Elective surgeries cancelled due to lack of anesthesiology

[deleted697127]

Starkman: Beaumont Faces Threat of Nurse Anesthetists Strike Over Declining Patient Safety Standards

www.deadlinedetroit.com

Bad to worse. It's a shame because the facility is actually quite nice.

“Beaumont Royal Oak’s acute staff shortage will soon be exacerbated because nearly one-third of the hospital’s CRNAs gave notice they want to reduce their hours.”

Lol.

---

Members don't see this ad.

 

[Blockit]

Starkman: Beaumont Faces Threat of Nurse Anesthetists Strike Over Declining Patient Safety Standards

www.deadlinedetroit.com

Bad to worse. It's a shame because the facility is actually quite nice.

The fish rots from the head. That axiom could apply both to Beaumont and North star.

 

[caligas]

How can they do “any license”?

Temporary Emergency medical licensing?

 

[deleted126335]

“Beaumont Royal Oak’s acute staff shortage will soon be exacerbated because nearly one-third of the hospital’s CRNAs gave notice they want to reduce their hours.”

Lol.

 

[deleted126335]

Just curious if anybody knows what the current situation is like for the docs? 1:4 (or higher ratios)? Dropping docs in rooms in the afternoon to relieve CRNAs? Offering emergency pay to get folks to work more or just trying to work them harder?

 

[deleted697127]

Just curious if anybody knows what the current situation is like for the docs? 1:4 (or higher ratios)? Dropping docs in rooms in the afternoon to relieve CRNAs? Offering emergency pay to get folks to work more or just trying to work them harder?

I mean high hourly rate doesn’t exactly incentivize efficiency. This story is great for our specialty. People take for granted the hustle private groups and physicians put in to get the work done. Let’s not forget that this all started with the physicians offering their services at a discount to help out during the emergency circumstances of the pandemic and the hospitals response was to fire the group.

 

[Beach bum]

Just curious if anybody knows what the current situation is like for the docs? 1:4 (or higher ratios)? Dropping docs in rooms in the afternoon to relieve CRNAs? Offering emergency pay to get folks to work more or just trying to work them harder?

Yes, yes, yes

 

[gasdoc77]

The fish rots from the head. That axiom could apply both to Beaumont and North star.

CRNA'S take note. "Deathstar" is not your friend. There are patients and there are providers, and any other entity that wants a piece of the pie is a parasite. Good for them for unionizing!

 

[Zekchar]

This was the official unsolicited recruitment email I got. This is for discussion only and not because I support their cause.
------------------------------------------------------------------------------------------------------------------------------------------------
Physician rates will be based on blocks of CONSISTENT availability as per below- With travel paid:

Less than 2 weeks a month/less than FT hours per week $300/h

2-4 week blocks including (including weekend and call) $350/h

8 week FT commitment- (including weekend and call) $400/h

12 week FT commitment (including weekend and call) $500/h

PRACTICE AND FACILITY INFORMATION:

Any state license can be accepted

· 12 PHY/ 10 CRNA care team model

· Average daily staffing 9 PHY and 8 CRNAs

· 12 OR’s (9 MAIN, 1 CV, 1 GI, 1 CATH, 1 EP, 1 OP, 1 OB)

· Can run up to 15 concurrent locations M-F

· Late room coverage includes 1 room until 11 p, 2 rooms until 7 p, and 7 rooms until 5 p

· 1 Physician in-house call (OB) with PCO, and 2 (Cardiac & OR) physicians pager call nights, weekends, holidays

· CRNAs do not take call

· CRNA shifts consists of 8, 10 hour shifts

· 90% of the time Physicians are doing own cases, 10% medically directing CRNAs (1:4 ratio)

· Total annual cases ~21,000

o General ~4700, Cardiac/Open Heart ~125, OB ~2400, GYN (non-OB) ~1000, ENT ~600, GI in OR only ~2200, Ophthalmology ~1700, Ortho ~1900, Urology ~1600, Neurosurgery Rare ~170, Podiatry Rare ~400

o Sometimes: Thoracic, Major Vascular, Pediatrics

o ~653 C-Sections w/out Labor Epidurals and ~200 sections with Epi’s, 1200 Vaginal with Labor Epidurals

o Rare Trauma, but Level 2

· 255 licensed bed Community Hospital, part of Advocate Health Care, one of the top 12 not-for-profit systems in the country and largest system in Illinois

· 2018-2019 Named a Best Regional Hospital by U.S. News & World Report, Additionally, “Has ranked high performing in aortic valve surgery, congestive heart failure, colon cancer surgery, COPD, diabetes and endocrinology, gastroenterology and GI surgery, geriatrics, hip replacement, knee replacement and pulmonology.”

