This page suggests a framework for analysing corporate culture and behaviour. It explores the behaviour and thinking of health and aged care corporations by a case study of Sun Healthcare and its charismatic founder Andrew Turner. They are representative of the US corporate health and aged care marketplace. Similar analyses could be performed on other groups. Some conclusions are drawn. Suggestions are made as to how the insights provided can be used to progress the health care debate.
This page and "The Corporate Health and Aged care Marketplace - August 2000 Review of Articles" were written concurrently and relate to one another.
I. A FRAMEWORK FOR ANALYSIS
II CULTURE ::::: SUN HEALTHCARE AND ANDREW TURNER
IV. AFTERTHOUGHT - A DIFFERENT ROAD
Simple concepts don't work:- It is perfectly legitimate to talk of health care criminals, the evils of elder abuse, neglect, fraud and rogue corporations. All of this is self evident and true. We can quite legitimately paint a picture of evil people and corrupt organisations in health care.
Almost all of the large corporate health care chains have defrauded taxpayers and short changed patient care in one way or another to increase their profits. Is it possible that almost all of these corporate groups; all of the largest health care corporations and their thousands of employees have deliberately and with criminal intent connived in compromising care and in health care fraud?
Our immediate reaction is to discount the allegations as exaggerated but there can no longer be any doubt about what is happening and how widespread it is. We are looking at major social pathology. There are a many precedents for major social pathology, many during the last 100 years. All too frequently we did not believe what was happening or heed warnings until it was too late. Is this another example? (see Ron Williams 1992 warning about corporate health care in Australia)
The immediate and also legitimate common sense response to what is happening in health and aged care in the USA and, more recently Australia is to regulate, to monitor, to prosecute and to punish. This also appears reasonable but. Repeated attempts have been made to do so and quite clearly it has not worked. We need to think again.
Instead of ignoring the evidence and applying solutions which have failed we should be asking ourselves why. What is wrong with our approach? If our framework for understanding criminal activity is not working then we need to find alternate ways to analyse the situation to see if they are more appropriate and explain why things are not working. The common sense framework is easy to understand but perhaps it is too easy -- there is more to it than this.
I am therefore suggesting an alternate framework of analysis, a framework developed when dealing with some of the major social pathologies of the 20th century. Many of the processes at work in the corporate health care marketplace are remarkably similar and the concepts and understandings closely fit what is happening. The concepts are not simple or obvious until you think about them more carefully. All have been used in other contexts by reputable social scientists and are not original. I have simply drawn them together.
AN ALTERNATE PERSPECTIVE:- The framework of analysis I propose is based on an insight which suggests that as social beings individual humans must "realise themselves" and seek an identity in whatever situation they find themselves - the context of their lives.
They need to create a world of ideas which make their world and what they do in it meaningful. They form social groups and interactively develop patterns of thinking which allow them to do so in the situations in which they find themselves. Individual identity is then developed by expressing these meanings through the things people do.
The "context" in which people find themselves therefore becomes a critical factor in determining how they will think and how they are likely to behave. Self realisation, identity and meaning are fundamental to human existence. We cannot function without them. Hard facts, reason and common sense may be sacrificed to meet these prior "existential" requirements. We can exist without them if we create an abstract world which ignores them.
Different contexts:- People with qualities which readily allow them to realise themselves and claim an identity in a particular context will achieve success, credibility and leadership. If the context requires competition people will compete and those who are competitive will thrive. If the context requires that we cooperate a different set of individuals will emerge. If the context requires that we fight and kill one another then another set of attributes will be called for. The very nature of being human demands that in each situation we develop patterns of thought to justify the actions needed to "become" someone in that situation. All this must be meaningful - make sense.
In the past we have glorified conquest and war, granting our great killers hero status. Warriors are the stuff of legends. We don't extend the same context and the hero status to those in the community who kill others. In Australian civil society we have a totally different meaning system for killers in our midst. This however can be even more context dependent. In countries where the context has generated a fundamentalist belief system or a religious or nationalistic rebellion then indiscriminate killers in society have become heroes.
The marketplace as context:- The marketplace creates a context within which trade occurs. Individuals realise themselves and establish an identity by self interested acquisition, and by competition for profit. The driving force is not so much greed but the identity which wealth and its display provides. Philanthropy can be no more than the display of wealth.
As a new market ideology evolved during the late 20th century new patterns of thought, a whole new language, and a whole new meaning system has been developed. This allows believers to make modern marketplace thinking legitimate and all encompassing. It provides a framework within which they can live the whole of their lives. John Ralston Saul argues that this now generalised reality has only a tenuous link with the real world and that as a consequence we have an "unconscious civilisation".
This market belief system does not differ from other ideologies which have an "of course" factor in one or more important facet of people's lives. To converts in need of a broad meaning system for all contexts this seems to have obvious, universal and unchallengeable relevance. Ideological belief systems become a form of ultimate reality for their adherents and they do not perceive any limitations.
Creating meaning:- It is conventional common sense that before acting we examine the evidence and our experience, reason it out and then reach conclusions. Doctors always believed that this is how they made diagnoses.
We now know that this is only very partly true. In practice we all try out - hypothesise understandings, and then test actions in our minds matching them against knowledge and experience. We may explore several different options before selecting one. Much of the reasoning comes after and not before we hypothesise. The particular context and the pressures it generates may therefore be a powerful determinant of how we reason, interpret, or even choose to ignore our past knowledge and experience. After acting or experiencing we again reinterpret and rearrange our knowledge in order to build meaning and identity around the new situation.
I am suggesting that this reinterpretation of our past experiences and knowledge in the light of our present situation to make both meaningful and coherent is very important. We create much of the meaning and reasoning in our lives after we have acted and not before. There can be strong pressures towards self realisation, identity and coherent meanings. There are well recognised psychological strategies which will allow us to reach an accommodation with the pressures which we face even when knowledge, reason and wider experience are discordant. We can understand how people in mismatched contexts will develop bizarre and inappropriate meaning systems.
Context and meaning:- When the context within which we find ourselves demands actions we are likely to carry out those actions and then develop meaning systems to accommodate them. The stronger the pressures the more likely we are to act in dysfunctional ways and to develop meaning systems which ignore fact, reason or sense. Personality structure is an important contributing factor.
Closed mindedness and meaning:- The concept of closed mindedness refers to our individual actions in looking past fact, compartmentalising unpalatable insights, and rationalising in order to create or maintain coherent meaning systems. We all do this to some degree. We shield ourselves from the true situation and the meaning system therefore does not truly reflect reality. A closed mind also describes a personality type, particularly prone to behave like this.
