The Nashville Post received a press release from Essent last year---almost a year ago---foretelling two events:
Essent consolidates Texas hospital campus By Erin Lawley
Posted on November 24, 2009 at 8:10 am Essent Healthcare will consolidate the acute-care services of Paris Regional Medical Center in Paris, Texas into a single campus by next fall. The move is designed to improve access for patients, strengthen the quality of care and provide for better coordinated services. Essent owns five hospitals and is in the process of acquiring its sixth.
Soooo, which proved to be true? Both? One? or, none (right answer)! So, does that mean that the access is poor, the quality of care needs strengthening, and the services are un-coordinated?
Hmmm.... I did say that it was a year ago, didn't I?
I wonder if that press release was from the same person that said Dux was leaving immediately, er ah, I mean, by October 1st. Probably going to announce that fall has been delayed.
Funny, as it was pointed out to me numerous times, how one day the Duck is being 'frog marched' to the door, with Essent saying the coup d'état was now...and the next day, he has a month to pack his pencils....
To ensure a smooth transition of the hospital’s leadership, Dux will remain at PRMC until Oct. 1. At that time, current chief operating officer Bill Porter will assume the position of interim CEO.
“He is telling his employees now,” Fox told The Paris News shortly before 10 a.m. today.
Bill Porter, PRMC’s current chief operating officer, will begin serving as interim CEO immediately.
Whoever writes the releases ought to learn the meaning and value of consistency.... Of course we hicks can't remember one day to the next, so why bother???
My question would be: Why, with all that time and effort to build a reputation in health care would a CEO of a hospital bail? ...and for an undisclosed endeavor???
You have to wonder what is going on. Apparently they are cleaning the place up in Paris (the fountain even works!), over-staffing in non-critical areas (2 nurses for 3 patients in some areas) and even Ducks and the Connster were seen roaming the halls "inspecting" everything this last week. Looks a whole lot like a potential buyer is looking to view the place or else they are expecting a "surprise" inspection from a state agency. I think I would go with the former.
Is Essent for sale? Maybe pieces of it. The Lowell Sun's article left a bit to interpretation. "...possible joint purchase (of the hospital) of some kind." could mean anything, including a management deal, or a trade out for the newly acquired facilities. But wasn't the one facility pledged on that loan????
Since the fall through of the Brown deal (number 4, wasn't it?), Essent's stock is probably at a new low--or would be if it was a publicly traded company. A pay freeze for the third year doesn't indicate any good news, as well.
Looks like Brown County General dodged the bullet...grapevine (rumours, not the town) has it that more guarantees were needed--by which party? Who knows.
But, that makes how many misses for Essent? There probably are only just so many fish in the sea. Ahh yes, but who's counting.... Just you...and me...and Charlie.
Been over to the ER lately? Recognize the staff? If you do, you're lucky, since the majority are temp service/agency nurses.
What's the harm, it infuses the hospital with new people??? Yeah, but when the location of the simplest things takes a question, and it pulls another nurse away from patients.....
But we can see if we like a nurse's work before we offer them a postion.... How many actually take an offer from here?
You really can't fault the nurses--the ones we had have a good chance of being agency in another hospital....
No truer words have been spoken than: Familiarity breeds contempt.
I probably wouldn't have even mentioned it, but a memo was passed my way. Remember Bill Heburn? He was involved with the purchase of PRMC, I believe. He was bounced from Essent when he developed a case of foot-in-mouth disease, and mentioned that Crossroads, their hospital in MO, had only been profitable for one year in five. Huddie didn't like that after I kind of mentioned it (and at least two selection committees should have taken notice, because that was not the way that Essent was presented to Sharon nor Paris), so Bill was in the wind.
He's apparently redeemed himself over the years, with Trinity, and now CHS. Bill will be taking the reins of Northwest Health System on an interim basis. Apparently the CEO and CFO simultaneously resigned. That in itself is probably significant. Also significant is the fact that while writing this, the web page with Doug Arnold (CEO) is still up--but probably not for long. The memo went out on the 18th. Good luck Bill.
M E M O R A N D U M
TO: Northwest Health System Members of the Board Members of the Medical Staff Employees Volunteers
FROM: Michael Portacci President – Division II Operations
DATE: March 18, 2010
SUBJECT: CEO Announcement ____________________________________________________________________________________ Doug Arnold, Chief Executive Officer, and Eddie Klein, Chief Financial Officer, have resigned their positions with Northwest Health System effective immediately.
