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A. Financial Conflicts of Interest
(Many sites below track your IP address; you can check their privacy statements.)
While searching for doctors, be aware of the stress they are under. A cardiologist writes, "We can't be perceived as less than 100% capable. We can't take medications in case it will affect our performance. We find it difficult to admit that we aren't the perfect person that our patients expect us to be. We belong to the only profession on the planet where we are accused of thinking we are God and then sued when we are not."
A. Financial Conflicts of Interest
Doctors get many pressures which affect patient care. The Journal of the American Medical Association (JAMA) May 2 2017 summarizes a lot of research and has a proposal that doctors be paid by salary, to avoid:
Practices with 2 or more primary care doctors were analyzed in a July 2015 study in Annals of Family Medicine (632 practices surveyed 2012-13):
Average incomes (after expenses) by specialty range from $200,000 per year for Pediatrics to $440,000 for Orthopedics, with wide variation. Wealth averages $1-2 million, depending on specialty. Half of some specialties would not choose medicine again if they had the chance, including Orthopedics, Plastic Surgery, Radiology, Urology and Dermatology.
Most doctors at hospitals work for large groups which contract to provide hospitalists, radiologists, emergency doctors, etc. Some companies provide doctors to hundreds of hospitals.
Payments from industry to doctors are discussed on the drugs page.
B. DOCTORS REVIEWED BY DOCTORS
Patients can use published surveys to find doctors recommended by other doctors.
Consumer Checkbook asks doctors to recommend other doctors in big metro areas, and provides the counts for doctors recommended most often (list of counties). They also count patient recommendations for primary care doctors (in Boston, Chicago, DC, Delaware Valley, Puget Sound, San Francisco, and Twin Cities areas), so you need to read column headings carefully to be sure whether you are seeing ratings by doctors or by patients. In "more filters" you can sort by number of recommendations or distance from a zip code (if you selected "search by zip code").
"We regularly send surveys to all actively practicing physicians in the 53 largest metropolitan areas in the U.S. and ask them to tell us which one or two specialists in each of 35 or more different specialty fields they 'would consider most desirable for care of a loved one.' " ($28 online). Their research says that in general these doctors also:
A 1999 study found that doctors were more likely to be in such lists "if they trained in prestigious residencies (P<0.01) or fellowships (P<0.05), or if they had an academic appointment (P<0.05) or 15 or more years of experience (P<0.001)."
Referral services also select doctors they think are high quality, and you pay for the referral.
Malpractice and disciplinary cases (rare) are another place where some doctors are reviewed.
C. DOCTORS REVIEWED BY STATISTICS
The best statistics are:
Groups which report outcomes often say they adjust for initial health to put all patients on a level field, but the adjustments are very weak. They have low explanatory power, and few variables: "the most assiduous work on risk adjustment has produced tools of only moderate power. The prospects for solving this problem with improved risk adjustment are not promising.,"
Consumer Checkbook rates individual surgeons on death (within 90 days) and total bad outcomes, SurgeonRatings.org. They use Medicare patients 2009-12, and only report surgeons with results significantly above average. Unlike their hospital data, they unwisely exclude hospice patients from the surgeons' results (p.3). Few patients would have these surgeries if they were on hospice, so they must have gone on hospice after surgery. These deaths are no more or less attributable to surgery than any other deaths in 90 days. They acknowledge a random level of deaths in any population, unrelated to surgery, and exclude it with statistical tests.
Surgeons' total bad outcomes for Checkbook include deaths within 90 days, atypically long hospital stays (indicating major complications), and readmissions within 90 days of initial hospital discharge. They seem to include all readmissions, even unrelated to the surgery, so they penalize surgeons who take on patients sicker than average. They say they adjust for patient riskiness, without details about which variables they use. They do list the "c statistic" for each adjustment, ranging from 0.626 to 0.913 (pp.14-39). The c statistic ha a scale of 0.5 to 1, where 0.5 means their equations do no better than chance, and 1 means their equations are perfect. So some equations are little better than chance, and they still rate surgeons with them. They cover (definitions on pp.9-13):
ProPublica almost simultaneously with Checkbook in 2015 released death and complication rates for all surgeons with at least 20 surgeries during 2009-13, in the categories below. They count deaths during the same hospital stay as the operation, and wisely do not exclude hospice deaths (p.5). As "complications" they count readmissions within 30 days if these are for diagnoses considered likely to be related to the original surgery. These are 46% of all 30-day readmissions (p.6). They count a surgeon as having a "high" complication rate, based on their best single estimate, even if his/her confidence interval extends all the way into the "low" range.
