Commentary from Dave Durenberger

January 17, 2008

HEALTH POLICY PROGRESS - 2007
Not a lot of legislation passed Congress last year that didn't get vetoed. But lots of change is occurring in the system. We all know of the efforts by state and local governments to expand access and coverage and to work hard at cost containment through greater access to provider performance information. The year saw a leveling off in employer interest in disease management and in new Leapfrogs and Bridges to Excellence, but a substantial increase in health risk assessment, health fitness and, especially, health maintenance programs reflecting employee commitment in reduced insurance deductible and cost-sharing incentives.

The rise in value-based health decision-making reflected in expansion of retail clinics, the sudden talks of value-based insurance benefits, reduction in use of radiology and related diagnostics and payer/provider focus on efficiency and productivity.

Accountability is the new goal of more policy changes. More insurance plans, including CMS, are refusing to pay for hospital errors and limiting payment for hospital re-admissions. Hospital charges and the unfairness of overcharge plus the continued efforts at all levels to define and demand community benefit from non-profits. The FDA is doing its best to hold drug and device companies accountable by raising the bar on clinical research and on effectiveness of new products.

From drug/device company payments to physicians and surgeons to corporate governance compensation, medical and corporate ethics and morality is alive and receiving well-deserved attention. If not yet as much change as needed. A comparative effectiveness public/private institute for technology and procedures proposal began the year, and Dr. Atul Gawande ended it with an incisive New Yorker piece on the simplicity and life-saving/money saving character of clinical intensive care check lists.

HOSPITAL CHECKLIST
American hospitals billed Americans $648.3 billion for their services last year. Experts like Don Berwick of IHI have been running 100,000 lives and 5 million lives campaigns for years to reduce that bill. Berwick keeps saying they are overcharging us by 25-35% for inefficiencies, mistakes and deaths that are "never events." Dr. Peter Pronovost at Johns Hopkins showed Michigan hospitals how to use airline pilots' check-lists to reduce costs annually by over $100 million and save more than 1,500 lives.

Minnesota hospitals were the first to voluntarily report events that should never occur in hospitals (to say nothing of mistakes and inefficiencies). Yesterday our Health Department reported hospital "never events" dropped in 2007 from 154 to 125. Deaths from patient falls dropped from 12 to 4, four died from misused or faulty medical devices, two from mismanaged blood sugar. Cases in which surgical items were left in patients dropped from 42 to 27. Unfortunately (if the previous isn't bad enough for those involved), the number of patients who received the wrong surgery doubled from 5 to 10.

So what? The Minnesota Hospital Association deserves praise for members' commitments to change, and to the embarrassment of public reporting as a learning tool. But it has been proven to be possible to get much closer to zero defects in every hospital. That's what we deserve. Because hospitals are 24/7/365 operations it isn't easy to shut down, install a zero-defect production system, and then start it up. Pronovost and others have demonstrated that it must be done and it can be done without shutting down and starting over six months later. An endorsement of systemic change as the key to Six Sigma medical production from every hospital and hospital association as a condition to pay increases from large public and private payers is a good place to start.

PHYSICIAN CHECKLIST
A group of Minneapolis-St. Paul area large health system chief medical officers have been meeting for two years as the Physician Leadership Policy Forum to tackle another systemic problem. This one - the over-reliance by physicians on drug and device companies to enhance physician incomes, life styles and eating habits - seems hard to change. Gradually each participating system is making it more difficult for drug/device sales folks to change their "entitlement" attitudes around hospitals and hospital staff. But ending the practice of providing gifts of any kind runs into such violent specialty medicine opposition that no one system, in a competitive community, seems to have the guts to "Just Say No." So we the patients are left to wonder to what degree our physician advice is being influenced by their own "entitlement" attitude.

MEDICARE PART D DRUGS A FINANCIAL HOMERUN
Judging from all reports, the 2003 decision to move prescription drug coverage from income-related state programs to Medicare Part D and from negotiated prices to medical market competition has made/saved money for everyone involved. Except the taxpayers. 43 million Medicare beneficiaries now have access to prescription drugs at average prices some 17 percent less than we had before the MMA. Employers who retain their commitments to retiree drug benefits are making more money than the costs to them of their drug programs.

