Background--The USA--Australia--Business Practices--Mayne--Conclusion--References
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Contents of this page
This page takes the story of the company Columbia/HCA, now called only HCA through tight economic conditions. It examines involvement in the price gouging scandal, concerns about staffing and care, allegations of insider trading, and finally a management led private equity buyout
Founded in the 1960s by the Frist family, HCA prospered but was involved in the psychiatric fraud scandal in the late 1980s and early 1990's. During this period a massive fraud was carried out and several Qui Tam law suits were commenced by whistle blowers. In 1994 it merged with Columbia to form Columbia/HCA with Columbia's chairman as CEO. Its aggression caused an outcry across the USA. In 1997 the FBI pounced and a massive fraud investigation commenced. The company collapsed and Scott became the scapegoat as Frist took control, claiming to be clean even though this fraud had been set up when he was CEO. It dropped "Columbia" from its name. It reached a US $1.7 billion fraud settlement in 2003.
HCA had remained relatively low key during this period trying to build a new clean image. It falsely claimed this to be a reversion to the sort of company it was when the Frist family ran it and before Richard Scott took charge. Frist, the company claimed, had saved HCA and turned it back into a respectable and ethical company. The market believed this.
Thomas Frist retired and become the elder statesman of health care. His track record was hidden in positive verbiage and market adulation. He became an instant authority advising on the business of health care. He was even brought up to Canada, presented to and accepted by government there as an authority advising them. Some Canadians had done their homework and this was short lived!
Frist was replaced by Jack Bovender, Thomas Frist's long time lieutenant.
Click Here to explore HCA's taudry track record on the main HCA page
This rosy picture could not last and HCA, like Tenet Healthcare (see for more information about the gouging scandal) was soon charging the uninsured and partly insured far more than the wealthy insured and then aggressively pursuing them for payment - even taking their houses.
The poor Latino population were pursued particularly aggressively by these companies. They banded together under the leadership of Kevin Forbes and fought back. Tenet and HCA were forced to be far more open and to offer the uninsured reasonable fees and reasonable terms for payment. The consequence of this was that the uninsured were no longer driven into not for profit competitor's hospitals. Tenet and HCA's bad debts increased dramatically.
P22 referring to price gouging at HCA
- - - - among the worst offenders, he (Kevin Forbes) says, are those affiliated with hospital giant HCA. The Nashville based company typically charges individuals many times more than insurance companies pay for the same services, then relentlessly badgers patients by threatening them with liens or seizures and forcing them to turn over substantial portions of their wages. The HCA cases, Forbes says are "the most appalling stories the Consejo has ever documented."
Forbes calculated that HCA alone overcharged the uninsured by $2.1 billion in 2002.
Critical Condition: How Health Care in America Became Big Business & Bad Medicine, Nov. 2004 by Barlett & Steele
While HCA continued to make positive predictions and claims it is clear that times were getting harder and harder. It was not making money and its prospects were bleak.
When corporate practices are tracked the behaviour in this sort of situation follows a pattern across the health and aged care industry. While these practices may be illegal their prosecution often depends on proving intent rather than coincidence, or showing a corporate policy when there is no paperwork. This is usually impossible.
For obvious reasons I must leave you to draw your own conclusions about what was really happening to staffing (medical and nursing), to patients, and to the market in HCA's shares. Insiders certainly made huge profits during this period.
One of the first strategies employed by corporations in trouble is to cut costs. The largest cost in health care is nursing. Standards of care are heavily dependent on adequate numbers of properly trained and motivated staff.
A union representing about 3,000 healthcare workers is threatening to strike at three Southern California hospitals owned by HCA Inc., the biggest U.S. hospital chain, over staffing and forced overtime, the union said on Tuesday.
The union says the hospitals are chronically understaffed and that staffing levels are dictated by company officials at HCA headquarters in Nashville, Tennessee, rather than by local administrators
"Things considered normal in competitive industries should be considered abhorrent when translated into healthcare," said Dana Simon, a negotiator for the union.
Union threatens strike at three HCA hospitals Reuters June 13, 2006
The industry's vital signs remain rather weak. Hospitals continue to struggle with mounting shortages of doctors, nurses and -- perhaps most importantly -- insured patients who actually pay their bills. As a result, they have wound up sharing some of their profits with available physicians while getting sued for allegedly sharing too little with the nurses who help those doctors out.
