How many times per case do our charts demand fraud?

[cthrowaway]

I was never a big fan of the "gateway hypothesis" that posited that marijuana was a gateway drug leading inexorably to addiction and ruin. The logic, as I understood it, went that marijuana wasn't all that terrible by itself, but using marijuana conditioned a user (typically, a teenager) to engage in other would-be harmful behaviors such as engaging with drug dealers, hiding activity from parents and authority figures, lying, subterfuge, rationalization...that end up with overdosing in back alley on heroin. (While it is very likely true that most heroin users probably used marijuana (or alcohol) before they first tried heroin, the same could also be said of mother's milk, dairy milk, or soda pop--to say nothing of tap water.)

However, I have come to see in my own practice that thousands upon thousands of times that I have had to commit fraud just to close a chart (specifically with electronic healthcare records, but also when presented with a stack of charts from weeks and months ago), I have now become comfortable with all sorts of behaviors that, were they to be interrogated in front of a jury, would make me (and my defense attorney) uncomfortable.

It is common at my shop to sign and date the PACU discharge note well in advance of PACU discharge. The PACU nurses then fill in the time. Some of my colleagues put a discharge hour well into the future. Having done some chart review, I note that some places leave the time out altogether, or place the PACU discharge note between the H+P/Risks and benefits portion and the physician's signature demand, so that one signature suffices.

That example is just an obvious one, and one that is easy talk about because the PACU discharge note is itself new within the last decade, so many of us performed literally millions of anesthetics safely without the extra paperwork, so we feel comfortable ignoring it.

But what about all the needless clicks on EHRs where we attest to chart review? I wonder how many thousands of times I've signed (under the threat of perjury) that I've reviewed the patient's chart, when unbeknownst to me a nervous surgeon (or, likely as not, his PA or helpful advanced nurse practioner) ordered a full set of labs and studies, even for simple procedures on healthy patients where a thoughtful physician would not need wasteful workups.

In the covid crisis, I have now become comfortable writing "WO (well-oxygenated), but deferred" or "WP (well-perfused), deferred) under lungs and cardiac exam. I am one of the holdouts in my group who still regularly uses (or used to use) a stethescope...but I can't exactly fault my colleagues for just scribbling WNL or its equivalent (in chart review I've seen simple checkmarks down the physical exam). I know for a fact they don't listen to hearts or lungs (and for routine cases, it is absurd to argue that any meaningful information can be gleaned from a cursory examination in a loud pre-op holding area). Is clicking a box on an EHR fraud? I guess your defense would be that you divined from a pulse oximeter tracing that the extremities were being perfused with oxygenated blood, therefore heart and lungs were performing adequately. And, you wouldn't be wrong. But I bet, once discovered, it would make juries uncomfortable.

"R+Bs explained, Qs answered" is another squishy term. I only write it to make the lawyers happy, but I know that when it comes right down to it, the patient will surely remember a wholly different conversation than I will remember. Am I being dishonest when I jot it down more out of muscle memory (or, more often, when it is pre-populated by the EHR), just so that I can get the case done?

And on and on.

I don't mean to act like I have the answer here. I don't know what the solution is. I do know that medical charts used to be for how doctors and nurses could communicate with each other. But that was decades ago. They have long since metastasized away from that purpose and now exist only to make billers and lawyers happy. Because of that, I don't feel that I owe the chart any true attention. The chart serves only as a means to divert attention away from my patient, so I engage with it as little as possible.

As a gateway "drug" to condition me to absolutely detest the role of administrators and billers, I'm not sure you could design a more perfect exercise than forced engagement with Epic software.

(Maybe that's the end game here. They have made the practice of anesthesia so much about clicking boxes that anymore it is only attractive to automatons who have come up through the CRNA training program. It can't be a coincidence that midlevels have strengthened their numbers exactly alongside a proportional rise in the references to "disruptive physician.")

Disrupt on!

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[IMGASMD]

How did you go from marijuana to chart fraud?!

We still mostly using paper, so I choose my wording carefully. But a my partners who are from a different generation may not.

 

[nimbus]

If they’re not dyspneic or tachypneic and I can’t hear wheezing from across the room, the lung exam is normal.

 

[sigrhoillusion]

If they’re not dyspneic or tachypneic and I can’t hear wheezing from across the room, the lung exam is normal.

