Merger Mania Redux: the Case of the Carilion Health Care System

The Wall Street Journal published an article on how one not-for-profit hospital system came to dominate its market, and the effects of that domination on local health care.

How the System Became Dominant

The WSJ article documented how a hospital merger created a vertically-integrated health care system. Note that in the old days of "merger mania," there was a lot of buzz in the health care research and policy circles about how creating such integrated systems to benefit quality and access, and lower costs. This rationale appears below.

In 1989, the U.S. Department of Justice tried but failed to prevent a merger between nonprofit Carilion Health System and this former railroad town's other hospital. The merger, it warned in an unsuccessful antitrust lawsuit, would create a monopoly over medical care in the area.

After the 1989 merger, Carilion continued to operate Roanoke's two hospitals separately. It later consolidated the hospital boards and in 2006, transferred most of Roanoke Community Hospital's staff and services to a renovated and enlarged Roanoke Memorial Hospital.

The moves eliminated any hospital competition in Roanoke proper....

[Carilion CEO Dr Murphy] was convinced that the cost and quality of care in Roanoke could be improved if doctors worked in a more centralized system. In June 2006, he announced a seven-year, $100 million plan to transform Carilion into a multispecialty clinic, like the Mayo Clinic.

Carilion began approaching private physician groups, offering to buy their practices and pay their salaries.

We shall see what effects CEO Dr Murphy's advocacy of more centralization had.

Effects on Costs

The domination by a single vertically integrated health care system apparently lead to rising costs.

Nearly two decades later, the cost of health care in the Roanoke Valley -- a region in southwestern Virginia with a population of 300,000 -- is soaring. Health-insurance rates in Roanoke have gone from being the lowest in the state to the highest.

That's partly a reflection of Carilion's prices. Carilion charges $4,727 for a colonoscopy, four to 10 times what a local endoscopy center charges for the procedure. Carilion bills $1,606 for a neck CT scan, compared with the $675 charged by a local imaging center.

Alan Bayse, founder of a local benefits-consulting firm who has sold health insurance in the area for 30 years, says health-insurance rates in the Roanoke Valley used to be 20% lower than in Richmond, Virginia's capital, and the lowest in the state. Today, he says, they are the highest in the state and 25% higher than in Richmond, citing rate information from insurer Cigna Corp. Anthem, another health insurer, says its rates are 6% higher in Roanoke than in Richmond.

Mr. Lionberger, whose construction company has about 100 employees, says his health-care costs have risen 50% over the past three years, hampering his ability to compete with contractors from other parts of the state.

While the increasing domination by the system been associated with increased health care insurance rates, its leadership has aggressively pursued patients who failed to pay their share of its exaggerated bills.

The Roanoke City General District Court devotes one morning a week to cases filed by Carilion. In its fiscal year ended Sept. 30, Carilion says it sued 9,888 patients, garnished the wages of 5,478 people and placed liens on 3,920 homes. Carilion says the people it takes to court have the means to pay their bills.

When some patients don't pay their bills, Carilion places liens on their homes. Carilion says it doesn't track how many liens it has outstanding, but the close to 4,000 it filed in 2007 'is representative of a typical year,' Mr. Earnhart says. Carilion doesn't foreclose on homes and only collects when properties are sold, he says.

Dr. Murphy says Carilion only sues patients and places liens on their homes if it believes they have the ability to pay. 'If you're asking me if it's right in a right-and-wrong sense, it's not,' he says. But Carilion can't be blamed for the country's 'broken' health-care system, he says.

Ah, yes, the "broken" health care system made me do it, says CEO Dr Murphy.

Decreasing Access

One effect of the merger seems to be a squeeze on physicians who are not part of the integrated system, which presumably will decrease, not improve access to health care.

Some doctors who chose to remain independent say the number of patients referred to them by Carilion physicians plummeted. Carilion controls a large proportion of Roanoke's referrals because it employs a majority of doctors who make them, such as family practitioners, pediatricians and emergency physicians.

Joseph Alhadeff, an orthopedic surgeon who is a member of a private practice called Roanoke Orthopedic Center, says the number of joint replacements he performed dropped off sharply after he stopped getting such referrals from Carilion doctors, prompting him to plan to relocate to Pennsylvania. 'I spent seven years building up a practice and watched it evaporate in six months,' he says.