Meanwhile, nurses have shown no real love for HCA lately.
Rather, they have banded together to sue some of the company's hospitals for allegedly underpaying them. In multiple class-action lawsuits filed earlier this week, nurses accuse hospitals in major cities like San Antonio -- where HCA operates four hospitals -- of colluding on nurse salaries and depriving them of literally hundreds of millions of dollars in lost wages as a result.
"Both in Florida and California, HCA consistently has the lowest man hours per patient admission of any hospital operator," Young (business consultant at HealthCare Strategic Issues) claims. Thus, "to our Wall Street friends, we suggest a substantial portion of HCA's net patient income is derived from seemingly overly aggressive labor savings practices that are not likely to be sustainable in the current business environment."
HCA Watchers Take Sides The Street.com (Melissa Davis) June 22, 2006
Unlike nurses doctors are not costs. They bring the patients from which profits are made. Corporations must compete for their custom and the only way they know how is by buying their support and that is illegal.
HCA was particularly constrained because of its recent fraud settlement which included allegations of paying illegal kickbacks to doctors. It was constrained by compliance and integrity undertakings it signed. Other companies were poaching its doctors and as in Australia there was a shortage. Tenet and HCA had the same problem. Could it be that this desertion was a consequence of cost cutting and understaffing. Doctors taking their patients where they would get the best care.
Look at the way the analyst sees it in the extract below. Its essential to secure doctors loyalty but you must find a way around the laws. The intention of the laws is to prevent the doctors independence, in choosing the best for their patients, being compromised by monetary considerations. That what they are doing is seeking to subvert the law that protects citizens is never confronted. This is market-think at its illogical best!
Carefully examine the way the Putnam hospital behaved when you come to that section below and ask yourself if there is any relationship between what happened there and the market pressures to recruit more money making doctors.
Just take a look at the company's latest quarterly results. Volume took a hit as available physicians, lured by competing hospitals, sent their patients elsewhere in Florida and Virginia.
Meanwhile, other hospital chains like Triad (TRI:NYSE) and HMA have taken expensive steps to keep their own doctors loyal. Triad has laid out plans to offer physicians stock in virtually all of its hospitals, Reuters has reported. Meanwhile, Skolnick says, HMA has put some doctors on the payroll and made them hospital employees.
At the same time, however, Skolnick understands that hospitals must seek new ways to attract doctors who are in increasingly short supply.
"You have to find some way to convince the doctors to love you -- and you've got to do it legally; that's a challenge," she says. So "these things are certainly being looked at."
HCA Watchers Take Sides The Street.com (Melissa Davis) June 22, 2006
A recurring problem in the health and aged care sectors is the way the law deals with medical and nursing negligence. While hundreds of citizens may suffer the consequences of company policy, they are forced to take hundreds of separate actions against individual doctors and individual facilities. Nursing home litigation is bedeviled by this. Another consequence is that the companies and the true culprits in their board rooms escape blame and adverse publicity.
HCA, Nashville, faces a federal class-action lawsuit seeking $12.25 billion in damages to compensate victims of what the lawsuit alleges is the company's systematic understaffing of its hospitals since 1996.
Class action accuses HCA of staffing too few nurses Modern Healthcare April 11, 2006
A federal judge in Wichita dismissed a class-action lawsuit this week claiming the nation's largest hospital corporation operates unsafe levels of nurse staffing.
"The court finds that plaintiffs' claims are in reality medical malpractice claims, and are not appropriately advanced as claims for consumer protection or unjust enrichment," Marten wrote in his ruling.
Marten said those cases involve medical malpractice that need to be examined on an individual basis, not in a consumer class-action.
HCA staffing suit dismissed The Wichita Eagle July 29, 2006
Marketplace disputes not only increase anxiety and cost for patients but can seriously disrupt care by interfering with continuity of care. Patients are forced to go to doctors unfamiliar with their history. We saw this in Australia when BUPA and Healthscope had a similar spat that had nothing to do with the real victims - the patients.
A contract dispute between HCA Inc., the country's largest for-profit hospital operator, and UnitedHealth Group Inc. has forced thousands of people in South Florida and the Tampa area to seek alternate hospital care or pay more for treatment.