Common PE with colleagues will note NO JVD for CV and NO STRIDOR for Pulm.

 

[nimbus]

Common PE with colleagues will note NO JVD for CV and NO STRIDOR for Pulm.

That works.

 

[deleted171991]

Common PE with colleagues will note NO JVD for CV and NO STRIDOR for Pulm.

Wouldn't it be easier just to put a stethoscope on for 10-20 seconds, and get a baseline? This is beyond lazy. And we wonder why CRNAs think they are our equals.

 

[coffeebythelake]

Common PE with colleagues will note NO JVD for CV and NO STRIDOR for Pulm.

presumably this is for healthy patients, with no cardiopulmonary concerns?

 

[cthrowaway]

Wouldn't it be easier just to put a stethoscope on for 10-20 seconds, and get a baseline? This is beyond lazy. And we wonder why CRNAs think they are our equals.

Maybe it's a corollary to the maxim "if you meet somebody known as 'Doc' in a social situation, that person is never a physician," but I see more CRNAs wearing white coats and hanging stethescopes around their neck than I do anesthesiologists.

I ever so rarely work at a high volume GI center. All the CRNAs come to work in long white coats.

On a related note, that GI center gives us a form, signed by the gastroenterologist, indicating to the insurance company why the patient required an anesthetist. The form has maybe 10 listed reasons. Into the category of "wholesale fraud" must go some of the reasons I've seen otherwise healthy patients described in ways that fit one of those ten diagnoses. "Anxiety disorder" is the most common, despite patients neither seeing a psychiatrist, nor taking any anxiolytics. Sigh.

 

[Hoya11]

I was never a big fan of the "gateway hypothesis" that posited that marijuana was a gateway drug leading inexorably to addiction and ruin. The logic, as I understood it, went that marijuana wasn't all that terrible by itself, but using marijuana conditioned a user (typically, a teenager) to engage in other would-be harmful behaviors such as engaging with drug dealers, hiding activity from parents and authority figures, lying, subterfuge, rationalization...that end up with overdosing in back alley on heroin. (While it is very likely true that most heroin users probably used marijuana (or alcohol) before they first tried heroin, the same could also be said of mother's milk, dairy milk, or soda pop--to say nothing of tap water.)

However, I have come to see in my own practice that thousands upon thousands of times that I have had to commit fraud just to close a chart (specifically with electronic healthcare records, but also when presented with a stack of charts from weeks and months ago), I have now become comfortable with all sorts of behaviors that, were they to be interrogated in front of a jury, would make me (and my defense attorney) uncomfortable.

It is common at my shop to sign and date the PACU discharge note well in advance of PACU discharge. The PACU nurses then fill in the time. Some of my colleagues put a discharge hour well into the future. Having done some chart review, I note that some places leave the time out altogether, or place the PACU discharge note between the H+P/Risks and benefits portion and the physician's signature demand, so that one signature suffices.

That example is just an obvious one, and one that is easy talk about because the PACU discharge note is itself new within the last decade, so many of us performed literally millions of anesthetics safely without the extra paperwork, so we feel comfortable ignoring it.

But what about all the needless clicks on EHRs where we attest to chart review? I wonder how many thousands of times I've signed (under the threat of perjury) that I've reviewed the patient's chart, when unbeknownst to me a nervous surgeon (or, likely as not, his PA or helpful advanced nurse practioner) ordered a full set of labs and studies, even for simple procedures on healthy patients where a thoughtful physician would not need wasteful workups.

In the covid crisis, I have now become comfortable writing "WO (well-oxygenated), but deferred" or "WP (well-perfused), deferred) under lungs and cardiac exam. I am one of the holdouts in my group who still regularly uses (or used to use) a stethescope...but I can't exactly fault my colleagues for just scribbling WNL or its equivalent (in chart review I've seen simple checkmarks down the physical exam). I know for a fact they don't listen to hearts or lungs (and for routine cases, it is absurd to argue that any meaningful information can be gleaned from a cursory examination in a loud pre-op holding area). Is clicking a box on an EHR fraud? I guess your defense would be that you divined from a pulse oximeter tracing that the extremities were being perfused with oxygenated blood, therefore heart and lungs were performing adequately. And, you wouldn't be wrong. But I bet, once discovered, it would make juries uncomfortable.