In fact, it appears that the integrated system was out to decrease the business of physicians not in the system.

Geoffrey Harter, an ear, nose and throat doctor at another Roanoke private practice, Jefferson Surgical Clinic, says Carilion-employed colleagues told him the hospital system asked them not to refer patients to doctors it didn't employ, calling such referrals 'leakage.' Keeping referrals within Carilion is lucrative for the hospital system because it ensures tests and procedures performed on patients take place at Carilion facilities.

Dr. Murphy says Carilion uses the term 'leakage' in internal marketing discussions and that he would rather see its doctors refer patients to other Carilion doctors to optimize their care. But he says Carilion doesn't require its doctors to keep referrals in-house even though it would be legal to do so.

Meanwhile, as the integrated system grew more powerful, its leadership appeared to use other tactics that have become all too familiar to readers of Health Care Renewal

Silencing Criticism

As tension between Carilion and Roanoke's independent doctors grew in 2006, a group of 200 doctors formed an organization called the Coalition for Responsible Healthcare to protest the Carilion Clinic plan. The group posted a petition on its Web site and put up billboards around Roanoke that read: 'Carilion Clinic. Big Dream. Big Questions.' The local newspaper, the Roanoke Times, covered the controversy in a series of articles written by its health-care reporter, Jeff Sturgeon.

A few months later, in March 2007, the Roanoke Times moved Mr. Sturgeon off the health-care beat after Carilion complained repeatedly about his coverage. Carilion says it communicated its displeasure to the paper's editors, but never asked that Mr. Sturgeon be reassigned. Carilion withdrew most of its advertising from the paper, but says it did that as part of a reallocation of its ad budget.

Follow the Money

As the system became more dominant, and more profitable, more money accrued to its top leaders, particularly, of course, its current and former CEOs.

In 2001, Dr. Murphy took the nonprofit hospital system's helm. Dr. Murphy, ... has a medical degree from Harvard but doesn't practice medicine....

Fueled by large, untaxed investment gains, Carilion's profits have risen over the past five years, reaching $107 million last year. Over the same period, the total annual compensation of its chief executive, Dr. Murphy, nearly tripled to $2.07 million. His predecessor, Thomas Robertson, received a lump-sum pension from Carilion of $7.4 million in 2003, on top of more than $2 million in previous pension payouts.

Carilion says Dr. Murphy's compensation is in line with comparable health-care organizations and notes he doesn't receive car allowances, a spousal allowance or club memberships. It says Mr. Robertson's pension accrued over a 32-year career at Carilion.

Members of Carilion's board of directors also seemingly profited from their relationship with the hospital system. The WSJ documented some major financial relationships among the hospital and companies in which board members had an interest.

A large part of the clinic conversion's costs have involved the construction of a new medical campus around Roanoke Memorial Hospital that began several years earlier.

The lead contractor building the site is Swedish construction giant Skanska. But one of the project's biggest beneficiaries has been J.M. Turner & Co., which is owned by Carilion board member Jay Turner. Carilion says it paid J.M. Turner a total of $14.9 million in direct contracting work from 2004 to 2007.

Dr. Murphy says Carilion's board authorized 'arm's length work' with J.M. Turner, but adds that "a case could be made that we shouldn't award work to J.M. Turner to avoid the appearance of impropriety."

Mr. Turner isn't the only Carilion board member with a financial stake in the new medical campus. Another board member, Warner Dalhouse, has invested in a hotel being built on the campus to accommodate patients and their families. HomeTown Bank, a local bank Mr. Dalhouse founded and of which he was until recently chairman, is financing the hotel's construction. Dr. Murphy and Mr. Turner sit on HomeTown Bank's board.

Carilion and Mr. Dalhouse say he didn't make his $130,000 investment in the hotel until after Carilion sold the parcel to Texas developers in early 2006. 'I wasn't dealing with Carilion. I was dealing with the new owners of that land who had paid fair market value for it,' Mr. Dalhouse says.

Management versus Mission

The Carilion Health System's statement of mission and vision are as follows

Mission Statement

Carilion Health System exists to improve the health of the communities it serves.

