What Will Happen with the Generic Drug Companies’ Lawsuit: Lessons from the Tobacco Settlement

The State Attorney General of Connecticut, William Tong, has sued generic drug companies claiming they conspired to inflate prices and defraud the public of billions of dollars (1). To date, 43 state attorney generals have joined the suit. Tong, who takes doxycycline for rosacea, saw the price increase from $20 for 500 tablets in 2013 to $1,829 a year later. Although several generic companies sell doxycycline, one of the largest is Mylan. Both Mylan and their CEO, Heather Bresch, became infamous for the $10,000 EpiPen and a 4000% price hike in albuterol after testifying before the Senate Judiciary Committee in 2016 (2). The committee took no action and itself came under scrutiny when it was revealed that Mylan had made substantial campaign contributions to nearly all members of the committee (2).  Other companies named in this lawsuit include Teva, Sandoz, Pfizer and 16 other drug manufacturers. 

Now the states’ attorney generals, like knights on their shining armor, are rushing to protect the public from these “evil generic drug company price gougers.” The present suit is reminiscent of a prior generation of states’ attorney generals who 20 years ago filed and eventually settled a lawsuit against tobacco manufacturers for $206 billion (not a typo that is b as in billion) over 25 years (3). Based on that Tobacco Settlement we can predict what will happen with the generic drug company lawsuit. After legal wrangling for several years, a settlement of at least several billion will be reached. Payments will be placed in the states’ general funds. Like the tobacco companies, the drug companies will negotiate as a condition of the settlement to continue their business largely unregulated.

In 2007, the Government Accountability Office (GAO) reported that 22.9 % of proceeds from the Tobacco Settlement had gone to close state budget shortfalls, often to make up deficits caused by tax cuts (Figure 1) (3).

Figure 1. GAO analysis of categories to which states allocated their Tobacco Settlement payments (fiscal years 2000-2005) (3).

Another 7.1 percent had been spent on “general purposes” and another 6 percent on the politically popular term “infrastructure.”  Other notable highlights were that 11.9 percent of funds were “unallocated” and 7.8 percent had been devoted to “Other.”  Only about a third of the settlement revenues had been spent on health and tobacco control.

Much the same is likely to happen with the generic drug manufacturers lawsuit. A settlement will be reached and go into state funds and be viewed as a cash cow by legislators enthusiastic to cut taxes and/or fund their own pet projects. It seems likely that only a small portion will be spent on the public who for years have suffered inflated drug prices. After the settlement the generic manufacturers will be free to conduct business and fix prices as before.

If we can learn from the Tobacco Settlement, interventions can be taken to ensure the money is spent appropriately. States attorney generals should not be allowed to settle the suit benefiting those who were not harmed by unscrupulous price fixing. The spending of any settlement money should be supervised by the courts and the money should go directly to the state departments of health, away from tampering by state legislators and others. The money should be used to supplement healthcare for those who need the financial assistance the most. Since market forces regulating generic drug prices have apparently been corrupted, generic drug companies will need to have prices in the future approved assuring fair competition. Lastly, as a condition of settlement, CEOs need to sign agreements that impose severe penalties on both them and their companies for price fixing in the future.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Simmons-Duffin S. States sue drugmakers over alleged generic-price-fixing scheme. All Things Considered. NPR. May 13, 2019. Available at: https://www.npr.org/sections/health-shots/2019/05/13/722881642/states-sue-drugmakers-over-alleged-generic-price-fixing-scheme (accessed 5/14/19).
2. Pramuk J. Senators probing EpiPen price hike received donations from Mylan PAC. CNBC.  Aug 26, 2016. Available at: https://www.cnbc.com/2016/08/26/senators-probing-epipen-price-hike-received-donations-from-mylan-pac.html (accessed 5/14/19).
3. GAO. States’ allocations of payments from tobacco companies for fiscal years 2000 through 2005. US Government publication GAO-07-534T. February 27, 2007. Available at: https://www.gao.gov/assets/120/115580.pdf (accessed 5/14/19).

