South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

The West Virginia Record had an article explaining why a resident's family sued the nursing home that neglected her and the parent company that controlled the budget, staffing, and equipment used at the facility.  

The article states that the woman died from injuries sustained in a Dunbar nursing home seeking compensatory and punitive damages. The suit is against Sunbridge Care and Rehab and the Sun Healthcare Group, Inc.

McCarty was admitted to Sunbridge Care and Rehab at the age of 79. Upon her admission, McCarthy suffered from dementia and could no longer handle her affairs. Her cognitive and physical skills were impaired. She died as a result of the injuries she sustained in a fall at the facility.

Among the injuries she sustained while at the nursing home were falls, weight loss, dehydration, malnutrition, constipation, a perforated bowel, infections, and ultimately, her death.  She suffered injuries, disfigurement, extreme pain, suffering, and mental anguish.

"The scope and severity of the recurrent wrongs inflicted upon Ferris McCarthy while under the care of the facility accelerated the deterioration of her health and physical condition beyond that caused by the normal aging process and resulted in physical and emotional trauma," the suit says.

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The Wall St. Journal had an article recently that made me think about the future of helath care when the baby boomers enter the nursing home industry.  Will there be a revolution in health care?  Will for profit chains dictate how the old and frail among us will conclude their lives? 

A nursing home in California wants to evict Jasmine Nguyen, a 32-year-old dependent on a ventilator to breathe and the facility's staff for her daily needs, and a dozen other residents in similar situations replacing them with short-term residents that bring more profit.

Across the country, nursing homes are forcing out frail and ill residents. While federal law permits nursing-home evictions in some circumstances, state officials and patient advocates say facilities often go too far, seeking to evict those who are merely inconvenient or too costly. Residents with dementia or demanding families are among the most vulnerable, particularly if -- like Ms. Nguyen and the other Lodi residents -- they depend on Medicaid to pay their bills, the officials and advocates say.

Assisted-living facilities have sprung up as alternatives for those who don't require nursing-home care but need assistance with things like taking medications or bathing and dressing. Each state regulates the industry differently, so eviction policies vary. But many states simply require facilities to give four- to six-weeks' notice, with no appeal guaranteed.

In Florida, for example, the state's 2,400 assisted-living facilities must give residents 45 days' notice before evicting them, but don't need to provide a reason or appeal process. 

No national figures on assisted-living evictions exist, but discharge-related complaints recorded by the federal Administration on Aging more than doubled in the decade before 2006, rising 177% -- nearly twice the growth for complaints overall.  Some attorneys are turning to federal fair-housing rules and the Americans with Disabilities Act to help assisted-living residents stay in their homes. They argue that those laws require all landlords, including assisted-living companies, to make reasonable accommodations for disabled residents, and prohibit them from evicting residents because their condition worsens.

And evictions may be even more widespread, since some eviction attempts are resolved without formal complaints. Residents may not know they can appeal or may be too ill to do so or fear retribution.  Federal law -- enforced by the states -- says residents can be discharged involuntarily for just six reasons: if they are well enough to go home; need care only available elsewhere; endanger the health of others; endanger the safety of others; fail to pay their bills; or if a facility closes its doors. Even so, nursing homes must give residents at least 30 days' notice, explain their appeal rights, and put together a plan to make sure the move doesn't harm them.

Even an orderly eviction can carry grave risks for the old and ill. Studies suggest "transfer trauma," or relocation-stress syndrome, can spur depression and weight loss and increase the risk of falls.

For example, the nursing home trying to evict Jasmine Nguyen, Lodi Memorial Hospital, told her and a dozen others that they would have to move by June 30 because the nonprofit organization was closing the facility -- for renovations.  All 13 residents were "sub-acute" patients, most of them dependent on ventilators or feeding tubes, or with other conditions requiring significant extra care.

Lodi Memorial told the state it planned to replace them with patients recently discharged from its hospital -- who typically require shorter-term care covered at a higher daily rate by private insurance or by Medicare. (Medicare pays for up to 100 days in a nursing home following a hospital stay of at least three days.)

In April, after Lodi Memorial sought state approval, administrators were told that they knew when accepting the sub-acute residents that they would need extensive care, probably for many years, and it couldn't simply stop. Moreover, the state said in a letter, "your facility is not ceasing to operate as you are not surrendering your license."

