Aug 25, 2012
Aug 24, 2012
Lauren Tenney's Testimony at New York State's Olmstead Hearing
"When ever a separation is made between liberty and justice, neither is safe."
Edmund Burke
via lauren10ePublished on Aug 24, 2012 by lauren10e
Lauren Tenney testifies at Olmstead hearing 8.22.2012 and makes calls that state-sponsored murder, slavery, and torture must end.
For more information: www.facebook.com/TenneyLauren
www.TheOpalProject.org www.StopForceNow.org www.NoIOC.org
Supreme Court Upholds ADA 'Integration Mandate' in Olmstead decision
Washington, DC, June 22, 1999 -- In rejecting the state of Georgia's appeal to enforce institutionalization of individuals with disabilities, the Supreme Court today affirmed the right of individuals with disabilities to live in their community in its 6-3 ruling against the state of Georgia in the case Olmstead v. L.C and E.W.Under Title II of the federal Americans with Disabilities Act, said Justice Ruth Bader Ginsburg, delivering the opinion of the court, "states are required to place persons with mental disabilities in community settings rather than in institutions when the StateÕs treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities. "
The 'integration mandate' of the Americans with Disabilities Act requires public agencies to provide services "in the most integrated setting appropriate to the needs of qualified individuals with disabilities." The high court upheld that mandate, ruling that Georgia's department of human resources could not segregate two women with mental disabilities in a state psychiatric hospital long after the agency's own treatment professionals had recommended their transfer to community care.
The lower courts ruled the state violated the ADA's "integration mandate" and Georgia appealed, claiming the ruling could lead to the closing of all state hospitals and disruption of state funding of services to people with mental disabilities.
However, the women were supported by a number of states, disability organizations and others, including the U.S. solicitor general, who said "The unjustified segregation of people in institutions, when community placement is appropriate, constitutes a form of discrimination prohibited by Title II [of the ADA]."
Originally, 26 states had signed onto an Amicus Brief in support of Georgia's position. However, an extensive education campaign by the disability rights movement reduced that number to just seven. read more here
Isaac August 2011
INVOLUNTARY COMMITMENT
AND FORCED PSYCHIATRIC
DRUGGING IN THE TRIAL
COURTS: RIGHTS VIOLATIONS
AS A MATTER OF COURSE
JAMES B. (JIM) GOTTSTEIN*
via Psychrights.org
Aug 21, 2012
Is There a Role for Clozapine in the Treatment of Children and Adolescents (Who Are Guinea Pigs)?
Can you tell the difference?
Is There a Role for Clozapine in the Treatment of Children and Adolescents?
Findling, Robert L.; Frazier, Jean A.; Gerbino-Rosen, Ginny; Kranzler, Harvey N.; Kumra, Sanjiv; Kratochvil, Christopher J.
Journal of the American Academy of Child & Adolescent Psychiatry, v46 n3 p423 Mar 2007
Journal of the American Academy of Child & Adolescent Psychiatry, v46 n3 p423 Mar 2007
"This article presents responses to the question of whether clozapine is ever appropriate to use in the pediatric population. Among others, Jean A. Frazier also agreed that clozapine is appropriate for use in the pediatric population. Clozapine has truly revolutionized the treatment of refractory patients with schizophrenia at any age. This agent was approved by the U.S. Food and Drug Administration (FDA) in 1989 for use in individuals ages 18 years or older with treatment refractory schizophrenia. Subsequent to clozapine, the FDA has approved a number of atypical antipsychotics for the treatment of psychotic disorders, but none to date are approved for use in children and adolescents. Despite the superior efficacy of clozapine, its use has been limited because of its complex side effect profile, consisting of hypersalivation, weight gain, metabolic abnormalities, cardiovascular side effects, sedation, seizures, and agranulocytosis. Children may be more prone to developing these side effects than adults because of developmental differences in the metabolism of this agent."
via Highbeam Business:
Is there a role for clozapine in the treatment of children and adolescents?
