiving federal funds."
Allowable Uses of Block Grant Funds--"In general, the amount of block grant funds a state spends for purposes other than providing coverage may not exceed 10 percent of the amount it expends for coverage. The funds spent for purposes other than family coverage may be used for administrative costs and certain other broadly defined activities including outreach, 'child health assistance' other than insurance coverage, and health services initiatives for 'improving the health of children.' "
Options for Providing Insurance Coverage--"The law permits states to use their block grant funds to expand coverage under the Medicaid program, to provide coverage under a separate state child health insurance program, or both. Under both the Medicaid expansion and separate state program option, a state must spend some of its own funds as a condition of drawing down the new federal funds. Regardless of whether a state elects the Medicaid or the separate state insurance program option (or a combination of both), it generally can use the funds to provide coverage only to children with family income below 200 percent of the federal poverty line."
Health Insurance Coverage Standards-- "If a state elects to use its child health funds to expand Medicaid coverage, the Medicaid program rules on benefits and the scope of coverage will apply to the group of children covered under the expansion in the same manner that they apply to children already eligible under the Medicaid program. If a state elects to use its child health funds to cover children under a state insurance program, however, the coverage it offers must meet the benefit and cost-sharing standards established in the new law."
Premium and Cost-Sharing Limitations--"The new law limits the extent to which states can impose premiums or cost-sharing (i.e., deductibles, coinsurance and co-payments) on children enrolled in separate state programs financed with child health block grant funds. In general, states cannot adopt cost-sharing or premium policies that favor higher-income families over lower-income families. They also are prohibited from imposing cost-sharing for well-baby and well-child care, including immunizations. Finally, states cannot count money raised through premiums or cost-sharing as state dollars for purposes of meeting the block grant's matching requirements."
"In the coming months, states will be making important decisions about how to use the new federal block grant funds to expand health care coverage to uninsured, low-income children. These decisions will determine how broad the expansion of coverage will be, whether the benefits provided will be affordable and adequate, where children will be receiving their care, and whether the new expansion builds on or at least coordinates closely with the state's current Medicaid program."
Untangling Fraud from Errors
The following article (and many similar ones over the last couple of weeks) easily leaves all of us with the false impression that 14 cents on every Medicare dollar is being lost to fraud. Medicare fraud is a serious financial, legal and moral problem, and deserves the attention it is getting. However, billing errors and honest misunderstandings of notoriously obscure government directions is not fraud, in any sense of the word.
In general the Feds have not made clear what portion of the now infamous "14%" is for necessary care, albeit not documented to exact federal specifications. They have not yet distinguished between what portion of the "14%" is best addressed through better government and provider management versus what portion deserves referral to the criminal justice system. Nonetheless we need to better understand the fraud that is occurring; from "System Easy to Cheat, Officials Say, and Many Abuses Go Undetected" by David S. Hilzenrath in The Washington Post, 8/8/97:
"A psychologist billed for more than 24 hours of therapy in a single day. A home health agency charged for visits to patients' homes when they were actually hospitalized. A nursing home submitted claims for surgical dressings on behalf of patients who had not undergone surgery. And a fictitious diagnostic firm collected payment for nonexistent lab work on dead people."
"The improper payments totaled $17.8 billion to $28.6 billion, an average of 14 cents of every dollar Medicare paid in medical fees, according to a recent federal audit. Much of that money was lost to widespread and systematic looting -- a testament to greed, creativity and the vulnerability of a government program that experts say is easy to cheat."
"Then there was the doctor who charged Medicare for collagen injections to erase the wrinkles on patients' faces and make their lips fuller -- cosmetic procedures that the program doesn't cover. The doctor got away with it for almost a decade by disguising the treatments as diagnostic tests."
"Some of the alleged abuses are more subtle. For example, a vendor of medical equipment submitted claims in Pennsylvania for goods sold in western New York to take advantage of a difference in reimbursement rates. On a grander scale, more than 4,600 hospitals have allegedly double-billed Medicare by submitting claims for blood tests, X-rays and other outpatient services performed during pre-admission workups. Those services are supposed to be included in the fee Medicare pays for a related inpatient stay. The government expects to recover $90 to $110 million in settlements."
"Similarly, major laboratories have been accused of gaming the system by 'unbundling' their claims -- for example, performing a set of more than a dozen automated lab tests on a single blood sample and charging separate fees for some of the tests, instead of the lower combined rate."
"The complexity of Medicare's voluminous billing regulations has been an invitation to manipulation -- as well as errors of interpretation. For providers, the risks and rewards can depend on the billing codes they use to describe their services -- for example, whether a hospital patient's initial consultation with a doctor is assigned code 99251 as 'problem focused,' code 99252 as 'expanded,' code 99253 as 'detailed,' or code 99254 as 'comprehensive.' Choosing the right code is 'not an absolute science. It's more of an art form, admittedly,' said George M. Reeb, HHS assistant inspector general for health care financing audits."