"R+Bs explained, Qs answered" is another squishy term. I only write it to make the lawyers happy, but I know that when it comes right down to it, the patient will surely remember a wholly different conversation than I will remember. Am I being dishonest when I jot it down more out of muscle memory (or, more often, when it is pre-populated by the EHR), just so that I can get the case done?

And on and on.

I don't mean to act like I have the answer here. I don't know what the solution is. I do know that medical charts used to be for how doctors and nurses could communicate with each other. But that was decades ago. They have long since metastasized away from that purpose and now exist only to make billers and lawyers happy. Because of that, I don't feel that I owe the chart any true attention. The chart serves only as a means to divert attention away from my patient, so I engage with it as little as possible.

As a gateway "drug" to condition me to absolutely detest the role of administrators and billers, I'm not sure you could design a more perfect exercise than forced engagement with Epic software.

(Maybe that's the end game here. They have made the practice of anesthesia so much about clicking boxes that anymore it is only attractive to automatons who have come up through the CRNA training program. It can't be a coincidence that midlevels have strengthened their numbers exactly alongside a proportional rise in the references to "disruptive physician.")

Disrupt on!

Yes Agree.

The chart is an annoying thing you have to do besides taking care of the patient.

The same is true in lots of other fields of medicine with the advent of computerized records and increased documentation for legal and billing

Have you seen some of these clearances or consult notes?

Pt does NOT have: Heart Disease, MI, etc.. you cant read it its just a jumbled computerized mess with tens of diagnosis (not sure which ones are relevant) and copy and pasted material , the gist of which could be summed up in a sentence or two..

 

[deleted697127]

Maybe it's a corollary to the maxim "if you meet somebody known as 'Doc' in a social situation, that person is never a physician," but I see more CRNAs wearing white coats and hanging stethescopes around their neck than I do anesthesiologists.

I ever so rarely work at a high volume GI center. All the CRNAs come to work in long white coats.

On a related note, that GI center gives us a form, signed by the gastroenterologist, indicating to the insurance company why the patient required an anesthetist. The form has maybe 10 listed reasons. Into the category of "wholesale fraud" must go some of the reasons I've seen otherwise healthy patients described in ways that fit one of those ten diagnoses. "Anxiety disorder" is the most common, despite patients neither seeing a psychiatrist, nor taking any anxiolytics. Sigh.

I’m not sure why the insurance companies are calling the shots on who gets anesthesia and who doesn’t for GI. Bad moderate sedation is the most common story for someone telling me they have a history of issues with anesthesia. We all know it’s a better experience with propofol and someone trained in airway management. What’s the cost? 1 or 2 vials of propofol and a trained person to manage the airway. It’s bizarre to me that the frequency of failed sedation with dangerous levels of narcotics is tolerated. Regardless of profits, I’m not looking to spend more time in the GI room but i certainly know what i would prefer for myself. I would also be willing to give an anesthesiologist 1-200$ cash for a 15 min colonoscopy. I’m surprised more places don’t approach it like dentists do wisdom teeth with accurate prearranged estimates and options for how you’d like it done.

 

[vector2]

I’m not sure why the insurance companies are calling the shots on who gets anesthesia and who doesn’t for GI. Bad moderate sedation is the most common story for someone telling me they have a history of issues with anesthesia. We all know it’s a better experience with propofol and someone trained in airway management. What’s the cost? 1 or 2 vials of propofol and a trained person to manage the airway. It’s bizarre to me that the frequency of failed sedation with dangerous levels of narcotics is tolerated. Regardless of profits, I’m not looking to spend more time in the GI room but i certainly know what i would prefer for myself. I would also be willing to give an anesthesiologist 1-200$ cash for a 15 min colonoscopy. I’m surprised more places don’t approach it like dentists do wisdom teeth with accurate prearranged estimates and options for how you’d like it done.

Depending on the insurance some practices or facilities were/are submitting $1200+ bills just for the anesthesia fee.

 

[chocomorsel]

Maybe it's a corollary to the maxim "if you meet somebody known as 'Doc' in a social situation, that person is never a physician," but I see more CRNAs wearing white coats and hanging stethescopes around their neck than I do anesthesiologists.

I ever so rarely work at a high volume GI center. All the CRNAs come to work in long white coats.