The nearest nursing home certified to care for patients like Ms. Nguyen is about two hours away with traffic, says Jasmine's 23-year-old sister, Mary. Their mother, Kim Nguyen, who runs the family nail salon in nearby Stockton, visits Jasmine twice a day.

 

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NHC Acquires Charleston, SC Facilities

National HealthCare Corporation (AMEX:NHC)(AMEX:NHC.PR.A), one of the nation’s leading operators of senior care services, announced today that it has added Trinity Mission Health and Rehabilitation of Charleston and Trinity Mission Assisted Living of Charleston in Charleston, South Carolina as affiliates effective August 1. NHC purchased the 132-bed skilled nursing and rehabilitation facility and the 60-bed assisted living facility for $13.25 million.

This acquisition increases NHC’s operations that are owned and managed in the South Carolina region to over 2,000 beds in 13 locations. The administrator for the new facilities, now renamed NHC HealthCare-Charleston and NHC Place-Charleston, is Angela Atkinson. Ms. Atkinson, previously with Trinity Mission of Charleston, joins NHC with 15 years of experience in healthcare administration, including licensure as both an assisted living and nursing home administrator.

“The superior quality of NHC’s services to the senior care community in the state of South Carolina is well known,” Steve Flatt NHC’s Senior Vice President of Development said. “While we have been a strong provider in the Upstate and Midland region for over 30 years, this additional location allows us to better serve the Low Country area as well. We are grateful for the help and cooperation of the staff of the center in making this a smooth transition.”

NHC has plans for more growth in the Low Country of South Carolina as construction is expected to start next month on a 120-bed skilled healthcare and rehabilitation center in Bluffton near Hilton Head Island.

NHC operates for itself and third parties 76 long-term health care centers with 9,772 beds. NHC also operates 32 homecare programs, seven independent living centers and 23 assisted living communities. NHC’s other services include managed care specialty medical units, Alzheimer’s units, hospice and a rehabilitation services company. Additional information about NHC, including the company’s Form 10-K, Form 10-Q, annual report and press releases, is available on our website at www.NHCcare.com.

Statements in this press release that are not historical facts are forward-looking statements. NHC cautions investors that any forward-looking statements made involve risks and uncertainties and are not guarantees of future performance. All forward-looking statements represent NHC’s best judgment as of the date of this release.

Contacts
National HealthCare Corporation
Gerald Coggin, Sr. V.P. Investor Relations, 615-890-2020

 

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Interesting article from the Courant.com about a deal to sell the bankrupt Haven Healthcare nursing-home chain.  Attorney General Richard Blumenthal said that Formation Capital, which owns Genesis HealthCare, notified the state that it was pulling out of an $85 million deal to take over 14 of Haven's homes in Connecticut and 10 in other New England states, without giving a reason.

Formation announced June 12 that it had signed a purchase agreement for the homes, but the company had two weeks to reconsider before the deal was to be finalized in bankruptcy court Thursday.

Many nursing homes across the country are owned by real-estate investment firms and managed by other entities — a form of ownership called a REIT, or a real-estate investment trust. By law, a REIT cannot operate a nursing home, but must hire a licensed provider to do so.

"The former management of Haven is history. We are all committed to a new day for these nursing homes, their residents and their dedicated employees," Blumenthal said.

Blumenthal and officials of the state Department of Social Services said they and the health department will be closely monitoring operations of the Haven homes while the future of the chain remains in limbo.   Occupancy in some Haven homes has fallen off dramatically since the chain declared bankruptcy seven months ago.

Haven — one of the largest chains in the state, with more than 1,800 beds — declared bankruptcy last November in the wake of a series in The Courant detailing its financial troubles and repeated citations for patient-care deficiencies. The company defaulted on millions of dollars in bills for supplies and utilities while its CEO used corporate assets to launch a Nashville recording company and make other personal purchases.

The Department of Social Services had offered Genesis sizable Medicaid rate increases and other incentives to take over the chain, but also had required that Genesis agree to provide detailed financial reports and meet certain staffing standards once it took over operations. 

Blumenthal said Thursday that a wide-ranging investigation of Haven's financial dealings will continue, regardless of the outcome of the sale of the chain.

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Connecticut Attorney General Richard Blumenthal wrote an editorial about the nursing home industry.  We have included it below.