Vision

- Assure accessible, affordable, high quality healthcare that meets the needs of the community
- Motivate and educate individuals to improve their health
- Champion community initiatives to reduce health risk

Yet, the investigative reporting by the WSJ has shown how the increasing domination of local health care by the Carilion Health System has made health care less accessible and less affordable, despite its leaders' proclamations to the contrary. It has "educated" the local newspaper to reduce its critical coverage of the system's activities. Thus, the bigger and more dominant the health care organization, the more mission-hostile its leadership is likely to be. Meanwhile, increasingly mission-hostile leadership tends to become increasingly lucrative for its practitioners.

I submit that if we really want better quality, more accessible, more reasonably priced health care, we need to bust the new health care "trusts." We need smaller health care organizations with ethical leadership truly devoted to the health care mission. We need organizations whose governance is representative of key constituencies; accountable to patients, health care professionals, and the public at large; open and transparent; and which upholds clear ethical principles.

Post Title → Merger Mania Redux: the Case of the Carilion Health Care System

Health Wonk Review, Health Care Renewal Style

Welcome to Health Care Renewal. Health Care Renewal was the product of brain-storming by some physicians and health care researchers who wondered why as health care costs inexorably rose, access decreased, and quality remained stagnant. With health care reform again looming, no one seemed to be able to explain this, much less have any solutions.

We found we all knew stories that suggested systemic problems with health care that provided some explanations, but seemed rarely to be discussed in polite conversation.

Basically, the problems arose from concentration and abuse of power. As health care organizations grew ever larger and more powerful, their governance became more unrepresentative of their constituencies, secretive and opaque, unaccountable, and unethical and amoral.

Resulting practices were marked by conflicts of interest, deception and dishonesty, intimidation and coercion, and sometimes outright corruption, bribery, fraud, and other criminal behavior.

Although many physicians knew of local examples of these issues, and some cases had been described in the local news media, they produced few echos. In particular, discussion of them in academia and the medical and health care and policy literature seemed taboo. We called this the "anechoic effect."

The mission of Health Care Renewal is to discuss these problems, end the anechoic effect, and help find solutions. We present this edition of Health Wonk Review in this spirit, and with an organizational framework derived from the discussion above. We feature submissions by many HWR regulars, but also note posts in many of the newer blogs that too are concerned with the dark side of health care.

Health Care Reform and Policy in General

On the Health Care Policy and Marketplace Review, Bob Laszewski noted the lack of differences among the health care reform proposals of the current US candidates for the presidency, suggesting "that you not cast your caucus or primary vote for a candidate based upon their health care reform plan because from 'thirty thousand feet' there isn't all that much difference" among them.

Governance

On Health Care Renewal, we have posted frequently on payments made by medical device companies to physicians and health care organizations. Of particular interest is the money that companies who make to artificial joints have been giving to the major national orthopedic associations and to some of their leaders, raising questions of whose interests these organizations really care about. (See posts here and here.) A recurring theme on Health Care Renewal is the pervasiveness of conflicts of interest that raise questions about whom health care professionals really work for, and what interests health care organizations really serve.

Practices

On the Canadian Medicine blog, Sam Solomon addressed the controversy about Canadian physicians' new practice of outsourcing their billing for uninsured services, and its implications for patient privacy.

On the Health Beat Blog, Maggie Mahar pointed out how Wall Street seems not to care about the ethics of health care corporations, "the Street doesn’t care about the ethics of what the company is doing; investors care about whether or not the company is making a profit." But, "meanwhile, both companies and individuals in our for-profit health care industry continue to engage in criminal activities."

Zagreus Ammon on the Physician Executive blog presented his "hyper realist" take on the Avandia controversy. Forgive me if I fear this "hyper realism" shades into the cynicism. For example, he asserted, "pharmaceutical companies insist on controlling and potentially suppressing clinical information about the drugs they wish to sell. This is natural and indignation is laughable." It may be natural, but it can harm patients by depriving them and their physicians of the accurate evidence they need to make decisions. It is also an ethical affront to the patients who participate in clinical research thinking they were taking part to advance science and patient care. For the latest Health Care Renewal discussion of the Avandia case, go here.

On the other hand, Dr Aubrey Blumsohn on the Scientific Misconduct Blog analyzed the shenanigans now going on in the analysis and reporting of the ENHANCE trial of ezetimibe (Zetia, and an active ingredient in Vytorin). Further commentary on this issue can be found in the Hooked: Ethics, Medicine and Pharma blog by Dr Howard Brody, and in the Medical Evidence Blog by Dr Scott Aberegg. This is just the latest of many examples of how health care corporations who "sponsor" clinical research may try to make sure the results favor their products.