· Location:Elgin, IL

· EMR:EPIC

 

[GassYous]

I am now emailing my group scheduler to get the next 3 months off.

 

[sevoflurane]

I am now emailing my group scheduler to get the next 3 months off.

F that…. let them burn.

 

[sevoflurane]

Wonder if that CEO has been fired yet

 

[Shimmy8]

Wonder how they pay out those call shifts if $500/hr is the expectation...

 

[Blockit]

F that…. let them burn.

Agreed.
Provider greed is how AMC’s came to power, and provider greed is what they are counting on to bail them out of this situation.
I wouldn’t want to be any part of that.

 

[deleted126335]

Agreed.
Provider greed is how AMC’s came to power, and provider greed is what they are counting on to bail them out of this situation.
I wouldn’t want to be any part of that.

Come on. There are no communists on this forum.

 

[Blockit]

Come on. There are no communists on this forum.

I meant what I said.
And before you try to say it, just because I would refuse to participate in Elgin doesn’t make me some sort of socialist. I just feel that I would not be able to live with myself if I “helped out” that CEO and Hospital board. They deserve to burn, as the prior poster said

 

[pgg]

Three thoughts -

1. I'm with sevo, let them burn.

2. People occasionally post here asking about working in a Persian Gulf state or North Korea to make $$$$$. I find it curious that there's more moral outrage about doing scab work for this hospital, than there is for outright mercenary compound-living jobs serving the ruling class of despotic regimes in places famous for human rights violations.

3. They claim 90% solo days. If you trust those guys to hold to that ... better get it in writing.

 

[deleted126335]

I meant what I said.
And before you try to say it, just because I would refuse to participate in Elgin doesn’t make me some sort of socialist. I just feel that I would not be able to live with myself if I “helped out” that CEO and Hospital board. They deserve to burn, as the prior poster said

I have no interest in going there, but at another time in my career, I would have considered it if the price was right.

Old Joke:

A man offers a woman $100 if she will sleep with him. She responds angrily, "What do you think I am?" He responds, "Will you sleep with me for $1,000,000?". She hesitates. He says, "We have established what you are, now we are just negotiating the price."

 

[Southpaw]

Agreed.
Provider greed is how AMC’s came to power, and provider greed is what they are counting on to bail them out of this situation.
I wouldn’t want to be any part of that.

yeah but someone will.....

@dr doze is right. At $500/hr for a 12wk commitment they won't have much of a problem finding people. If they do, they'll raise the rate. If they can't find people there, they'll raise it again. Gotta be honest, if they're really doing their own cases $500/hr is pretty freaking sweet.

 

[Shimmy8]

Depending on what they really put in writing and call hours needed, etc. you’re talking about $250k+ for 3 months. They will find people.

 

[coffeebythelake]

Did thry say anything about minimum number of hours a day? A week?

 

[narcotics999]

Did thry say anything about minimum number of hours a day? A week?

40 hrs guaranteed, I believe.

 

[undalay]

This was the official unsolicited recruitment email I got. This is for discussion only and not because I support their cause.
------------------------------------------------------------------------------------------------------------------------------------------------
Physician rates will be based on blocks of CONSISTENT availability as per below- With travel paid:

Less than 2 weeks a month/less than FT hours per week $300/h

2-4 week blocks including (including weekend and call) $350/h

8 week FT commitment- (including weekend and call) $400/h

12 week FT commitment (including weekend and call) $500/h

PRACTICE AND FACILITY INFORMATION:

Any state license can be accepted

· 12 PHY/ 10 CRNA care team model

· Average daily staffing 9 PHY and 8 CRNAs

· 12 OR’s (9 MAIN, 1 CV, 1 GI, 1 CATH, 1 EP, 1 OP, 1 OB)

· Can run up to 15 concurrent locations M-F

· Late room coverage includes 1 room until 11 p, 2 rooms until 7 p, and 7 rooms until 5 p

· 1 Physician in-house call (OB) with PCO, and 2 (Cardiac & OR) physicians pager call nights, weekends, holidays

