Monthly Review & Commentary On Health Policy Issues From A Rural Perspective - August 1st, 1998


Medicare Sausage from Rural Road Kill
By Tim Size, RWHC Executive Director:
Modern Healthcare reported (7/7/98) that the American Hospital Association (AHA) is attempting to mediate a major dispute among hospitals about Medicare payment changes proposed to become effective October 1st. The process includes a cross section of AHA affiliated executives and representatives from a few other hospital groups, such as the Federation of American Health Systems and the National Rural Health Association.
To that end, this article intends to provide some general background as the closed door negotiations proceed through the summer as well as to solicit your input into the process. AHA has used a similar mediation process only twice before, with mixed results. Public policy has frequently been compared to sausage--the consumption of the end product should never be tainted by watching its making. As the current proposed change in Medicare payments would transfer 20 million dollars from already underpaid rural facilities, it might be more apt to see current Medicare policy debates as making sausage from rural road kill.
Medicare has a complex formula to determine what it pays any hospital for providing a particular service to a Medicare beneficiary. In brief, about three-quarters of that payment is increased or decreased by applying a "hospital wage index." The index is intended to adjust for the fact that market wage rates for nurses and other hospital employees vary somewhat across the country.
The index actually goes well beyond the original intent, adjusting not only for differences in local wage rates but also ewarding hospitals in areas where a greater than average number of employees are hired (even after adjusting for hospitals with sicker patients).
As a result of these manipulations, the wage index already swings widely, ranging from a low of 70% of the national average in rural Mississippi and South Dakota to nearly double that or 140% of the national average in some urban areas of California and New York. The current wage index is the primary reason payments to rural hospitals and their resulting Medicare inpatient margins ("profits") are less than half that of urban hospitals (4.4% versus 9.7% in 1995.)
Medicare is now proposing to further distort the wage index under the guise of assisting teaching hospitals--a lousy means to a reasonable end. Major teaching hospitals have the highest Medicare inpatient margin of all hospitals (19.4% in 1995) but if you look at total hospital margins, they are the lowest of any hospital category (3.8% in 1995), including rural hospitals. The concern is that those large teaching hospitals serving high proportions of uninsured patients will be at higher risk of closure as both the number of uninsured and health care competition increases.
Due to complex reasoning well beyond my ability to understand, HCFA is proposing to address the financial pressures of urban teaching hospitals by counting as wages physician salaries that are not paid as part of the above described Medicare formula. This has the effect of increasing the Medicare wage index, and consequent Medicare payments for all hospitals (teaching and non-teaching alike) in the teaching hospital rich north east section of the country at the expense of almost everyone else. (See map above.) This change also comes as Medicare is expanding the use of the hospital wage index to be used to adjust payments for hospital outpatient, HMO, home health and nursing home services--the wage index isn't just for hospitals anymore.
From a study by Vaida Health Data Consultants for the Federation of American Health Systems which calculated the "Impact of Including Part A Physician, Intern and Resident and Certified Registered Nurse Anesthetist Labor Costs":
The Big Medicare Wage Winners in 1999
New York +$97 million +$133/discharge
Pennsylvania +$63 million +$ 94/discharge
Maryland +$14 million +$ 74/discharge
The Big Medicare Wage Losers in 1999
California -$79 million -$ 95/discharge
Florida -$37 million -$ 53/discharge
Wisconsin -$13 million -$ 60/discharge
These are significant dollars that substantially effect the ability of all hospitals to provide needed services. This newest tinkering with the wage index, under the rubric of helping protect teaching hospitals, increases payments to teaching and non-teaching hospitals alike in the northeast and reduces it from most other hospitals, including teaching hospitals with the poor judgment to have been located elsewhere. (As an example, the University of Wisconsin Hospital and Clinics will lose $117 per discharge due to this change.)
Any claims to policy considerations have worn thin as the already corrupted hospital wage index is being stretched well beyond the breaking point with Medicare's most recent proposal. If some semblance of a rational, creditable distribution of increasingly scarce Medicare dollars can not be determined, the whole system begins to unravel into one giant food fight which in the end will be destructive to all hospitals and those they serve. On a more practical note, hopefully having California as a major loser under this formula will facilitate getting the necessary attention for a more balanced approach. Such an approach might include the following components:
(1) Agreement that the Balanced Budget Act's expanded use of the hospital wage index requires a wage index methodology that only measures the geographic variation in relevant wage rates. Any other appropriate geographic variations should be separately and explicitly addressed.