 Recent revelations of shameless self-dealing, massive mismanagement and substandard care at one of the state's largest nursing home chains, Haven Healthcare, have rightly shocked the public. Haven, which operates 15 nursing homes in the state, received tens of millions in taxpayer dollars, but often failed to pay its medical and other suppliers, even at times its utility bills.

When it came to patient care, managers constantly cut corners, endangering residents' health and well-being. Adding insult to injury, Haven CEO Ray Termini improperly diverted money to fund his fantasy of becoming a country music mogul. Termini's name for his failed label — Category Five —proved prescient: His mismanagement devastated Haven like a Category 5 hurricane.

After The Courant broke this story, causing Haven to seek bankruptcy protection, my office successfully sought appointment of a chief restructuring officer who is currently supervising the chain's operations until a responsible buyer is found and a patient care officer has stabilized and improved care at the facilities. This remedy required a Herculean legal battle, which took tremendous time and determination from my office, as well as the court. In addition to wasting state tax dollars and endangering residents, this abysmal episode exposed severe deficiencies in state oversight of nursing homes.

Haven's secret self-serving diversion of scarce resources exemplifies the dark side of nursing home consolidation, leading to a fiscal debacle and endangering patient well-being. As nursing homes are swallowed by corporate chains and conglomerates such as Haven, state supervision becomes more difficult. Byzantine corporate constellations — like the 45 interlocking entities established by Haven's owners — conceal and confuse, frustrating accountability and oversight. Such improper practices must be prevented, not just punished.

The state must demand more financial disclosure and transparency to prevent plunder of nursing home assets. To forestall future bankruptcies or insolvencies — as happened to Haven — the state should impose expanded auditing and reporting requirements, prohibitions on bleeding or abuse of resources, accountability of landlords and other measures that safeguard public dollars and cents — the lifeblood of patient care.

Symptoms of fiscal crisis should immediately land nursing homes on a watch list with the same stringent monitoring and scrutiny as a patient in intensive care, and with prompt state intervention when necessary. I have proposed a package of reforms to guard against abuses, better protect patients and ensure that state tax dollars are properly spent.

My proposals include:

 • Empower the state comptroller to monitor and review nursing home finances through regular forensic financial audits of nursing homes and their owners. The comptroller could subpoena records, compel testimony and review financial information of nursing home operators and their affiliates.

 • Provide for a court-appointed receiver upon a finding of gross financial mismanagement. Currently, a receiver may only be appointed if financial mismanagement threatens patient care — a higher bar that hindered our ability to obtain a receiver for Haven sooner.    

 • Cap management fees and rental payments that nursing homes pay to related entities at the amount allowed under Medicaid reimbursement rates and prohibit use of nursing home assets as collateral for loans unrelated to operations. This step will prevent nursing home affiliates from soaking taxpayers through sweetheart contracts with related management or landlord companies.

• Require a minimum level of malpractice and liability insurance coverage for nursing home owners and management companies.                 

• Clarify and strengthen the state Department of Public Health's authority to regulate and approve nursing ownership structures and agreements. As happened with Haven, nursing home operators too often disperse ownership among numerous limited liability corporations, affiliates, subsidiaries and wholly owned partnerships — hindering efforts to identify, evaluate and hold accountable a home's real owner.

 • Make landlords legally responsible for nursing home repairs and maintenance. The health department should also be authorized to seek appointment of a building monitor to do repairs and divert rent to pay for the work if the home's owner fails or refuses to do it.

Massive nursing home conglomerates like Haven Healthcare are leaving mountains of financial ruin after squandering massive public funding, imperiling patient care and safety. The regulatory landscape of nursing homes in Connecticut must be reformed to halt these abuses.

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Clark Kauffman, staff writer for DesMoines Register wrote the following review of recent nursing home fines in Iowa.

Clearview Home, Mount Ayr:
A nurse aide was improperly transferring a resident who had a long-standing, serious head injury when the two lost their balance and the resident fell face-first to the floor. The resident was treated at a hospital for broken teeth and facial lacerations, then returned to the home. The resident died the next day. The home was fined $10,000.

Denison Care Center, Denison:
A resident was injured while being transferred, suffering spiral fractures in both legs, but was not taken to a hospital for three days. At the time of the accident, the resident told workers, "You broke my leg." The resident died at the hospital. A physician concluded the accident and injuries were the cause of the resident's death. The home was fined $10,000.