A graphic example of the sorts of people some pharmaceutical companies hire to perform clinical research appears on the Clinical Psychology and Psychiatry blog. Warning, it includes how a pharma-sponsored physician researcher managed to personally give two of his patients genital herpes simplex infections.

Dr Daniel Carlat on the Carlat Psychiatry Blog reprised (here and here) his New York Times Magazine article on his brief career as a part-time paid pharmaceutical company lecturer. The article provided a vivid narrative showing the ethical challenges of one pharmaceutical company's stealth marketing practices. See also comments on Dr Carlat's article on the Health Care Organizational Ethics blog.

Cost

Dr Adam J Fein at Drug Channels examined "how the upcoming disappearance of Average Wholesale Prices (AWP) will affect Pharmacy Benefit Managers (PBMs). He argues that PBMs should not be materially impacted by a shift in the drug pricing benchmark from AWP, especially as private payors start using the new CMS benchmark called Average Manufacturer Price."

Jason Shafrin on the Health Care Economist blog analyzed the reasonableness of expecting physicians to compete on the price of procedures. He noted that this may work for very routine, low risk procedures, but may not make sense in more complex situations in which outcomes are unpredictable.

Rob Cunningham on the Health Affairs Blog reported that "Congressional Budget Office Director Peter Orszag warns that policymakers have 'misdiagnosed' the biggest problem facing both Medicare and the health economy in general by overstating the projected impact of population aging and the impending retirement of the baby boom."

On GoozNews, Merrill Goozner provided an example of how expensive procedures are hyped, while the shortcomings of the evidence supporting the procedures, and the conflicts of interest of the hypers are buried.

The next three posts related to the seeming irrationality of how government agencies pay for procedures versus "cognitive" services.

David Harlow at HealthBlawg noted that the "CMS efficiency and effectiveness machinery turns its attention (again) to diagnostic imaging, field-testing four measures which will eventually be used in denials," and "asked what about bringing the same brains and brawn to bear on the CMS approach to physician compensation generally, rather than on one piece of ancillary income?"

Henry Stern at the InsureBlog wrote "One criticism of nationalized health care is that care may be rationed. But what about paying for procedures with no health benefits at all? InsureBlog's Henry Stern has the story of how one system pays for elective hymen-replacement surgery."

Jon Coppelman at the Workers' Comp Insider blog looked "at the pending Full Parity for Mental Illnesses bill that is before Congress, and explains why it is unlikely we will see parity for occupational injuries and illnesses any time soon."

Some insights on why US government reimbursement is so seemingly irrational and inexplicable come from this post on DB's Medical Rants. The anonymous DB reminds us that all US Medicare physician reimbursement is heavily influenced by a secretive AMA committee called the RBRVS Update Committee (RUC), whose membership is not public, but seems to be dominated by proceduralist physicians. Similarly, James Gaulte on the Retired Doc's Thoughts blog explained how the RUC undermined the rationale for setting up the RBRVS (Resource Based Relative Value System) in the first place, to more equitably reimburse primary care and "cognitive" services.

On the Covert Rationing Blog, DrRich wondered if a lawsuit trying to void Medicare's irrational physician reimbursement could succeed.

On the other hand, David Williams at the Health Business Blog addressed how the US government funds, or does not fund, small health care businesses. He interviewed "BIO's Alan Eisenberg re: SBIR grant eligibility for majority-VC [venture capital] backed companies, [letting] ... Eisenberg tell BIO's side of the story."

One post addressed the weirdness that seems to infect normal people when they try to write about health care costs. On the Health Beat Blog, Maggie Mahar critiqued the "muddle" that a New York Times editorial produced when it addressed health care costs, weaving "truth and error together in such a way that it would take a knitting needle to separate the two." and finally collapsing "into a confusion of contradictory clichés." Unfortunately, the same could be said about a lot that is written about health care policy, particularly the cost side, (but not by our HWR bloggers).

Quality

Loraine Lawson on the Good Ideas That Work blog asked, "Want to know how to curtail the spread of AIDS? Ask Brazil, where, in the early 1990s, health authorities feared the epidemic could 'grow out of control' (whatever that means). According to Reuters, new AIDS cases in Brazil fell to 17.5 per 100,000 people, which is down considerably from the 22.2 per 100,000 recorded in 2002."