(2) Implement a hospital wage index that adjusts only for differences in wage rates by either (a) occupationally mix adjusting current cost base data or (b) working off of a separate Bureau of Labor Statistics wage survey.
(3) If Medicare cost report data continues to be used to develop the hospital wage index, it must to be "cleaned" and consistency among the multiple state fiscal intermediaries needs to be assured.
(4) Non-teaching hospitals within a single wage area should not be paid at a higher (or lower) rate due to the presence (or absence) of teaching hospitals.
(5) Develop transition language to provide stability against major payment changes in one year.
(6) To the degree that the FFY '99 wage index is used to support "social" missions such as graduate medical education and uncompensated care, we should develop a package of companion recommendations to continue these purposes outside of the wage index.
For a classic interpretation of this issue, read "Darwin, Congress & Slopping Hogs," Eye On Health, 5/98.
Wisconsin Specific Footnote: Wisconsin, unlike Lake Woebegone is already well below the national average for Medicare payments, estimated to have received $3,795 per enrollee in 1996, eighth state from the bottom and 25% below the national average of $5,034 (House Ways and Means 1997 Green Book).
Dog Bites Man--Only Healthy Need Apply
The following is from "New Study of Marketing by Medicare HMOs" by the Kaiser Family Foundation web site <http://www.kff.org>:
"As the number of Medicare HMOs competing for new enrollees has soared, HMOs have increased their marketing efforts to attract Medicare beneficiaries. Plan advertising and marketing activities have become a primary source of information about HMOs for Medicare beneficiaries."
"A new study by the Kaiser Family Foundation examines how HMOs market to elderly and disabled Medicare beneficiaries. It finds that the message most frequently conveyed by HMOs is that they offer more generous benefits with lower costs than the traditional Medicare program. (Most HMOs offer better benefits and lower costs, both as an incentive to enroll and because HMOs are required to distribute savings under Medicare to beneficiaries in the form of additional benefits or lower premiums and copayments.)"
"The report also finds that Medicare HMO marketing activities appear to target physically active seniors, rather than the full range of Medicare beneficiaries, such as those who are in poor health or disabled. More than half of the television ads portray seniors engaged in physical or social activities such as running, biking, swimming, snorkeling, riding amusement park rides, and playing with grandchildren. None of the visuals in either newspaper or television ads show people in hospitals or using wheelchairs or walkers. Nearly one-third of the 21 HMO marketing seminars attended by researchers were not wheelchair accessible."
"Although Medicare has 5 million beneficiaries who are under age 65 and disabled, none are pictured in any of the television or newspaper advertisements. Fifty of the 70 newspaper ads do not explicitly mention eligibility for the under-65, disabled population at all. Eight of the 70 newspaper ads reviewed incorrectly state that beneficiaries must be age 65 or older to enroll."
"'As the number of plan choices under Medicare increases in the future,' said Drew Altman, President of the Kaiser Family Foundation, 'the challenge facing policymakers will be to develop marketing guidelines that will give all Medicare beneficiaries the information they need to make good choices without placing undue burdens on plans.'"
HMO Reform or Election Year Posturing?
It is still unclear whether all of the recent talk in Washington about HMO reform will lead to actual legislation or whether Congress would rather keep the issue unresolved in order to use it to attract votes in the fall elections; the following update on the various proposals is from AMA News 7/27/98:
"Washington--Republican Senate leaders July 15 unveiled an outline of their managed care patient protection proposal that will compete with the House GOP plan and Democratic leadership legislation." Included in the Senate plan are provisions that would:
· Institute a prudent layperson standard for emergency care.
· Prohibit gag clauses.
· Require plans to offer internal and external appeals processes to patients who believe they've been wrongly denied care.
· Ban the use of genetic information to deny insurance coverage or set premium rates.
· Require insurers to provide consumers information on such topics as what services the plan covers and how much patients must pay in deductibles and co-pays.
· Expand medical savings account availability to all Americans.
· Allow the self-employed to deduct all health care premiums from their taxes starting next year.
· Establish the Agency for Healthcare Quality Research to foster improvement in health care quality.