Eldora Nursing Home, Eldora:
A resident with a history of respiratory problems was found dead on a floor one morning. Employees said they had not checked on the man for at least nine hours, even though the resident was to have been checked every two hours. The home was fined $10,000 for failing to provide a safe environment. Three months later, the home was fined $300 for the same type of violation. In that instance, a resident had been physically attacking and threatening other residents for several months. Five months later, the home was again cited for failing to provide a safe environment.

The Manor, Malvern:
A physician was to be contacted if a resident with end-stage liver disease became drowsy or lethargic. Nurses documented that the resident was "noticeably lethargic" and napping in the lobby, but they did not contact the doctor. A nurse allegedly told a concerned co-worker that the resident was "going to die anyway." Several hours later, an employee noted that the resident was still in the lobby and was dead. A doctor told inspectors the resident might have lived had he been contacted. The home was fined $10,000.

New Homestead Care Center, Guthrie Center:
Six workers reported to managers and supervisors that a male employee had committed multiple acts of abuse and neglect against residents. Managers did not act on those concerns, which allowed the abuse to continue. In one instance, the man allegedly put a chair against the door of a female resident's room while he was inside. Another worker forced her way in and saw the employee bent over the mentally disabled resident, who was partially undressed and bleeding from her vagina. The man turned his back on the other worker and claimed he was cleaning the resident, but he had no washcloths, towels or other supplies. The home was fined $7,000. Eleven months later, inspectors returned to the home and filed a 64-page report of violations.

Park Place, Glenwood:
Four workers noted that a mentally retarded female resident was moaning and groaning in pain one night after having refused food and medication for days. The workers repeatedly asked the nurse on duty to check on the woman, expressing concern that the woman was dying and in serious pain. The nurse did not respond or contact a doctor. Hours later, the woman was found dead, face down at the foot of her bed. Two workers alleged the nurse was often talking on her cell phone or text-messaging her boyfriend. The home was fined $10,000.

Risen Son Christian Village, Council Bluffs:
A resident was placed in a bed with a broken side rail and fell to the floor, suffering a broken leg. The resident was taken to a hospital and died. The fall was the underlying cause of death. Several workers were aware the side rails on the bed were not working properly. The home was fined $10,000.

Scottish Rite Park, Des Moines:
A female resident fell in a shower, causing a serious, overlapping break in the bones of one leg. At the time, the woman told workers, "I guarantee you my leg is broken," but none of the employees notified the woman's family or doctor, or ordered an X-ray, until the next day. Three workers told inspectors they were fearful of losing their jobs or state licenses. The resident later died, and the home's medical director told inspectors the death was directly related to the fall. The home was fined $10,000.

Windmill Manor, Coralville:
A resident was entering other residents' rooms, blocking their exit and then hitting and threatening them. One of the victims tearfully told inspectors she was afraid of the man and wished she could live somewhere else. The director of nursing told inspectors she was aware of the attacker's history but said the victim who complained was "over-dramatic." While inspectors were at the home, they noticed the attacker was sleeping in the nurses' station. A worker explained that is where the man stayed, otherwise he would enter the rooms of other residents and "make them scream." The home was fined $500. Two weeks later, inspectors were back at the home investigating a death. A resident had been admitted to the home after a leg amputation. While at the home, the resident's skin deteriorated. The director of nursing never looked at the wounds. Eventually, the resident was hospitalized and doctors alleged the home had failed to treat a large, open sore. The resident was diagnosed with an infection, developed complications and died. The home was fined $10,000.

Clark Kauffman also has an excellent article about how the nursing home lobbyists have limited the amount of fines for neglect and abuse to a maximum of $10,000.  Continue reading for a brief summary.

Iowa's nursing home owners can pay only $10,000 for serious health and safety violations, abuse, and negelct causing death.  The amount of fines have not changed in 22 years.

"I tell you, somebody's been doing a great job of lobbying to keep the fines at that level," said John Tapscott, an advocate for seniors who spent six years in the Iowa Legislature. "The reason the fines haven't changed is all the political influence these homes have." 

Nursing home corporations are aggressively lobbying state legislators. They host campaign fundraising events for key lawmakers, and are collecting information on the registered nurses who work as state nursing home inspectors.