ProPublica limits the data to elective surgeries, which usually involve healthy patients, but can include patients with other serious conditions, as long as these do not prevent the operation, conditions such as diabetes, dialysis, weak immune systems, etc. They say they adjust data based on the sickness of the patients, but they tried only one summary measure of all health conditions, and it had little effect (pp.10-11, with column heads defined on p.4). Age has the most effect, but they group it into 5-year categories, instead of using exact years of age (maybe because of data availability?). They do not provide summaries of their equations' power, but do acknowledge that their adjustments for surgeons' differing patients make only a "small difference" (p.13). For each equation they provide the standard deviation of the random effects (ranef sigma), which they interpret to mean most of the variation is among surgeons, not hospitals (p.15). They cover (definitions on App.1-3):
Levy says the profession keeps secret a better scorecard, NSQIP.
Chest surgeons show 3-star ratings on about 500 hospitals and 500 group practices (typically the group of surgeons operating at a hospital), for
Cardiologists show 4-star ratings for use of recommended drugs by a few hospitals after
California has a rating system for doctor groups with HMO members:
New York shows deaths within 30 days after a procedure for individual heart surgeons and cardiologists. You can filter by name of doctor and/or hospital, and region of the state. They describe methods and definitions for the surgeon and cardiologist data. Another NY site has profiles of all doctors, but does not link to the death rates.
CMS Qualified Entities are allowed to use Medicare claims data, in order to provide quality measures on doctors, but it is not clear if any have yet released quality measures.
D. DOCTORS REVIEWED BY PATIENTS
Patient reviews tell if a doctor speaks clearly and listens, as well as giving early warning of problems. Dr Wen of George Washington U and Dr Kosowsky of Harvard say doctors need to communicate well with patients to get information for a good diagnosis:
Wen's and Kosowsky's book goes on to describe in detail how patients need to prepare before seeing a doctor.
Patient reviews tell you the style of different doctors, especially in the written comments.
Some doctors have required patients to sign contracts which prohibit negative reviews or let doctors remove negative reviews. The "Consumer Review Fairness Act of 2016" makes those clauses unenforceable. 3,000 doctors had these contracts available in 2011, though not all used them. These doctor-patient contracts are not mentioned by any of the review sites as a reason for removing reviews, but one assumes they do it, or doctors would not bother with the contracts.
Before patients choose any doctor based on positive reviews, it is important to ask the doctor's office: Do patients have to sign a contract controlling patient reviews?
Rules about the reviews they keep are important. Here are rules at the 3 biggest sites:
Allowable reviews: They have few restrictions: "post only truthful, non-libelous, and relevant ratings and posts."
Removing reviews: "We remove ratings for a number of reasons, but it is usually due to one of our automated spam filters thinking there were multiple ratings coming from the same rater... We generally do not remove ratings. This site is for people to report on their experiences...
Are reviews anonymous? Possibly. They keep patients' names anonymous unless subpoenaed, but they let advertisers and social media companies track which pages you see, so those companies can see your IP address when you post reviews. You can be anonymous if you post your reviews from someone else's computer, like a library, and don't identify yourself on that computer (eg. logging in to Facebook or email). Using your computer at a coffee shop gets you a new IP address, but your computer probably has persistent identifiers which their advertisers can track.
Are searches anonymous? Only if you use someone else's computer. Their advertisers track IP address and every page visited, so they can see what you're searching for. To foil advertisers you can turn off cookies, but not necessarily beacons. Buttons for Facebook, Twitter, and Google+ on every page presumably report every page visit to those companies.
Multiple ratings and updates: They limit patients to one rating "for the same doctor from the same computer or user." "If you were logged into your account when you submitted the rating, you can edit your star rating in your profile. Comments are not editable, but you can leave a new comment... If you were not logged in when you submitted the rating, the only thing you can do is to try to remove it and then enter a new rating."
Can patients report why they didn't go to a doctor? Yes.