Bill Heburn will lead the system as Interim Chief Executive Officer, providing operational oversight during the transition. Bill is a veteran hospital executive who has worked with CHS-affiliated hospitals, most recently as a chief executive of the 349-bed Trinity Medical Center in Birmingham, Alabama.
A national search for new officers has begun; board and medical staff leaders will be involved in identifying the best candidates to lead this system.
Through the strength of our medical staff and employees across the Northwest Health System, I am confident that your focus will remain on delivering quality patient care. Thank you for your commitment to being the healthcare resource in our communities.
MTP/gf
“Community Health Systems” is a registered trade name of Community Health Systems Professional Services Corporation
More commentary, seemed fairly poignant, so it gets its own post: I'm not sure anyone reads this blog any more, but I'll give my last 2 cents worth of commentary.
Truism: A business exists to benefit the owner, not the employee. It is what it is. The sad fact is, it seems Essent only cares about corporate earnings statements and not the people who support the business; customers and employees.
That being said, what has happened to this community is a terrible thing. Many previous posters have talked about every issue possible, offered their solutions to many, many problems only for them to fall on deaf ears. Most didn't have Harvard MBA's but had experience a degree couldn't provide.
Although Essent is reading these comments, they are much like the current administration in Washington and that is; "Full speed ahead, damn the torpedos."
It's too bad that they didn't listen to the troops on the ground. After all, it wasn't their money and prestige they were squandering, it was other peoples.
I don't know of one single person, me included, that has left that place without bitterness in their heart. It used to be such a nice place to call home. And, it was home to thousands of people in Paris and surrounding areas. Not any more.
I believe the hospital will survive, but it will take many years to regain the trust of the people in Paris and NE Texas.
A lot of people wonder why the posts have dried up. It's not that there isn't anything to discuss or cuss, it's just that the discussion seems rather futile. It doesn't change.
The ER loses good staff, and they hire locums. Clinical or nursing loses staff, and locums replace them at twice or three times the cost.
The spread-out services continue to make it difficult for Essent's showplace to be truely functional.
The 401Ks go begging for a second year, but a new hospital is acquired.
When ever you ask someone that works here how things are, the first thing they do is look over their shoulder...that says a lot. (Try it sometime, you'll see what I mean.)
But, apparently the only thing we lose is customers. Paying customers, that is.
Maybe it's the wave of the future, but this is a future that doesn't float my boat. I think it's about time that I plot a different course. There are enough locum jobs that don't involve Essent and provide a safe way to evaluate an employer--and an area.
There are a number of former staff that have made the move--I'll probably have mates to commiserate with. I just hate the idea of the bad guys winning...by default.
By now most know that Essent is in the due-diligence phase of the Brown County General Hospital in Ohio. It is also noted that they didn't bring the commissioners to Paris....
I particularily liked the quote in The Ledger Independent:
"Essent will breathe new life into Brown County General Hospital," Edwards said.
And,
Essent will also provide capital for facility and equipment enhancements and proposed to invest "significant amounts of capital over the next three years to include the construction of two new floors with approximately 50 private inpatient rooms," according to a press release.
Wonder how that plays in the new hospital in Ayer, MA--Oh yeah, they decided not to build that one. And when was that move to the North Campus taking place...let's see now...Oh yeah, in the beginning of the year. This year or last year?
Must be a real good price, and who in the organization is getting their raises and matching funds? Divide that rumored bonus by 2000 hours to find approximately what your actual hourly bonus is.
I'm just waiting for the naming contest. Bet Georgetown Regional Medical Center takes the prize.... Has a ring to it--like the Gong Show....
Remember when Essent was negotiating for Nachez Regional Medical Center--and they backed out because the other hospital in town wasn't included in the deal? Well, for the first time in five years, NRMC is projecting a profit of approximately 3/4 of a million. Timing is everything, I'd say.
'Course they're also projecting $12.5 Million in bad debt--unpaid bills. Now, if Obama-care makes it through, would those debts be unpaid? That would suddenly transform these small, un-profitable hospitals into cash machines...or so it's touted.
A lot of folks don't remember, but one of Hud's (the original CEO of Essent) catch phrases was, "We want to make this 'the' hospital in the area..." Hud really meant, the only hospital in the area. They were actually going to try to repeat the Paris condition.