On a related note, that GI center gives us a form, signed by the gastroenterologist, indicating to the insurance company why the patient required an anesthetist. The form has maybe 10 listed reasons. Into the category of "wholesale fraud" must go some of the reasons I've seen otherwise healthy patients described in ways that fit one of those ten diagnoses. "Anxiety disorder" is the most common, despite patients neither seeing a psychiatrist, nor taking any anxiolytics. Sigh.

I just like your writing is all. I have no answers.
But I actually carry a stethoscope and listen to patients too normally. Even the healthy ones.
Except rarely during Covid. I had been putting down rales/rhonchi at first but when I listened they actually sounded quite clear.

 

[dannyboy1]

Wouldn't it be easier just to put a stethoscope on for 10-20 seconds, and get a baseline? This is beyond lazy. And we wonder why CRNAs think they are our equals.

I never order a test if I don’t know how to interpret the result. Maybe that’s why I never use a stethoscope

 

[habibimarwan]

In America, I write "alive" in CV and Pulm area. No problem!!

When I am back home, I don't write anything! Charting? What's that!!!

 

[IlDestriero]

I reviewed a case where the post op note was written timed and dated electronically 15 minutes after drop off in the pacu indicating complete recovery and dc home when ready, after post op instructions, etc. HOWEVER the patient never woke up, needed to be transferred to the ICU, Anesthesiologist was solo providing another case at the time and couldn’t return to the bedside for over 2 hours per detailed nursing notes. And when he did, it actually got worse. Bad look for a case that could see a jury.

 

[IlDestriero]

I’m not sure why the insurance companies are calling the shots on who gets anesthesia and who doesn’t for GI. Bad moderate sedation is the most common story for someone telling me they have a history of issues with anesthesia. We all know it’s a better experience with propofol and someone trained in airway management. What’s the cost? 1 or 2 vials of propofol and a trained person to manage the airway. It’s bizarre to me that the frequency of failed sedation with dangerous levels of narcotics is tolerated. Regardless of profits, I’m not looking to spend more time in the GI room but i certainly know what i would prefer for myself. I would also be willing to give an anesthesiologist 1-200$ cash for a 15 min colonoscopy. I’m surprised more places don’t approach it like dentists do wisdom teeth with accurate prearranged estimates and options for how you’d like it done.

That super fast colonoscopy would be at least a 5 unit bill, probably 6, so figure about $800-1000 for the physician fee.

 

[46Long]

I’m not sure why the insurance companies are calling the shots on who gets anesthesia and who doesn’t for GI. Bad moderate sedation is the most common story for someone telling me they have a history of issues with anesthesia. We all know it’s a better experience with propofol and someone trained in airway management. What’s the cost? 1 or 2 vials of propofol and a trained person to manage the airway. It’s bizarre to me that the frequency of failed sedation with dangerous levels of narcotics is tolerated. Regardless of profits, I’m not looking to spend more time in the GI room but i certainly know what i would prefer for myself. I would also be willing to give an anesthesiologist 1-200$ cash for a 15 min colonoscopy. I’m surprised more places don’t approach it like dentists do wisdom teeth with accurate prearranged estimates and options for how you’d like it done.

Because the whole system is completely broken. The whole reason the system is collapsing and perverted is because of the middleman. Its truly not a free market. And I disagree with the above poster. In a strictly cash negotiated system no patient will come up with 800 for anesthesia. They may come up with 250-300. You do 15-19 of them per day. Thats a healthy days work.

 

[IlDestriero]

What I bill for and what average insurance pays and what Medicaid pays are 3 data points. The cash fee would be somewhere in the middle. Maybe $300?
One of my partners called an imaging center and negotiated a very reasonable $650 fee for an abdomen and pelvis MRI with and without contrast, including radiology reading fees, for his uninsured mother. I’ve had the same exam and I think they billed over $8000. Obviously they didn’t get all of that.

 

[DrZzZz]

I reviewed a case where the post op note was written timed and dated electronically 15 minutes after drop off in the pacu indicating complete recovery and dc home when ready, after post op instructions, etc. HOWEVER the patient never woke up, needed to be transferred to the ICU, Anesthesiologist was solo providing another case at the time and couldn’t return to the bedside for over 2 hours per detailed nursing notes. And when he did, it actually got worse. Bad look for a case that could see a jury.

Back in residency, I remember a colleague of mine being asked to take care of some postops from the day before that got missed. Wrote postops for each patient without seeing them or even reading the charts. Well, the attendings weren't too happy when they found out that one of the patients who, according to this resident's note, was "recovering well postop" had actually died postop in the ICU about 10 hours earlier than that note being written.