Health dispute affects patients Orlando Sentinel (Associated Press) September 1, 2006
Regulators have also identified some serious problems in HCA facilities.
Still, after finding problems with five patients placed in restraints, the Agency for Healthcare Administration declared the facility presented ''an immediate threat to public health and safety'' and took the highly unusual move of closing it to all admissions except those entering through the emergency room.
Alan Levine, secretary of the Agency for Healthcare Administration, said, ``It's very rare that the agency will take such an aggressive action. It's only when there is a potential danger to the safety, health or well being of patients.''
Capezuti noted that the lack of documentation suggested not just lax record-keeping but also a failure by staff to coordinate care.
State labels hospital a health threat : The state ordered Aventura Hospital to stop admitting nonemergency patients, citing five cases of inappropriate use of restraints. MiamiHerald.com June 2, 2006
In 2006 HCA negotiated a sale to private equity groups (see later). The New York Observer made some predictions about what would happen to staffing and patients - see "A Health-Care Deal That'll Make You Sick" later. These mirror what was found in private equity owned nursing homes in the USA in September 2007 (see report on Aged Care Crisis Centre web site) and what I predicted in a submission (659KB pdf file) to the Australian senate earlier in 2007.
The Putnam hospital
What happened is reminiscent of Tenet's Redding hospital. In their search for profitable physicians, the Tenet hospital's administrators employed and promoted an untrained and uncertified doctor as chief of cardiology and rewarded him hugely for doing more work. he protests of other doctors were ignored. Some 700 patients are alleged to have had unnecessary cardiac surgery.
At the Putnam hospital administrators bypassed the normal credentialing procedure for physicians and appointed an Osteopath. He was then allowed to operate. He was not trained as an orthopaedic surgeon, let alone a surgeon. In Australia most osteopaths would not have a medical degree and be properly medically trained. The comments of the senior surgeon at the hospital suggest that this may be so in the USA as well.
This appointment would undoubtedly have aroused the angst of doctors at the hospital, but if so, this would have been attributed to professional jealousy. I don't have information on this but that is the way marketplace managers think and behave.
The consequences for patients was predictable but this is not the sort of thing that constrains managers under extreme market pressures. About 120 of the patients who were harmed, or relatives of those who died, sued for damages. The reports are sequential.
Another issue of interest is the ruling by the judge. Traditionally doctors are responsible for decisions relating to the care of patients and are liable when there is a failure in care and this is the legal situation. They guard this independence.
At the same time companies and their managers control the way the hospital is run and the appointment of doctors, and influence their credentialing. The environment that they create has a major impact on the way doctors practice and what happens to patients. It is legally almost impossible to succeed in an action hat holds the hospital or the company responsible for what the doctors do. As this case shows there are indirect ways of getting around this in the USA in some situations but not in most other countries. It is worth noting that the decision was taken by a jury rather than a judge.
In the early 1990's I attempted to change this by pursuing Tenet (then called NME) and not doctors through the courts outside the USA. An appeal judge ruled that the company did not have to disclose the documents I needed. I was advised that my action would not be successful and withdrew.
HCA Inc.'s plan to sell five hospitals, including its four in West Virginia, is a ruse to avoid hundreds of millions of dollars in potential damages from malpractice allegations against a doctor, according to lawyers who have asked the state to review the $330 million deal.
The lawyers represent 71 former patients suing over the alleged negligence at Putnam General Hospital in Hurricane, W.Va. Putnam General is among the five hospitals Nashville, Tenn.-based HCA wants to sell to LifePoint Hospitals Inc., a company HCA spun off in 1999.
But the plaintiffs link their sale to possible damages from more than 100 lawsuits lodged since mid-2003 alleging that King killed, maimed or otherwise harmed scores of patients while at Putnam General, largely through botched orthopedic surgeries.
Lawyers Question Motives in Hospital Sale The New York Times October 10, 2005
Besieged by malpractice lawsuits targeting one of its former doctors, Putnam General Hospital will cease all inpatient services at the end of the month and try to operate instead as an urgent care center, officials announced Tuesday.
Lewis cited lawsuits filed by more that 100 patients or their survivors alleging malpractice by osteopath Dr. John Anderson King, who spent seven months at the Hurricane hospital working as an orthopedic surgeon.