National Rural Health Association's

5th Annual National Symposium

On Rural Hospital Issues

Reno, Nevada

October 16-18, 1997

Keynote Address:

The Public-Private Politics of Rural Health Care

Town Hall Meeting for policy input into NRHA

Workshops include:

Developing Provider Sponsored Organizations

Fraud & Abuse: New Developments

Corporate Compliance--Curse or Blessing

Managed Care in the Rural Health System

Physician Recruitment and Compensation

Legislative and Regulatory Update

New 401(k) Options for Hospitals

Please call NRHA for information: 816-756-3140

or check out on their web site at:

Pharmaceutical Foxes Guarding Chickens
From "Drug Firms Said to Pressure Doctors" by David S. Hilzenrath in The Washington Post, 8/14/97:
"Pharmaceutical companies are compromising patients' health by pressuring doctors and pharmacists to switch prescription drugs for commercial reasons, according to a report issued yesterday by a New York City watchdog agency."
"The report argues that drug makers are taking advantage of their ownership of companies that manage prescription drug benefits for health insurance plans."
"Citing sealed records in an industry lawsuit, the report by New York Public Advocate Mark Green alleges in particular that drugmaker Eli Lilly and Co. planned to use its ownership of one such firm to favor Lilly medications Prozac and Axid over rival products."
"A Lilly spokesman yesterday denied that its practices compromise patient health, adding that all products favored by PCS 'must meet the high standards of therapeutic excellence and offer a cost-effective option for the customer.' "
"So-called pharmaceutical benefit managers (PBMs) aim to reduce prescription drug expenses by obtaining rebates from manufacturers and by steering doctors and pharmacists to products for which they have negotiated a competitive price. For example, PCS has offered pharmacists as much as $12 each time they successfully substitute a drug on PCS's list of favored products for one excluded from the list, said Rashmi Vasisht, an analyst who worked on the report."
"Critics have long questioned whether PBMs can serve as impartial brokers for clients when their owners, major drug companies, have strong vested interests."
AMA Takes on Mantle of HMO Watch Dog
How do you understand something without vigorously seeking both sides of the story? This concern does not appear to have troubled the American Medical Association's (AMA) as it has issued a call to arms in in the 8/4/97 American Medical News as part of a now fashionable backlash against managed care:
"The American Medical Association's (AMA) Division of Representation is asking that AMA members report the problems that they and their patients are encountering with health plans. The Association wants to understand and document what's going on as well as to provide representation to member physicians and local medical societies. Among the areas that the AMA would like to know about are":
"Among the latest twists, and one that the AMA would like to hear more about, is plans confusing what's medically unnecessary with what's not covered by the plan. Physicians deliver what they believe is necessary care and are then barred from billing for the service or telling patients it is not covered. The implication left in the minds of patients is that the treatment is unneeded, but what is actually going on is that the plan is veiling its own refusal to cover the service."
"Increasingly, AMA's advocacy role includes going to bat for individual physicians by speaking with or writing to health plans. Individual advocacy can lead to changes in health plan policies and broader reforms. The AMA also participates in lawsuits on large-scale and precedent-setting cases through the Litigation Center it operates in conjunction with state medical societies."
"The AMA may be able to help you. And by reporting these situations, you will have helped patients and other physicians who are facing the same problems. Contact: Carol O'Brien (312) 464-4367 or e-mail:"
Columbia/HCA Shifts Physician Strategy
Columbia/HCA's new chief executive officer Thomas F. Frist Jr., M.D. is unlikely to be much in demand as an eulogist following his remarks about recently ousted executive Richard Scott. But of greater significance is the massive hospital company's decision to unwind its controversial strategy of having physicians own part of local hospitals. From "Frist: It's Time For A Culture Shock" by Patricia B. Limbacher with Bruce Japsen in Modern Healthcare, 8/4/97:
"He also criticized the departed Columbia chief's management style and questioned the company's strategy, especially its physician ownership deals... 'This is a new approach, a new management and a new commitment not to be adversarial,' Frist said. 'This will be more than an entrepreneurial leadership. It will be more operational.' "
"Frist said he wanted to inject a new value system and culture at Columbia, something the employees were "starving for years" to get. While he repeated his past accolades of Scott for making Columbia the nation's largest for-profit healthcare company, Frist-for the first time publicly-was equally critical."
" '(Scott's aggressive style isn't) the foundation for operating a company in the long term,' Frist said. 'We need to take a deep breath and get in an operational mode. This is a style issue that needs to be changed. We have to put in a new culture . . . a value system.'... 'The Scott style was beginning to harm the company,' Frist said."