This is the one where patients are shuttled back and forth by ambulance from ER to ER, based on an initial diagnosis which may or may not be accurate? And where they are moved, again by ambulance, to the North to have an MRI, and then back to the South?
To heck with hospitals, I'm investing in ambulance services! That is the growth industry.
But, if either Obama-care, or the proposed Republican health care plan go through, the county hospitals that Essent has been scooping up will suddenly be gold--in 2010-13. Isn't that when the phase in goes into effect?
You might have wondered why I started covering the national health care issue, rather than more local problems. The latest poll that came through might be a reason. Currently 48% of the surveyed population are rating the health care system we have as good or excellent, as opposed to 29% last year. And, we're going into a congressional recess.
What does that mean, locally? With the announcement of the possibility of increased taxes on the "middle class", there is a real chance that the health care bill will stall, if not fail. Medicare cuts have already been projected. What are most of the Essent hospitals dependent on? Federal programs.
PRMC is currently, if I'm not mistaken, considered as part of the metroplex in Medicare reimbursement levels. The new cuts will leave the rural rates alone and cut into metro. So, a quandary: Will the new rates drop below the rural, equal them, or stay above? How much of a cut will PRMC take? Hmmm?
Quite possibly Nashville was sitting back, confident that a lot of the self-pay/no-pay would now be covered, pushing their revenue levels up. Now, the projection might not be so rosy...possibly equivalent to a lump of coal in their stocking.
Remember, years ago, when the Medicare renewal was let slip through the cracks and the reimbursement rates went to rural, rather than that of the metroplex? Well, under what is being cussed and discussed in Congress, that might be a good thing in the future.
Apparently, rural hospitals and physicians (medically under served areas) will not sustain the level of cuts that are being proposed to current Medicare levels. My take is that they are afraid of the egress of physicians from those areas to more profitable practices.
Understand, this is proposed, not a done deal.
So, PRMC and the other Essent hospitals might actually make out better. Who'da thunk it?
But, here is the kicker: While the percentage of insured would go up, the levels of reimbursement would still go down. The plan still doesn't cover everyone of those that are 'counted' in that 46, 47, or 50Million that is being bandied about.
What will happen, is more taxes--tax the wealthy will descend to tax the working. And I'll foretell something additional: Both Social Security and Obamacare both become means tested. So, if you've been responsible, saved, and invested in your retirement--tough. We're giving it to the ones that overspent their income (you saw it in the home loans, why not here as well?) All others pay cash.
All I'm saying, is that those who ignore history are doomed to repeat it. We've seen the examples: Federal programs with spending 300% over their estimates. Bailouts for the poorly managed (corporations as well as family finances.) Earmarks attached to "essential" funding...and we're willing to turn our health care to those people (who aren't crazy enough to opt for the same program)?
Dr. Cerel has come to view, as of late. A few comments stored up directed me to two locations. The Mass Board of Registration, and "rateMDs".
The Mass Board of Registration had this to say: Hospital Discipline: This section contains several categories of disciplinary actions taken by Massachusetts hospitals during the past ten years which are specifically required by law to be released in the physician's profile.
1. Facility: Nashoba Valley Medical Center Action Begin Date: 2/10/2005 Action End Date: 6/20/2005 Action: Other
Basis or Allegation:
Failure to follow internal by-laws, rules, etc.
Interpersonal skills/personal behavior
Delay in treatment
Lack of informed consent-surgery related
Failure to prescribe
- ------------------------------------------------------------------------------- 2. Facility: Emerson Hospital Action Begin Date: 2/17/2005 Action End Date: 3/16/2005 Action: Suspension of right or privilege
Basis or Allegation:
Failure to follow internal by-laws, rules, etc.
-------------------------------------------------------------------------------- Board Discipline: This section includes final disciplinary actions taken by the Massachusetts Board of Registration in Medicine during the past ten years. --------------------------------------------------------------------------------
1. Date: 3/16/2005 Case #: 2007-024 Action: Practice Restrictions
I would say that he's on staff, with no restrictions, other than what was imposed by the Mass Board. Unless there's something current, the last action was three years ago. However, that put him on training wheels. Wonder when that ends?
RateMDs.com had this:
He has privleges in one hospital, and is rated 2.3 on a 5pt scale.
This is an awful lot of reading. Some of us will just go with the flow. But, read some of the provisions and compare them to the language of the actual bill (attached). Or go through and pick the ones that piss you off—and verify them.