The greater the pressures towards dysfunctional actions the more likely we are to behave in a closed minded way in justifying those actions. Closed minded personalities are less able to confront the dissonance caused when fact and reason are not congruent with what is required in the particular context. When the context is not appropriate for the activity then closed minded people more readily develop meaning systems which allow them to realise themselves and develop identities through dysfunctional activities. To maintain their position they tend to be dogmatic and overconfident. They discount their critics. This has nothing to do with intelligence.
When there is a mismatch between actions dictated by the context and the desired outcome (e.g. profit and patient care) then there can be strong pressures towards a dysfunctional culture. Those who promote it become leaders - successful and admired. Those who identify with it become team players. A form of Social Darwinism develops which selects for the sort of people least suited to the task of achieving the desired outcomes.
Dissent and whistle blowing:- In these situations reason and fact challenge the meanings which give legitimacy to actions and the identity of individuals. Those who do not embrace the meanings are not team players and are marginalised. If they can manage it they leave and go elsewhere. Whistle blowers are an extreme threat to the meaning system and to identity. The well documented extreme response to them is therefore not surprising.
A new context for social services:- A marketplace ideology and a globalised economic framework has now been imposed on all of society regardless of its applicability. This radically changes the context within which many people live and work. Cooperative humanitarian community services like health and aged care have been turned into competitive corporate businesses. The pressures towards dysfunctional activities and a discordant inappropriate identity are very strong - the stresses considerable. One need only examine the behaviour of the medical profession in the USA - particularly the psychiatrists in the 1988 to 1991 period to understand the way in which this has impacted on the conduct of doctors.
Context and health care:- I argue that the activities and the meaning systems which are required for self realisation and identity in the context of a corporate marketplace are not congruent with the functions of the health system. They directly challenge the humanitarian value systems and ethical traditions which society embraces in dealing with its vulnerable members. Profit and care compete directly for the same dollar and there are consequently very strong competitive pressures to develop meaning systems which allow increasing amounts of money to be diverted from care to profit. There are strong pressures to accommodate to the context. Glib meaning systems cloaked in market jargon make this legitimate.
Implications:- I suggest that if we want to understand what has happened to health care in the USA and increasingly in Australia then we need to examine the way in which people have realised themselves, obtained identity and created meaning in the health care marketplace.
What are the patterns of thought which have developed in the corporate health care system? To what extent has hard information, experience, reason and common sense been compromised in order to meet the prior imperatives of self realisation, identity and meaning in the marketplace? What sort of individuals have become the leaders? Does this account for what we now know about marketplace medicine? Does this explain why conventional wisdom has failed to resolve the problems? Does this help us understand what is happening in Australia? How does the information we have about Mayne Nickless, Revesco, and even Dr. Wooldridge fit with these concepts? (also see recent articles about Mayne Nickless and Revesco) Can we draw any conclusions about the likely consequences? Does it provide the sort of insights which would allow us to provide health care in a context which might have better outcomes?
I have in the past analysed National Medical Enterprises (now Tenet Healthcare) along these lines in order to challenge the marketplace paradigm.
If we examine Columbia/HCA, Vencor, IHS or many of the other large groups in exactly the same way the same patterns emerge. Sun Healthcare and Andrew Turner have come to Australia and I have plenty of information. To illustrate the concepts I will examine the way the pressures of the marketplace dictated Sun's culture and its practices, and how the self serving meaning systems which were developed had little relationship with reality. I will examine the actual words used by Turner and his staff as well as the attitudes reflected in the press analysis and reports. We need to ask ourselves whether this has relevance to Mayne Nickless and Revesco.
Entrepreneurialism:- The marketplace values entrepreneurialism - the ability to see and seize financial opportunities and to maximise profit from them. It is not surprising that people with these attributes should see the profit potential offered by health care. In the past this sort of thinking in health care was unacceptable and would not have been tolerated. Social control based on ethical traditions that are now considered obsolete prevented it. With the omnipotence of market belief systems, the commercialisation of medicine and the dominance of the corporate marketplace this sort of activity has become not only legitimate but desirable. Large sections of society admire it. Eamer, Frist, Jones and others first saw the opportunities offered by Medicare in the 1960's. National Medical Enterprises (NME), Hospital Corporation of America (HCA) and Humana lead the way in the 1960's.
Andrew Turner:- Unable to join the army because of his health Turner was asked by his pastor to manage the local church's nursing home. He realised the potential for profit and soon moved to the nursing home company Hillhaven, which at that time was owned and run by NME. Richard Eamer, NME's founder was its chairman. Here Turner would have been inducted into a corporate culture which saw dishonest marketing as legitimate and fundamental to success. Financial success was proof of high quality care. This was a marketplace and in a marketplace people shopped and they would not buy anything inferior. NME made more money than anyone else therefore its care was better than theirs. I have described the culture of the stockmarket and how NME's own meaning systems were developed in this context.
Turner and a friend Elliott broke away from Hillhaven in 1986 to form Horizon Health Care. In 1989 Turner took seven poorly performing homes and broke away to form Sun Healthcare. Both companies set up headquarters in Albuquerque, New Mexico. Horizon dominated in New Mexico whereas Sun's concentrated on other states so they did not compete directly.
Seizing opportunities:- Enormous opportunities were identified in aged care because of the greying of America. As the pressures on acute care mounted Turner also seized the opportunities for profit offered by the idea of progressive care and appropriated the concept for his commercial ends. By moving patients rapidly from acute hospitals to nursing homes the restrictions placed on in hospital profits by DRG's could be circumvented. DRG's were a response to the abuse of fee for service medicine in acute care hospitals. They were not applied to therapies given in nursing homes.
Vast profits could be made from providing fee for service care to nursing home patients - as they could in psychiatry in 1988-91. The more therapies provided the greater the profit. As I read the literature only about 10% of nursing home beds were ever filled with post acute care patients eligible for Medicare funding and fee for service therapies. Patients insured by HMO's were similarly funded. The remainder were paid for at a lower fixed rate by Medicaid. The real profits were made from providing therapies to this 10%. The extent to which this small fraction were overserviced with therapies to boost profits is reflected in the rapidity with which the corporations who made their money this way collapsed. Clearly none of them saw anything wrong in what they were doing. It was legitimate business and they had a fiduciary responsibility to shareholders to make as much profit as they could.