Article from: Journal of the American Academy of Child and Adolescent Psychiatry | March 1, 2007 | Findling, Robert L.; Frazier, Jean A.; Gerbino-Rosen, Ginny; Kranzler, Harvey N.; Kumra, Sanjiv; Kratochvil, Christopher J. | Copyright Journal of the American Academy of Child and Adolescent Psychiatry
IS THE USE OF CLOZAPINE EVER APPROPRIATE IN THE PEDIATRIC POPULATION? IF APPROPRIATE, WHEN AND HOW WOULD YOU MANAGE ITS USE IN CHILDREN AND ADOLESCENTS?
Robert L. Findling, M.D.
The question of whether clozapine is ever appropriate to use in the pediatric population is an important one. At present, according to the U.S. Food and Drug Administration (FDA), clozapine is indicated for patients with treatment-resistant schizophrenia and may be prescribed for patients with psychotic illnesses to lower the risk of suicidal behavior. The reason that clozapine is reserved for use with patients who are not responsive to other interventions is because clozapine therapy can lead to agranulocytosis, seizures, and myocarditis. Clozapine is currently not approved for use in pediatric patients.
Despite these facts, treatment with clozapine is considered for some children and adolescents who are suffering from severe, disabling psychopathology who do not respond to or cannot tolerate first- or even second-line medication interventions for which clozapine therapy may be considered. Although the use of clozapine has been described in several pediatric patient populations, the best evidence supporting its use in children or adolescents are in youths with treatment-resistant psychotic illnesses or in young people with treatment-resistant bipolar illness (Findling et al., 2005). It should be emphasized that the use of clozapine has not been rigorously studied in aggressive youths with primary diagnoses of disruptive behavior disorders. Because of this lack of evidence and the side effect profile of clozapine, use in aggressive patients with primary diagnoses of disruptive behavior disorders is not recommended. Although some of the data relating to clozapine's use in the young may not be methodologically stringent or extensive, what information is available does suggest that clozapine may be helpful when reserved for use in some seriously ill patients with treatment-resistant schizophrenia or bipolar illness.
In short, the answer to the question posed is "yes." Clozapine therapy may be appropriate for some pediatric patients with psychotic disorders or bipolar illnesses who do not respond to other forms of pharmacotherapy.
Now that the diagnoses of the patients for whom clozapine therapy may be beneficial have been identified, the more complicated and difficult issue is the question of at what point in the course of treatment does one consider clozapine therapy for patients with psychotic disorders? When only typical antipsychotics and clozapine were available, the time at which one may have considered clozapine therapy for patients may have been clearer. Patients who failed treatment with one typical antipsychotic often failed treatment with another. Thus, a patient who failed to respond to two typical antipsychotic medication trials may have been considered an acceptable candidate for clozapine therapy. However, in this era of multiple pharmacologically distinct first-line atypical antipsychotics (as well as continued availability of typical antipsychotics), it is not clear when one may consider the use of clozapine for young patients with treatment-resistant schizophrenia. In the absence of definitive data, clinical judgment and patient/family choice become the key factors. It may be suggested that one could consider only clozapine for a patient who had clearly failed to have a substantive reduction in psychopathology after treatment with at least three different antipsychotics (two atypicals and one typical). As part of the general evaluation of patients who are failing to respond to therapy, it is strongly recommended that one considers the many reasons that patients may not be responding to treatment. A careful diagnostic reassessment is often prudent. In addition, environmental factors and possible nonadherence to prescribed medications should also be considered. At that point, I would think about discussing the option of clozapine therapy with the patient's guardians and, as appropriate, with the patient.
Expert consensus guidelines have recently been published for pediatric bipolar illness … here
All due respect to the "experts," without clinical trial data, or data from real world clinical practice, their consensus "opinion" is not an ethical treatment recommendation. Without definitive evidence of Clozapine being effective, not simply "efficacious;" and definitive evidence that the benefits out-weigh the tremendous risks for disabling adverse effects, how can a group of "medical scientists" ethically recommend a treatment based only upon agreement? The Guideline is based on a consensus of agreement and was published in a so-called "peer-reviewed professional journal" in 2007, it was developed from answers on a survey! Subjective observation,and/or subjective opinion is considered to be the weakest most unreliable 'evidence' in scientific research, for this reason, it is used to support empirical clinical data; it is not a substitute! Expert Consensus Guidelines are a commercial product, they are not a derived from scientific research or clinical trial data.