· CRNAs do not take call

· CRNA shifts consists of 8, 10 hour shifts

· 90% of the time Physicians are doing own cases, 10% medically directing CRNAs (1:4 ratio)

· Total annual cases ~21,000

o General ~4700, Cardiac/Open Heart ~125, OB ~2400, GYN (non-OB) ~1000, ENT ~600, GI in OR only ~2200, Ophthalmology ~1700, Ortho ~1900, Urology ~1600, Neurosurgery Rare ~170, Podiatry Rare ~400

o Sometimes: Thoracic, Major Vascular, Pediatrics

o ~653 C-Sections w/out Labor Epidurals and ~200 sections with Epi’s, 1200 Vaginal with Labor Epidurals

o Rare Trauma, but Level 2

· 255 licensed bed Community Hospital, part of Advocate Health Care, one of the top 12 not-for-profit systems in the country and largest system in Illinois

· 2018-2019 Named a Best Regional Hospital by U.S. News & World Report, Additionally, “Has ranked high performing in aortic valve surgery, congestive heart failure, colon cancer surgery, COPD, diabetes and endocrinology, gastroenterology and GI surgery, geriatrics, hip replacement, knee replacement and pulmonology.”

· Location:Elgin, IL

· EMR:EPIC

This is a good bait for the locums company to collect cv and all your license information for future use. This is a red flag too good to be true.

 

[Leinie]

This is a good bait for the locums company to collect cv and all your license information for future use. This is a red flag too good to be true.

If you already know the hospital and group staffing the facility reach out directly with those rates as a template.

 

[undalay]

yeah but someone will.....

@dr doze is right. At $500/hr for a 12wk commitment they won't have much of a problem finding people. If they do, they'll raise the rate. If they can't find people there, they'll raise it again. Gotta be honest, if they're really doing their own cases $500/hr is pretty freaking sweet.

Yeah for some companies backed up by Wall Street start ups there is unlimited funny money printing ability and ordinary anesthesia groups will never be able to splurge. I think once a Hospital gets locum Comp to staff their anesthesia, it’s a perpetual cycle. In reality if honest groups cannot run a place without subsidy, how will the maths work out for AMC? The AMCs have to run huge losses to get market share. But don’t worry, Enron accounting professionals can make all the numbers look rosy and sell it to another larger company. And all these stock options can be exercised

When it is time for the bigger company to come clean, the insiders would have all their options exercised and will be heavily shorting these stocks via hedge funds. Too big too fail, Uncle Sam will be happy to take over and medicare for all will be a reality.

 

[Zekchar]

When it is time for the bigger company to come clean, the insiders would have all their options exercised and will be heavily shorting these stocks via hedge funds. Too big too fail, Uncle Sam will be happy to take over and medicare for all will be a reality.

I disagree. You will have parallel systems. One will be medicare for all, run by NPs, CRNAs, PAs, and figurehead docs overseeing it. The 2nd will be private institutions and facilities which will have direct physician care and concierge style medicine. In system 2 a well-visit will be some vital signs and a physician note saying "No issues, come back in 6 months" and will be paid all the same as the current 10 page progress note with endless insurance mandated information that boils down to the original 6 words in quotations. Nobody with any means will go to system 1.

 

[nimbus]

I disagree. You will have parallel systems. One will be medicare for all, run by NPs, CRNAs, PAs, and figurehead docs overseeing it. The 2nd will be private institutions and facilities which will have direct physician care and concierge style medicine. In system 2 a well-visit will be some vital signs and a physician note saying "No issues, come back in 6 months" and will be paid all the same as the current 10 page progress note with endless insurance mandated information that boils down to the original 6 words in quotations. Nobody with any means will go to system 1.

What percent of us do you think will work in each system?

 

[GassYous]

I disagree. You will have parallel systems. One will be medicare for all, run by NPs, CRNAs, PAs, and figurehead docs overseeing it. The 2nd will be private institutions and facilities which will have direct physician care and concierge style medicine. In system 2 a well-visit will be some vital signs and a physician note saying "No issues, come back in 6 months" and will be paid all the same as the current 10 page progress note with endless insurance mandated information that boils down to the original 6 words in quotations. Nobody with any means will go to system 1.