Allowable reviews: They have woolly restrictions: "accurate, truthful and complete in all respects" (10) and not offensive, harmful or distasteful, among many other criteria (16).
Removing reviews: They pose the question and answer it several different ways: "Angie's List may modify, adapt, or reject Your reviews if they do not conform with Angie's List's publication criteria, which may change from time to time at Angie's List's sole discretion" (10g). "we never remove reviews unless the member who posted the feedback contacts us to delete it." "If ever we question the legitimacy of a review, we take it down."
Are reviews anonymous? No. They reveal the author of each review to the doctor (10f), though not to other members. Writing any review waives privacy and lets doctors publicly post "Your private or confidential health information in response to Content You submit" (15). "Angie's List may in our sole discretion share your User Generated Content with others."
Are searches anonymous? No. They disclose personal information when "permitted by relevant law," and they have four tracking companies on their search pages (see a table at the bottom of this page), so those companies know what you're searching for. They allow themselves to "link the information we record using tracking technologies to Personal Information we collect."
Multiple ratings and updates: "You have the right to share your honest opinions at any time."
Can patients report why they didn't go to a doctor? Yes. Reviews by people who checked out a doctor but did not go there are posted, but not weighted as heavily as people who did choose the doctor. So good or bad experiences before getting care can be read, though the doctor's average rating is not much affected.
Allowable reviews: must be "true and accurate" and not offensive, harmful or "otherwise objectionable," and not "deemed confidential by any contract or policy," among many other criteria.
Removing reviews: They say they provide "The complete list of all reviews from patients just like you." However they'd suppress reviews that violate their lengthy criteria, so it is not really "all." They sell to doctors a service called: "Reputation Management." It "enables providers to append responses to specific reviews [and] Opportunities to encourage patients to write additional reviews." Vitals' CEO is quoted in Buzzfeed saying the site can remove an "outlier" negative review at the doctor's request.
Multiple ratings and updates: "post only one (1) Submissions regarding the same Healthcare Provider, entity, procedure or subjectduring any thirty (30) day period."
Can patients report why they didn't go to a doctor? No. "By clicking Submit, I... verify that I have received treatment from this doctor."
E. PATTERNS OF COMPLAINTS BY PATIENTS
Consumer sites carry complaints about doctors, justified or not. Also, some doctors are formally charged by authorities or investigative reporters, correctly or not. The complaints on consumer sites often give early warnings about doctors who are later investigated. Second opinions are almost always a good idea, and especially in any of these situations where others have reported concerns.
DOCTORS CHARGED BY INVESTIGATORS: What Their Reviews Look Like
The first list below summarizes consumer reviews for 8 doctors who have faced charges (and citations for the charges). All the doctors denied the charges. The second list shows there have been fewer complaints for a control list of doctors who have not been charged, and who do many knee replacements, a risky procedure. So consumer complaints do show a difference between the two groups of doctors.
DOCTORS WHO DO KNEE REPLACEMENTS: What Their Reviews Look Like
The following shows the range of consumer reviews for 5 surgeons who do high volumes of knee replacements. These have not been the subject of investigations and may be considered "normal" high-volume doctors:
F. NO PRIVACY ON THE WEB: TRACKING YOUR SEARCH FOR DOCTORS
- Breast Cancer: Oncologists recommended: Dana Farber-Boston, Mayo-Rochester, MD Anderson-Houston, Memorial Sloan Kettering-NYC, U of Michigan-Ann Arbor. All doctors recommended: Memorial Sloan Kettering-NYC, MD Anderson-Houston, Mayo-Rochester, Dana-Farber-Boston, Cleveland Clinic-Cleveland, Hopkins-Baltimore, Stanford Health Care-Stanford (CA), City of Hope Helford-Los Angeles, Duke-Durham, U of California-San Francisco, Brigham+Women's-Boston.
- Prostate Cancer: Oncologists recommended: Dana Farber-Boston, Hopkins-Baltimore, Mayo-Rochester, MD Anderson-Houston, Memorial Sloan Kettering-NYC. All doctors recommended: Memorial Sloan Kettering-NYC, MD Anderson-Houston, Mayo-Rochester, Hopkins-Baltimore, Cleveland Clinic-Cleveland, Dana-Farber-Boston, U of California-San Francisco, Massachusetts General-Boston, Duke-Durham, Stanford Health Care-Stanford (CA).