Access

Ian Walsh at the Agonist blog observed that problems with health care access may arise because those who make health care policy, for example, the US Congress, have a special deal on health coverage that mean they do not have to struggle with the problems ordinary citizens face, "the fact that they live in a privileged bubble and that the reason they don't even try to fix the problems of ordinary Americans is because they don't share them."

On the Managed Care Matters blog, Joe Paduda examined how US universal coverage plans could deal with illegal immigrants, but noted that meanwhile, Mexico may come up with a universal coverage system before the US does.

Louise Norris on the Colorado Health Insurance Insider blog discussed obstacles to mandatory health insurance, noting the need to trim costs, starting with amazingly well paid hospital and managed care CEOs.

Anthony Wright on the Health Access WeBlog reviewed "two articles on the SCHIP fight, California’s pending decision as a result to disenroll kids from coverage, and why the problem is both worse than we think (violating 10 years of outreach and trust) and better (there’s a certain political resolution)."

Thanks again for visiting Health Care Renewal and perusing the Health Wonk Review. The Health Wonk Review web-site is here. Also, see our side-bar for a nearly complete listing of previous Health Wonk Review editions.

Post Title → Health Wonk Review, Health Care Renewal Style

BLOGSCAN - Review of Fixing American Healthcare

On the Health Business Blog, this post by David Williams favorably reviews the just published book by Richard N. Fogoros, Fixing American Healthcare; Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare. Fogoros blogs on the Covert Rationing Blog.

Post Title → BLOGSCAN - Review of Fixing American Healthcare

Health Wonk Review Hosted This Week on Health Care Renewal

Welcome to Health Care Renewal. We are a multi-author blog which focuses on external threats to health care's core values, especially those due to concentration and abuse of power. Please feel free to browse our main page and archives.

We are proud to host this edition of the Health Wonk Review.

[Addendum 1/11/2007 - Please note - the original version of this post had several weirdly scrambled links. Also, the version put up by Google seemed to have entirely lost one of my citations. In some cases, the link appeared correct in HTML, but was scrambled in the posted version. I have tried to fix all of these problems. If anyone notices any more bad links, please email me a rposes at firmfound dot org. I also added two more citations, one whose submission was lost in the spam filter. Sorry about all that and thanks for the corrections.]

Access and Insurance

On the old version of the Health Business blog, David Williams argued that the rich are not given exceptional health care.

And on the new Health Business blog site, David Williams wondered what the very long wait currently required to see a dermatologist in Boston has to say about the usual arguments (long queues in Canada) against a single-payer health insurance system.

Mike Feehan, on InsureBlog, suggested that the rising prevalence of uninsured patients is an indictment of Medicaid, the US state-federal health care system designed for people who can't afford health insurance.

Jason Shafrin, on the Healthcare Economist blog, reviewed Governor Schwarznegger’s plans for universal health insurance in California, and wondered if they will save costs.

Joe Paduda, on Managed Care Matters, suggested that health care economics is of the “supply-side” variety.

Jon Coppelman, on the Workers’ Comp Insider blog, discussed why health care provided under workers’ compensation insurance costs so much.

Leif Wellington Haase from the Century Foundation , suggested why the idea of universal health insurance may be becoming more appealing today.

James Gaulte, on the Retired Doc’s Thoughts blog , noted the disparity between how rigorously the US Federal Trade Commission (FTC) enforces anti-trust regulation to prevent even small groups of physicians from talking about fees, but ignores how a few large health care organizations, such as hospitals or insurers, may dominate local or regional markets.

And regarding the power of a few large insurers, Graham, on the Over My Med Body blog , described the many reasons California insurers find not to write individual policies for individuals with often trivial diseases, or with “dangerous” jobs.

Matthew Holt, on the Health Care Blog, stirred up some controversy by suggesting that the amount spent on the late US President Ford's medical near the end of his life was inappropriate.

Health Care Management

Marcus Newberry, on the Fixin’ Healthcare blog , suggested that as long as health care is a business focusing on disease, things will not improve.

Information Technology

Shahid Shah, on the Healthcare IT Guy blog, had an invitation for health care bloggers to meet in person at the HIMSS '07 conference in New Orleans.