Putnam General to close all inpatient services The Gazette Mail (Associated Press) August 1, 2006
HCA officials announced last week that the hospital has to close because the lawsuits filed against King hurt business and dramatically increased employee turnover.
But Sturgeon (lawyer for patients) contends in his letter that HCA currently has $10 million in insurance coverage for each malpractice suit filed against King, Putnam General and HCA itself.
Nashville, Tenn.-based HCA reached an agreement last year to sell Putnam General and three other West Virginia Hospitals to another big hospital company, LifePoint Hospitals Inc. of Brentwood, Tenn. But before the deal went through, HCA had to remove Putnam General from the package amid complaints from a major LifePoint shareholder.
Putnam hospital safe from suits, lawyer says The Gazette Mail August 7, 2006
Dr. John King is the defendant in 110 medical malpractice complaints accusing him of killing or maiming patients while a surgeon at Putnam General - which at the time was owned by Nashville, Tenn.-based Hospital Corporation of America Inc., the country's biggest hospital chain.
Copenhaver (judge) focused his ruling on just one set of issues, determining that King was not in "a partnership or joint venture" with Putnam General or HCA. As such, Health Care Indemnity "has no obligation to indemnify John A. King, D.O. [doctor of osteopathy], in the underlying state court lawsuits pending in the Circuit Court of Putnam County," Copenhaver wrote.
King entered into a "recruiting agreement" with Putnam General on Oct. 21, 2002, Copenhaver's ruling notes. That agreement said that King "is and shall be an independent contractor and not a servant, agent or employee" of Putnam General.
It let King see patients and perform surgeries at the hospital but did not "create any type of employment, agency, servant, partner or joint venture relationship between physician [King] and [Putnam General] Hospital," Copenhaver stated.
Leonard Fichter, chief of surgery at Putnam General when King performed surgeries there, testified in a legal deposition last year that King was incompetent to practice medicine.
Fichter blamed Putnam General executives and the hospital's parent company for allowing King to be hired.
Fichter stated he could not "make an informed decision" about King's professional credentials because he was misled by Frank Molinaro, Putnam General's chief executive, and Jackie Frame, head of the hospital's credentialing service at that time.
He has surrendered or had his medical licenses revoked in West Virginia and eight other states: Florida, Georgia, Michigan, New Jersey, Ohio, Pennsylvania, Texas and Virginia.
Hospital giant could escape John King liability The Gazette Mail February 19, 2007
A jury says Putnam General Hospital was negligent when it hired an osteopathic physician who later was accused of more than 100 acts of medical malpractice.
The Putnam County Circuit Court jury deliberated about an hour Tuesday afternoon before holding the hospital responsible for allowing Doctor John King to practice there. The verdict means Putnam General will be a co-defendant in 122 medical malpractice lawsuits filed against King.
The jury found that Putnam General failed to meet the standard of care in considering King's applications for credentials in 2002. Jurors also said the plaintiffs can seek punitive damages against the hospital.
Jury Says Hospital Negligent WHSV.com (Associated Press) August 1, 2007
Trading in shares
The illegal sale of large numbers of shares by insiders just before a market crash has become so common as to be normal. It is seldom possible to prove that this was on the basis of inside knowledge and prosecutions are unusual.
There was an outcry in 2005 when large numbers of shares were sold by insiders and by senate majority leader Bill Frist, whose family had founded and operated the company and still owned much of it.
No one was prosecuted.
When Senate Majority Leader Bill Frist asked a trustee to sell all his stock in his family's hospital corporation, a large-scale sell-off by HCA insiders was under way.
Shares of the Nashville, Tenn.-based hospital company were near a 52-week peak in June when Frist and HCA insiders were selling off their shares - just about a month before the price dropped.
The sales, which included moves by Hospital Corporation of America's chief executive, treasurer, senior vice president for government programs and several directors, were among the largest insider sell-offs analysts had seen, LoPresti said. Many officers made their largest trades ever in April, only to top them again in May and June, LoPresti (of Thomson Financial) said.
Uninsured patient admissions were rising faster than those of insured patients, federal reimbursements were declining in real terms and payments did not keep up with cost increases.
For years, Frist, a heart surgeon, was criticized for holding stock in the nation's largest for-profit hospital chain while directing legislation on Medicare reform and patient issues. HCA was founded by his father, the late Thomas Frist Sr.; and his brother, Thomas Jr., is a director and leading stockholder.