The battle could come to a head during this year's legislative session, with lawmakers being asked to side either with state inspectors or with an industry that has a team of lobbyists and a well-funded political action committee.

The debate over fines first surfaced 14 months ago when USA Healthcare nursing home in Urbandale was fined $400 after being accused of failing to protect residents from numerous instances of assault and sexual abuse. According to state records, elderly residents and workers at the care center were choked, kicked, punched, sexually assaulted and threatened by at least two residents who suffered from dementia. There were at least 18 attacks - some by a man wielding a coat hanger - that were documented by the home. One of the attackers broke the clavicle of a fellow resident. 

A private foundation that surveys Iowa nursing homes about the inspection process gives the state inspectors high marks for professionalism and courtesy.

Iowa's fines are lower than those imposed by other states in the Midwest. The Government Accountability Office reported earlier this year that fines are so small nationally that some nursing homes view them as part of the "cost of doing business."

It's now cheaper for an Iowa nursing home to pay a Class 1 fine every year than it would be to hire just one additional nurse aide.

The finances of Iowa's for-profit nursing homes are not subject to public-disclosure laws. But the state's nonprofit care centers - which pay no income tax - must disclose some of those details. The latest available reports show that some of these nursing homes and their owners are doing well financially.

For example, Care Initiatives of West Des Moines, which owns 47 Iowa care centers, posted $140 million in revenue during 2006. Although that was $13 million less than the charity spent, Chief Executive Hulon Walker collected $2.1 million in salary, benefits and deferred compensation. The chief financial officer was paid $1.5 million, and members of the board of directors were paid up to $412 an hour.

The company, which is considered a public charity, has its own for-profit insurance company in the Turks and Caicos Islands, an off-shore tax haven. At the end of 2006, that insurance company, which provides coverage exclusively for Care Initiatives, had almost $1.4 million in cash on hand.

The Evangelical Lutheran Good Samaritan Society, a South Dakota charity that owns 230 nursing homes, including 21 in Iowa, collected $851 million in revenue in 2006, which was $30 million more than was spent operating the facilities. The charity paid its chief executive $437,784 and spent $87,000 on lobbying.

The organization, which has $1.2 billion in assets, also has its own for-profit insurance company, based in the Cayman Islands, another off-shore tax haven. At year's end, that insurance company, which provides coverage exclusively for Evangelical Lutheran Good Samaritan Society, had $4.8 million in cash on hand.

A spokesman for the "charity" said the insurance company is in the Cayman Islands because a "consultant" determined that was the "best fit" for the corporation.

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The indictment alleges that the men ran about 70 nursing homes in Texas and other states and were responsible for a $200 million operation but hid their control of the facilities. Payroll companies: More than 150 sham payroll companies were created to avoid paying taxes, according to the indictment.

A former Hurst nursing home executive who crisscrossed the Atlantic as part of a tax-evasion scheme pleaded guilty Wednesday to conspiring to cheat the IRS out of $34 million.

As part of a plea agreement, Larry G. May will cooperate with the prosecution of two of his former North Texas business associates, who the government said helped control the nursing homes involved.  May, Stephen Michael Ewing of Bedford and Gary R. Trebert of Frisco were indicted in March on 29 federal counts including mail fraud, making false statements to a government agency, and defrauding the IRS and the U.S. Health and Human Services Department.

May also pleaded guilty Wednesday to perjuring himself by signing false tax returns for 63 nursing homes with payroll taxes totaling $4.45 million.  

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I was sent this great editorial regarding how much staff could be hired if CEOs were compensated reasonably instead of exorbitantly like Manor Care's CEO Paul Ormond.

SNF CEO'S WINDFALL COULD HAVE PROVIDED MORE STAFF AND SERVICES

To the Editor:

Reports that Manor Care’s CEO Paul Ormond would personally realize between $118 and $186 million when his company, the largest nursing home chain in the United States, is acquired later this year by a private equity group got us thinking about staffing in nursing homes. Knowing that the federal government has reported that more than 90% of nursing homes do not have enough staff to take care of their residents, we wondered how many nurses and nurse aides could be hired for a year at Manor Care’s nursing facilities with that same money.