Stock prices for the corporate intermediaries - health insurance plans and pharmacy benefit management companies went up last year from 55% for Humana to 120% for Express Scripts.

On the other hand, research shows Medicare pays about 12% more on average for prescription drugs for seniors it covers than the state Medicaid programs paid before MMA. Medicare spending increased 18.1% in 2006, twice the increase in 2005. Hospital costs were a record $648.3 billion.

COMMUNITY BENEFIT
Surprisingly, the IRS has taken a relatively short period of time in responding to Congress' deepening concerns about the American not-for-profit hospital industry. Expressed as new disclosure rules via IRS Form 990, the information required of hospitals will likely lead to re-evaluation by federal, state and local government of the long-time tax exemption of non-profits in an industry where tax-paying for-profits are finding increasing financial opportunity. The new rules indicate someone will redefine "community benefit" as something other than bad debt and Medicare underpayment to charges. The IRS will also require disclosure of executive and governance compensation and "perks", the implication being that non-profits should be held to different comp standards than for-profits (why I'm not sure, but that's how many $165,000 a year members of Congress think, and your million dollar a year lobbyists are unlikely to change those minds.

©2008 Roger Schillerstrom, Modern Healthcare

Modern Healthcare's "poster child" for the implied pain of disclosure is our own Mayo Clinic, whose revenue is in the $6-7 billion a year category. Cover girl is Minnesotan Christie Lohkamp, the clinic tax director, who says she'll have to hire a full-time assistant to comply with new 35 to 60 page report forms at each Mayo location. Like many systems, Mayo claims charity care, underpayment for Medicare and Medicaid, as community benefit. It also reports $266 million in 501(c)(3) qualified contributions to the Mayo Clinic Foundation in 2006, an amount which appears to exceed its charity care and "losses" from caring for Medicare and Medicaid patients.

Why worry? We have been counseling hospital folks for several years that the cost of getting to universal coverage is likely to be the loss of the hundred plus year tax exemption. Unless non-profits can better define the unique mission that drives their systems and its community benefit. My point is accountability. The driving force in pay for performance/value whatever will be accountability. What do patients and payers get for their money? The exact same is true for non-profits.

How do communities know what they are getting for the tax subsidy, unless you prove it to them with year after year of reliable, consistent performance against stated mission goals? It seems this is the message that the Catholic Health Association has been striving to get across. Putting the messengers to the test of practicing what they preach is likely to be the next step in the process even before the IRS starts translating their new information into legislative policy in 2009-10.

MEDPAC STARS DEPART
Deputy Director Sarah Thomas leaves soon to join the health policy team at AARP where she will be Director of Health Policy in Susan Reinhardt's Public Policy Insitute. Jack Ashby plans to culminate 19 years at MedPAC with his unique insight into hospital payment policy, to start a new life in Hawaii.

New commissioner, Dr. Tom Dean of Wessington Springs, SD, is back at work part-time today after surgery for a hip fracture caused by a melanoma which is being treated by colleagues in the Avera Health Care System out of Sioux Falls, SD. Tom is upbeat about his third venture into the medical system in his 61st year, and the one with the toughest prognosis. Nothing works as well right now as well-meant prayers for his wife and family and for all his caregivers and practice colleagues.

The January 10th MedPAC meeting to recommend payment updates was by far the hardest in my six years on the commission. In the early days members and Congressional staff eagerly sought MedPAC consensus to guide their decision-making through the conflicting pressures of strong self interest and fiscal realities. Several years of fighting off the impact of the Part B SGR on physician pay policy and its politics made MedPAC updates less relevant. We knew it. What put it all in perspective last week was Commissioner Jay Crosson's observation, "I feel like the guy who is lining up a 10 foot putt for a triple bogey."

CHANGING THE BEHAVIOR
Urban Institute CEO and former CBO Director Bob Reischauer has little faith that change in the health sector is likely to produce either better health policy or greater value in the next few years. "This is a long time a-coming and unlikely before the 2016 election." Not too surprising, then, to hear Abdul Qadir, the Defense Minister of Iraq, predict while shopping at the Department of Defense in Washington this week that the United States will be required to have a presence in Iraq until at least 2018. He wasn't talking about Marriott or McDonalds or Starbucks.