People have been saying this for 10+ years

 

[Big Swinging Doc]

This was the official unsolicited recruitment email I got. This is for discussion only and not because I support their cause.
------------------------------------------------------------------------------------------------------------------------------------------------
Physician rates will be based on blocks of CONSISTENT availability as per below- With travel paid:

Less than 2 weeks a month/less than FT hours per week $300/h

2-4 week blocks including (including weekend and call) $350/h

8 week FT commitment- (including weekend and call) $400/h

12 week FT commitment (including weekend and call) $500/h

PRACTICE AND FACILITY INFORMATION:

Any state license can be accepted

· 12 PHY/ 10 CRNA care team model

· Average daily staffing 9 PHY and 8 CRNAs

· 12 OR’s (9 MAIN, 1 CV, 1 GI, 1 CATH, 1 EP, 1 OP, 1 OB)

· Can run up to 15 concurrent locations M-F

· Late room coverage includes 1 room until 11 p, 2 rooms until 7 p, and 7 rooms until 5 p

· 1 Physician in-house call (OB) with PCO, and 2 (Cardiac & OR) physicians pager call nights, weekends, holidays

· CRNAs do not take call

· CRNA shifts consists of 8, 10 hour shifts

· 90% of the time Physicians are doing own cases, 10% medically directing CRNAs (1:4 ratio)

· Total annual cases ~21,000

o General ~4700, Cardiac/Open Heart ~125, OB ~2400, GYN (non-OB) ~1000, ENT ~600, GI in OR only ~2200, Ophthalmology ~1700, Ortho ~1900, Urology ~1600, Neurosurgery Rare ~170, Podiatry Rare ~400

o Sometimes: Thoracic, Major Vascular, Pediatrics

o ~653 C-Sections w/out Labor Epidurals and ~200 sections with Epi’s, 1200 Vaginal with Labor Epidurals

o Rare Trauma, but Level 2

· 255 licensed bed Community Hospital, part of Advocate Health Care, one of the top 12 not-for-profit systems in the country and largest system in Illinois

· 2018-2019 Named a Best Regional Hospital by U.S. News & World Report, Additionally, “Has ranked high performing in aortic valve surgery, congestive heart failure, colon cancer surgery, COPD, diabetes and endocrinology, gastroenterology and GI surgery, geriatrics, hip replacement, knee replacement and pulmonology.”

· Location:Elgin, IL

· EMR:EPIC

Just for information about anybody considering taking advantage of Team Health's desperation: I made a very casual inquiry, and eventually got connected to a recruiter. The recruiter gave the distinct impression that she was totally and completely overwhelmed. Long story short, because I was unwilling to promise 12 continual weeks, she more or less told me she isn't interested in my application.

I'm happy for the docs whose schedules are so forgiving that they have three solid months available starting immediately. And I can't blame them for extracting a premium from TeamHealth.

But my allegiances still lie with the displaced group. I hope Team Health loses millions of dollars (but very few lives).

 

[FutureInternist]

If hospital thought subsidizing the private group was expensive, they’re going to hurt paying for locums and with less money A/R coming in from canceled cases to do so.

another reminder to have an emergency fund and vote with your feet.

Best reason to live below your means and get to “F you” money ASAP.

Don’t have to FIRE but not having a house payment or other major loan payment to worry about, lets you “vote with your feet” much more easily

 

[IMGASMD]

Just for information about anybody considering taking advantage of Team Health's desperation: I made a very casual inquiry, and eventually got connected to a recruiter. The recruiter gave the distinct impression that she was totally and completely overwhelmed. Long story short, because I was unwilling to promise 12 continual weeks, she more or less told me she isn't interested in my application.

I'm happy for the docs whose schedules are so forgiving that they have three solid months available starting immediately. And I can't blame them for extracting a premium from TeamHealth.

But my allegiances still lie with the displaced group. I hope Team Health loses millions of dollars (but very few lives).

Doing the real work, this guy! I salute you. Thank you!

 

[FutureInternist]

Dumb ****s

Save a dime lose a dollar

My hospital didn’t give nurses any raise (perhaps could have called a “temporary hazard pay” so its not a permanent increase in cost), and then they started leaving for travel work, and now have hired travelers themselves at TWICE the rate with the obvious loss of institutional memory and hence many missed issues.

 

[ambiturner]

My hospital didn’t give nurses any raise (perhaps could have called a “temporary hazard pay” so its not a permanent increase in cost), and then they started leaving for travel work, and now have hired travelers themselves at TWICE the rate with the obvious loss of institutional memory and hence many missed issues.

