 of Paris 1, in the awful-looking Tolbiac tower building, where most of the lectures to Master’s students in economics were being offered (this in France was called the Diplôme d’Études Approfondies, DEA). Bernard Ducros, who had been a doctoral thesis advisor of Alain Parguez and the author of the foreword of his first book (Parguez 1975), and who also turned up to be my PhD thesis advisor, was teaching one of the four courses offered in the advanced macroeconomics field, and for some reason could not attend several of his lectures. His replacement would then be Alain Parguez, who at that time was a maître-assistant at the University of Paris 1, before he became professeur agrégé during the 1977competition. Alain would sometimes be stuttering during his presentations, but what many students found most remarkable was the powerful loudness of his delivery. Almost each week, teachers lecturing in an adjacent room would knock on our door and shyly ask Alain if he could speak less loudly, as their own voice would be buried by Alain’s delivery, through the wall, of his comments on modern macroeconomic theory.
This week’s projections for the 1 month Treasury bill rate (investment basis) steepen dramatically at 2015 resulting in higher forecasts at the intermediate and long ends. The projected 1 month rate of 4.165% in May 2023 is up 13 basis points from last week. The 10 year U.S. Treasury yield is projected to rise steadily to reach 4.302% on May 31, 2023, 17 basis points higher than projected last week.
The effective yield on 15 year fixed rate mortgages is projected to rise from 3.141% today to 5.443% in 10 years, down 3 basis points compared to last week. The 15 year fixed rate mortgage spread over 15 year amortizing Treasury yields is forecasted to widen from its current level of 0.865% to 1.157% in 10 years, down 19 basis points from last week.Over nearly a decade, Indiana University Health Physicians has built one of the largest physician networks in the nation—about 1,800 doctors—by acquiring one independent group after another: cardiologists, rheumatologists, ophthalmologists and more.
Now, IU Health Physicians is setting its sights on one of the state’s last independent holdouts, the neurosurgical Goodman Campbell Brain and Spine.
Bringing the Indianapolis-based group of about 50 doctors—including 35 neurosurgeons—into its fold would fill the last big hole in IU Health Physicians’ specialty lineup and give it a formidable boost in the high-prestige brain and spine market.
It could also add another stream of physician referrals to IU Health and give it more heft in dealing with insurers and competitors.
“It’s really an exciting possibility to try to bring them in,” said Dr. David Ingram, president of IU Health Physicians, a joint venture of IU Health hospital system and the IU School of Medicine.
But it won’t be a slam dunk. Eight-year-old Goodman Campbell has a proud history of independence and says it has no plans of giving that up. Goodman Campbell neurosurgeons practice in multiple hospitals, and say they are concerned that, if they joined IU Health Physicians, they would be limited to its hospitals.
“Our goal is to continue to be independent,” said John Moeller, the group’s executive director of operations.
Some observers say Goodman Campbell has a strong hand, because its physicians are in demand by all health systems in the area.
A major factor behind IU Health’s decision to build its $120 million neurosciences center, which opened in 2013, was to woo Goodman Campbell physicians. The neurosciences center also houses a raft of other specialists already employed by IU Health Physicians: psychiatrists, neurologists and physical rehabilitation specialists.
So from IU Health’s perspective, bringing the neurosurgeons from Goodman Campbell into its practice would represent a crowning touch to a decade-long strategy of building a multi-specialty practice.
But it also would represent the latest step in consolidation that is sweeping medicine and turning physicians into hospital employees at a dizzying pace.
In 2000, 57 percent of the nation’s physicians were independent, according to Accenture, a global management consulting firm. But that figure had fallen to just 32 percent in 2016.
The two concerns physicians cited most about remaining independent were reimbursement pressures and overhead costs, according to an Accenture survey.
It’s hard for many of the independent physicians to compete against huge health systems, which have economies of scale and competitive contracts with insurers, said Kristin Ficery, managing director of Accenture’s provider business in Atlanta.
In addition, many younger Americans no longer even have a primary care physician. Instead, they visit a walk-in clinic or urgent-care center when they have medical problems, from ear infections to serious fevers, she said.