- Lung Cancer: Oncologists recommended: Dana Farber-Boston, Hopkins-Baltimore, MD Anderson-Houston, Mayo-Rochester, Memorial Sloan Kettering-NYC. All doctors recommended: MD Anderson-Houston, Memorial Sloan Kettering-NYC, Mayo-Rochester, Dana Farber-Boston, Hopkins-Baltimore, Cleveland Clinic-Cleveland, Duke-Durham, City of Hope Helford-Los Angeles, U of California-San Francisco, Stanford Health Care-Stanford (CA).
- Hip Replacement: Surgeons recommended: Cleveland Clinic-Cleveland, Hospital for Special Surgery-NYC, Mayo-Phoenix, Mayo-Rochester, New England Baptist Hospital-Boston. All doctors recommended: Hospital for Special Surgery-NYC, Mayo-Rochester, Cleveland Clinic-Cleveland, Rush Univ-Chicago, New England Baptist Hospital-Boston, Hopkins-Baltimore, Massachusetts General-Boston, Duke-Durham, U of California-San Francisco, Cedars-Sinai-Los Angeles.
- Cardiac Conditions: Cardiologists recommended: Brigham+Women's-Boston, Cedars-Sinai-Los Angeles, Cleveland Clinic-Cleveland, Mayo-Rochester, Mount Sinai-NYC. All doctors recommended: Cleveland Clinic-Cleveland, Mayo-Rochester, Presbyterian-NYC, Massachusetts General-Boston, NY, Hopkins-Baltimore, Cedars-Sinai-Los Angeles, Brigham+Women's-Boston, Stanford Health Care-Stanford (CA), Duke-Durham, U of California-San Francisco, Mount Sinai-NYC, U of Pennsylvania-Philadelphia.
- Interventional Cardiac Surgery: Cardiologists recommended: Brigham+Women's-Boston, Cleveland Clinic-Cleveland, Hopkins-Baltimore, Mayo-Rochester, Stanford Health Care-Stanford (CA). All doctors recommended: Cleveland Clinic-Cleveland, Mayo-Rochester, Presbyterian-NYC, Massachusetts General-Boston, NY, Hopkins-Baltimore, Stanford Health Care-Stanford (CA), Brigham+Women's-Boston, Cedars-Sinai-Los Angeles, Duke-Durham, U of California-San Francisco, U of Pennsylvania-Philadelphia.
- Stroke: Cardiologists recommended: Brigham+Women's-Boston, Cedars-Sinai-Los Angeles, Cleveland Clinic-Cleveland, Mayo-Rochester, All doctors recommended: Mayo-Rochester, Presbyterian-NYC, Massachusetts General-Boston, NY, Cleveland Clinic-Cleveland, Hopkins-Baltimore, U of California-San Francisco, Duke-Durham, Stanford Health Care-Stanford (CA), Northwestern-Chicago, Brigham+Women's-Boston. Cedars-Sinai-Los Angeles.
- Infectious Disease HIV and Infectious Disease specialists recommend: Cedars-Sinai-Los Angeles, Emory-Atlanta, Hopkins-Baltimore, Massachusetts General-Boston, NY Presbyterian-NYC. All doctors recommended: Mayo-Rochester, Hopkins-Baltimore, Massachusetts General-Boston, Cleveland Clinic-Cleveland, NY Presbyterian-NYC, Emory-Atlanta, U of California-San Francisco, Duke-Durham, U of Michigan-Ann Arbor, U Pennsylvania-Philadelphia.
- Multiple Sclerosis: Neurologists recommended: Brigham+Women's-Boston, Cleveland Clinic-Cleveland, Hopkins-Baltimore, Mayo-Rochester, U of Texas Southwestern-Dallas. All doctors recommended: Mayo-Rochester, Hopkins-Baltimore, Cleveland Clinic-Cleveland, Massachusetts General-Boston, NY Presbyterian-NYC, U of California-San Francisco, Brigham+Women's-Boston, Duke-Durham, Stanford Health Care-Stanford (CA), U of Michigan-Ann Arbor.
Medicare reports many issues as quality measures, and imposes financial penalties which are estimated in the hospitals' financial statements on this site: HAC, VBP, IQR, EHR, and readmissions. Unfortunately all these measures create incentives for hospitals to give less treatment to sicker patients, since sicker patients hurt the hospital's statistics and earn penalties.