This "expert" guideline was issued one year after my son had become an adult. By his 18th Birthday, he had been taking Clozapine for 5 years...without consent and in spite of my protests---The psychiatric "doctors" refused to discuss lowering the dosages, or the profound deleterious adverse effects my son was experiencing. One actually told me it doesn't matter what my son's diagnosis is/was. Both of them said I had no say; like Jon McClellan had. Supposedly, since my brain-damaged son was over the age of 13, my informed consent wasn't needed...
via Highbeam Business:
Is there a role for clozapine in the treatment of children and adolescents?
Article from: Journal of the American Academy of Child and Adolescent Psychiatry | March 1, 2007 | Findling, Robert L.; Frazier, Jean A.; Gerbino-Rosen, Ginny; Kranzler, Harvey N.; Kumra, Sanjiv; Kratochvil, Christopher J. | Copyright Journal of the American Academy of Child and Adolescent Psychiatry
IS THE USE OF CLOZAPINE EVER APPROPRIATE IN THE PEDIATRIC POPULATION? IF APPROPRIATE, WHEN AND HOW WOULD YOU MANAGE ITS USE IN CHILDREN AND ADOLESCENTS?
Robert L. Findling, M.D.
The question of whether clozapine is ever appropriate to use in the pediatric population is an important one. At present, according to the U.S. Food and Drug Administration (FDA), clozapine is indicated for patients with treatment-resistant schizophrenia and may be prescribed for patients with psychotic illnesses to lower the risk of suicidal behavior. The reason that clozapine is reserved for use with patients who are not responsive to other interventions is because clozapine therapy can lead to agranulocytosis, seizures, and myocarditis. Clozapine is currently not approved for use in pediatric patients.
Despite these facts, treatment with clozapine is considered for some children and adolescents who are suffering from severe, disabling psychopathology who do not respond to or cannot tolerate first- or even second-line medication interventions for which clozapine therapy may be considered. Although the use of clozapine has been described in several pediatric patient populations, the best evidence supporting its use in children or adolescents are in youths with treatment-resistant psychotic illnesses or in young people with treatment-resistant bipolar illness (Findling et al., 2005). It should be emphasized that the use of clozapine has not been rigorously studied in aggressive youths with primary diagnoses of disruptive behavior disorders. Because of this lack of evidence and the side effect profile of clozapine, use in aggressive patients with primary diagnoses of disruptive behavior disorders is not recommended. Although some of the data relating to clozapine's use in the young may not be methodologically stringent or extensive, what information is available does suggest that clozapine may be helpful when reserved for use in some seriously ill patients with treatment-resistant schizophrenia or bipolar illness.
In short, the answer to the question posed is "yes." Clozapine therapy may be appropriate for some pediatric patients with psychotic disorders or bipolar illnesses who do not respond to other forms of pharmacotherapy.
Now that the diagnoses of the patients for whom clozapine therapy may be beneficial have been identified, the more complicated and difficult issue is the question of at what point in the course of treatment does one consider clozapine therapy for patients with psychotic disorders? When only typical antipsychotics and clozapine were available, the time at which one may have considered clozapine therapy for patients may have been clearer. Patients who failed treatment with one typical antipsychotic often failed treatment with another. Thus, a patient who failed to respond to two typical antipsychotic medication trials may have been considered an acceptable candidate for clozapine therapy. However, in this era of multiple pharmacologically distinct first-line atypical antipsychotics (as well as continued availability of typical antipsychotics), it is not clear when one may consider the use of clozapine for young patients with treatment-resistant schizophrenia. In the absence of definitive data, clinical judgment and patient/family choice become the key factors. It may be suggested that one could consider only clozapine for a patient who had clearly failed to have a substantive reduction in psychopathology after treatment with at least three different antipsychotics (two atypicals and one typical). As part of the general evaluation of patients who are failing to respond to therapy, it is strongly recommended that one considers the many reasons that patients may not be responding to treatment. A careful diagnostic reassessment is often prudent. In addition, environmental factors and possible nonadherence to prescribed medications should also be considered. At that point, I would think about discussing the option of clozapine therapy with the patient's guardians and, as appropriate, with the patient.