A 1996 article "Watch them grow, And grow" in the New Mexico Business Journal enthusiastically describes the opportunities, the pressures and the way in which these two companies competed for takeover targets, expanding to position themselves to take advantage of this potential market. 117 It also reveals the patterns of thought in the marketplace. The article describes the early takeovers and further plans. I quote extracts:-
"Horizon's and Sun's extraordinary growth hasn't stopped yet. Turner and Elliott aren't pausing very long for deep breaths, about which more later. Both are billion-dollar companies, for the moment, but additional mergers and acquisitions could make them the two biggest kids on the health care block."
"Both companies' histories have been of mergers and acquisitions in what appears to be a race to position themselves for the niche being created by the pressure to curtail stays in regular acute hospitals"
Subacute Care:- Together with Hillhaven and Horizon Turner marketed his nursing homes, rather than hospitals as the venue for subacute care - even though this would disrupt continuity of care. Its only real advantage was in bringing patients nearer to their homes. The same care was needed as in on site progressive care in acute hospitals, and the same sort of staff. The mobility and savings when able to move staff to areas of need was lost so the cost saving was a convenient rationalisation. That nursing homes overall were cheaper per patient was a convenient way to rationalise. I quote:-
"Long-term health care companies are in a unique position to provide lower cost care than traditional hospital settings for patients who hospitals can no longer afford to keep but who still need 24-hour supervision or the services of special medical equipment before they can go home. Post and subacute care are providing higher profit margins for companies like Sun and Horizon/CMS as they position themselves to take care of the increasing number of patients being discharged early from hospitals."
The promise that the same care could be provided cheaply in nursing homes made it difficult to then provide the same more expensive staffing which these patients would have received in hospitals where auditing and peer review systems were better developed. Staffing was a major expense and in the nursing homes there was little oversight so that staffing could be reduced. Recent developments show the extent to which Turner and other groups were prepared to understaff and compromise care in order to increase cash flow. The human cost has been staggering.
The critical role of DRG's rather than cost containment:- DRG's paid a fee per hospital service and the sooner a patient was discharged the less the cost to the hospital. Ancillary services were I believe included in the DRG's so they were a cost if provided in hospital and cut into profits.
The financial opportunity seen by Turner was that by moving patients to nursing homes their continuing care would once again be funded by Medicare. This would circumvent the cost cutting restraint imposed by DRG's in hospitals. Vast quantities of money making ancillary therapies, paid per item of service could be given in nursing homes.
As a consequence the corporate meaning systems generated a massive "demand" for these services and thousands of therapists were employed - a demand which disappeared the moment the funding system was changed. It was not the potential cost cutting, or the needs of patients which fueled the explosion in subacute care but the opportunities for profit provided by avoiding the DRG system. Once again the care which patients received was determined not by their needs but by the profit oriented money games played by government economists and corporate directors. I quote from the same article:-
"One factor driving higher profit margins for these companies are their exemption from prospective payment and Diagnostic Related Groups (DRG) --government imposed caps that currently hamstring hospitals."
Reality and Care:- Care is a very personal thing - individual and cultural. Motivation and interpersonal factors are all vitally important. This is why smaller groups, community services and church groups with local contact and local input provide superior nursing home care - and more cheaply. Self realisation and identity are attained through service to the community.
Self realisation and identity in the marketplace create a different imperative - competition. Success is measured in size and dominance. Health and aged care corporations readily embraced the bigger is best philosophy and competed to attain it. There was frenzied competition - take over or be taken over! The meaning systems were adjusted to accommodate this. I quote:-
"Smaller operators will find it hard to compete because of the increasing complexity of medical services, growing regulatory and compliance requirements, and increasingly complicated reimbursement systems. Other factors squeezing small operators out of the business are a lack of sophisticated management information systems, a lack of operating efficiencies, and a lack of financial resources to keep them going when Medicare or Medicaid reimbursements are either delayed or curtailed."
Financial irresponsibility:- Once again systems of explanation and justification were developed which encouraged extremely irresponsible financial behaviour. The cash flow which could be generated by cutting care allowed vast sums to be borrowed to fuel expansion. Success depended on reducing the cost of care. The exponential growth to create vast empires was funded using the money paid by taxpayers for the care of the elderly citizens of America - their mothers and fathers. To compete others had to follow. The extent of this is reflected in the rate of corporate growth. The industry and their analysts justified and applauded all this. The irresponsible borrowing by these corporations left them acutely vulnerable to the smallest downturn.
Social Darwinism:- The competitive pressures in the competitive corporate marketplace selected for those who squeezed more out of Medicare and who spent less on care. Fraud and neglect of care were consequently both rewarded. Personalities and corporations who were able to develop meaning systems which accomplished this prospered - at least temporarily.
Worlds apart:- How different the real world proved to be to the corporate claims. It was the big successful corporations which provided inferior care and the big corporations which were more unstable and failed when Medicare and Medicaid reimbursements were adjusted. The smaller groups and the not for profits which were closer to care and which had a more realistic grasp of the world survived. 50 Note also in the New Mexico Journal 1996:-
"The strategy today is growth and expansion through mergers and acquisitions for Sun and Horizon as they jockey for position for tomorrow's consolidated long-term and subacute health care dollar. But the growth is not only in nursing home centers and post and subacute care units but in other ancillary services. Diversification is also the name of this game."
Corporate style integration:- These groups diversified into interlinked integrated services so that they could profit from internal referral and shift patients through the system. This did not serve patients or the community and provided endless opportunities for extra prescriptions and increased referrals - undetectable fraud and impossible to prove. I quote:-
"Both use these ancillary services to contract with their own and other non-affiliated facilities. Horizon/CMS for instance stands to gain a lot from providing pharmacy services to its newly acquired CMS facilities. Sun profits in the same way with every ancillary service acquisition it makes."
The opportunities presented for ever greater profits by manipulating the system caused many to fiddle the books in order to defraud Medicare and Medicaid. Virtually all of the large groups, including Sun are accused of defrauding taxpayers of hundreds of millions of dollars.
This integration strategy also made them even more vulnerable to economic changes. Now the system has been changed they are divesting. Instead of "diversifying" they are concentrating on "core business". It is clear that all this diversification and integration had nothing to do with the needs of patients and everything to do with profit.
Where did the profit come from? The profits in 1996, only 7 years after Turner had started Sun with 7 money losing homes were "impressive to say the least" and were predicted to soon exceed US $1 billion. What better proof for the validity of the marketplace beliefs promoted by Turner -- but on reflection what a clear pointer to what was happening to the care of patients. The market does not for a moment think that way. After all it requires some simple common sense. Four years on and Sun is bankrupt!