Then, write a letter (a real one, not an email, not an on-line petition—they get round-filed) to your congressman (the link will take you to where you find out who yours is.) You can say that you’re mad as hell and that mad is going to stay around through the next election. Cite the provisions that bother you. Get your spouse to sign as well.
Think about this: There hasn’t been a President elected from an independent party in recent history. Too much stacked against them. But, Congress is a different story. And the weight of the independents when the two major parties are deadlocked is significant. More actually than a long-term incumbent.
Maybe we do need to make a change, but I want to know that my representatives are aware of the provisions and can vote intelligently—like we supposedly did when we voted them in. Passing a bill with only the vaguest idea of what it contains is not responsible. Too many people respond to the “this won’t last long in this market” and “if you snooze, you lose.” ***
This is a bill that we have no idea as to what it is going to cost. No one does. Yet. The time to find out the cost is before it passes. This is the time for competitive bids.
Or don’t feel so superior when those people who bought houses for which the payments are more than their total income are paraded on TV. You’ll be one of them.
The included listings of specific hot-button items is in comments. The post would have been far too long. You can download the bill from the previous post's comments.
*** I would include, "And Congress responds to, "We have to pass this NOW!" Less reading."
And, another chipped in:
Yes, healthcare for the elderly will be seriously ... Yes, healthcare for the elderly will be seriously limited. Tests and surgeries deemed too expensive will not be allowed. Can euthanasia clinics be far behind? And yes one congressman did state that the healtcare bill was too long to read and he didn't need to read it anyway. Now I ask you, if someone handed you contract filled with fine print and clauses would you just sign it? Or would insist on reading it and having your lawyer read it too before you signed it? Yet that is what Obama is asking congress to do. Sign it into law without knowing what's in it. Obama has even admitted he hasn't read the damn thing. Who's driving the bus?? I urge everyone to email their congressmen and senators while they are on recess. Let them know this healthcare bill is not what you want!!!
I admit, if someone dropped a 1000+ page contract on my desk, I'd want some serious review done. Either by myself, or by someone with my interests at heart. We don't have that here.
An added inclusion, submitted in a comment, but since it doesn't display there, I thought I'd bring it forward.
Frank, check out Pg932-6 and see how this applies:
The latest figures indicate that Congress should come under whatever health care program that the citizens are being forced into. Is 'forced' the correct term? Possibly not, but there are reservations--from physicians, from health care workers, and from citizens, as well as Congress itself.
What are those reservations?
Cost
Ability to keep what some already have.
Congress being lax in reading the 1000+ pages of the House bill.
Congress's adamant refusal to come under the provisions of the bill.
Taxing employer provided health care (didn't they criticize McCain for that proposal?)
Forcing out the commercial policies.
Possible federal mandated restricted care (MRIs, CTs, and C-sections are what were touched on. Probably more to come.)
Exaggeration of the numbers of the uninsured.
Who is going to pay for it?
If you are going to limit costs, are you going to enact tort reform (litigation is a major source of medical costs?)
Limiting treatment to those with terminal diseases...like YOUR parents, or you.
Fewer applications to medical schools might be fortelling the future. One reason is the overwelming amount of paperwork mandated by the federal government. And you think it'll be less???? We've been depending on FMGs (Foreign Medical Graduates) covering the rural and inter-city areas. What happens to their incentive to stay if the Fed gets involved to this extent?
Change...an interesting word. We've definitely had change in Paris. But, we're talking about the Federal Government--managing 1/6 of our Gross National Product. This is the same government that has yet to come in under budget on almost anything?
This is the same administration that said they didn't understand the severity of the recession?
The same administration that let Billions in pork get attached to the stimulus package.
This is the same administration that wants to include 10+ MILLION illegals in the care process....because if they're citing the justification for 50 Million uninsured, they're part of that number. Of course, that also includes those young adults that are not covered--by choice: those healthy enough to roll the dice, and mostly win. That's an extra latte a day.
That also includes those that are counting on the guaranteed access to emergency treatment, reguardless of ability to pay, that already exists. They are estimated at 18 Million, with many over the $50k income level. So, what happens when the government runs hospitals? Take the VA...look at Walter Reed. One of the formost military hospitals...and what was it that they were having problems with? Oh yeah, patients falling through the cracks. Almost literally, since there were holes in the floors and walls. So, if these patients are heroes, what's in store for the rest of us????