Cite as: Robbins RA. What will happen with the generic drug companies’ lawsuit: Lessons from the Tobacco Settlement. Southwest J Pulm Crit Care. 2019;18(6):155-6. doi: https://doi.org/10.13175/swjpcc032-19 PDF

The Implications of Increasing Physician Hospital Employment

Several years ago, Dr. Jack had a popular, solo internal medicine practice in Phoenix. However, over a period of about 15-20 years, the profitability of Jack’s private practice dwindled and he was working 60+ hours per week to keep his head above water. This is not what he planned in his mid-50’s when he hoped to be settling into a comfortable lifestyle in anticipation of retirement. Jack eventually closed his practice and took a job as a hospital-employed physician. Jack’s story has become all too common. The majority of physicians are now hospital-employed (1).

The increase in hospital-employed physicians raises at least 2 questions: 1. How can a busy private practice not be profitable? and 2. Is it good to have most physicians hospital-employed? Like Jack, it seems most physicians seek hospital employment for financial and lifestyle reasons. But how can a primary care practice like Jack’s not be profitable when the cost of healthcare has risen so markedly?

To understand why a practice can be busy but not necessarily profitable we need to follow the money. First, reimbursement for private practice has decreased in real dollars (Figure 1) (2). 

Figure 1. Inflation and Medicare physician fee schedule (MPFS) growth in percent from 2006-2017 (2).

Private practice physician reimbursement is the only major cost center that the Centers and Medicaid Services (CMS) has singled out for asymmetrical negative annual fee schedule adjustments. The other major cost centers—hospital inpatient and outpatient, ambulatory surgical centers, and clinical laboratories—all had fee schedule adjustments that were nearly equal to and typically greater than inflation (2). Of course, private insurance companies follow CMS’ lead and so reimbursement to private practice physicians dramatically decreased (3).

In addition, increased requirements for documentation and paperwork were imposed by CMS and quickly picked up by private insurers. These required more physician time and/or the hiring of additional personnel. In addition, there were increasing annoyances and burdens placed on physicians to review and sign forms and prescriptions which already been electronically submitted. Often these annoyances were so the durable medical equipment provider, pharmacy, etc. could be reimbursed. These later burdens now take up to one-sixth of a physicians’ time, decrease office efficiency, and not surprisingly, greatly decrease physician job satisfaction (4).

The second question is whether hospital-employed physicians is a good thing for patients. Although hospitals have argued that hospital-based physicians provide better care, patient outcomes appear to be no different (5). Hospitals have engaged in a number of practices resulting in physicians being financially squeezed. The American Hospital Association (AHA) has lobbied CMS and Congress for payments that are much higher than independent physicians’ offices, assuring hospital profitability. However, under the Trump administration, CMS proposed to pay the same rate for services delivered at off-campus hospital outpatient departments and independent doctors' offices (called site neutrality) (6). This would result in about a 60% cut to the hospitals for these services (7). Not surprisingly, hospitals complained and lobbied Congress to rescind the rule (7). Later the AHA sued CMS challenging the "serious reductions to Medicare payment rates" as executive overreach (8). The case is currently pending before the courts.

Hospitals have also engaged in a number of practices to limit competition from physicians’ offices. First, several have employed a non-compete clause as a condition of obtaining staff privileges. These clauses mean that should a physician leave a hospital, the physician is unable to reestablish a practice within a specified distance of the hospital (often within a radius of 50 miles) (9). Of course, in a metropolitan area this means the physician has to leave the city, or in the case of a large hospital chain, the physician may have difficulty finding areas to practice even in the same state. Second, with the “hospitalist movement” many hospitals have seized on the opportunity to essentially self-refer. That is, the hospitals schedule follow-up appointments with primary care or other physicians employed by the hospitals.

A study documents that healthcare costs for four common procedures rose with increasing hospital physician employment (10). A 49% increase in hospital-employed physicians led to CMS paying $2.7 billion more for diagnostic cardiac catheterizations, echocardiograms, arthrocentesis and colonoscopies delivered in hospital outpatient settings than it would for treatment in independent facilities. CMS beneficiaries footed an additional $411 million.