 

[46Long]

What I bill for and what average insurance pays and what Medicaid pays are 3 data points. The cash fee would be somewhere in the middle. Maybe $300?
One of my partners called an imaging center and negotiated a very reasonable $650 fee for an abdomen and pelvis MRI with and without contrast, including radiology reading fees, for his uninsured mother. I’ve had the same exam and I think they billed over $8000. Obviously they didn’t get all of that.

But the thing is, many times they do get the 8000 dollars..
SOrt of like back in the day, they were billing 3000 just to float a swan and were getting it. Thats not even billing for the case..
THats not sustainable

 

[chocomorsel]

Because the whole system is completely broken. The whole reason the system is collapsing and perverted is because of the middleman. Its truly not a free market. And I disagree with the above poster. In a strictly cash negotiated system no patient will come up with 800 for anesthesia. They may come up with 250-300. You do 15-19 of them per day. Thats a healthy days work.

Agreed. I mean why do we need 800 for a 15 minute procedure. Because we can collect it is the answer
This whole system is greedy. Including us.
I guess it balances out with Medicare.

 

[chocomorsel]

What I bill for and what average insurance pays and what Medicaid pays are 3 data points. The cash fee would be somewhere in the middle. Maybe $300?
One of my partners called an imaging center and negotiated a very reasonable $650 fee for an abdomen and pelvis MRI with and without contrast, including radiology reading fees, for his uninsured mother. I’ve had the same exam and I think they billed over $8000. Obviously they didn’t get all of that.

And that’s why this whole system needs an overhaul.

 

[Ronin786]

But the thing is, many times they do get the 8000 dollars..
SOrt of like back in the day, they were billing 3000 just to float a swan and were getting it. Thats not even billing for the case..
THats not sustainable

Keith Smith on Free Market Health Care - Econlib

Entrepreneur and Anesthesiologist Keith Smith of the Surgery Center of Oklahoma talks with host Russ Roberts about what it’s like to run a surgery center that posts prices on the internet and that does not take insurance. Along the way, he discusses the distortions in the market for health care...

www.econtalk.org

 

[kidthor]

Back in residency, I remember a colleague of mine being asked to take care of some postops from the day before that got missed. Wrote postops for each patient without seeing them or even reading the charts. Well, the attendings weren't too happy when they found out that one of the patients who, according to this resident's note, was "recovering well postop" had actually died postop in the ICU about 10 hours earlier than that note being written.

I guess that's why residents shouldn't be scutted out for something that's a TERFA requirement.

 

[IMGASMD]

Keith Smith on Free Market Health Care - Econlib

Entrepreneur and Anesthesiologist Keith Smith of the Surgery Center of Oklahoma talks with host Russ Roberts about what it’s like to run a surgery center that posts prices on the internet and that does not take insurance. Along the way, he discusses the distortions in the market for health care...

www.econtalk.org

Just marking for myself.
Thanks will listen

 

[sigrhoillusion]

Wouldn't it be easier just to put a stethoscope on for 10-20 seconds, and get a baseline? This is beyond lazy. And we wonder why CRNAs think they are our equals.

I think it's the fact that most of them don't carry a stethoscope. So if you note that there's no JVD or audible wheezing or stridor, you've done a"physical". We actually can't finish our pre-op timeouts any more unless the card, pulm and airway exams are filled out in the EMR.

 

[abolt18]

I think it's the fact that most of them don't carry a stethoscope. So if you note that there's no JVD or audible wheezing or stridor, you've done a"physical". We actually can't finish our pre-op timeouts any more unless the card, pulm and airway exams are filled out in the EMR.

Physical Exam
Cardiac :RRR (from palpating the pulse)
Pulm: non-labored breathing on room air. Symmetric chest rise.

Those are frequent ones I see

 

[habibimarwan]

Physical Exam
Cardiac :RRR (from palpating the pulse)
Pulm: non-labored breathing on room air. Symmetric chest rise.

Those are frequent ones I see

Palpating the pulse? Touching patient?? No-good in COVID19 times, unless you want to dress up in clown suit to touch patient wrist!!

 

[abolt18]

Palpating the pulse? Touching patient?? No-good in COVID19 times, unless you want to dress up in clown suit to touch patient wrist!!