Using federal wage estimates for nursing home workers, we calculated that Manor Care’s 278 nursing homes could hire an additional 5346 certified nurse aides or an additional 2198 registered nurses if $118,000,000 were spent on staff (19.2 aides or 7.9 RNs at each Manor Care nursing home). If Mr. Ormond’s $186,000,000 windfall were spent on staff, Manor Care could hire an additional 8427 certified nurse aides or an additional 3464 RNs (30.3 CNAs or 12.5 RNs at each Manor Care nursing home).

Like all nursing home chains, most of Manor Care’s revenues come from public programs, Medicare and Medicaid. How should our public health care dollars be spent? One man’s windfall or certified nurse assistants and registered nurses in nursing homes?


Sincerely,

Toby S. Edelman
Center for Medicare Advocacy
California Advocates for Nursing Home Reform
The John A. Hartford Institute for Geriatric Nursing
National Conference of Geriatric Nurse Practitioners

Documentation supporting statements made in the letter-to-the-editor:

Two weeks ago, Manor Care, the largest nursing home chain in the United States, announced that it had agreed to be purchased by the Carlyle Group. Early reports indicate that Manor Care’s CEO Paul Ormond will personally realize between $118 and $186 million when he exercises his stock options at the time of the sale.[1] The Center for Medicare Advocacy wondered how many nurses and nurse aides could be hired for a year at Manor Care’s nursing facilities with that money.

Referring to the Bureau of Labor Statistics’ wage estimates for nursing home workers, (the average nursing home nurse aide earned $22,070 and the average registered nurse, $53,690 in May 2006)[2] and to the 278 facilities operated by Manor Care as of December 1, 2006,[3] the Center did some calculations. Here are the results:

Documentation about staffing: The nurse staffing study submitted to Congress by the Centers for Medicare & Medicaid Services in 2001 documented that more than 91% of facilities fail to have sufficient staff to prevent avoidable harm and that 97% of facilities do not have sufficient staff to meet the comprehensive requirements of the Reform Law. CMS, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report, pages 1-6, 1-7 (Dec. 2001), http://www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp (scroll down to Phase II report).

Solutions: In testimony before the Senate Aging Committee on May 2, 2007 on the 20th anniversary of the federal Nursing Home Reform Law, Professor Charlene Harrington of the University of California, San Francisco, discussed, as one of her key points, the issue of financial accountability for public funds. She described the ability of nursing facilities, under current law, to spend their Medicare reimbursement, once they get it, as they choose, not necessarily as Congress intended. Professor Harrington’s solution is prohibiting nursing facilities from shifting costs across cost centers. Her testimony is at http://aging.senate.gov/events/hr172ch.pdf, pages 9-11.

--------------------------------------------------------------------------------
[1] Homer Brickey, “Manor Care sale would enrich execs; Toledo firm’s officials may receive more than $200 million for stock,” The Toledo Blade (July 6, 2007), http://toledoblade.com/apps/pbcs.dll/article?AID=/20070706/BUSINESS03/707060449/-1/BUSINESS.

[2] Bureau of Labor Statistics, Department of Labor, 2006 National Industry-Specific Occupational and Employment Wage Estimates, NAIC 623100, Nursing Care Facilities, http://www.bls.gov/oes/current/naics4_623100.htm#b00-0000.

[3] Meg LaPorte, “Top 50 Nursing Home Chains; Manor Care Soars Above The Pack By 18,000 Beds,” Provider 37 (June 2007), http://www.providermagazine.com/pdf/2007/survey_top50_2007.pdf.

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Drug-maker freebies can lead to harm for patients, a new report from the highly respected New England Journal of Medicine warns. Consumers have reason to be concerned about the study's findings.

Gifts (bribes?) showered upon doctors by drug- and medical device-makers have become so pervasive that they are a standard part of every physician's practice. 94 percent physicians have a  relationship with the drug industry, according to a study scheduled to be published Thursday in the New England Journal of Medicine.

Consumers should care about such relationships because drug companies market the most expensive brand names; gift-giving influences prescribing behavior and therefore how much patients spend on prescriptions.

The study proves that many doctors do not follow the AMA voluntary guidelines. It notes, for example, that 35 percent of respondents accept reimbursement for continuing medical education or for travel, food or lodging for medical meetings.

A National Survey of Physician–Industry Relationships
E. G. Campbell and Others

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