Turner - the man:- A recent review describes Turner:- 112
"The son of a career military man, Turner is a tall, trim man with a blunt way of speaking, an air of self-confidence and impatience with what he perceives as lack of initiative or short-sightedness that some interpret as cockiness."
Turner's radical marketplace views and his character are revealed in another 1996 article - Andy Turner wants the government out of health care, Period - also in the New Mexico Business Journal. 116 Sun and Turner were the big success story in New Mexico. This is an interview with Turner.
The opening line is revealing particularly when the comments in the press about Eamer, Scott, Elkins and Smedley are compared. I quote:-
"ANDY TURNER. THE DYNAMIC. OUTSPOKEN and sometimes controversial CEO Of Sun Healthcare Group. Inc."
I see a man who has no doubts and will not tolerate disagreement or any challenge to his views and his plans. His answers in the interview reported here are clear concise and uncompromising. They do not permit discussion nor invite alternative understandings. His success is proof enough. He does not listen to incongruent points of view. He dominates and the interviewer dare not challenge his answers. He is a man who is focussed. He knows where he is going and will not allow anything to distract him. He sees opportunities and goes after them - the best sort of entrepreneur - the sort of person the market idolises.
Cutting the fat:- Very early in this interview he blames the less competitive market system which had existed and claims it resulted in "redundancy and fat in the system". He may be correct about some sectors of the health system during the 1980's but certainly not the nursing homes which have always had difficulties in recruiting staff.
His solutions based on this premise of fat in the system compounded the problems. This belief was strongly asserted and widely accepted in the marketplace which used it as justification for "cutting the fat" across the health care system. Fat was cut where there was none to cut.
The company traded on the dedication of motivated nurses who worked far beyond the time for which they were paid in order to provide some sort of care for their patients. Money intended for the care of helpless people who could not resist was diverted to profit and growth. The myth was repeatedly reinforced whenever there was a need for more profit. More cuts were made. The consequences are now apparent.
The role of government:- It is clear from the interview that Turner resents any sort of control over his activities. He doesn't want anyone looking over his shoulder and asking questions. He wants control. When asked about the government he responds dogmatically
"The government should butt out. If that happened, market forces would quickly resolve the problems in the industry. The government has an obligation to support poor people, but it should fund them through the private sector."
Contracting care to the market:- When asked how government would go about this he says that they should hire a private company to organise it all - he lists some HMO's.
The other 1996 New Mexico Business Journal analysis of Sun and Horizon I referred to above quotes an analyst
"if Republicans in Congress have their way, government reimbursement will be funneled through the private sector via an acceleration of enrollment into Medicare risk managed care plans, which this investment firm expects to be a plus for the industry." 117
This is Turner's solution and is exactly what the republicans did with Medicare patients and it has not worked. There have been multiple problems and many HMO's have simply dumped their Medicare patients at considerable human costs. These Medicare patients became pawns in the money games played by economists, businessmen, and politicians.
Turner rejects regulation:- Turner's views about government regulation were even more telling. He said "The government regulators are out of control. There are too many of them and they contribute directly to the cost of providing health services."
The urgent need for government regulation and control to protect citizens from the market is revealed by Sun's own conduct and the situation in corporate nursing homes across the USA. The failure of government oversight has now been clearly demonstrated. Many of the government departments are blaming underfunding and understaffing. Other credible nursing chain owners were saying the same things as Turner. Perhaps those politicians supporting corporatisation acted on this advice and deliberately did not fund the departments responsible for oversight.
Turner is correct about the very considerable costs of oversight. These costs add considerably to the cost of a corporatised system and are never factored into the costs of care. In a civil society where attention is paid to context rather than ideology oversight might "rest lightly" and be seldom required - so making health care less costly.
Turner was asked "Do we really want to get rid of regulators? Won't the quality of health care-suffer?" His response is illuminating in the breathtaking way in which sense and reason are ignored.
"The quality of health care suffers because of governmental support and regulation. The system takes away incentives to improve. The marketplace would close poor operators. If the government were to withdraw, disparities in quality would show. People would shop. They would find out which hospitals really offered the best care, and the ones that didn't would be out of business. We don't think about free enterprise in the health care industry"
How the market controlled care:- In a practical sense Turner got his wish. Government regulation of nursing homes was ineffective and useless. Market competition was unfettered and so able to self regulate care. Four years later we have a situation where numerous studies and incontrovertible evidence has shown a dreadful situation in corporate nursing homes across the country and Sun is a prime offender. The marketplace and competitive corporate practices are directly responsible for this.
My framework suggests that the sort of people who prosper in this marketplace would be almost incapable of admitting they were wrong. Most of these chains including Sun continue to maintain the claim that they are committed to quality and that their homes provide high quality care. They make these claims every time they are confronted with their own disturbing practices. When all else fails they blame Medicare and the nursing shortage for failures in care.
A different world:- We should not doubt that they genuinely believe what they are saying. The framework used for analysis of human behaviour predicts that people like this will resolutely maintain their position in the face of all evidence. The concepts were developed in dealing directly with fascism and apartheid where exactly this happened. They were amplified when analysing Tenet/NME's similar behaviour and its persistent denial of the consequences of its business practices for patients.
Turner like Alberta's Ralph Klein and Australia's Michael Wooldridge sees little future for our sort of Medicare. He says "There shouldn't be a Medicare program as written today" and "It was improperly designed from its inception". In his criticism he stigmatised the Veteran's Affairs system by claiming the cost was high and the care awful - exactly the criticisms which can now be made about Sun Healthcare. I have not heard much criticism of the VA system in the USA. Some very skilled people with international reputations work in the system.
The morality of market medicine:- The morality of providing health care as a business was raised in the interview, indicating that many felt that it was "wrong to talk about providing health services as a business". Turner points out that government, not for profit and for profit facilities already coexist. He evades the question of morality and the newspaper does not challenge him on this.
He does not consider that the question is asked because for profit corporate health care is recent and is growing rapidly wresting care from others who have a good track record. He says "I think operating health care as a business is a must. As long as the government operates the system there will be no incentive to do better" His views closely mirror Dr. Wooldridge's views expressed in his speech in May 1996. Seventy percent of health care in the USA has been "not for profit". Turner, like Wooldridge sees a very different future. I quote Turner:-
"I think private businesses will become the primary purveyors of health care services and that the government-run homes are going to be fewer. I don't see much of a future for not-for-profit homes. I just don't think that the religious orders are going to have the incentive to stay in the health care business that they have today."