Although many decry a fee-for-service healthcare system as being too expensive, the increase in hospital-employed physicians seems to only have increased healthcare costs. Action by CMS is needed not only for site neutrality but also a number of other areas to ensure health competition in healthcare.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Kane CK. Updated data on physician practice arrangements: For the first time, fewer physicians are owners than employees. Policy Research Perspectives. American Medical Association. 2019. Available at: https://www.ama-assn.org/system/files/2019-05/prp-fewer-owners-benchmark-survey-2018.pdf (accessed 5/11/19).
2. Cherf J. Unsustainable physician reimbursement rates. AAOS Now. October, 2017. Available at: https://www.aaos.org/AAOSNow/2017/Oct/Cover/cover01/ (accessed 5/11/19).
3. Clemens J, Gottlieb JD. In the shadow of a giant: Medicare's influence on private physician payments. J Polit Econ. 2017 Feb;125(1):1-39. [CrossRef] [PubMed]
4. Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians' working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635-42. [CrossRef] [PubMed]
5. Short MN, Ho V. Weighing the effects of vertical integration versus market concentration on hospital quality. Med Care Res Rev. 2019 Feb 9:1077558719828938. [CrossRef] [PubMed]
6. Robbins RA. CMS decreases clinic visit payments to hospital-employed physicians and expands decreases in drug payments 340b cuts. Southwest J Pulm Crit Care. 2018;17(5):136. [CrossRef]
7. Luthi S, Dickson V. Medicare's site-neutral pay plan targeted in hospitals' lobbying. Modern Healthcare. September 25, 2018. Available at: https://www.modernhealthcare.com/article/20180925/TRANSFORMATION04/180929928/medicare-s-site-neutral-pay-plan-targeted-in-hospitals-lobbying (accessed May 11, 2019).
8. Luthi S. Hospitals sue over site-neutral payment policy. Modern Healthcare. December 04, 2018. Available at: https://www.modernhealthcare.com/article/20181204/NEWS/181209973/hospitals-sue-over-site-neutral-payment-policy (accessed May 11, 2019).
9. Darves B. Restrictive covenants: A look at what’s fair, what’s legal and everything in between, Today’s Hospitalist. April 2006. Available at: https://www.todayshospitalist.com/restrictive-covenants-a-look-at-whats-fair-whats-legal-and-everything-in-between/ (accessed May 11, 2019).
10. Kacik A. Hospital-employed physicians drain Medicare. Modern Healthcare. November 14, 2017. Available at: https://www.modernhealthcare.com/article/20171114/NEWS/171119942/hospital-employed-physicians-drain-medicare (accessed May 11, 2019).

Cite as: Robbins RA. The implications of increasing physician hospital employment. Southwest J Pulm Crit Care. 2019;18(5):141-3. doi: https://doi.org/10.13175/swjpcc025-19 PDF 

More Medical Science and Less Advertising

A recent article appeared in JAMA Open Access reporting that wait times to see a provider in the Department of Veterans Affairs (VA) have improved (1). You might remember that in the not so distant past the VA was embroiled in a controversy for reporting falsely short wait times (2). The widely publicized scandal was centered in Phoenix and led to the firing, resignation or retirement of a number of administrators in VA Central Office, the Southwest Veterans Integrated Service Network (VISN) and the Phoenix VA. What was not as well publicized, but perhaps even more disturbing, was that up to 70% of VA facilities also were reporting deceptively shortened wait times (3). Congress appropriated additional money for the VA to fix the wait times but it is unclear how the money was spent (2).

Now the VA reports that the wait times have shortened and compares favorably to the private sector. The VA’s history has to lead to some skepticism about the data. Is it true? Is it accurate? The short answer is that we do not know because the VA data is largely self-reported. The VA used a different method, the secret shopper approach, for the private sector assessment. In this method a caller requests a routine appointment with a randomly selected care physician in a given health care market. The reported VA data may not be representative of the VA as a whole. Only some metropolitan areas were selected and did not include non-metropolitan facilities and no facilities from the Southwest VISN where there was a known problem. Furthermore, the data is only for new patients requesting a primary care, dermatology, cardiology, or orthopedic appointment. Data for wait times to see other specialties is not reported.

