Because you try to analyze all of this Healthcare activity in all of the politics and all of the ramifications and look at the new products and look at the new changes and look at the growth and look at the decline and look at the problems. I urge you to go back to a very fundamental Theory and it's the theory of the working nature of supply and demand and as we see more Supply into the market as we see more Physicians who has we've learned this morning basically Drive the system as we see that group increasing you can only see an increasing amount of competition out in the marketplace.So with that theory is a framework that helps you understand why in Minnesota with our vast number of Physicians that theory should help you understand why some of these Alternatives that I'm going to talk about now are growing very quickly. First of all, let's talk about the Physicians. And what I'm going to do is simply give you a line item listing of some of the Alternatives and very quickly give you some of the issues that I see on the horizon. First of all with Physicians I think we can talk about the numbers, but we can put it into a very clean framework the population from 1970 to 1980 in the Minneapolis. St. Paul metropolitan area was absolutely flat. No population change in that 10-year period of time the number of physicians in active practice in that same 10-year period of time as a doubled you have twice as many doctors taking care of the same number of people and as a result Physicians being as bright as they are they are going to compete they are going to find Alternatives. They are going to try to figure out ways to survive in practice. Many of you from the rural areas for five years ago one of the big stories you were probably writing about was the local community who would put their money together to send someone to medical school. So that individual could come back and practice in your community. I scan the newspapers from rural Minnesota and I don't see those stories anymore. The reason I don't see those stories anymore. You don't have to do that anymore because you can get physicians in your town and you don't have to guarantee anyone's education and that that change occurred in many of your communities within the last three to four years. And you don't see these Community emergency meetings to try to go out and find Physicians Physicians are coming to you. And then we have as you continue to look at the Physicians and the hospital's interest and you see communities and Hospital saying, you know, if we could only get a few more docks in our little town our Hospital Will Survive and lo and behold three years ago new doctors arrived and lo and behold in many of those same Communities Hospital utilization went down even further. And what's happened is that the new Physicians were coming out of medical school are trained not to use the hospital unless they absolutely have to so the savior of the hospital in many of these rural communities. The Savior was supposed to have been the two or three new doctors just coming out of medical school and we're going to help make the hospital survive in most cases. That's not the case. The opposite is happening. It's accelerating the decline of that local hospital. In fact, there are a couple of hospitals in this state. That one Hospital in our community that I'm particularly aware of where they have 15 Physicians and in most situations, you would expect that hospital of 60 some beds to be going Full Tilt that hospital runs at an occupancy of less than 45% The Physicians have determined that they need to keep their practice and one way to keep their practice is to manage the patient on an outpatient basis. They don't need to put the patients in the hospital. So we've talked about the Physicians and I'll now go rather quickly through some of the other line items and maybe try to lay out some of the issues. Let's talk about hospitals hospitals went from a situation years ago where they were viewed as death houses. That's the place you went to die. And then as as we move forward in our capability and Technology, they became the the most important ingredient in the medical environment and people had good feelings and you never said anything negative about the local hospital. But there's some information that nags at us out there as we look forward to the past few years and on into the future. First of all hospitals do have a cost problem. Second of all, there was some data published in the 1981 issue of the New England Journal of Medicine that talks about iatrogenic disease disease inflicted by the hospital you come in with one problem and you leave with two problems and in the articles that were presented in the New England Journal of Medicine in 1981. They estimated that approximately 20 percent of all cases coming in have iatrogenic type of diseases accomplished on patients might be medication errors surgical errors, who knows what so people started questioning the the hospital in those questions continue There was a strike back in 1969 by physicians in Southern California and Milton Romer did a study where he found that while the Physicians were on strike not operating and not doing elective care the death rates in Southern California fell and as soon as the strike, Over the death rates continued back up and went back to where they were in a pre-strike situation. So people are beginning to think about what alternatives are there to the hospital. We do have the hmos that currently constitutes about 36 percent of the market. And for those of you who don't know it's easy for us to assume that you