Stock sale by blind trust came during sell-off by HCA insiders : Senator's role raises questions Houston Chronicle (Associated Press) September 22, 2005
The senator's spokesman, Bob Stevenson, said Wednesday that Mr. Frist "made a conscious decision to divest himself of all HCA assets" so he could pursue an ambitious agenda of health care legislation free of any appearance of self-interest.
Since joining the Senate, Mr. Frist had been dogged by accusations about conflicts of interest from his HCA holdings, including "no fewer than 19 instances" of articles or other public accusations, Mr. Stevenson said.
The question, Professor Coffee said, is whether Mr. Frist received private information about the company performance from his brother or other insiders.
"There is no prohibition against a family member's dumping his stock in a company, unless it can be shown that the family member was tipped as to material nonpublic information," he said. "That seems to be the missing link."
On June 13, his spokesman said, Mr. Frist told the managers to sell all his shares. The stock hit its peak at $58.22 a share nine days later, on June 22. By July 8, all the shares held by Mr. Frist and his wife and children were sold, his spokesman said, adding that Mr. Frist did not control the exact timing.
Five days after that, on July 13, HCA announced that its second-quarter earnings would fall below Wall Street projections because of lower than expected hospital admissions and higher than expected numbers of patients lacking insurance. Its stock fell 9 percent, to $50.05 a share, that day on the New York Stock Exchange, and closed on Wednesday further down, at $47.41 a share.
Senate Leader Explains His Sale of a Stock That Then Plummeted The New York Times September 22, 2005
Senate Majority Leader Bill Frist is facing questions from the Justice Department and the Securities and Exchange Commission about his sale of stock in his family's hospital company one month before its price fell sharply.
SEC, Justice Investigate Frist's Sale of Stock Washington Post September 24, 2005
HCA Inc. is being hit with a class-action lawsuit related to a profit warning the company issued this summer, an event that sent shares of the hospital chain down 9 percent.
HCA (NYSE: HCA) and its officers are accused of artificially inflating the company's stock price through false statements about HCA's financial success. HCA's stock prices grew by almost 50 percent from Jan. 11 to more than $58 per share on June 22.
During that time, officials sold nearly 1 million shares of HCA stock, netting $48 million in proceeds.
HCA profit warning draws class-action lawsuit Nashville Business Journal November 7, 2005
A little later Jack Bovender, now CEO also decided to cash in his options and share holdings.
The leader of HCA (HCA:NYSE) has announced plans to sell a large chunk of company stock in the midst of a tough industry environment.
HCA CEO Jack Bovender intends to cash out options for up to 420,660 shares of stock -- about 17% of his stake in the company -- between now and April 2007. The options are set to expire two years later.
In a press release issued Thursday, HCA said that Bovender is selling the stock for "estate-planning purposes." But the announcement came just one day after HCA reported another quarterly increase in uninsured patients who rarely pay their bills. It also coincided with analyst reports predicting even tougher times ahead.
Bovender himself has portrayed HCA stock as a very good investment. He did so just before he revealed his own planned sales, in fact.
In recent months, a slew of HCA executives have been cashing in their stock. Bovender is simply the latest -- and highest-ranking -- official to join that selling spree.
"When HCA's paid admissions actually decline, that tells you where the industry is headed. This," he (Peter Young, a business consultant for HealthCare Strategic Issues) declared, "is a big, big problem."
HCA Chief Sets Sale The Street.com (Melissa Davis) February 6, 2006
Frist and the insiders were not prosecuted but a civil suit where the level of proof is very different was settled for US $20 million without any admission of fault.
The Securities and Exchange Commission has decided not to file insider-trading charges against former Senate Majority Leader Bill Frist in connection with the sales of stock in the hospital chain his family owns, The Washington Post reported Friday.
The sales came in 2005 as Frist was weighing whether to run for the Republican nomination for president, which he eventually decided against. When the sales came to light, he denied having any insider information about HCA.
No Charges Against Frist in Stock Sale The New York Times April 27, 2007
HCA Inc. would pay $20 million to stockholders who sued the company claiming that executives made false statements causing them to purchase stock at inflated prices, under a preliminary settlement approved by a federal judge in Nashville. - - - - - does not admit wrongdoing - - - .