Expert consensus guidelines have recently been published for pediatric bipolar illness … here
All due respect to the "experts," without clinical trial data, or data from real world clinical practice, their consensus "opinion" is not an ethical treatment recommendation. Without definitive evidence of Clozapine being effective, not simply "efficacious;" and definitive evidence that the benefits out-weigh the tremendous risks for disabling adverse effects, how can a group of "medical scientists" ethically recommend a treatment based only upon agreement? The Guideline is based on a consensus of agreement and was published in a so-called "peer-reviewed professional journal" in 2007, it was developed from answers on a survey! Subjective observation,and/or subjective opinion is considered to be the weakest most unreliable 'evidence' in scientific research, for this reason, it is used to support empirical clinical data; it is not a substitute! Expert Consensus Guidelines are a commercial product, they are not a derived from scientific research or clinical trial data.
This "expert" guideline was issued one year after my son had become an adult. By his 18th Birthday, he had been taking Clozapine for 5 years...without consent and in spite of my protests---The psychiatric "doctors" refused to discuss lowering the dosages, or the profound deleterious adverse effects my son was experiencing. One actually told me it doesn't matter what my son's diagnosis is/was. Both of them said I had no say; like Jon McClellan had. Supposedly, since my brain-damaged son was over the age of 13, my informed consent wasn't needed...
What do you want to bet the clinical trial data these "experts" did have, did not support their "expert" opinions; which is why they took surveys to to write these marketing manuals, er. I mean guidelines.
If these "doctors" had data to support their opinion, they wouldn't have had rely on the weakest data in scientific endeavors that other fields of scientific research, use to support empirical data---not as a substitute or a replacement!
I must admit I am extremely biased. I bear witness to how my precious child was treated like a guinea pig by a psychiatric research 'expert' who repeatedly traumatized, and ultimately disabled him. My son is struggling to recover from what he describes as "torture," being "traumatized over and over and over" by the people who were "supposed to be helping me." Mental health and social service 'professionals' continue to treat my son as if his diagnosis lowered his worth as a human being, as if his psychiatric diagnosis somehow means my son is unworthy of respect. Traumatic treatment experiences are denied altogether, it's demoralizing to be continually invalidated by mental health and social service professionals who are supposed to be helping, but instead repeatedly traumatize, then invalidate my son entirely---by denying therapeutic treatment for his profound iatrogenic injuries and impairments caused by the biological "treatment;" and the emotional injuries caused by mental health 'standards of care', i.e. manipulative, coercive mistreatment.
I must admit I am extremely biased. I bear witness to how my precious child was treated like a guinea pig by a psychiatric research 'expert' who repeatedly traumatized, and ultimately disabled him. My son is struggling to recover from what he describes as "torture," being "traumatized over and over and over" by the people who were "supposed to be helping me." Mental health and social service 'professionals' continue to treat my son as if his diagnosis lowered his worth as a human being, as if his psychiatric diagnosis somehow means my son is unworthy of respect. Traumatic treatment experiences are denied altogether, it's demoralizing to be continually invalidated by mental health and social service professionals who are supposed to be helping, but instead repeatedly traumatize, then invalidate my son entirely---by denying therapeutic treatment for his profound iatrogenic injuries and impairments caused by the biological "treatment;" and the emotional injuries caused by mental health 'standards of care', i.e. manipulative, coercive mistreatment.
Aug 20, 2012
Jaakko Seikkula Speaks on Finnish Open Dialogue, Social Networks, and Recovery from Psychosis
Here I interview with Jaakko Seikkula, PhD, a professor of psychotherapy at the University of Jyväskylä in Finland who is best known for his work with Finnish Open Dialogue. He speaks about the value of engaging social networks in crisis situations, the development of the Finnish Open Dialogue approach, the idea that there is meaning behind psychosis, and some unexpected benefits in Western Lapland of including family members in therapy with people experiencing psychosis.
via TAOS Institute:
Department of Psychology, University of Jyväskylä
Box 35, FIN-40014 Jyväskylä, Finland
After moving to University of Jyväskylä he has become involved in many development and research projects. Recently ideas of open dialogues have been applied in social work with children’ problems, in organization consultation, supervision and teaching. Research has focused on outcome and process studies on family therapy of psychosis and depression and social network interventions. Concerning outcome studies in psychotherapy the main focus is on developing methods for naturalistic designs to see how the psychotherapy affect in real world, in every day clinical practice.