"Unlike the bipartisan, Democrat-authored legislation, the Senate GOP plan would not expand medical malpractice liability to employer-sponsored health plans. 'You can't sue your way into better quality health care,' said Sen. Bill Frist, MD, (R, Tenn.)."
"The Senate GOP plan differs from the House Republican plan in several areas. For example, the Senate proposal does not include provisions that would allow associations to develop health plans for their members or that would permit employers, consumers, insurers and providers to create health insurance purchasing pools, called health marts." (The Republican sponsors describe HealthMarts "as private, competitive, and voluntary 'supermarkets' Structured as joint ventures involving employers, providers, insurers, and consumers, HealthMarts serve as a group marketplace in which employees may choose from a menu of fully-insured coverage options at group rates.")
HMO Reform or Not, Ask Questions
If you have a choice when choosing an HMO, here are ten good questions to ask before signing up, from "Survive Your HMO," by Steve Brooks, Family Money, Summer, 1998:
1. What does it consider a medical emergency? Does it use the "prudent layperson" standard that gives you more authority to seek the care you feel is necessary?
2. If you have, or develop, a complex illness, will you be required to visit your primary care physician each time before you see a specialist?
3. If you want a particular type of treatment or drug for your illness what right will you have to receive that treatment or drug?
4. What's the average waiting time for an appointment with a primary care physician?
5. Are a physician and hospital within 30 minutes of your home?
6. What's the process for changing primary care physicians?
7. What percentage of members left the plan last year?
8. How do you appeal a decision that denies coverage?
9. What happens if you get sick while you're traveling.
10. Are there financial incentives for doctors to provide less care, or penalties for doctors who exceed treatment guidelines?
 
HMO Mecca Calls for Increasing Choice
The lack of choice among HMOs by individual employees is a major source of dissatisfaction about HMOs, particularly in rural areas where employers are less likely to be large enough to offer their employees multiple plans. The following is from "The Managed Care Backlash And The Task Force In California, lessons for consumers, physicians, health care workers, health plans, and politicians from California's task force on managed care" by Alain Enthovan and Sara Singer in Health Affairs, 7/98. Enthovan was the task force's chair and Singer its staff director; the article presents their interpretation of the task force's work.
"More consumers should be given a wide range of choice of plans, such as those in the Federal Employees Health Benefits Program. According to one survey, persons in managed care who did not have a choice of plans were 57 percent more likely to be dissatisfied with their insurance plans; 22 percent were very or somewhat dissatisfied with their insurance plans, compared with 14 percent of persons with a choice. Different health plans have different operating rules, some of which will be burdensome to some and acceptable to others. Persons with preferences will be happier with their choices. Moreover, if consumers do not have a choice of plans, market forces will not be able to pressure the plans with unpopular practices to change."
"Many consumers in California today have no choice of plans, and few have a full range of choices. According to KPMG Peat Marwick data, 46 percent of employees whose employers provide coverage have no choice of plans. A reasonable minimum choice set might be two HMOs and one plan that offers open access to providers of the member's choice such as a point-of-service or preferred provider insurance plans. Three health plans would provide choice for persons who need or want the less costly format of a closed-ended HMO and would require all plans to compete head-to-head on price."
"Recognizing its importance, the task force sought ways to expand consumer choice of plans but found it very difficult to identify specific ways of implementing that choice. In the end, the task force recommended only that more employers voluntarily offer individual choice of health plans. The task force considered requiring employers to offer individual choice. However, to compel choices at the state level would require changing the federal preemption of state law under the Employee Retirement Security Act (ERISA) of 1974. Task force members were appropriately concerned that as long as employer-sponsored insurance remains voluntary, compelling individual choice may reduce small employers' willingness to offer coverage. Expanding choice of plans in the small-group market requires pooled purchasing arrangements such as the Health Insurance Plan of California (HIPC).
Medicine Is Still First About People
From "With House Calls and Humanity, Doctor Wins Iowa Town's Heart" by Jon Jeter on the front page of The Washington Post, 6/30/98:
"McGREGOR, Iowa-Clifford Smith was making his retirement home rounds when a nurse wheeled 87-year-old Marie Moses into the reception room for her checkup. 'Hi, Marie,' Smith said, without peering up from her medical chart. Nurses paused in anticipation as Smith pivoted toward Moses. Slowly, a grin stretched across her face, followed by laughter, a full, throaty rumble."