Several shareholder lawsuits, consolidated into one action in January 2006, claimed that company leaders misstated the HCA's financial status during the first half of 2005.
HCA settles insider trading lawsuit for $20 million The Tennessean August 13, 2007
A Private Equity funded buyout
It became increasingly clear that the market was about to panic with disastrous consequences for the company. A buyout took the company off the share market. It was less accountable and no longer vulnerable to marketplace panic. This was one of the largest buyouts in US history. This pushed the share price up and there is a suggestion that insiders may have benefited again.
The buyout group is led by the family of Senator Bill Frist, the majority leader, whose father, Thomas Frist Sr., and his son, Thomas F. Frist Jr., founded HCA.
Hospital Giant HCA Is Close to a Record Buyout The New York Times July 24, 2006
In fact, it appears that somebody started making money even before the starter's gun was fired. The Wall Street Journal reports that the Securities and Exchange Commission is looking into trading in HCA before the announcement was made, which gives rise to the suspicion that insiders, knowing that the company's stock would go up once the news was made public, bought first, cheap and profitably.
Besides the purchase price of $21 billion, the new owners of HCA will have to assume a corporate debt of $11.7 billion-a total debt of about $32 billion, which doesn't bother them at all. One of the reasons it doesn't is that this group of sharks faithfully follows rule No. 1 of high finance: never use your own money. They are going to borrow the dough.
Does that mean they will spend long years scraping together the money to pay off the debt bit by bit? No, because rule No. 2 of high finance is to start milking the company once you've got hold of it.
In all this speculation, one group was consistently not mentioned: the patients. No one wondered how this debt might impinge on patient care, though it stands to reason that every dollar taken out of medical care in profits is one less dollar available for taking care of sick people.
Will there be fewer supervising nurses? Nobody can deny that the quality of nursing care ain't what it used to be. Will it mean an extra hour of lying in one's own filth because there is no one on duty to clean the incontinent patient? Does it mean an extra 45 minutes of awful pain because there are not enough people on duty to respond promptly to someone in agony?
Or does it mean more people die?
A Health-Care Deal That'll Make You Sick The New York Observer August 28, 2006
The giant hospital chain arranged one of the biggest leveraged buyouts ever, an effort to satisfy shareholders who would have otherwise pummeled the stock because of the company's lousy performance.
An internal presentation, made public through a regulatory filing last month, offers a chilling glimpse of just how tough the hospital business has become.
In the presentation, financial experts discuss the outlook for HCA -- under the code name "Hercules" -- and point to an LBO as the only quick cure for the company.
The presentation is brutally direct: The company's second-quarter results were "materially worse" than Wall Street expectations.
Moreover, the quality of the company's earnings was "extremely low" because of one-time gains.
HCA management, together with other private investors, offered to buy the stock for $51 a share instead.
Hospital Fans Watch HCA The Street.com (Melissa Davis) October 16, 2006
HCA, Nashville, said it will conduct a special meeting of shareholders on Nov. 16 to seek approval of a planned leveraged buyout by private equity groups, members of the Thomas Frist Jr. family and management. The deal is valued at $33 billion in cash and debt.
HCA schedules vote on planned buyout Modern Healthcare October 17, 2006
The new owners of HCA Inc., the nation's largest for-profit hospital chain, will collect $175 million in transaction fees as part of a completed $21.3 billion leveraged buyout to take the company private.
The affiliates of HCA's new owners will also get an additional $15 million or more a year in management fees from the company, according to a report filed by HCA on Friday with the Securities and Exchange Commission.
The hospital chain was sold on Nov. 17 to HCA management and Hercules Holding II LLC, a consortium of private investment funds including Bain Capital Partners LLC, Kohlberg Kravis Roberts & Co. and Merrill Lynch Global Private Equity.
Hospital Chain Buyers Get $175M in Fees The New York Times November 25, 2006
This deal has generated much more buzz than larger corporate takeovers (such as AT&T's pending $88 billion purchase of BellSouth) because it's the biggest going-private deal in history. The price-about $21.5 billion for HCA's shareholders, plus the assumption of about $11.7 billion of debt - - - - .
A Very Private Moment : More companies like HCA are eliminating pesky shareholders and avoiding government regulators. MSN Television August 7, 2006
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This page created Oct 2007 by Michael Wynne