Medicare reports the death rate within 30 days after a hospital stay. However their death rate excludes patients who go on hospice. This exclusion reduces the apparent death rate, and creates a strong incentive for hospitals and doctors to urge the sickest patients onto hospice, whether they have a real chance of cure or not, since deaths on hospice don't hurt the hospital's statistics. As with most medical incentives, medical staff who urge hospice do not reveal their incentives. (methods)
Veterans' Hospitals have data on each hospital's size, volume, staffing, deaths, infections, readmissions, patient satisfaction, etc.
US News and World Report does not show an exact death rate, but shows hospital death rates (within 30 days) in deciles for particular diseases. They do not exclude hospice or palliative care, so they don't create an incentive for hospitals to hide deaths by referring to hospice. They generally omit transfers from other hospitals, to avoid high death rates in major hospitals which receive many transfers of the very ill. So they are trying not to penalize hospitals which serve the sickest patients. They adjust to reflect all patients, not just the elderly, and slightly adjust to reduce random variation in the smallest quarter of hospitals. (methods)
Consumer Checkbook (subscription $22 for 2 years) shows hospitals' exact risk-adjusted death rates (within 90 days), for medical patients, surgical patients, and combined, based on 10 serious medical diagnoses and 14 surgical. They use Medicare patients from Oct 2009 - Sept 2012, and do not exclude hospice or palliative care patients, so hospitals can't hide deaths by referring to hospice. They also show a combined "adverse outcomes" rate for surgical patients, the total of deaths, atypically long stays, which indicate major complications, and readmissions within 90 days of initial hospital discharge. Penalizing readmissions does penalize care for the sickest patients, who are more likely to need another hospital stay within 3 months. (methods)
Ratings of doctors by Checkbook, ProPublica and others are discussed on another page.
Hospitalinspections.org counts and describes "deficiencies cited during complaint inspections at acute-care, critical access or psychiatric hospitals throughout the United States since Jan. 1, 2011. It does not include results of routine inspections or those of long-term care hospitals. It also does not include hospital responses to deficiencies cited during inspections." (emphasis added)
Healthgrades does not show an overall death rate, but reports hospital death rates for over 20 diagnoses. For non-surgical diagnoses, they ignore deaths of patients discharged to hospice. Starting in 2014 they no longer ignore deaths of patients who saw a palliative care doctor in the hospital. Through 2013, for half of diagnoses, they omitted patients from the death rate who saw a palliative care doctor in the hospital (methods: 2014 and 2013).
Healthgrades has a risk calculator for 6 common surgeries, which shows hospitals near you with low rates of death and complications, and it shows high-volume doctors at those hospitals. Their definition of high volume is a mix of high volume on the procedure you need along with total volume for all procedures. You can get more specific information on experience with these 6 and all other procedures on another page.
NICHE (Nurses Improving Care for Healthsystem Elders) no longer lists hospitals which have adopted strong programs in Geriatric nursing, so here is a spreadsheet of their old data. Many of these hospitals have Acute Care for the Elderly (ACE) units. They encourage walking, try not to interrupt sleep, and they minimize prescriptions. They encourage hospitals to help caregivers as well as patients.
Commonwealth Fund brings together data, mostly from Medicare, and lets you compare hospitals in different areas. (methods)
Leap Frog Group asks hospitals how well they comply with certain quality standards, and has answers for about a quarter of hospitals. (methods)
QualityCheck has limited information from the Joint Commission (which accredits hospitals and other health care organizations).
Dartmouth Atlas has multiple lists with unique information on hospitals:
- Types of health care used during last 2 years of life by Medicare patients who died in 2010. Also some earlier years. This shows use of doctors, hospitals, nursing homes, hospice, home health: average days and spending. (methods)
- Readmission rate, and use of doctors during 30 days after discharge from a hospital, for Medicare patients who were admitted in 2010. Also some earlier years (methods)
Truven, (subscription) formerly part of Thomson Reuters, now uses Medicare data on deaths and readmissions (methods) at hospitals.
Consumer Reports (subscription $7/month or $30/year) groups Medicare data on readmissions into categories, and shows many hospitals at once, so it may be easier to use though less precise than the Medicare site. (methods). They also have heart surgery data on hospitals, described in the next paragraph.