"Moses has done this for nearly 20 years -- even before the Alzheimer's -- at the mere sight of Smith. Amused at her amusement, Smith put down her chart, leaned toward Moses's wheelchair so their noses were no more than 12 inches apart, and he began to laugh too. When Moses poked out her tongue at him, he mimicked her, and for a good 20 seconds, there they were, doctor and patient, face to face, laughing with childlike glee."
"Smith, 72, is a country doctor with a bedside manner not likely to be found in any medical school textbook. But the black doctor with the unorthodox style has fit in nicely in this all-white Mississippi River town on the Wisconsin border, becoming one of its most cherished citizens."
"The National Rural Health Association named Smith its Rural Health Practitioner of the Year in May, ... about 15,600 doctors practice family medicine in rural areas, according to a 1996 survey by the American Medical Association. While the number of physicians nationally has increased from 443,502 in 1980 to more than 716,000 in 1996, the number of general practitioners in rural America rose by only about 725 during that same span, the survey found. The city, and more specialized medicine, is where the money is."
"'We have major, major problems with the distribution of physicians,' said Tim Size, executive director of the Rural Wisconsin Health Cooperative. 'The commitment that [Smith] has to his patients is certainly a hallmark of rural medicine, but the idea of an individual being on call 24 hours a day, seven days a week is one thing that people aren't as willing to do anymore.'"
"'You just don't see many doctors like him anymore,' said 82-year old Bill Menze, a patient of Smith's for a quarter century. 'If you have a problem, you can sit and talk to him and he will listen, however long it takes. Most doctors nowadays . . . it's in and out, in and out. Everybody has a schedule to keep. But Cliff really cares about his patients.'"
"'These small towns are pretty prejudiced,' Menze said. 'But Cliff is just Cliff to me, and if you ask anybody here, they'll say he's a good man and we'd hate to lose him.' But he has no plans to retire, which is just as well. Few here can imagine the town without Doc, or Doc without his patients."
"'I swear,' said Alice McGrath, 79, 'that man's heart beats in his patients.'"
Warning of Non-Profit Backlash
The following editorial, "Slide In Healthcare Donations Should Be Warning To Execs," is from Modern Healthcare, 6/29/98:
"Think of the slump in charitable donations to hospitals as a loud warning that the public is confused and upset about the radical changes in healthcare. Halting that downward spiral in gift-giving will require renewed management commitment for healthcare organizations to improve communications and emphasize community service."
"In recent years, the public image of hospitals has been blurred by the whirlwind of mergers, acquisitions, cost cutting, network building and managed-care mania. To some potential donors it must have seemed like the friendly community hospital had turned into a cunning, cutthroat corporation. Reports of hospitals hastily assembling integrated delivery systems, slashing budgets and fretting over managed-care contracts tended to dominate the headlines."
"Furthermore, providers have been unable to distance themselves from the HMO backlash as patients voice deep concerns about the financial incentives, structure and performance of the healthcare system. As a result, charitable gifts to hospitals, the financial backbone of not-for-profit/community-based healthcare, plunged 9% in 1997 to $5.2 billion. The Association for Healthcare Philanthropy said it was the biggest dip in hospital giving since 1991. While cash contributions decreased by only 3%, other categories were battered. Pledges plummeted 27%, planned gifts dropped 19%, and nonmonetary gifts fell a whopping 34%."
Community of Spectators is No Community
From "Up From Apathy" by David Broder in The Washington Post National Weekly Edition, 7/6/98:
"Two recent reports show why reviving civic spirit in America is probably the only cure for rampant public cynicism--and why that is going to be devilishly difficult... The common conclusion: Americans must regain the habit of active citizenship and take more personal responsibility for what is happening in their communities, states and nation. Stipulation: It will be hard to do."
"The first was financed by the Pew Charitable Trusts, it's called 'A Nation of Spectators' and can be obtained by calling (301) 405-2790. The second, the latest in a series of National Issues Forum reports, is called 'Governing America: Our Choices, Our Challenge.' It was prepared by John Doble Research Associates, under the auspices of the Kettering Foundation, which can be reached at (937) 434-7300."
"The starting point for both reports is stated bluntly in 'Governing America.' Despite peace and prosperity, people continue to feel alienated and disaffected. They are dissatisfied with government, especially at the national level, and distrustful of the way power is exercised by those who have it."