I'll consider making that change...when Congress makes the same one....
OK,OK,OK, I get it........you have a situation with medical care in Paris,Texas. I have been reading this blog for 2 years and HAVE NOT ONCE heard of a solution. This country is full of whiners and finger pointers. Come on people, step up and put some backbone in it and solve the problem. I am a physician and have watched things fall apart. I cannot agree more that the Big Boys snookered the "ownership" of the not-for-profits and sold you down the river.
OK, now for the solution....take back control of your destiny. It is too expensive to "buy back" the facilities that exist with dwindling profits and ownership is now private (not subject to oversight). You need a new facility with options for inpatient care and cooperation with a larger facility for transfers. You need a robust outpatient facility for the majority of ambulatory care. Allow the hospitals to carry on with their "for profit" management and they will soon learn that Paris no longer "needs them". Once this occurs, the doors to the meeting room will fly open.
10:03AM Anonymous said... "OK, now for the solution....take back control of your destiny. It is too expensive to "buy back" the facilities that exist with dwindling profits and ownership is now private (not subject to oversight). You need a new facility with options for inpatient care and cooperation with a larger facility for transfers. You need a robust outpatient facility for the majority of ambulatory care. Allow the hospitals to carry on with their "for profit" management and they will soon learn that Paris no longer "needs them". Once this occurs, the doors to the meeting room will fly open."
best idea i've heard yet, doc. how do we make this happen?
I'd like to say the county could come up with something at this point, but truth is, some of those physicians that have been "reading this blog for 2 years and HAVE NOT ONCE heard of a solution" need to step up and become players again. (The blog has been here for three, and there have been suggestions of that nature....)
Yes, I know your retirement investments have been sorely depleted. Yes, I know that Obama-care gives you chills. And, finally, I know that a struggle over the healthcare industry in this town is going to have some unpopular side-effects, but you know, sometimes the medicine just can't be sugarcoated.
Don't know if you caught the Snooze article on ERs.
Emergency room challenges
By Sally Boswell
Published July 12, 2009
We’ve all heard the horror stories.
A friend, a loved one, is injured or falls ill. They go to the emergency room at the local hospital and once there, are forced to wait — and suffer — an interminable length of time until they are seen and treated by a physician. In the most extreme versions of the story, the patient dies of neglect, sitting unattended in a chair in the emergency department waiting room, hours later.
Sadly, the story — at its base — is rooted in an undeniable truth: Emergency room wait times have gone up.
According to a report issued earlier this year from information gathered at more than 7,000 hospitals across the nation, the average wait time in emergency departments across the country went up to 4 hours and 3 minutes, an increase of 27 minutes since 2002. In Texas, wait times in 2008 averaged 4 hours and 8 minutes, putting Texas 31st in the nation in that ranking.
In August 2008, the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention and the National Center for Health Statistics, issued a report on the state of emergency departments nationally. The report linked patients’ inability to access a primary care provider in a timely fashion with the increasing frequency of ED visits. This was compounded by a decreasing number of EDs across the country as well as decreasing numbers of inpatient beds.
“EDs nationwide are under increasing pressure to provide care for more patients,” the report reads, “resulting in crowding and increased waiting times for minor illnesses.”
“What most people don’t realize is that the term ‘wait time’ is considered the total time spent in the ER,” said Chris Dux, CEO of Paris Regional Medical Center. “At this hospital, the total wait time is 3 hours and 10 minutes. The time from when a patient comes in the door until they are seen — not by a triage nurse, but by the nurse that is going to care for them — averages 42 minutes.”
“These numbers are just averages,” Dux continued. “Some waits will be much shorter, some longer.”
“The ER is not a primary care provider,” Dux said. “An ER is designed to treat medical emergencies. Patients with a true emergency will be seen right away. Non-emergencies, where there is no danger of loss of life or limb, no danger of bodily system failure, will wait while more critical patients are seen.”
“The reality is that the sicker a patient is, the faster they will get seen,” Dux said.
Many who complain about long wait times at the ER cite a lack of staff as part of the problem. Dux and other hospital officials dispute that claim.
“Our numbers show that our busiest days are Sundays and Mondays,” said Connie Murchison, CNO at PRMC. “and afternoon hours are the busiest. We try to anticipate the need and have appropriate staffing for known peak times, but there are never less than five nurses on duty at any time in the ER. And the nurses work overlapping shifts so there is no lack of coverage.”