By then we will be equally invested in Iran, Afghanistan and Pakistan and maybe Bangladesh as well. All of this because President Bush chose to fight the "War on Terror" launched subsequent to 9-11-01 in both Afghanistan and Iraq. By consequence of that decision and others that flowed from it, and of the way we fought that war, we are now committed to land presence in a large number of Islamic countries from the Middle East across central to south Asia. Monday four terrorists walked into the Kabul Serena Hotel - one of my favorite chains - and blew themselves up in the lobby.

PRESIDENTIAL LEGACY
President Bush 43 is working hard to build reputation in the last two years of his term. Some way for the people of this country and the world to see the benefit of our war on Iraq is linchpin critical. Staying the course on spending for the U.S. force and whatever is to replace those forces that will "stand down" by the end of 43's term is on course and unlikely to change. So, too, is spending on the Medicare Modernization program launched in 2003 to turn this giant program over to private insurance and medical industries. Beyond that, the legacy includes those who have found ways to enrich themselves by the privatization of the policy process in Washington and the privatization of mercenaries in every phase of the military-industrial-democratization process. Top staffers from the Contract with America flow in and out of Congress, lobbying, White House staff, corporate America redefining "Pay-Go" as they move unobtrusively thru the many revolving doors they've helped build in DC since the mid 1990s.

PRESIDENT BUSH GOES ON THE ROAD
While presidential aspirants campaign to succeed him, and Democratic House Speaker Pelosi reaches out to Republicans to find a way through the 2008 Congressional schedule, President Bush is doing the first of six scheduled legacy laps around the world. To quote every President's least favorite critic, "It took Bush almost his entire presidency to embrace diplomacy, but now that he's in the thick of it, or perhaps the thin of it - given his speed-dating approach to statesmanship - he is kissing and holding hands with kings, princes, emirs, sheiks and presidents all over the Arab world and is trying to persuade them that he is not in a monogamous relationship with the Jews." Maureen Dowd in the New York Times, January 16.

Pundits will have a field day comparing what the President says in his last year in office with what he actually did in his first seven years. There are clear inconsistencies. The one that is most troubling for future Presidents is the muddle he has made of "democracy" and "freedom" and "national security." The Middle East trip just ended makes this very clear. With the exception of the oily emirates (Kuwait, UAE, Bahrain) most countries are substantially less well off and all are much less secure. Israel, Lebanon and Jordan are close to basket cases. No one knows what to expect of the United States when its "vital national interests" are perceived to be threatened. See Pakistan.

©2008 Kevin Kallaugher

Father Bush talked during and after "Desert Storm" in 1991 about "a new world order". Son Bush in Abu Dhabi said "this new era is founded on the equality of all people before God (and) is being built with the understanding that power is a trust that must be exercised with the consent of the governed - and must deliver equal justice under the law." Tell that to the 95% percent of the UAE people who are not part of the ruling family. Or to the Dubai's ruler who says "we believe that helping build a strong regional economy is our best opportunity for lasting stability in the Middle East."

Then in one of the least democratic of the countries, Bush salutes Egypt's President for life (or until is son takes over) Hosni Mubarak for "Your long and proud tradition of a vibrant civil society." I'll always remember August 29, 1990 in President Mubarak's palace in Alexandria hearing him inform a large delegation of U.S. Senate and House members for the first time that his friend President Bush had forgiven $6 billion in loans in exchange for Egypt's participation in war against Iraq and, in exchange for Mubarak's help with that war by starting a spreading the rumor that the invasion of Kuwait was a grand design by the monarchs of Jordan, Yemen, and Iraq.

LOOK OUT AFRICA
Swede Lars Thunell, the CEO of the International Finance Corporation, announced recently that the IFC - private arm of the World Bank - is setting up a $500 million private investment fund for small and medium sized medical enterprise investments in countries of Africa. The Economist tells us this is welcome news for Africa's poor and under-served who "may at last get the health services they deserve."

NOT SO
Around the globe, but especially in the U.S., there are hundreds of newly-minted "medical enterprises" simply waiting for foundation and public donor money to buy the theory private is better and find a way around inept and corrupt government health departments to the people in need of medical care. It is not that simple nor is it easy.