An accompanying editorial by two VA investigators does a good job in explaining the nuances of the study (4). Editorials in response to a specific article are often authored by the reviewers. If these editorial authors were also the article’s reviewers, they can hardly be blamed for saying nice things about the manuscript since “biting the hand that feeds you” is usually a dangerous practice. However, why JAMA published the article in the first place is puzzling. Certainly, lack of timely access to healthcare is very important and lack of access has been associated with higher costs and worse outcomes (4,5). However, this article reports nothing about how the VA achieved this improvement in access. Was it by hiring additional physicians to see the patients or by hiring additional scheduling clerks or additional practice extenders such as physician assistants or nurse practitioners?

The VA data could be easily manipulated. If access by a limited number of new patients is all that is being reported, there may be a tendency to underfund other areas. What about other specialty areas such as oncology, nephrology, pulmonary, neurology, general surgery, ENT, audiology, and ophthalmology to name just a few? What about established patients? What about financial incentives? Were the administrators given bonuses for improving access in these highly selected areas but none or less in others? This is the system the VA used during the wait times scandal and likely contributed to the falsification of data (6).

As it now stands the manuscript represents more advertising than medical science. Medical journals owe their readers better. Hopefully, we at the Southwest Journal are doing a better job of publishing articles that allows the practitioners to better care for their patients and not administrators make their bonus.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Penn M, Bhatnagar S, Kuy S, Lieberman S, Elnahal S, Clancy C, Shulkin D. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. 2019 Jan 4;2(1):e187096. [CrossRef] [PubMed]
2. Wagner D. Seven VA hospitals, one enduring mystery: What's really happening? The Arizona Republic. October 23, 2016. Available at: https://www.azcentral.com/story/news/local/arizona-investigations/2016/10/23/va-hospitals-veterans-health-care-quest-for-answers/90337096/ (accessed 1/25/19).
3. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/ (accessed 1/25/19).
4. Kaboli PJ, Fihn SD. Waiting for Care in Veterans Affairs Health Care Facilities and Elsewhere. JAMA Netw Open. 2019 Jan 4;2(1):e187079. [CrossRef] [PubMed]
5. Roemer MI, Hopkins CE, Carr L, Gartside F. Copayments for ambulatory care: penny-wise and pound-foolish. Med Care. 1975 Jun;13(6):457-66. [CrossRef] [PubMed]
6. Robbins RA. VA scandal widens. Southwest J Pulm Crit Care. 2014;8(5):288-9.

Cite as: Robbins RA. More medical science and less advertising. Southwest J Pulm Crit Care. 2019;18(1):29-30. doi: https://doi.org/10.13175/swjpcc005-19 PDF 

Cite as: Robbins RA

The Need for Improved ICU Severity Scoring

How do we know we’re doing a good job taking care of critically ill patients? This question is at the heart of the paper recently published in this journal by Raschke and colleagues (1). Currently, one key method we use to assess the quality of patient care is to calculate the ratio of observed to predicted hospital mortality, or the standardized mortality ratio (SMR). Predicted hospital mortality is estimated with prognostic indices that use patient data to approximate their severity of illness (2). Examples of these indices include the Acute Physiology and Chronic Health Evaluation (APACHE) score, the Simplified Acute Physiology Score (SAPS), the Mortality Prediction Model (MPM), the Multiple Organ Dysfunction Score (MODS), and the Sequential Organ Failure Assessment (SOFA) (3).

Raschke et al. (1) evaluated the performance of the APACHE IVa score in subgroups of ICU patients. APACHE is a severity-of-illness score initially created in the 1980s and subsequently updated in 2006 (4,5). This index was developed using data from 110,558 patients from 45 hospitals located throughout the United States, and encompassed 104 intensive care units (ICUs) including mixed medical-surgical, coronary, surgical, cardiothoracic, medical, neurologic, and trauma units. The final model used 142 variables including information from the patient’s medical history, the admission diagnosis, and physiologic data obtained during the first day of ICU admission (4). Although it subsequently has been validated using other large general ICU patient cohorts, its accuracy in subgroups of ICU patients is less clear (6).