For the past nine years, the neurosurgeons and IU Health Physicians have been working together through an agreement under which Goodman Campbell physicians perform a wide variety of brain and spine surgeries at all of IU Health’s neurosurgery departments across the state.
But the agreement expires in December 2019, and both sides are in early talks on how to proceed.
IU Health Physicians says its goal is to have Goodman Campbell under its umbrella as employees. Already, it is laying its expectations on the table and using language that strongly states its desired outcome.
Ingram said he is not interested in having the relationship continue as is but wants it to evolve a model of physician-employees that IU Health Physicians has successfully built for nearly a decade through acquisitions.
IU Health Physicians formed in 2009 as the Indiana Clinic, and grew over the years by acquiring about 65 specialty practices. Like many other physician groups formed by large health systems, including Mayo Clinic and Cleveland Clinic, its goal is to bring a steady stream of patients into IU Health hospitals and clinics.
But it says another goal is to coordinate care across its system, from treatment protocols and electronic medical records to physician salaries and patient billing. Doing so, it says, improves patient care.
“It’s pretty clear from the evidence in the [medical] literature that the highest quality of care at the lowest cost is delivered in these large group practices that are fully integrated and aligned,” Ingram said.
To no surprise, independent physicians disagree, and say that large physician groups owned by health care systems actually raise the cost of care. That happens because the health system can pile on “facility fees” that can boost the price tag for a doctor visit or a medical procedure from three to 10 times, said Marni Jameson Carey, executive director of the Orlando, Florida-based Association for Independent Doctors.
On top of that, she said, large health systems often require their physicians to refer patients only to other specialists in the system, as well as to hospital-owned imaging centers and surgical centers, and that restricts the access patients have to affordable care and a competitive marketplace.
“Anything outside of that is called leakage, and the doctor gets a severe reprimand and sometimes a pink slip,” she said.
David Blish, director of health care consulting at Katz Sapper & Miller in Indianapolis, said hospitals increasingly want to “lock in” a patient base by employing physicians.
Doctors, for their part, faced with growing expenses and regulations, are often happy to be acquired, he said. That includes newly minted physicians, who often have no interest in managing a practice.
“Younger physicians are less interested in putting up a shingle and would rather be employed,” Blish said.
Whether Goodman Campbell can withstand the market pressures and remain free from outside control remains to be seen. But the group has an independent streak that goes back to its founding.
The group formed in 2010, when the neurosurgeons in the IU medical school’s Department of Neurological Surgery merged with the Indianapolis Neurosurgical Group. At the time, the newly formed IU Health Physicians was already trying to woo specialty groups into its orbit.
“By bringing together these esteemed surgical, scientific and academic resources, we are fulfilling a belief held by the former leaders of these two groups that patients would be best served if the walls between the operating room, the lab and the lecture hall were torn down,” according to a brief history on the Goodman Campbell website.
The group still serves as faculty members of the IU medical school—the only department in the school not staffed by IU Health Physicians.
“It’s unique to have a private practice as your department,” Moeller of Goodman Campbell said with a note of pride in his voice.
The group points to many firsts. Predecessor Indianapolis Neurosurgical Group pushed in 1974 for Methodist Hospital to order Indiana’s first computed tomography scanner, becoming just the 25th hospital in the world to possess this capability. For three years, this was the only CT scanner in Indiana.
Its surgeons also performed Indiana’s first microlumbar discectomy, and were the first in Indiana to clip aneurysms with the microscope. They also introduced radiosurgery for the treatment of brain tumors and vascular malformations, among other achievements.
With that rich history, Goodman Campbell is making no sounds that it is interested in being acquired. It said it is satisfied with the current relationship but will negotiate with IU Health Physicians and see where things go.
I'm really surprised we haven't got the triple chain thing yet in the game. Have it be like: 


Dragon's Lockdown, Spell Continuous  

Special Summon 3 Normal Dragon Monsters with the same Name from your deck. Only 1 of the monsters Summoned by this effect can attack