Pharmaceuticals and Biotechnology

Erik Turkewitz, on the New York Personal Injury Law Blog, had an update on counterfeit drugs.

HS Ayoub, on the BioHealth Investor blog, chronicled the tale of a former drug “pirate” in India which is now going into the international generic drug business.

Paul Howard, on Medical Progress Today, argued that, based on the European example, direct negotiation of drug prices by the US government would stifle innovation.

On the other hand, David Harlow, on the HealthBlawg, suggested points in favor of Medicare negotiating drug prices.

Adam Fein, on the Drug Channels Blog, discussed implications of the Cardinal Health settlement and the issue of counterfeit drugs.

Fard Johnmar, on the Envisioning 2.0 blog , discussed differences in how consumers and pharmaceutical company executives view the industry. He saw pharmaceutical executives as mainly well meaning, but having to cope with an onslaught of negative publicity about the industry. Readers should peruse some of the stories about some of the leadership of the biotechnology and pharmaceutical industry on Health Care Renewal, and think about just how well-meaning they have been, and whether some of the bad publicity was not deserved.

In that vein, Merrill Goozner, on GoozNews blog , noted how the world’s most famous medical journal “de-fanged” an article about conflicts of interest affecting guideline development, in this case, how one large biotechnology company helped to fund the development of guidelines that, surprise, suggested aggressive use of one of its expensive products.

DB, on DB's Medical Rants, discussed the pheonomenon of "too many diagnoses," otherwise know as disease mongering.

“Jack Friday,” on the PharmaGossip blog , announced the debut of the PharmedOut web-site, devoted to teaching physicians more about misleading practices used to market pharmaceuticals.

The Clinical Psychology and Psychiatry blog , commented on how at least one academic physician who worked on trials sponsored by a pharmaceutical company was willing to admit he withheld data from the trial that was unfavorable to its sponsor, and advocated that “industry and academia need to get out of their shared bed.”

Finally, Aubrey Blumsohn, on the Scientific Misconduct blog, chronicled his continuing efforts to get the original data from a drug study for which he was the principal investigator, yet which was withheld by the study's sponsor. This case, which is not well known outside of the UK, is a chilling reminder of how the supposed sponsors of drug trials may try to influence clinical science.

Quality and Safety

On the Antidote: Counterspin for Health Care and Health News blog, Emily DeVoto reviewed recent evidence that the sort of health care quality measures often proposed for pay-for-performance systems for doctors do not seem to correlate very well with some important clinical outcomes.

Rita Schwab, on the MSSP Nexus blog, argued that interviewing physicians for medical staff positions involves medical safety issues.

Summary

We have been delighted to be able to showcase some of the lively discussion of health care policy going on in the blogsphere. We hope it has provided food for thought.

Post Title → Health Wonk Review Hosted This Week on Health Care Renewal

Poverty Amidst Plenty

In my local paper, the Providence Journal, was this story about the now annual winter event, the hospital capacity crunch. With even a small and routine uptick in influenza and respiratory illnesses, local hospital emergency departments overflow, and patients wind up in every corner. Everyone seems bewildered by this, although the article notes that the new leaner hospitals run an 90% capacity, so any increase in demand overwhelms them. Furthermore, it seems impossible for hospitals to get enough nurses, although no one seems to care to think about why.
Similarly, in Houston, a story from the Chronicle about how the new Texas law designed to make mental health care more efficient has resulted in long waiting lists for anyone not overtly psychotic, and an apparent dearth of chronic care.
At the same time, the Chronicle reported how the latest trend in Houston general hospitals is patient amenities. It described, for example, the University of Texas M.D. Anderson's new Ambulatory Clinical Building, "with its commissioned artwork, hotel-like lobby, waiting rooms with wireless internet access and garden terraces."
So we have poverty amidst plenty. In the US, where health care costs increase annually much more than the inflation rate, where we spend more than $1.5 trillion on health care, we cannot provide enough emergency room and hospital capacity for the predictable acute respiratory illness surge in winter. In one city, the wait for an out-patient mental health care appointment for the poor is 3 1/2 months, but a state-supported hospital now displays commissioned artwork and provides wireless internet access? What does this say about the values of our health care leaders?

Post Title → Poverty Amidst Plenty