Is there any hospital that actually didn’t cheap out during all this and gave big bumps to their staff? Mine did a market adjustment for nurses/techs/APNs but that still was probably only 5-7% in the end, not enough to prevent many from going traveler or retiring. And of course no adjustment for the docs…

 

[undalay]

Just for information about anybody considering taking advantage of Team Health's desperation: I made a very casual inquiry, and eventually got connected to a recruiter. The recruiter gave the distinct impression that she was totally and completely overwhelmed. Long story short, because I was unwilling to promise 12 continual weeks, she more or less told me she isn't interested in my application.

I'm happy for the docs whose schedules are so forgiving that they have three solid months available starting immediately. And I can't blame them for extracting a premium from TeamHealth.

But my allegiances still lie with the displaced group. I hope Team Health loses millions of dollars (but very few lives).

I know a few physicians who do locums all the time and do have 12 continuous weeks. He has Illinois license and also has cardiac experience, and he called them , only to be considered for reserve (extra4 players in amer football). They probably have their candidates from other team health institutions close by. Locums need is propping up in Danville, illinois, South bend Indiana etc. This is bait and switch operation going on. In the middle are the locums company doing their own drama to get a cut of this.

I can relate to your sentiments re allegiance with displaced groups. Not all of the members can follow through on that cohesion. Eventually some of the physicians from the previous group will come back and join team health. we just have to watch and figure out who blinks first.

Team health will soon become too big to fail. They may loose few million dollars, but their backers have unending money supply. It will show up as higher taxes for all of the rest. Some of our physicians can see the writing on the wall. And they are jumping ship and joining AMC and after one or two years becoming regional directors. This is the cold reality now

 

[nimbus]

In my area, we now have an out of town corporate Emergency Medicine practice recruiting for anesthesia locums at a local hospital. Strange world.

 

[anes121508]

Sutaria said the Advocate’s decision to sever ties with the practice was especially galling given the additional hours the private anesthesiologists worked during the COVID-19 pandemic, going beyond what was required in their contract. There times when the doctors worked 24-hour shifts because of the caseload, he said.

“We were on the frontlines putting ourselves in the face of COVID patients,” Sutaria said.
Earlier this year the practice informed Advocate that its anesthesiologists would be following the contract guidelines and not doing any additional work for one day, Sutaria said. They wanted to demonstrate the services they provide that would go unfilled if they stuck to their contract, he said.”

———————————-

I understand the sentiment but I am not sure it applies here. My group does not have a predatory buy in, however, I will say when we are deciding whether or not to add someone, it has little to do with what our competition is offering. In fact, the money actually has less to do with it than the work life balance. There are a lot of moving parts and it is hard to predict our needs. There is a tight balance between not enough work to go around and too much call. Doing your own cases and billing let’s you see exactly how much your time is worth. There are good jobs out there. It seems insane to me that people do the work they do for those partnership tracks or AMCs knowing what the billing brings in.

If anything, I think this hospitals outcome demonstrates the need for anesthesiologists and doctors in general to grow a pair and not just meet unsustainable demands outside of contracts in hopes of building goodwill. Round 1 of covid was an unforeseeable emergency. Administrators inability to meet the incoming staffing needs at this point in the pandemic is not my problem. Picking up weird tiring high risk out of specialty work covering emergency covid demands for less than you’d make for the opportunity cost of that time working as an anesthesiologist is a poor business decision. Pay me.

amen.

unfortunately this seems to be the hospitals new move. short staff, refuse to pay market rate, look into whatever bodies they have available that they can take advantage of and shift more work onto

 

[anes121508]

You can be paid some vague sum of money with unspecified benefits, job obligations, and hours? Sign me up.

as an employee of TH, i can say that's pretty much standard move by them

 

[anes121508]

I am saying sometimes the amc doesn’t want to deal with you directly, because of their accounting practices.

Even though they maybe paying 300+/hr to locum company, and you getting 200. The money coming out of locum pot is different than the money coming out of their regular operating pot.