Citizens did not buy Turner's solution. There was an outcry when Columbia/HCA and Tenet/NME started to buy up not for profit hospitals and community assets. States across the USA passed laws and took steps to limit this PACMAN activity.
Turner and choice:- When it is suggested to Turner that the market is actually limiting choice he agrees that this is an inevitable consequence of cost cutting. This is the same choice which he feels consumers will use to eliminate substandard operators.
Turner amplifies " I have no complaint with the concept of choice, but I do think that one avenue for cost containment is the limitation of choice. And some of that also has to do with rationing." He does not identify a problem in rationing care to boost profits, yet this is exactly what was happening at this time in Sun's nursing homes.
When asked whether government pressure has brought down costs Turner correctly asserts that it was the private sector which did so. It is now clear that they did so by denying care and by rationing, cutting the staff needed to care for people. They continued to make vast profits. They took much more from care than simply reducing costs. They rationed for profit.
Cutting costs and its impact on care:- Turner denies that constraining costs has compromised care. He goes back to his rationalisation about fat in the system. He says "We haven't even begun to cut the fat." When asked about the fat he pin points bureaucracy and administrative structure. "So I think the first place to start would be to cut all that bureaucratic crap at the top." At the same time Turner himself was building a massively impressive administrative centre in Albuquerque and surrounded himself with a very large number of compliant staff who were very well rewarded.
More importantly he identifies fat in actual care. I quote "Then at the actual bedside I think there is fat. Why do we have to have a registered nurse change a bedpan? That's primary care. Somebody had a theory that this would be better care. A licensed practical nurse or nurses aide could be used. We've gone way off the deep end in terms of that kind of thinking. There is tons of fat in the health care delivery system." Nursing groups had been struggling to expose the serious staffing problems in Sun's homes since 1994. The validity of their claims has been confirmed by investigation after investigation across the USA.
Future Healthcare:- When asked about the future Turner says "I think we're going to see a significant reduction in costs. and I think the role of government is going to be dramatically diminished" The results of cutting costs for profit are now only too apparent. Worse still not only must the current deficiencies be corrected but costs are rising steeply again. Citizens and doctors across the nation are calling for more government involvement pointing to Canada where corporate medicine has been prohibited and where superior care is provided equitably at nearly half the cost.
Turner sees fewer staff taking care of patients and claims:-
"You're going to spend less time in the hospital and you're going to get quickly shuttled to what we now call a nursing home where I think the care will be pretty similar to what it is right now."
Turner believes that he is providing good care! The standard of this "good care" is exactly what US citizens and now even government are so angry about.
Self realisation and identity:- In my framework of analysis I suggested that it was not the acquisition of wealth but the identity and status which it provided. Its not as simple as greed. Financial success was a confirmation of the views beliefs and meanings. Turner paid himself a massive salary with large bonuses. He lived lavishly.
The framework I am using expects wealth to be displayed, sometimes in philanthropy. American Hospitals are largely built on the philanthropy of very successful businessmen who endowed vast numbers of buildings and laboratories as permanent memorials to their wealth and status. This is not greed. While Sun's patients existed in appalling conditions the money intended for their care was expended in ostentation. Turner's headquarters in Albuquerque are described as follows:- 116
"Probably nothing better symbolizes Turner's vision and the success of his corporation than the Sun Healthcare corporate headquarters visible from I-25 North in Albuquerque. The strikingly modern building prominently features a number of sculptures and other art works, an aesthetic reflection of his commitment to the Southwest, and is crowned by an oval running track. Indeed this is not just first-class Office space; it is a work of art in itself. Two more buildings were recently added to the complex, including the 12,000 square foot Glaesner Training Center, which features state-of-the-art communications and teleconferencing facilities to enable Sun Healthcare to train and communicate with its employees worldwide."
A 1998 article in the Albuquerque Tribune - Sun's torrid pace lets some workers shine, burns out others 114 - tells us much more about Sun and Turner, but by now he has learned not to give interviews himself. At Sun's headquarters we learn of
"elegantly appointed buildings ----- the walls are covered with paintings of desert landscapes ---- kachina dolls and Indian pottery, displayed in track-lit niches --- custom-designed Ernest Thompson office furniture, filling office interiors with the hues of a sunlit desert mesa. --- an indoor pool and a gym nestled four stories up, their wall-sized windows spilling panoramic views of the Sandias across the massive rooms. --- It is a slice of big-time corporate America right here in small-town Albuquerque."
"And it comes complete with a work environment that's variously called fast-paced, high-pressure, demanding, ever-changing, stressful, fair and unfair. ---- All but one of the former employees insisted on anonymity before they would agree to talk to the newspaper. They said they did not want to burn bridges with Sun. ---- It was an awesome experience. I got to take on a lot of responsibilities that I wouldn't have gotten to do at another company."
Sun's culture:- The article speaks of " -- Sun's exponential growth, which has become the stuff of legend around Albuquerque. The growth is the primary shaper of corporate culture at the company " As nursing homes were squeezed by the corporate administrators their administrative centre in Albuquerque itself was exploding. It is reported that the company leases 55,000 square feet of space in several buildings around town. "We're bursting at the seams," said Sun corporate spokeswoman Phyllis Goodman. An employee talking of the meteoric expansion says "We ran out of space, out of people, out of equipment. It made for a stressful workplace."
Some found it stressful - others exciting and challenging. " The comments included "It's all in how you cope. ---- Big demands, big pay --- Sun clearly expects a lot from its employees. Even the boss says so. --- Working for Sun is not an easy job. We demand a lot of people. --- We pay the most but we demand the most." The underpaid nurses in Sun's homes would hardly endorse the last comment. Sun refused to discuss the salaries of its staff with the paper.
Status is clearly important and is reflected in the remark "They're an international company, up there with Intel". The way in which unpalatable facts are ignored is reflected in "We've never had a philosophy that we're going to get rich off the backs of our employees," Well what about the nursing homes?
Open and closed minds:- Very interesting are the contrasting remarks of employees - perhaps closed minded team players and more open minded non-team players. Contrast "It's a great atmosphere to work in. People are helpful and friendly, and the pay and benefits package is great." with "It was a bizarre company that emphasized odd things." In retrospect the latter was the more accurate and insightful assessment. The speaker had paused and reflected on what was happening. The pace and workload tended to burn people out and the turnover of staff was high. There was no time for reflection - no time to think about what they were doing.