know, what an HMO is but what an HMO really is is a situation where you as a patient for a fixed price. Provide that those dollars of cover those dollars to an HMO like share or Med Center and Med Center makes a commitment to take care of you and to manage your care for you. Hmos are growing. It's becoming a national phenomenon. It has moved very slowly over the past eight to 10 years, but it is increasing at a very rapid rate Cigna health plan out of Houston, Texas has some tremendous programs in place and they're now beginning to roll out in the top 20 markets within the United States. We have another phenomena that largely is the result of the private fee for service sector. It's called PPO or preferred provider organizations. This is a an organization where doctors were largely fee-for-service get together and they say to the patient. If you come to me as a physician and then to our selected groups of hospitals will cover you a hundred percent. If you elect to go to someone outside of the panel or outside of the program will cover 80% but you'll have a co-payment and it's a methodology to try to manage care into certain hospitals and certain physician groups. Ppos have been kind of interesting to me because it was so easy for Physicians to talk about how easy it would be for them to get into ppos and I cannot tell you the number of times where I've talked with Physicians and they said well, you know, I know the president of XYZ Corporation and he's my patient and therefore our PPO will be in there next year. But when that position goes to call on the president of XYZ Corporation of the president begins to ask questions quite apart from the physician-patient relationship and ppos of had a very very slow level of activity here in the state. And in fact, there are a number of Articles now being written by such Publications as Modern Health Care and hospitals magazine talking about the likely slow growth of the original PPO concept. We need to talk very briefly about Medicare so that you understand some of the problems that we've had historically there. What happens is that the client who comes into a hospital to or to see a doctor and is a Medicare patient that individual will pay a very small payment for the first couple days of care. And then after that, it's allegedly all paid for by the government what actually happens. However, is that the hospital will build the federal government and the government discounts that bill and pays the hospital a discount of the bill mainly or namely 40% 50% and I've seen rates even higher that's an effective tax and the senator durenberger talked about cost shifting and what he was referring to is that when a hospital sends in a bill to a payer and the payer discounts that bill Back 40 50 % those dollars have to get shifted somewhere and that's precisely what's been happening historically. We have some New Alternatives out there. We have surgery centers. For example a Center is a place where you go on a have your outpatient surgery, you will arrive early in the morning have your surgery stay around for a couple of hours and they send you home surgery centers really started in the Phoenix area. They've done very well there they've had a slower growth here as an independent freestanding operation. I think it's very likely you're going to see Physicians willing to take care of you where you drop in leave your name, they give you a beeper you go out and shop at Sears and when they beep you you come on in and get your care and go from there. I think this is highly likely in fact Sears is experimenting with these kinds of Concepts and I think you're going to see them take a very keen interest in this market Pearle Vision is another company that is been very successful in shopping malls in terms of provision I centers and I think you're going to see Pearl Vision move into the medical Market because it's so easy to Find a physician who will staff the centers that used to be the big stumbling block. You couldn't get anyone to staff these centers now, that really is not a problem. There are some additional programs Home Health you're now seeing advertised a lot where people instead of getting their care in the hospital. They're able to send them home earlier and they're visited postoperatively buy a home health nurse again. I think it's going to become a very important product component that I think is going to grow very rapidly over the next several years in our own organization. We have a hotel like accommodation center of a hundred and twenty five beds located right on our campus and we have a program where we will discharge patients a couple of days early to the Home Health Care Center. So as opposed to spending two hundred and some dollars for the hospital care in a daily basis. We can move you to a $35 per day hotel room and have the nurse come and visit you twice a day and it's a it's an alternative to sending you home immediately, but it's also a better alternative to having to remain in the hospital. Talked a little earlier about the level of Technology. We have laser surgery. We have implants. We have artificial Hearts. I think it's interested in the Wall Street Journal over the last week. There have been three front page articles within the past week talking about new tests new devices new technology. One of the problems that I see we have here in the state of Minnesota is we want to talk about on the one hand maybe containing some of this new technology but yet on the other hand, we want to be a high-technology state in terms of our corporations and we have companies out there that virtually