Heart surgeons show 3-star ratings on about 500 hospitals and 500 group practices (typically the group of surgeons operating at a hospital), for
- Coronary artery bypass grafts (CABG) and
- Aortic valve replacements (AVR).
- For 60 hospitals they rate surgery on congenital heart defects
Cardiologists have a spreadsheet of 4-star ratings for use of recommended drugs by 550 hospitals after
- Implanting Cardiac Defibrillators, and
- Diagnostic Catheterization and Percutaneous Coronary Intervention (PCI/Angioplasty)
California rates hospital quality on:
- Hip/knee replacments: Medicare 30-day unplanned readmissions, all ages' surgical site infections, and 8 Medicare patient complications which are: heart attack within 7 days, pneumonia-7 days, sepsis/shock-7 days, surgical site bleeding-30 days, pulmonary embolism-30 days, death-30 days, mechanical complications-90 days, joint/wound infections-90days
- COPD (Emphysema or Chronic Bronchitis): readmissions and non-hospice deaths
- Childbirth: cesareans (spelling), episiotomies, breastfeeding in hospital, vaginal birth after cesarean, cesarean infections.
- Cancer screening of adults 50-75
- Lower back pain patients who had X-ray, MRI, or CT scan within 28 days of the diagnosis (fewer is considered better)
- Diabetes/blood: kidney function screenings, HA1c blood sugar testing, HbA1c <8.0%, blood pressure <140/90, cholesterol screenings, cholesterol LDL-C <100
- Pediatric care: upper respiratory infections and immunizations
Luxury Suites are available at many hospitals for $250 to $2,500 extra per day.
Review article in 2010 covered similar information at that date. It recommended that hospital staff should learn how hospice and palliative care affect the ratings from each group, so each hospital can get ratings as high as possible.
2. Other Incentives to Leave Patients Untreated
- "Patients who are not receiving adequate preventive care will be excluded [by doctors, from getting care], and providers who take on care of these patients can be financially penalized.
- "The patients most in need of care coordination will be excluded, and providers who provide coordination to complex patients may be financially penalized.
- "Providers can be financially penalized for keeping their patients healthy...
- "[P]erverse incentive for a physician not to become involved with a patient who already incurred significant healthcare spending earlier in the year, even though these are the patients who may most need additional help...
- "Spending Measures Do Not Distinguish Appropriateness of Services ...
- "Risk Adjustment Systems Do Not Adequately Adjust for Patient Needs"
Medicare publishes death rates to help people choose safe hospitals. However they omit your death if you have been in hospice any time in the past year. It is in the hospital's interest (even if not the patient's) to promote hospice for at least a day per year to patients who they think are most likely to die. Hospice takes them out of the reported death rate. Hospitals cannot ethically suggest coming off hospice after a day, so the patient's treatment shifts to hospice.
Medical groups (ACO - Accountable Care Organizations) have a quality standard to avoid high hospital-wide readmissions (HWR) of their patients, but patients who die within 30 days of the first discharge are excluded from that standard (p.11 and p.53523). Hospitals were rated on the same measure starting October 2014. In either case when a patient is readmitted in less than 30 days, the group or hospital looks better if the patient dies within the same 30 days, so the readmission can be excluded.
Hospitals are rated on hospital-wide readmissions from all causes, and some procedures have more readmissions than others, especially among the elderly, so hospitals have an incentive to minimize these procedures.
Healthgrades death rates ignore your death if the hospital has sent a palliative care doctor to see you, or if you are discharged to hospice. Hospitals know that some consumers use Healthgrades to evaluate hospitals, so they have an incentive to promote palliative care and hospice.
Consumer Checkbook hospital data, ProPublica surgeon data, and US News and World Report do not exclude hospice or palliative, so they provide a more complete picture, and less incentive to push patients into hospice.
The US Department of Justice prosecutes hospitals and doctors for billing Medicare for care outside Medicare guidelines, even if appropriate under other expert guidelines. The investigations chill the willingness of doctors to provide care.
3. Doctors' Quality
legal or medical advice.
The site does not
hospitals or anyone. It
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you can decide.
Dates are assigned
arbitrarily to sort
the articles. Most
articles have been
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