I know what many of the third world African countries are like. And I know the IFC and its medical enterprise. I once introduced IFC/medical to a Nepalese businessman whose "Karma" was building medical education and hospitals in the remote areas of Nepal. He already built a medical school and had plans for a teaching hospital with 500 beds which would cost $50 million.

IFC in Washington referred us to IFC Delhi which said it couldn't be done. They had invested $500 million in a 500 bed hospital in Thailand and insisted that was the price. What I found out was they used their friends in the consulting/architectural construction/medical education business for both estimating and implementing. Last Friday the World Bank, IFC parent, reported at length on fraud in use of their loans in India, including health facilities.

I believe, because I have seen it, that enterprising individuals with a "heart for Africa" and an understanding of business can provide medical and health delivery systems for a much lower cost than African governments or the "medical industrial - get-rich-quick" complex. I do not believe the IFC or Mr. Thunell know this or appreciate it.

IOWA WITHOUT NEW HAMPSHIRE MAKES NO SENSE
David Brooks is consistently pointing out in the New York Times and on the Jim Lehrer NewsHour that "The central issue in this campaign is the crisis of leadership." Because public distrust of Washington DC as represented by Presidential misjudgment and Congressional duplicity is at all-time high, the primary elections have become an interesting way to tap into the public psyche on what leadership means. As Mark Shields said on the January 7th NewsHour, "Iowa without New Hampshire makes no sense", so South Carolina is not California, nor Michigan, Texas. That's one reason that personal wealth or contributed wealth will keep the primary contests going until there is a clear winner in both parties. It is within the realm of possibility that a couple head-to-head campaigns can go right into Denver in August and St. Paul in September.

TAKE YOUR PHONES ON BOARD
I am resisting the inevitability of mobile phones on airplanes. I am of necessity brought together with an unknown person(s) next to me for hours and I can choose to leave it that way or seize an opportunity to learn something other than my laptop or brief case contents. I like not having the decision forced on me by voice(s) from another world intruding on mine. The excuse that our mobiles interfere with air traffic isn't. The reality is that our mobiles interfere with ground networks as thousands of us pass overhead is valid. But new technology eliminates that as well. Text messaging and e-mailing is occurring today on several airlines around the world, but is slow to come in the U.S. I sit at Board and Commission meetings next to members who are texting half the time. That's raising another set of issues about paying for full-time attention and getting half-time! But I'll deal with that rather than sounds. The FCC in March decided no voice phones allowed, but when foreign carriers create the habit, which they will, I am going to be forced into a "no phones" section on NWA. About 2012!!!

DOONESBURY
Some of you boomer fans of Gary Trudeau discovered me in a recent column and assumed I was still lobbying my former colleagues. First, I did register as and lobby for some interesting health policy issues in the mid to late 1990s, but terminated that activity a year before accepting appointment to the Medicare Payment Advisory Commission (MedPAC) in April 2002. Second, much as I loved Bob Packwood, I haven't seen him in years, but have recruited former Louisiana Senator Bennett Johnston to the Board of the Americans for Generational Equity which was chaired by Ambassador Dick Fairbanks and now by former Colorado Governor Dick Lamm. Third, my wife, Susan B. Foote, was in the Boalt Hall (University of California, Berkeley) class of 1977. You very long-time Doonesbury readers may recall that the Doonesbury character Joanie Caucus was admitted to Boalt in 1974. When Susan (and Joanie) were set to graduate in 1977, Gary Trudeau was the commencement speaker and a special chair on stage was reserved for Joanie.

FROGS IN BOILING WATER
One of the fine new additions to the capital mall in Washington is the Smithsonian's National Museum of the American Indian. Minnesota "Mankato limestone" decorates the exterior. Inside the building, in the 4th floor's patrons' lounge, you will find a portrait of the Museum's founding director Richard West by New York artist Burton Silverman. West spent $48,500 of museum funds for the portrait of himself by Silverman because he "couldn't find a Native artist who did formal portraits like this" meaning, what West wanted. West went off the Smithsonian payroll at the end of December and was not available for comment.