The Cult of Andrew Turner:- The comments about Turner himself are made under the heading of The cult of Andy. These are fascinating in hindsight and I include the whole segment:-
The cult of Andy
As constant as the change at Sun is the influence of Sun's founder Andrew Turner, who is the cultural touchstone for the company's headquarters staff.
Sun Healthcare officials would not make Turner available for an interview.
But his presence is felt throughout the company.
Workers, former and current, refer to him as "Andy," as if the founder of the behemoth company was part Friday night poker buddy, part father-figure whom they don't want to disappoint.
Andy selected the art that adorns the walls of the five-building headquarters complex.
Andy wants workers to remember why they are there, employees say.
Andy's "vision" drives the company, current and past employees say.
"Andy is the classic visionary," Goodman said. "It's important to Andy that we remember that we're here to take care of frail, elderly people."
Even the most vitriolic ex-employee has good things to say about Turner: "He seems like a fine man."
"He is very committed to health and wellness of his employees," says another.
Some current employees speak with an almost missionary-like zeal about Sun Healthcare's work, as articulated by Andy.
"There are so many people who are interested in just working for a paycheck," Wernee said.
"(But) Andy has his objective and goal and that's to take care of the elderly. If you can see that you're part of that, then you feel like you're accomplishing something."
Given the level of devotion to the company that current employees express, it's easy to see how a non-believer could fall by the wayside quickly. Sun is no place for doubters.
"(Working at Sun) is more a way of life for us than a job," Wimer said.
Here is a man with enormous energy, vision and dedication, a man with total conviction. He has no doubt. He has the charisma to inspire people and make those around him accept and believe in everything he does. None doubt his commitment to the care of patients and this is what they believe they are doing - this despite all the cost cutting.
The real Turner:- Contrast this with the views of the nurses and the families of patients. They view him as the ultimate villain and Sun as the evil empire, and there is plenty of information which confirms this. This is a man who is totally out of touch with reality and he has a cult following who reinforce that illusion. As the article states "Sun is no place for doubters." This is exactly the situation which you would expect from the framework of analysis I am using. The information we have about Eamer, Scott and even Mayne Nickless in 1994 shows exactly the same behaviour. The corporate ethos and workplace pressures are similar.
Response to changed funding:- In a 1998 article -- Sun revolves around health care's changes 115 - the Albuquerque Tribune describes Sun's growth as doubling in size every 6 months since 1993. Its revenues have increased "--from $39.2 million in 1990 to just over $2 billion last year. Sun Healthcare expects to bring in $3.5 billion in net revenue this year."
The article examines the likely impact of the new Medicare regulations and Sun's response. We would expect a sober and accurate analysis but instead we get wishful thinking, inaccurate predictions and uninformed claims. I quote:-
"Sun officials concede the company's phenomenal growth will have to slow, but they stress that they plan to remain in the health-care acquisition business ---- 'I don't know how large a company can get and still be effective; my current belief is that we can get a lot bigger than we are today' said Mark Wimer, Sun Healthcare's president and chief operating officer."
(Note that Mark Wimer took over from Turner as CEO in July 2000)
The article accurately reports the "significant threat to the cash flow" but the response from the company is "When one door closes, another opens" and "Every time we have one of those waves of change, there are many more opportunities to acquire facilities. Any time there's turmoil, there's opportunity." Sun simply ignores the position it is in and that it can no longer focus on growth.
Who's fault is it?:- The reason Medicare was changed is attributed by the market as due to rising costs and government's unwillingness to increase taxes. The corporations are not blamed. This article puts what we all know into words. It was the way in which the system was misused and defrauded by corporations that lead to the changes. They brought it on themselves. I quote:-
"Plagued by huge cost overruns and fraud associated with the current Medicare reimbursement system, the government is ordering providers like Sun to "capitate" their charges -- to deliver care at or below a federally mandated level -- or get out of the Medicare system"
Escaping the situation:- This new system is an enormous threat to those companies which have borrowed too much and if they have a few calculators handy they should know it. They have a fleet of accountants and still ignore it.
The newspaper has used its calculator and indicates "The potential loss of cash flow from Medicare may impact Sun's ability to service its debt. Sun appears to be more undercapitalized than most". One way to address the problem is to sell stock and pay back loans. Sun indicates it is not " -- going to sell stock for $6 and $7 dollars, when we know it's worth $25." Two years later it is selling for 6 cents! Here is how Sun escapes the hard figures:-
"Ironically, the imminent loss of billions of dollars in payments to its nursing homes under the new Medicare rules presents an opportunity for Sun. It stands to pick up a whole new market with its newest subsidiary, SunSolution, which will offer help to small nursing-home operators struggling to survive in the changing Medicare environment, Sun officials said."
Sun claims that the changes will "mean more cost-cutting, paperwork and headaches for the nation's smaller, mom-and-pop nursing-home operators." The corporate chains have dominated the media and the hyped up discussion about aged care. We now learn that there are only 2000 corporate nursing homes and 16000 Mom and Pops. They are to be Sun's new market. How odd that it is the corporate homes which feature so prominently in allegations of fraud and patient neglect , corporate homes which are being sued by patients and their families across the USA.
Presumably all those little Mom's and Pops were quietly getting on with the business of using the money they were paid to really look after the elderly -- free from the pressures and distractions of the market. As it turned out the Mom and Pops were more stable and more able to cope with the new system and provide care than the big corporations. They did not want or need SunSolution.
The company and Turner were so oblivious to the impending financial problems that Turner himself was awarded a massive increase in remuneration in 1998 even though Sun had already started losing money.
De-ja-vu:- Here is a company which by any sensible analysis faces a huge crisis which threatens its viability and the patients in its homes. Shareholders allege that they were deliberately deceived and have taken to the courts claiming damages. This is not the first time. Sun paid angry shareholders US $26 million in 1996 because it misinformed them and they lost money. It is clear that on both occasions Sun was in denial and hopelessly out of touch with the real world. It had created its own world and developed its own meanings and explanations. It only saw the illusions it needed to maintain its position. In Saul's words it was unconscious. They believed what they wanted to believe. This is the sort of behaviour predictable as very likely within the framework I have suggested. We saw it with fascism and we saw it with apartheid.