Another line of developing and research has focused on research methods for dialogues in family therapy settings. A new method – at the moment named as Dialogical Methods for Investigations in Happenings of Change – is in progress. The main aim is to develop tools for making sense of what happens in multi actor dialogues, especially focusing on the responses in dialogues.
This is related with Jaakko’s main language philosophical interest on Mikhail Bakhtin’s works for 25 year. Jaakko wrote first text referring to Bakhtin 1987 and since then Bakhtin has been the main inspiration for understanding the power of dialogue in human life. During last years the importance of the being present in the moment in the “once occurring participation in being” has become the most important aspect of therapy and writing and teaching about therapy. Jaakko is invited for tens of workshops and congress presentation every years.
Healing Elements of Therapeutic Conversation: Dialogue as an Embodiment of Love
Open Dialogues With Good And Poor Outcomes For Psychotic Crises: Examples From Families With Violence
Inner and outer voices in the present moment of family and network therapy
Psychotherapy Research. Five-year experience of first-episode non-affective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies
For more on Open Dialogue, see: http://psychrights.org/research/Digest/Effective/fiveyarocpsychotherapyresearch.pdf
Open Dialogues With Good And Poor Outcomes For Psychotic Crises: Examples From Families With Violence
Inner and outer voices in the present moment of family and network therapy
Psychotherapy Research. Five-year experience of first-episode non-affective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies
For more on Open Dialogue, see: http://psychrights.org/research/Digest/Effective/fiveyarocpsychotherapyresearch.pdf
Daniel Mackler's website: Essays for the Truth Seeker Healing from Childhood Trauma
photo credit thizzlerice on photobucket
originally post with just the video 7-31-2011
photo credit thizzlerice on photobucket
originally post with just the video 7-31-2011
why I remember
Have you ever really wanted it just be able to come to a place within yourself that you just:
"Forgive your enemies, but never forget their names."
John F. Kennedy
The man had a point.
My awareness of just how precious a moment can be
takes my breathe away...
experience is...
why I remember
takes my breathe away...
experience is...
why I remember
a brief conversation:
Becky @yobluemama2
@HealthCulture Calling a treatment a 'Standard Practice' is used by medical professionals to deny legal liability for harm done to #patients
Jan Henderson @HealthCulture
@yobluemama2 That sounds like something you've learned, unfortunately, from experience
Becky @yobluemama2
@HealthCulture Indeed it is. I am #grateful I know--but knowing is not a comfort. Taking care of my son is an honor; #bittersweet privilege.
@HealthCulture Calling a treatment a 'Standard Practice' is used by medical professionals to deny legal liability for harm done to #patients
Jan Henderson @HealthCulture
@yobluemama2 That sounds like something you've learned, unfortunately, from experience
Becky @yobluemama2
@HealthCulture Indeed it is. I am #grateful I know--but knowing is not a comfort. Taking care of my son is an honor; #bittersweet privilege.
These are the days of the endless summer
These are the days, the time is now
There is no past, there's only future
There's only here, there's only now
Oh your smiling face, your gracious presence
The fires of spring are kindling bright
Oh the radiant heart and the song of glory
Crying freedom in the night
These are the days by the sparkling river
His timely grace and our treasured find
This is the love of the one magician
Turned the water into wine
These are the days of the endless dancing and the
Long walks on the summer night
These are the days of the true romancing
When I'm holding you oh, so tight
These are the days by the sparkling river
His timely grace and our treasured find
This is the love of the one great magician
Turned the water into wine
These are the days now that we must savor
And we must enjoy as we can
These are the days that will last forever
You've got to hold them in your heart.
Aug 19, 2012
The GCBH RSN: the five prescribers who made the neuroleptic drug top ten prescriber list
3 out of 5 of the prescribers on the top ten neuroleptic drug prescribers list, work for CWCMH.
(no surprise here)
Washington State' public mental health system has a "Regional Support Network" model or “RSN,” which acts as an intermediary between the State and Counties. It is a gate-keeper which distributes mental health funds to Counties, the Counties then contract for mental health services in the community. Densely populated counties, have their own RSN, such as King and Pierce Counties where Seattle and Tacoma are located. The RSN where we live is in the Greater Columbia Behavioral Health RSN which is a consortium of eleven counties. The region’s main industry is agriculture; with a lot of orchards, vineyards and hopps, crops which demand a lot of manual labor. Part of the Confederated Tribes and Bands of the Yakama Nation's tribal lands comprise roughly a third of the total area of Yakima County. Much of the tribal lands in Yakima County are not at all accessible for any purpose whatsoever; the Nation's land borders the Yakima Training Center, a military training ground.