"Frist also said the company will unwind the company's controversial physician partnerships. He didn't give a schedule for when that would be completed. 'You don't need financial ties,' with physicians. Frist said the physician partnerships, which were criticized by Columbia competitors and government regulators, weren't necessary, and only gave people another reason to target the company. 'Take them off the table,' he said."
"All the syndications have buyout clauses that allow Columbia to unravel the deals with physicians by purchasing their stakes. Columbia has said only 4% of physicians affiliated with the company's hospitals have an ownership interest."
" 'The industry we're in is a not-for-profit industry,' Frist said 'I don't think (Scott) ever understood that.' Scott's 'if you don't join me, I'll beat you' mentality doomed Columbia from ever building a strong, healthy foundation for long-term growth. Plus, it left the company with few friends in its time of need, Frist said."
National Coalition Invites In A Rural Voice
The National Rural Health Care Association has accepted an invitation to join a diverse list of national businesses, unions, non-profits and professional societies to promote an educational and policy agenda to "assure quality, contain costs and maintain access in a competitive marketplace." The National Coalition on Health Care is the nations largest and most broadly representative alliance working to improve America's health care.
A sample of the membership includes the American Academy of Family Physicians, Blue Cross & Blue Shield of Iowa, General Motors Corporation, Service Employees International Union, AFL-CIO, United States Catholic Conference. Honorary Co-Chairs are Former Presidents Jimmy Carter and Gerald Ford.
The Coalition's mission is "a firm belief in the following principles:
Supported by its members and grants from the W.K. Kellogg, Henry J. Kaiser Family and Robert Wood Johnson foundations, the Coalition has launched a multi-year educational campaign on the realities and challenges of the health care system. For more information contact the Coalition at (202) 637-6830 or on the Internet at
Two-by-Two: 2% Uninsured by 2002
From a column by Bill Petasnick, President, Froedtert Memorial Lutheran Hospital, in the Wisconsin Health & Hospital Association's News & Views, 8/14/97:
"The WHA task force (a work group of WHA's Council on Public Policy) identified a vision for the future that would dramatically reduce the number of uninsured in the state to an unprecedented level. The task force recommends that Wisconsin set a goal to reduce the number of uninsured individuals to 2% of the total population by the year 2002. This goal of 2% by 2002 (two-by-two) can be achieved through a partnership that uses both public and private resources. Fulfilling that vision will make Wisconsin the nation's leader in providing health insurance protection to its residents."
Medicare HMOs - Now Real Work Begins
While more equitable payment rates from Medicare to HMOs has the potential to allow for more equitable reimbursement to rural providers, it does not guarantee it. As noted by the Rural Policy Research Institute in a report to Congress on May 29th, the effect on rural providers of higher payment rates are dependent upon:
To the extent that changes in capitation payments result in Medicare beneficiaries enrolling in managed care plans, there are significant implications for rural providers and communities. Instead of receiving payment determined by HCFA regulations, health care providers would instead be paid based on their contracts with managed care plans. Since most rural providers receive a significant proportion of their revenue for serving Medicare beneficiaries, they are likely to experience a substantial increase in the amount of revenue controlled by HMOs with a corresponding decline in the amount controlled by the federal government.
Health Care's Swiss Army Knife?
From "Weaving A New Web: Web Browser Technology Holds Promise To Become All-Purpose Information Tool," by John Morrissey in Modern Healthcare, 8/11/97:
"Ward Keever says he doesn't have much use for the Internet. But in his effort to bring medical information to clinicians, Keever plans to make a basic World Wide Web technology known as a browser as common at University of Pennsylvania Health System as stethoscopes."
"There's no contradiction here. Penn's chief information officer and his staff are turning the technology that simplified Web travel to another use. Browsers enable the pooling of information from multiple databases, even ones crafted in different computer languages, into a variety of multimedia formats."
"But instead of using browsers to travel the Internet, Penn and other health systems are using them within the confines of their own emerging networks in configurations called 'intranets.' "
"Browsers eventually will be tapped to deliver clinical information at the point of care. In providing the means for this, browser technology may become the Swiss Army knife of healthcare improvement-the all-purpose tool to reshape clinical practice by providing the right data at the right time for a diagnosis or decision."
"As important, Keever says, the familiarity of the Web format will work in Penn's favor. 'We are trying to facilitate the practice of medicine. We are not trying to make (clinicians) computer literate,' "
Community Values Do Matter
From "Study Links Rate of Violence to Cohesion in Community" by Fox Butterfield in The New York Times, 8/17/97:
"The largest study ever undertaken of the causes of crime and delinquency has found that there are lower rates of violence in urban neighborhoods with a strong sense of community and values, where most adults discipline children for missing school or scrawling graffiti."
"In an article published last week in the journal Science, three leaders of the study team concluded, 'By far the largest predictor of the violent crime rate was collective efficacy,' a term they use to mean a sense of trust, common values and cohesion in neighborhoods."
"Dr. Felton Earls, the director of the study and a professor of psychiatry at the Harvard School of Public Health, said the most important characteristic of 'collective efficacy' was a 'willingness by residents to intervene in the lives of children.' "
"Specifically, Earls said in an interview, this means a willingness to stop acts like truancy, graffiti painting and street-corner 'hanging' by teen-age gangs. But cohesion, or efficacy, seems to be still another quality, Sampson suggested, 'a shared vision, if you will, a fusion of a shared willingness of residents to intervene and social trust, a sense of engagement and ownership of public space.' "
"The finding is considered significant by experts because it undercuts a prevalent theory that crime is mainly caused by factors like poverty, unemployment, single-parent households or racial discrimination. These problems do play a role, according to the new study. But some neighborhoods in Chicago are largely black and poor, yet have low crime rates, it found -- so some other explanation is needed for the causes of crime."
"The study at least indirectly contradicts the highly acclaimed work of William Julius Wilson who traces many of the troubles of poor black families in Northern cities to the disappearance of factory jobs as industries moved to the suburbs or overseas. Both Earls and Sampson said they thought that the results of their study suggested that Wilson's argument was too narrow and did not account for the differences in crime they found in largely black neighborhoods. Still, Sampson acknowledged, concentrated poverty and joblessness 'make it harder to maintain' cohesion."
RWHC Aims to Enhance Cooperation
The voting members and affiliates of the Rural Wisconsin Health Cooperative adopted Guidelines To Enhance Cooperation: Among Rural Providers, Systems & Insurers at our last quarterly forum. The guidelines intend to identify and promote behaviors that encourage cooperation in rural communities. It was understood that all participants are free as individual corporations to act as they choose.
However, RWHC believes that rural communities are better served when various organizations are able to cooperate around particular services or initiatives. Cooperation "rural to rural" and "rural with urban" is seen as complementary to the broader context of regional systems competing with each other. A summary of the guidelines follows:
#1: Respect the Need to Effect One's Own Future--The preference for autonomy needs to be respected through the promotion of collaborative solutions that enhance the local delivery of health care and the health of the community. Example: Regional systems talk with local providers and community leaders about what specialty services can be provided locally and which are in the community's interest to be centralized."
#2: Involve the Community and Providers in the Planning Process--The planning is interactive, with the plan for the joint enterprise being the result of, and feeding into, the plans of local and regional participants. Example: Regional systems communicate with local providers about changes in referral protocols while there is still time for feedback and adjustment.
#3: Assure All Participants Know They Are Needed--All participants must know that they are needed for the success of the joint enterprise. Example: Timely communication by urban medical centers back to rural primary care providers when patients are referred for services.
#4: Share Your Big Picture--Participants need to know where the joint enterprise is headed. HMOs do not sell local employers an insurance plan without explaining adequately that enrollees have to go out of town for services (which are available locally).
#5: Agree on Methods of Accountability Up Front--Participants must always know up front what the rules are and what is expected of them. Example: HMO shares case management criteria and guidelines.
# 6: Assure that a Fair System of Arbitration is Available--A clear non-threatening arbitration mechanism in case of contractual or other disputes should be agreed to before disputes arise. HMOs don't unilaterally change the interpretation of significant contract terms.
#7: Design an Approach Where Participation Makes Sense--Organizations may start participating to explore a group's potential; they remain only if they perceive that they are receiving a good return on their investment of time and money. Example: A regional trauma system recognizes the classical rural dichotomy--rural providers want to fend for themselves, but are also looking for ways to help their neighbors.
#8: Make Yourself a Partner Who Can Be Trusted--Develop a relationship based primarily on mutual trust so that the collaborative effort is not limited to the minimum performance inherent in written agreements. Example: A regional system builds a clinic in a neighboring town to a rural hospital and refers to the local hospital as clinically appropriate.
The complete text is available on the RWHC web site at .