“There are patients who get it into their minds that if they come by ambulance they automatically go to a room,” added Phyllis McDaniel, nurse manager of the ER. “That is not the case. Someone who comes in an ambulance goes through triage just like anyone else. They are assessed and if it is determined they do not have a true emergency, they get triaged back out to the waiting room just like everyone else.”
So what is the solution to increased wait times in hospital emergency rooms?
“To start off, every person, if they don’t already have one, needs to establish a relationship with a primary care physician,” Dux said. “If they have a chronic condition such as diabetes or a pulmonary or coronary condition, the physician will be familiar with their case. If problems arise, the patient should call their PCP first. The PCP can advise them if they need to go to the ER or if they can wait and come to the office the next day.”
“A physician’s office visit is also going to be infinitely less expensive than a visit to the ER,” Dux added. “It’s not cheap to staff an ER with physicians and nurses and therapists and lab techs 24 hours a day, seven days a week. People think, well, it’s the ER, it’s free.’ It’s not free. We’re going to bill you for it and we’re going to expect to get paid. Our doctors and nurses have to put food on their table as well.”
Calling a PCP first also has other benefits, according the Dux.
“The doctor may advise the patient to go to the ER,” Dux said. “He can call the ER and give them a heads up and instruction for the patients care when he arrives.”
“The PCP can also call the hospital and order the patient to be admitted directly into the hospital,” added McDaniel. “The patient can bypass the ER and all that expense.
Patients should bring an updated list of all medications when they come to the ER, Dux added, as well as a list of all allergies the patient may suffer. The patient should, if at all possible, never come to the ER alone.
“Bring someone with you who can see that you get home safely when you are released,” Dux said. “Someone who is in a position to act as your surrogate and can help the staff understand your condition and communicate for you. However, the patient should not be accompanied by a large group of people. There is a limited amount of space in the ER. There can be problems with issues of contagion and privacy if there are a lot of unnecessary people in the ER.”
PRMC is also implementing ways to help make wait times at the ER more bearable.
“We encourage people to make use of the hospital’s Wet Paris Clinic at 2224 Bonham St.,” Dux said. “We would like them to call for an appointment but if the show they will be seen. It’s also cheaper than a visit to the ER.”
“We are also making sure that our patients and their families are informed about the process,” he said. “If you know why you are waiting, it’s easier to wait, than if you are sitting there with no information.”
Dux noted that PRMC has formed an Emergency Department task force, consisting of Murchison, McDaniel and several staff physicians to examine process issues in the ED and look for ways to streamline the way patients are cared for. Hospital officials are also studying the use of rapid testing modalities, which can be done in the ER itself and make lab work faster.
“We want the people of this area to know that, according to the numbers, we are 20 percent better than most of the people out there,” Dux siad. “And we are working to get even better than that.”
I don't know, maybe their average is better than most...when you factor in the patients that arrive at 5AM....and in some hospitals, even 5AM is busy. Staffing needs to meet the needs of the customers, the patients...and when ER rooms are closed to patients because of staffing shortfalls, then one has to worry about management. And the West Paris Clinic isn't open on a lot of the peak times.
So pull up the intake statistics (that's what Meditech and computers are for, after all) and do some flexing. We'll get happier patients, and a happier staff, that's for sure.
Awwww, you guessed it. Yep, Huddy was back in his town.
Job-shopping, perhaps? Hey, Hud, hope you got some good leads.... (Probably even updated his Linked In profile.... I could have said, 'Monster.com', but that would have been typecasting.)
Bet he just tapped one of his buddies...you know, one of the ones he fired....and they got him right in. Networking at the highest level. Nothing personal, you understand.
This is not an anti-Essent blog, it is to counter their current business model. That which values the individual staff member or patient less than the buck. Business sense is one thing, creating an atmosphere of Stalinist Russia is another.
Do not log in on a PRMC computer, they are monitored.
E-mail comments, questions, or criticisms.
fac_p@hotmail.com!
If you click on the title of the post, it will display the post and comments separately from the rest. If you click on The-Paris-site heading, it will take you back to the full blog. If you click on the month link (Aug(3)), it will show the posts for the month, only.
answer)! So, does that mean that the access is poor, the quality of care needs strengthening, and the services are un-coordinated?