"Both reports are full of common-sense suggestions about ways in which the major institutions of the country could alleviate these complaints. The press, the churches, the schools, elected officials at all levels have important roles to play."
"What is striking, however, is the common theme that it is only by becoming active participants in civic life--"'being players, not spectators', that a genuine sense of empowerment and trust is likely to be rekindled."
"The Kettering report suggests that many people find it almost impossible to imagine being part of an engaged, purposeful citizenry, taking responsibility on themselves for getting things done. It quotes a Delaware woman as saying, 'Idealistically, this choice is wonderful. But it's not practical. How do you convince apathetic people that, if they'll stop being apathetic, they'll be able to help society and help themselves?'"
"The irony is that there are people all around us, including in some of the most poverty-burdened neighborhoods in our cities, who have discovered that liberating truth. But not enough of them. Not nearly enough."
NRHA Works to Expand Who Is at the Table
The National Rural Health Association (NRHA) is launching a national program to bring rural community leadership into the development of rural health policy with the major assistance of a $500,000 grant from the W. K. Kellogg Foundation. The following is from the executive summary of the funded proposal:
"Rural America has entered a time of change that presents tremendous opportunities for rural communities to develop policies positively affecting their resident's lives. Perhaps the most noted change is in the delivery of health care services. Changes in the national health care system present unique challenges and opportunities for rural communities. The NRHA has established a policy of community involvement in developing a grassroots voice for rural health care policy development to ensure these changes result in positive outcomes for rural communities."
"This policy is being accomplished by involving community residents from all walks of life--not just health care providers--in grassroots efforts of working together to find positive solutions to their community's health care needs. The result is a health care system that ensures the unique health needs of each community are met. The NRHA recognizes that this system of policy development also can achieve positive results when expanded to other policy realms--foremost among them are education and economic development. This can be achieved by national grassroots involvement of rural community members in the development of the policies that universally affect them through the creation of a rural leaders to provide key input regarding their real needs and policy that addresses those needs." The goals of this initiative are as follows:
"Development and Expansion of Rural Community Leadership--The NRHA will establish methods to identify and develop rural community leaders to identify and facilitate the communication of needed policies to enhance rural economies, health care and education."
"Expanded State Cross-sector Policy Development--The NRHA will work with state offices of rural health and NRHA-affiliated state rural health associations to facilitate their creating with other state rural associations statewide, cross-sector forums to jointly address public policies related to community development, e.g., the interwoven issues of rural health, education and economic policy."
"Expanded State Participation and Leadership--The NRHA will work with NRHA-affiliated state rural health associations to actively expand participation in their associations by community members and their organizations, along with a concurrent development of organizational leadership from this constituency."
"Expanded National Participation and Leadership--The NRHA will actively expand participation in the association by community members and their organizations, along with a concurrent development of association leadership from this constituency."
"The NRHA will continue its focus on rural health, but do so with a greater awareness of the context and inter-connectivity of rural health with other rural issues."
"The NRHA will become more accessible and responsive to advocacy efforts of other state and national rural groups as we hope they, in turn, will be to ours."
"The NRHA will become more complex, but more real--discussions would not be as much what the association can do for rural communities, but what rural communities can do for themselves through the association and state and national policy."
Rural Telehealth Applications Up
The Rural Health Care Corporation (RHCC) administers a Universal Service support program authorized by Congress to make telecommunications services affordable for rural health care providers. Support applies to monthly telecommunications service charges and installation charges. More information is available at <www.rhccfund.org>. From a RHCC Update, 7/2:
"The RHCC is pleased with the steady flow of applications submitted from health care providers. A total of 1166 applications have been received from 47 states since May 1, 1998. 573 have been approved, another 577 are in various stages of completion and the RHCC is working with these applicants to finalize their applications. Only sixteen applications have been denied." The large telecommunication companies used the initially small number of applications as an argument that the program was not needed; the growing number of applications is now undercutting their opposition.
For Corporate Health, Encourage Dissent
From "Caution: Optimism! Why Unbridled Positive Thinking Can be Bad News for Your Business" by Bob Pricer in Madison, July, 1998:
"Because business so highly values optimism, it's easy to create a culture where pessimism, or even realism, can be interpreted as disloyalty. In this culture consistent bearers of 'bad or contrary news' are usually passed over for promotions; some are forced to leave."