And so it goes on:- The incongruity becomes even greater when we examine Turner's current behaviour. This is the man who has created an "evil empire", which is accused of deliberately neglecting helpless elderly for profit, of financial irresponsibility and of defrauding Medicare. He is not going to grab his undeserved termination bonus and run. He is sacrificing this so that he can start another health care company and continue making money out of patient care. Is he deluded enough to convince others and pull it off? He may move overseas and one wonders if our leaders in Australia are so wedded to their market solution that they will swallow his line and welcome him here.
The framework of analysis I used predicts that the "closed minded" people who rise to the top when context and desired outcomes are not congruent will resolutely refuse to confront reality when it is finally forced on them. Instead they will attack and blame their critics. When Turner was asked for an interview by the Albuquerque Journal his response was to claim that " the Journal has smeared him in its stories about Sun Healthcare. He questioned the newspaper's ethics and journalistic standards before hanging up". 140
THE LATEST REPORT -- An Overview says it all - almost every word
The Albuquerque Journal on 7 August 2000 in an article "From boom to bust" reviews the companies rise and fall closely examining its history, Turner's behaviour, the response of the marketplace and the way the establishment embraced him. 140 This article became available after I had already written this. It is an excellent review of Turner's behaviour, compliments my assessment and fills out the framework of analysis I have used. I will simply quote bytes from the fairly lengthy article to make the points.
The article repeats the story of Turner and Sun and adds more detail. It says that it is "hard to recognize -- [Sun and Turner] -- for the high-flying financial stars they once were".
Response of the market and the establishment:-
"Throughout much of the '90s, Wall Street analysts touted the company's stock, and local business people cited Turner as a model of corporate success. ---- An Industry Pac-Man --- gobbled up enough properties to earn it the nickname Pac-Man ---- Sun's aggressive growth won Turner a reputation as a visionary. --- On Wall Street, his name carried weight with analysts who thought Sun's stock was a golden investment ----- one of the really exciting growth stories in the industry ---- and doing a good job of keeping costs in line. (Turner's) reputation was as a very skilled operator ---- he was considered a guy who "thought outside the box, ---- Turner was the man of the hour."
" When the Albuquerque Economic Development Corp. was looking for a speaker who would grab the attention of participants at an event to honor growing businesses, the organization chose Turner ------ The business community saw Turner as an entrepreneur certainly he demonstrated that he is a person of vision."
Sun developed and promoted an image to match all this.
"From the European cobblestones lining the drive to the Olympic-size pool, the multimillion-dollar complex is a salute to corporate confidence."
And in hindsight
"Sun's aggressive growth initiative saddled it with debt that had to be paid regardless of whether times were tough. ---- [if it had] paid more attention to business fundamentals, it never would have happened,
" Even as the firm was impressing investors and shareholders, trouble was brewing. --- -- [Various authorities] launched a probe of billing practices that still has not been entirely resolved. ---- [In Connecticut] Sun had improperly billed for expenses such as luxury condominiums, a corporate jet and a trip to Italy by some employees. ---- The investigation wiped some of the luster from the firm's reputation ----- [but] analysts continued to recommend the stock."
" Sun's finances are in tatters --- Shareholders have filed several class-action lawsuits claiming the firm knew it was headed for financial trouble months before it warned investors. Other lawsuits against the company allege wrongful death and inadequate care in Sun facilities in several states ---- A federal bankruptcy court judge holds the company's future in her hands.
The Outcome for Turner --- his considerable assets
"If the 53-year-old Turner is in the market for a new job, it is also unlikely he will have to pinch pennies until the phone rings with an offer. --- He has been selling off large blocks of the stock since the beginning of the year ---- Turner has significant assets here in Albuquerque. ---- And the private North Valley equestrian center he and his wife own across from El Pinto Restaurant is assessed at a shade less than $5 million." (These are assets acquired by the profits he took from the money intended for patient care.)
The industry's current response
" --- we would be honored if Andrew Turner would consider joining our organization."
" --- the Journal has smeared him in its stories about Sun Healthcare. He questioned the newspaper's ethics and journalistic standards before hanging up".
What hope is there for the future of our health system, our citizens and our society when a major sector of our society behaves like this; when its leaders have no insight and when our political establishment follows the marketplace slavishly in its views and behaviour?
And More -- March 20001 142
Turner is not letting the grass grow under his feet. He has formed or joined four new companies in the USA and Israel, all in aged care. He has persuaded one to move to Albuquerque so that he can run it. He is planning another in the UK. He is on the board of other companies. He has developed a new business model and he has persuaded the banks to invest in his activities. Here are some recent statements made by or about Turner.
A business mind never remains still.
"I could have retired, but chose not to. I wanted to continue to work. I had the energy and I had the desire. My work is important to me. I feel an obligation to continue working with the elderly."
"I have one skill," he said. "I know how to take care of the elderly. I've been doing it my whole life. I don't believe in diversification."
"There are several elements of treating geriatric patients who are institutionalized. I've taken the elements and isolated them in different businesses."
"We see explosive growth for EnduraCare. We're very optimistic."
"In the month of January, we expect to make our first profit," Turner said. "Our plan is to end 2001 with 50 homes."
"I hope Code Blue will become a nationwide concern with a significant market share,"
"The patients are the same. I've been in nursing homes from Singapore to Abu Dhabi, and when you walk down the corridor, the patient population is exactly the same as in Albuquerque," Turner said. "I know how to treat them."
He said financing for his new ventures has come from The Bank of Albuquerque. "They've been very supportive about my business activity," he said. "They are the reason things have gotten off the ground so quickly."
"I'm optimistic I will be involved in a variety of companies similar to the ones I've gotten off the ground," he said. "I hope to have several others started in a year to two years hence."
"I'm happy with the way things turned out. It is my intention to continue to be actively involved in businesses, primarily those rendering health-care services to the frail elderly, in an investor and board capacity. I consider my health-care work to be my obligation and my mission by comparison to just viewing it as a profit-making enterprise."
"As the years go by, there is no end in sight. I will pursue the mission until I die."
What a man!
In May 2003 the present chairman of Sun Healthcare summed up Turners reign. The extracts are from the Albuquerque Journal 143
His (Andrew Turner) era truly ended last weekend when the 550-piece $2.3 million art collection he meticulously acquired with investors' money was put up for sale in a meeting room on the Sun campus.
Present chairman Richard K. Matros hated that art collection.
On the second floor of the Masthead NE building, the visitor walked a hallway lined with American Indian art. During the building's construction, special niches were designed to properly display pieces. While Turner was in charge, workers were told what they could and could not display in their own cubicles and offices so that the Sun esthetic would not be compromised.