Map found at Washington State Department of Ecology
The Confederated Tribes and Bands of the Yakama Nation, have been historically excluded from any meaningful participation in how mental health services and public policies affecting them are planned, provided, and/or administered by Yakima County government. As one can imagine, this situation has added insult to injury; to say the very least. For years and years, Yakima County has administered mental health funds which are distributed to the County to contract for mental health services for all of the citizens in Yakima County, including Tribal members. The GCBH RSN had one of the worst offenders on Washington State's Top Ten Prescribers list compiled at the request of Iowa Republican Senator, Charles Grassley's Investigation into the illegal marketing of psychotropic drugs. The list is comprised of the top ten prescribers for each drug; so there are more than 10 offenders, i.e. prescribers who prescribed neuroleptic, or "antipsychotic" drugs in extraordinarily high volumes. In any case, a psychiatrist who worked in Walla Walla and Benton Counties made the top ten list for four neuroleptic drugs. In 2009 he made the top ten list for both the Managed Care System, and in the fee for service system by writing a total of 1261 prescriptions for Abilify. In 2008 he wrote 2120 prescriptions for neuroleptic drugs, the following year he nearly doubled that amount.
Walla Walla, Walla Walla County and Richland, Benton County Jose Cardell, M.D.
2008 574) $219,374.69 $189,049.13 Geodon
2008 1040 $357,963.10 $308,137.76 Risperdal
2008 1006 $235,977.13 $202,334.52 Seroquel
Totals 2120 $813,314.92 $699,521.41
2009 78 $33,604.94 $0 Abilify MCO
2009 1183 $612,219.58 $432,670.68 Abilify FFS
2009 662 $305,056.18 $218,710.57 Geodon Average $460.81 $330.38
2009 904 $456,102.36 $252,049.20 Risperdal
2009 1214 $383,517.94 $252,300.52 Seroquel
Totals: 4041 $1,756,896.06 $1,155,720.97
Theoretically, if this psychiatrist saw a total of 336 patients regularly once a month in 2009, and every one of them got a prescription every single month that would be a total of 4032 prescriptions---let's further suppose that he had a normal 5 day week with an average of 23 office days a month--he would have needed to see 14-15 patients every single day.
I was not surprised to find the psychiatrist who treated my son when he went to CWCMH on this list:
Yakima
Philip Rodenberger, M.D. Medical Director, Central Washington Comprehensive Mental Health, CWCMH.
2008 564 $155,700.98 $148,769.89 Risperdal
Nor was I surprised to find him on this list:
via ProPublica Dollars for Docs:
Payment Disclosure
Period 2010 Q1-Q4
Amount $15,300
Payee PHILIP RODENBERGER
Listed Practitioner Rodenberger, Philip
Location Yakima, Wash.
Service Speaking
Payment Disclosure
Period 2009 Q1-Q4
Amount $1,200
Payee PHILIP D. RODENBERGER, MD
Listed Practitioner RODENBERGER, PHILIP D.
Location YAKIMA, Wash.
Service Healthcare Professional Educational Programs
Number of activities 3
#prescriptions Billed Reimbursed
2009 293 $233,178.95 $213,696.19 KATHLEEN A MACK ARNP - FP Yakima
235 $225,197.86 $190,843.84 ANGELO A BALLASIOTES PHARM Yakima
207 $127,953.72 $97,709.28 MICHELLE R WILLIAMS ARNP - FP Richland
No prescriber in the GCBH RSN made the Zyprexa top ten list. Three of the five prescribers from this RSN who made the list for Risperdal, work at the Yakima community mental health clinic run by Central Washington Comprehensive Mental Health under Medical Director, Philip Rodenberger, M.D.; who was my son's psychiatrist in 2008. The only other prescriber who is on the Risperdal list in the GCBH RSN practices in Benton County.
I want to thank Jim Stevenson from Washington State's Health Care Authority for his prompt response to my request for the data for this post.
Top Ten Fee for Service
Top Ten Managed Care
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