To benchmark whether the APACHE IVa performed sufficiently, Raschke et al. (1) employed an interesting and logical strategy. They created a two-variable severity score (2VSS) to define a lower limit of acceptable performance.  As opposed to the 142 variables used in APACHE IVa, the 2VSS used only two variables: patient age and need for mechanical ventilation. They included 66,821 patients in their analysis, encompassing patients from a variety of ICUs located in the southwest United States. The APACHE IVa and 2VSS was calculated for all patients. Although the APACHE IVa outperformed the 2VSS in the general cohort of ICU patients, when patients were divided into subgroups based on admission diagnosis the APACHE IVa showed surprising deficiencies. In patients admitted for coronary artery bypass grafting (CABG), the APACHE IVa did no better in predicting mortality than the 2VSS. The ability of APACHE IVa to predict mortality was significantly reduced in patients admitted for gastrointestinal bleed, sepsis, and respiratory failure as compared to its ability to predict mortality in the general cohort (1).

The work by Raschke et al. (1) convincingly shows that APACHE IVa underperforms when evaluating outcomes in subgroups of patients. In some instances, it did no better than a metric that used only two input variables. But why does this matter? One might argue that the APACHE system was not created to function in this capacity. It was designed and validated using aggregate data. It was not designed to determine prognosis on individual-level patients, or even on subsets of patients. However, in real-world practice it is used to estimate performance in individual ICUs, which have unique cases mixes of patients that may not approximate the populations used to create and validate APACHE IVa. Indeed, other studies have shown that the APACHE IVa yields different performance assessments in different ICUs depending on varying case mixes (2).

So where do we go from here? The work by Raschke et al. (1) is helpful because it offers the 2VSS as an objective method of defining a lower limit of acceptable performance. In the future, more sophisticated and personalized tools will need to be developed to more accurately benchmark ICU quality and performance.  Interesting work is being done using local data to customize outcome prediction (7,8). Other researchers have employed machine learning techniques to iteratively improve predictive capabilities of outcome measures (9,10). As with many aspects of modern medicine, the complexity of severity scoring will likely increase as computational methods allow for increased personalization. Given the importance of accurately assessing quality of care, improving severity scoring will be critical to providing optimal patient care.

Sarah K. Medrek, MD

University of New Mexico

Albuquerque, NM USA

References

1. Raschke RA GR, Ramos KS, Fallon M, Curry SC. The explained variance and discriminant accuracy of APACHE IVa severity scoring in specific subgroups of ICU patients. Southwest J Pulm Crit Care. 2018;17:153-64. [CrossRef]
2. Kramer AA, Higgins TL, Zimmerman JE. Comparing observed and predicted mortality among ICUs using different prognostic systems: why do performance assessments differ? Crit Care Med. 2015;43:261-9. [CrossRef] [PubMed]
3. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;14:207. [CrossRef] [PubMed]
4. Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today's critically ill patients. Crit Care Med. 2006;34:1297-1310. [CrossRef] [PubMed]
5. Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL. Intensive care unit length of stay: Benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV. Crit Care Med. 2006;34:2517-29. [CrossRef] [PubMed]
6. Salluh JI, Soares M. ICU severity of illness scores: APACHE, SAPS and MPM. Curr Opin Crit Care. 2014;20:557-65. [CrossRef] [PubMed]
7. Lee J, Maslove DM. Customization of a Severity of Illness Score Using Local Electronic Medical Record Data. J Intensive Care Med. 2017;32:38-47. [CrossRef] [PubMed]
8. Lee J, Maslove DM, Dubin JA. Personalized mortality prediction driven by electronic medical data and a patient similarity metric. PLoS One. 2015;10:e0127428. [CrossRef] [PubMed]
9. Awad A, Bader-El-Den M, McNicholas J, Briggs J. Early hospital mortality prediction of intensive care unit patients using an ensemble learning approach. Int J Med Inform. 2017;108:185-95. [CrossRef] [PubMed]
10. Pirracchio R, Petersen ML, Carone M, Rigon MR, Chevret S, van der Laan MJ. Mortality prediction in intensive care units with the Super ICU Learner Algorithm (SICULA): a population-based study. Lancet Respir Med. 2015;3:42-52. [CrossRef] [PubMed]