Matros considers it a waste of investors' money.
The money should have gone into Sun's nursing homes to improve operations and patient care, Matros said in his first Journal interview, in November 2001 when he had taken over Sun.
Besides, Matros said, much of the revenue Sun collected came from Medicare and Medicaid. Taxpayers, in other words. It was simply "unacceptable" to spend their money on a palace, Matros said.
The Turner era is over, but a legacy of underperforming assets remains.
"The company was fundamentally flawed in the way it was built to begin with," Matros said earlier this year while discussing Sun's 2002 earnings.
Matros was not exercising 20-20 hindsight. He saw the flaws in Sun's Pac Man strategy of continuous debt-backed acquisition long before Wall Street did.
Matros says Sun was so busy acquiring, it never operated its businesses properly.
"Every time an asset was acquired it was mortgaged to the hilt," Matros said. The borrowed money was used to fund more acquisitions.
In an article "Founder of Sun is still in business" on July 13, 2003 the Albuquerque Journal describes Turner's current activities.
Since leaving Sun, Turner has founded two health care companies. One, EnduraCare Therapy Management Inc., is based in Las Vegas, Nev., and provides occupational, speech and physical therapy services. Another, Code Blue Staffing Solutions, is headquartered in Albuquerque. It finds temporary professional help for health care operations.
He is also on the boards of a company that develops athletic clubs, called The Sports Club/LA, and a drug maker, Watson Pharmaceuticals Inc.
Turner abandoned efforts to develop a 24-acre property with an equestrian center on Fourth Street NW. He sold some of the property and traded the rest for a North Valley residence.
Court documents show that Turner and his wife, Nora, began divorce proceedings last year.
I venture to suggest that the behaviour of Sun Healthcare and Andrew Turner very closely match what you would expect when the situation is analysed within the framework which I have suggested. This rather general model of human behaviour was developed in a different context but it has held up when set against the behaviour of Tenet/NME and Columbia/HCA. The conduct of Vencor and IHS is congruent. A detailed analysis of Sun Healthcare and its founder reveals a high degree of congruence. It is therefore suggested that the framework has overall predictive value in health and aged care.
Mayne Nickless' Smedley and Revesco are new arrivals in the Australian health care marketplace. We have more limited information about them but the information so far available about their business philosophy and intentions is congruent. Revesco has embarked on a PACMAN buy up of other groups and General Practice clinics. I suggest that the framework of analysis which I have outlined may well be equally applicable to them. It should direct our attention to the importance of context when redesigning our health system.
IV. AFTERTHOUGHT - A DIFFERENT ROAD -- (contents)
Canada is following a similar "reform" program to that advocated by Dr. Wooldridge. In her 1998 book "Caring For Profit" the Canadian author,Colleen Fuller described the pressures towards corporatisation of health care in her country in the light of the US experience. The book concluded that Canada had taken the wrong road. They should turn back and try another. Another Canadian author John Ralston Saul, one of the foremost thinkers in the world today has also been highly critical of the direction in which Canadian health care is going. He is best known for his Massey lectures, published as "The Unconscious Civilisation". If we are to try another road then the first step is to change the context within which health care is provided.
Context and Metaphors:- In 1995 Annas in the New England Journal of Medicine wrote of the impact of different metaphors on health care. Each created a different context. First the war metaphor -- the warrior fighting disease. This resulted in excessive effort to keep people alive and do everything possible so increasing costs. He then examined the marketplace metaphor and found it wanting.
The consequence of failing to take note of the assessments made by Annas and more particularly Relman, who has been writing about this since 1980 are now only too apparent. Annas proposed an ecological metaphor as being more useful but this too has problems.
I suggest the "community" metaphor. Care after all started with empathic members of the community looking after one another. Christianity too brought to society a Samaritan ethic which has been embraced by secular society and the health care professions. We are all members of our communities and we recognise a responsibility to one another.
The context of a community working together to help one another stretch limited resources for the benefit of all is I suggest a much more appropriate context from which to address the problems which we face in health and aged care. It sits well with Eva Cox's concept of a civil society and the creation of social capital.
The Australian federal government has made much of the concept of a civil society, but these have been very empty words - a hollow facade. What they have done to promote this has little resemblance to Cox's ideas. You cannot develop a civil society using corporations as the driving force (e.g. the oil company Shell). The context is totally incongruent and it is simply another marketing exercise for both parties -- another way to deceive the electorate.
Health and aged care test government's commitment to society rather than to their careers. More than any other activities they call for civil values, humanness and people helping one another - the development of social capital. What greater opportunity to build social capital and a civil society. Health and aged care give government an opportunity to put meat into their words. They cry out for civil and human solutions. If they don't do it here then it is clear that they will not do it anywhere else. They are exposed as hypocrites.
Articles used -- (contents)
Bigger isn't better; Our first Post-Acute-Care Survey finds that
larger firms are faring worst in turbulent industry
Modern Healthcare July 24, 2000, Monday 24/7/2000
Sun founder announces intention to step down By Elise Nakhnikian
POSTACUTE PAYMENT REPORT: 7/14/2000
Sun's torrid pace lets some workers shine, burns out others
Albuquerque Tribune October 08, 1998, Thursday
Sun revolves around health care's changes
Albuquerque Tribune October 08, 1998, Thursday
Andy Turner wants the government out of health care, Period,
New -Mexico Business Journal. April. 1996 Vol 20; No 4: pg 10
Watch them grow, And grow.
New 'Mexico Business Journal, April. 1996 Vol 20; No 4; pg 15
140. From boom to bust --- Sun founder
leaves; firm still in bankruptcy
Albuquerque Journal August 7, 2000, Monday
141. Annas G. J. Reframing the debate on
health care reform by replacing our metaphors
N Engl J Med 1995; 332:744 [Copy not included with articles]
Obligation to the elderly
Albuquerque Tribune January 22, 2001
143. Sun Healthcare's art was a huge misuse
Albuquerque Journal (New Mexico) May 22, 2003
Colleen Fuller -- "Caring fo Profits. How corporations are taking over Canada's health care system" New Star Books, Vancouver 1998
John Ralston Saul -- Massey Lectures "The Unconscious Civilisation" Anansi Press Toronto 1995
Eva Cox -- ABC Boyer lectures "A Civil Society"
LINKS TO MAPS
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Overview ... Arguments ... Documents ... Criticism letter ... FIRB
This page created August 2000 by Michael Wynne
Minor modifications October 2000
Minor Editing and updating August 2003