"Make New Mistakes"

- heard on car radio 8/97

RWHC Mission Steady Since 1979
A friend came across a long forgotten article about RWHC from the December, 1981 issue of The Rural Primary Care Newsletter. RWHC was just over two years old when it received this national exposure in the newsletter of the predecessor organization to the National Rural Health Association. Entitled "Rural Wisconsin hospitals work cooperatively to maximize community-controlled services," the description of RWHC's vision as an alternative for rural communities could have been written yesterday:
"While multi-hospital systems are... drawing on corporate personnel and capital resources, members of RWHC believe the community pays heavily in loss of local control in developmental decisions and responsiveness to local conditions, as well as outflow of dollars from the local economy. A second hazard to small community hospitals tends toward the opposite extreme of attitudes. Resistance to any multi-hospital arrangements by community boards may cause them to wait too long, causing the hospital to go under."
The full text is available at the RWHC web site:

The Dartmouth Health Atlas
From Perspectives, A Report From The Robert Wood Johnson Foundation, 6/97:
"The Dartmouth Atlas of Health Care series analyzes the country's 306 hospital referral regions--the natural markets for tertiary care services--and 3,436 local health care markets or hospital service areas. This wealth of information is available in numerous useful forms--hard cover and soft cover books, as well as on diskettes or CD-ROM. Nine regional supplements make detailed comparisons possible on a wide range of critical issues, such as use, efficiency and cost of health services."
"For ordering information call 800/AHA-2626, or visit the Dartmouth web site for a complete table of contents and other information on this remarkable resource" at:

Also can be ordered from the Wisconsin Health & Hospiutal Asociation at

"Trouble In The Boardroom"
From "Trouble In The Boardroom" by James Orlikoff in the Healthcare Forum Journal, 8/97:
    "The Seven Deadly Sins of Ineffective Governance
    1. Representational governance
    2. Lack of mission focus
    3. Tendency to resist change rather than lead it
    4. Making do with irrelevant, useless information
    5. Reluctance to dump the deadwood
    6. Maintaining cumbersome, outmoded structures
    7. Working without job descriptions"

Tip To Reduce Phone Solicitations At Work
I've been plagued at work with unsolicited calls from aggressive salesmen (gender intended) of "investment opportunities." Aside from not being a particularly prime candidate due to all spare change being allocated for multiple tuition payments, even screening these calls is an irritant. If you have the same problem, try calling 1-800-234-DUNS; I was able to have my name removed from a widely circulated "active trader's list" as well as several other lists sold top marketers.

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