Cite as: Medrek SK. The need for improved ICU severity scoring. Southwest J Pulm Crit Care. 2019;18:26-8. doi: https://doi.org/10.13175/swjpcc004-19 PDF

A Labor Day Warning

Today is Labor Day, a public holiday honoring the American labor movement and the contributions that workers have made to the strength, prosperity, laws, and well-being of the country. Though this holiday dates back to the end of the nineteenth century, the concept of organized labor is under increasing attack. While many of the physician and nurse readers may think that “labor” does not apply to them, after all they are professionals, management would likely disagree.

In Arizona v. Maricopa County Medical Society in 1982, the Supreme Court ruled that when physicians negotiate collectively with insurers about fees, and as a consequence do not compete with one another, such negotiations represent a horizontal agreement among competitors to fix prices (1). This was based on the concept of physicians being independent from hospitals or healthcare systems. However, more physicians are now hospital employed which has been in no small part due to cuts in physician compensation by Medicare with the insurers rapidly following. This increase in physician employment has been associated with increased billings leading to increased profits and decreased physician compensation (2,3).

The Nation’s largest healthcare system is the Department of Veterans Affairs (VA). The pace of VA hiring has not kept pace with the growth of patients leading to prolonged wait times first reported in Phoenix (4). Two recent decisions will likely affect physician hiring and retention at the VA. First, President Trump announced cancellation of the the planned salary increase for civilian employees (5). Second, VA Secretary Robert Wilkie, cancelled collective bargaining rights when it comes to professional conduct and patient care by VA providers (6). In the private sector, hospital employed physicians seem to becoming increasingly discontented because of 1. Having to deal with a lot of rules; 2. Having to deal with a large bureaucracy. 3. Not having a staff under their control; and 4. Having little control over compensation models (7).

All in all, this does not bode well for physicians or patients. The data suggest that the Medicare has helped destroy independently employed physicians while over compensating hospital employed physicians whose fees are collected by the hospital (7). This trend will likely continue until Medicare realizes that the existence of the independent practitioner keeps healthcare costs down. By financially squeezing the independent practitioner Medicare’s actions lead to decreased competition and increased healthcare costs.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Halper HR. Arizona v. Maricopa County: a stern antitrust warning to healthcare providers. Healthc Financ Manage. 1982 Oct;36(10):38-42. [PubMed]
2. Lowes R. Hospital-employed physicians cost Medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772#vp_1 (accessed 9/3/18).
3. Kane L. Medscape physician compensation report 2018. Medscape. April 11, 2018. Available at: https://www.medscape.com/slideshow/2018-compensation-overview-6009667#12 (accessed 9/3/18).
4. Davidson J. VA doctor shortage fueled by management issues, poor pay The Washington Post. July 16, 2018. Available at: https://www.washingtonpost.com/news/powerpost/wp/2018/07/16/va-doctor-shortage-fueled-by-management-issues-poor-pay/?utm_term=.070275d06e2a  (accessed 9/3/18).
5. Liptak K. Trump cancels pay raises for federal employees. CNN. August 31, 2018. Available at: https://www.cnn.com/2018/08/30/politics/trump-cancels-federal-employee-pay-raises/index.html (accessed 9/3/18).
6. Department of Veterans Affairs. VA secretary clarifies collective bargaining authority for patient care. August 29, 2018. Available at: https://www.managedhealthcareconnect.com/content/va-secretary-clarifies-collective-bargaining-authority-patient-care?hmpid=cmlja3JvYmJpbnNAY294Lm5ldA== (accessed 9/3/18).
7. Mertz GJ. Physicians employed by hospitals. Medscape. January 01, 2018. Available at: https://www.medscape.com/viewarticle/891120#vp_1 (accessed 9/3/18).
8. Lowes R. Hospital-employed physicians cost medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772 (accessed 9/3/18).

Cite as: Robbins RA. A labor day warning. Southwest J Pulm Crit Care. 2018;17(3):95-6. doi: https://doi.org/10.13175/swjpcc106-18 PDF