feed on the medical community the medtronic's the variety of medical companies and that's a that's a bit of a problem as we try to grow our technology. But yet at the same time contained cost. There are a number of Home testing devices that you used to go to the obstetrician to find out if you're pregnant you can now do that by buying a small kid at the drugstore and doing it at home and saving the 30 40 $50 charge that Might take in fact, there's now a new test on the market. That's just trying to get FDA approval. It was on television within the past week that talks about determining the sex of your baby by buying a little device at the drugstore bring it home and you can make that determination at home for just a few dollars. Again, a variety of options. I don't need to talk about all the technology. But the technology is just exploding at a tremendous rate. And as long as there's just there's no sight or no end in sight is to the level of explosion and that kind of Technology. There are some other delivery services that I think you need to be aware of second opinion programs a number of health insurance plans suggest and in fact now mandate that if you're going to have a procedure done, you need to have a second opinion by a physician. In fact a recent article in hospitals magazine again talked about the explosion of second opinion programs as a way of saying to the patient you need to take a stake and cutting your cause and if you want to have the procedure done, you will have a second opinion and the idea being that the second opinion will cause both the first position to be more conservative and the second second position to give a look-see as to whether or not the procedure might be indicated evening hours and house calls. There's a service out of New York. That's now being franchised across the United States called a house call service. These are Physicians who basically do not have an office practice. They do not work out. The routine medical situation they drive around in vehicles and will take telephone calls on their van and provide house calls. Now. This isn't something that the physician Market got into just out of the goodness of their heart and they recognize that people were out there in pain and couldn't make it to the doctor's office fact is that this is a direct result of the oversupply of Physicians and the need for Physicians to move into what most people would consider a lesser than the most upstanding kind of practice opportunity for physician evening hours is also becoming rather routine here in Minneapolis. Most major clinics have office hours that may go on till 8:00 9:00 10:00 at night. They're open Saturdays and Sundays and again in order for a physician to compete in this market the consumer can shop wherever he wants. There are a lot of Alternatives and if you're open at night, you might get my business if you're not I'll go and find someone who will Be willing to do that. Hospice centers instead of having the patients die and Humane fashion in the hospital. We are finding hospice centers gaining some ground in terms of providing for the last days of invalids and people who are going to die from disease. And again, it's a less expensive alternative, but it's an alternative that is organized around the patient and organized around trying to help the patient and meet the patient's needs urgent care centers were the Cinderella stock of the New York Stock Exchange back in 1983 and all across the country were finding that urgent care centers are indeed having problems many of the stocks that were that went out on the market that were medically related in 1983 at 20 and $30 a share. You'll Now find traded if they haven't been suspended already in the neighborhood of three to five dollars a share. Outpatient dialysis centers are another program where you don't have to use a hospital. It's an alternative many of these are run by physicians and again another alternative to that inpatient setting again, most of these operations and most of these alternatives are physician dominated physician run physician controlled and their Alternatives Alternatives that Physicians are into because I believe the supply and demand curve we learned about an economics 101 is beginning to work. Finally, I would just like to talk very briefly about a program that has been experimented with in Boston and that program where the Blue Cross program said to ladies having babies. You can come into the hospital and you can stay for days if you like, but if you can see fit to go home after 24 hours, we'll send you a rebate check of $200 in cash. It is amazing. How many people in that experiment were able to see fit to go home after 24 hours to take their $200 in cash a very different kind of thinking in a different way of providing care and certainly a economic benefit to patients. I think it's safe to say that they're going to be a lot of changes out there. I think as we look at the Fargo-Moorhead of the world and that's one of the most fascinating situations to me it historically has been a very conservative medical community, but there are Physicians and those two major clinics virtually fighting for their economic lives, and they're making life very difficult for a 75-mile radius. They realize that there are more physicians in Fargo than there are patients to take care of and as they reach out they're not reaching out necessarily out of the goodness of their heart. They're reaching out to gather in patients, and it's a normal natural process as a result of the supply and demand curves that we talked about earlier. Thank you.