Also to the management, there’re other costs when they hire you directly. All the benefits, training, 401k and whatever else is they have to pay for.

bingo

nothing made sense to me until i realized it's the accounting practice that accounts for the silly stuff

the real interesting part is how the a place like team health is short staffed at a location and the locums company DY locums or whatever is a part of teamhealth

different pots of money with different budgets and different goals i guess

 

[IMGASMD]

bingo

nothing made sense to me until i realized it's the accounting practice that accounts for the silly stuff

the real interesting part is how the a place like team health is short staffed at a location and the locums company DY locums or whatever is a part of teamhealth

different pots of money with different budgets and different goals i guess

I think they all have some sort of interest in staffing companies.

I always knew these companies goal is making money, just didn’t realize that’s the “only” thing they recognize. My SO just recently changed job, the company basically wants to fire 100 of the full time senior worker by hiring “independent contractors”. She’s trying to save some of those jobs by telling the company they do much better job than the independent contracts ever does, and sometimes cheaper. Part of the matrix is also how flexible they can just fire the independent contractors at the end of their busy season. Their goal and only goal is to “save $x” so they can show that to their investors. The company isn’t in financial industry, either. Sound familiar?

We just need to really get that through our heads. The only thing is the almighty dollar, there’s nothing else in the world. If they can make their balance sheet look better, so they show they’re making money. They sure will.

 

[Guillemot]

Word on the street is that this fall Advocate is giving Team Health the boot.

 

[narcotics999]

Word on the street is that this fall Advocate is giving Team Health the boot.

Where does Advocate get its providers?

 

[epidural man]

Where does Advocate get its providers?

What is a provider? Are you asking who sells them their cable service, or their phone service? Those guys are providers. Maybe the gas or electric bill? I guess they are providers also.

 

[Dr. Rude]

What is a provider? Are you asking who sells them their cable service, or their phone service? Those guys are providers. Maybe the gas or electric bill? I guess they are providers also.

What’s in a Name? The Problematic Term “Provider”

www.ncbi.nlm.nih.gov

First, the origin of the term provider is deplorable. During its ascent to power in the 1930s, the Nazi Party promoted the devaluation and exclusion of Jews in German society, including the medical community. Due to its eugenics campaign, the Nazi Party first targeted pediatrics, a specialty in which nearly half of its practitioners were Jewish.2 Beginning with female pediatricians, all Jewish physicians were redesignated as Behandler (provider) instead of Arzt (doctor.)2 This is the first documented demeaning of physicians as providers in modern history. Jewish doctors were soon restricted to treating only Jewish patients and were further persecuted during the Holocaust. Knowing this background, what health care organization would use a term once associated with Nazi ideology?3

 

[narcotics999]

What is a provider? Are you asking who sells them their cable service, or their phone service? Those guys are providers. Maybe the gas or electric bill? I guess they are providers also.

lol, so harsh.

Advocate is running multiple ads on gaswork ranging 550-625K. A lot of calls.

 

[epidural man]

Speaking of GASWORKS -

I never look on there but did today. Holy Crap. There are A LOT of very high paying jobs in California. Historically, CA has been pretty low on the scale. There is one in Manteca that says up to 1 million!

I suspect none of those numbers are true...but still.....

 

[anbuitachi]

lol, so harsh.

Advocate is running multiple ads on gaswork ranging 550-625K. A lot of calls.

how do these jobs compete against locums. no one wants lot of calls... for that price

 

[narcotics999]

Speaking of GASWORKS -

I never look on there but did today. Holy Crap. There are A LOT of very high paying jobs in California. Historically, CA has been pretty low on the scale. There is one in Manteca that says up to 1 million!

I suspect none of those numbers are true...but still.....

If you read further, there are multiple posts about the position. The number probably is right. You need be on call q2 or q3.

 

[rowsdower88]

Speaking of GASWORKS -

I never look on there but did today. Holy Crap. There are A LOT of very high paying jobs in California. Historically, CA has been pretty low on the scale. There is one in Manteca that says up to 1 million!

I suspect none of those numbers are true...but still.....

I got my job off gasworks and the numbers quoted were significantly less than I ended up making a year later. YMMV

 

[nimbus]

Speaking of GASWORKS -

I never look on there but did today. Holy Crap. There are A LOT of very high paying jobs in California. Historically, CA has been pretty low on the scale. There is one in Manteca that says up to 1 million!

I suspect none of those numbers are true...but still.....

$1mil is not enough to live in Manteca.

 

[pgg]

$1mil is not enough to live in Manteca.

Not since they closed the water slides, anyway.