"Because going contrary to the optimistic culture of an organization can in fact be demoralizing, managers encourage employees to develop optimistic attitudes. Indeed, we all like to be around 'can-do' people. But there's a danger of overpromoting the happy talk and discouraging dissent. Here's why: Suppressing pessimistic opinions can inadvertently result in mutual reinforcement of the consistently upbeat points of view. Further, unrealistically optimistic views can easily be validated by group approval - which is why we so often see organizations make significant decisions based on unrealistically optimistic predictions of the outcome."
"Where does this unrealistic optimism come from? Typically from managers who overestimate their ability to successfully manage risk. These are leaders who believe risks are nothing more than challenges that can be overcome by management wisdom and skill. Underestimating risk is compounded by managers who almost always consider themselves to be significantly more effective than the next guy. (Based on self-ratings of managers, it appears that all managers are impossibly above the mean!)"
"Unrealistic optimism can have obvious negative consequences in terms of allocating resources and evaluating performance. That doesn't mean it's all bad--optimism is contagious and can provide a motivating force for organizations to achieve high standards and goals."
"To guard against the high cost of mistakes, though, outside views should be sought before important resource decisions are made."
"In addition, managers should remember that while encouraging positive thinking, they should recognize and reward more realistic projections. It's in that environment that sound decisions will be made."
RWHC Moving to Independence Trail
RWHC will celebrate its twentieth anniversary next year at 800 Independence Trail, Sauk City, Wisconsin. The big difference, is that for the first time RWHC will own the building and it will be designed for its unique business. After renting seven offices in three towns (typically outgrowing the available space, once a major downsizing), the board of directors has decided that RWHC is now beyond the new business start-up phase and should have its own central office.
The prairie style 9,100 square foot building will be located in Sauk City's growing business park, with easy access to both internet and interstate highways. Among other improvements, the new office building will allow RWHC to bring in house most of the over 200 meetings it sponsors each year as well as allowing for enhanced opportunities for meeting attendance via phone or the internet.
RWHC is particularly appreciative to our current landlord, the Village of Sauk City for renting us half of their municipal building for the last several years and for their support in getting us into their business park. The architect is Gary Brink & Associates, Madison; the builder is Howard Lenerz & Sons, Sauk City. Ground is expected to be broken on August 1st with occupancy by January 1st.
RWHC Cuts Provider/HMO Paper Work
Every two years hospitals are required to review the credentials of physicians on their medical staff--a time consuming, complex process for everyone. Now HMOs and other health plans are duplicating the process for the same physicians. It is not unusual in southern Wisconsin for physicians to contract with a dozen different health plans and to have hospital privileges at multiple hospitals, each requiring their own version of the same information. In addition, regulatory agencies then require hospitals and health plans to verify at its primary source each piece of information they receive .
Increasingly physicians, hospitals and health plans are taking advantage of the Credentials Verification Service offered by RWHC. Since 1991, RWHC has been collecting and verifying physician credentials for both hospitals and health plans. RWHC collects, collates and keeps all credentials data up to date, including, but not limited to licensure, education, experience, references, health status and practice history. RWHC makes sure the requests from hospitals, health plans and other payers are processed accurately and timely.
Centralizing the process, makes sense, because by having the volume of files to process and maintain, RWHC is able to dedicate staff to the service on a daily basis. The staff are experts in interpreting standards and understanding the often times unclear requests for credentials data. RWHC currently has on file primary source verifications for more than 700 health practitioners. According to Pat Klestinski, Quality Coordinator at Reedsburg Area Medical Center, "We find the RWHC Credentialing Service efficient, expedient and precise. It is a real cost effective advantage to have this type of service available to hospitals."
The RWHC credentials verification process complies with the national credentials standards that hospitals and health plans must meet so they can be comfortable delegating the labor intensive clerical process to an outside source. This September, the RWHC service will be reviewed by the National Committee on Quality Assurance (NCQA), the quality "gold standard" for HMOs. In the meantime, "RWHC has provided us with exceptional service and quality work. We feel that the organization works hard to maintain a high quality standard and genuinely cares about their customers," Cindy Case, Credentialing Coordinator at Physicians Plus Insurance Corporation, Madison, Wisconsin.
Choosing Fragmentation or Cooperation
The cartoon below is a restatement of one of the great, classic cartoons regarding the value of cooperation:



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