So dramatic

 

[coffeebythelake]

Agreed. I mean why do we need 800 for a 15 minute procedure. Because we can collect it is the answer
This whole system is greedy. Including us.
I guess it balances out with Medicare.

Who do you mean by "us"? Because I certainly dont see that kind of money

 

[chocomorsel]

Who do you mean by "us"? Because I certainly dont see that kind of money

Neither do I. But there are our counterparts who truly believe that we deserve to make 1000 for a 20 minute colonoscopy. I mean it's good that there are those options, but it is totally unsustainable. I agree with the poster saying pay 250 to 300 per procedure, 15 of those a day and that's a healthy sum.
The whole game we play with the insurance companies is ridiculous. Everyone, including us is price gouging in order to make the highest buck. No one knows what anything costs, no one can give you a quote, you have no clue when you go to the hospital what your out of pocket is going to cost sometimes, I mean, it's too much. Without so many insurance companies all paying whatever they see fit, and hospitals and doctors trying to bill ridiculous sums, it would make for a less complicated world.
I got a foot nevus biopsy and was billed $1500. Are you serious? I bet I could have gone to a cash paying place and paid $300-400 bucks. My options were limited in that small town at the time. My mom's three day hospital bill was 78K. Non ICU mind you. Not including the physician fees. It's out of control, and yes, we are part of the problem.

 

[46Long]

I think we(physicians) only "price gouge"because we see it as follows:
If WE dont get the money, somebody will... ie the hospital, the network, the insurance company, your employer, the surgeon, the gi center..... If we ask for less money, it is not going to cost any less to the patient or society , you just simply get less money; the balance is disbursed amongst the fat executives..

Armed with that knowledge, would you ask for less money to make the fat executives fatter?

The only way to solve this is to agressively cut the middleman out and keep the relationship between the patient and physician as close as possible. Get rid of relationships (contracts) between hospitals and physicians. Get rid of health NETWORKS. Bring back fierce competition between hospitals within local areas.

 

[Urzuz]

...and doctors trying to bill ridiculous sums...It's out of control, and yes, we are part of the problem.

Are we? I agree with most of what you said, but how many doctors are actually in control of what is billed to the patient? The vast majority of doctors are paid either based on a predetermined salary or a previously negotiated contract. As long as I am billing units ethically, how am I responsible for the problems you laid out?

 

[chocomorsel]

Are we? I agree with most of what you said, but how many doctors are actually in control of what is billed to the patient? The vast majority of doctors are paid either based on a predetermined salary or a previously negotiated contract. As long as I am billing units ethically, how am I responsible for the problems you laid out?

Ok, maybe not us directly. I don’t know how my billers approach billing but I was never partner for long. I never did find out the few months I was a partner. But partners know or should know.
Have you tried to find out? Where do these numbers come from?
I suspect we bill some ridiculously high number knowing we aren’t going to get it from the insurance company.
Speaking from the receiving, patient side, I can tell you that some of the doctor bills I see are ridiculous. But worse are the hospital and facility fee.

 

[deleted162650]

I suspect we bill some ridiculously high number knowing we aren’t going to get it from the insurance company.

That’s only true if billing OON. Under normal circumstances you have a predetermined contracted rate with the insurance company.

 

[chocomorsel]

I think we(physicians) only "price gouge"because we see it as follows:
If WE dont get the money, somebody will... ie the hospital, the network, the insurance company, your employer, the surgeon, the gi center..... If we ask for less money, it is not going to cost any less to the patient or society , you just simply get less money; the balance is disbursed amongst the fat executives..

Armed with that knowledge, would you ask for less money to make the fat executives fatter?

The only way to solve this is to agressively cut the middleman out and keep the relationship between the patient and physician as close as possible. Get rid of relationships (contracts) between hospitals and physicians. Get rid of health NETWORKS. Bring back fierce competition between hospitals within local areas.

If that included get rid of the greedy insurance companies, then yeah. I am all for it.
I pay about $900 a month for my moms insurance. And they are always trying to deny ****. It’s ridiculous.
Get rid of it all damn it! Free market! Yeah I am all for it.

 

[46Long]

Get rid of it all damn it! Free market! Yeah I am all for it.

That is exactly right!
THat's the solution.
Only then will we know what is going on. WHo's in bed with who(m)?
NOw it is almost impossible to decipher even to those who study this.