BILL MCGUIRE IN LIMBO
If there is such a place, Bill is in it for some time, thanks to U.S. District Judge James Rosenbaum who has responsibility for the litigation arising around United Health Group's stock options back-dating for directors and officers. A few weeks ago a couple of retired Minnesota Supreme Court Justices, whom Rosenbaum appointed to make recommendations relative to Bill McGuire's alleged back-dating, did the "Minnesota Nice" thing and found a way for Bill and his corporate counsel, David Lubbens, to walk on water without drowning. Return $468 million and $24 million respectively in options without having to acknowledge any responsibility for actions to the public, shareholders, customers and community reputation. Rosenbaum wasn't satisfied and the case goes on.

In San Francisco this week, U.S. District Court Judge Charles Breyer sentenced Greg Reyes, former CEO of Brocade Communications Systems to 21 months in prison and a $15 million fine for backdating. The case is different from the United case in that Reyes was accused of defrauding investors by making Brocade appear to be more profitable than it was thus making it appear more profitable which allegedly duped investors into pushing up the value of its stock and of Reyes' stock options.

But Breyer's comment is telling: "This offense is about honesty." It was about "lying." I guess a good lawyer can distinguish lying to investors from withholding information from directors and investors about the base on which compensation is determined. Judge Breyer will appear at the University of St. Thomas Holloran Center April 2 in a program on ethics in the professions with Watergate felons John Dean and Egil "Bud" Krogh. Breyer's brother Stephen is on the U.S. Supreme Court.

Our hero Garrison Keillor and his wife Jennie Lind Nillsen are suing their next door neighbors in St. Paul to keep them from adding a three-stall, two-story garage to their home. Garrison is of the opinion the addition would "impair an adequate supply of light and air" to his 5200 sq. ft home in St. Paul. The neighbors are Paul Olson, former CEO of Blandin Foundation in Grand Rapids, MN, and his fiancé who is one of the many Lori Andersons in Lake Wobegon. They are now in negotiations via third parties at a judge's request.

Sarah-Maud Weyerhauser Sivertsen, the last surviving granddaughter of MN lumber magnate Frederick Weyerhauser, died at 100 in her St. Paul home last Saturday. Sarah-Maud and her second husband, Robert Sivertsen, were most instrumental in financing the start-up of the St. John's University radio station's early network which Bill Kling and others, including Garrison Keillor and his Prairie Home Companion, built into Minnesota Public Radio and many related enterprises. Fred Weyerhauser, who in 1998 was declared the eighth richest American of all time, would have been proud of his grand-daughter's foresight.

Elsewhere in Lake Wobegon, there was Republican delight and Democratic disappointment with a Federal Transportation Safety Board finding that 40-year old structural design failure was a cause, not necessarily the proximate cause, of the 1-35W bridge collapse last August. Supposedly that lets our MNDOT and Governor off the hook because they weren't around in the 1960s. But accountability demands that those of us who use these public transportation facilities must be able to rely on whoever owns and maintains I-35W - and thousands of other bridges in MN - to assure our safety.

©2008 Steve Sack, Star Tribune

Northwest Airlines was founded in St. Paul in 1927 and has been THE economic powerhouse in this community ever since. Locals have paid to keep the airline here through fees, through taxes, through subsidized loans, and through 21 to 40% higher average fares out of MSP. This includes $380 million in a federal tax subsidy which is money NWA owed the IRS and dumped in bankruptcy. So the news that NWA is talking to its former CEO Richard Anderson at Delta about a merger is a little unsettling. Folks I know who travel a lot much prefer a merger with Continental because of route structure, relationships, and deep commitment to its customers.

Good news from Lake Wobegon is that UMN Gopher men's basketball coach Tubby Smith is about to win his 400th basketball game. Other good news is that the St. Paul Minnesota Wild hockey team is playing its 300th straight sold-out NHL hockey game - a tribute to Senator (former Mayor) Norm Coleman, owner Bob Naegele, and GM Doug Risebrough who said it would happen when so many others in the area said it couldn't. They sell 16,000 season tickets in an 18,000 - seat Excel Energy Center and have 7,000 on the waiting list. Naegele this week sold his interest in the Wild to Craig Leipold, a hockey fanatic from Racine, Wi who married an heir to Johnson wax and invested in the Nashville Predators before joining the Wild.

Bad news from Lake Wobegon is that we are in a recession. So says Minnesota's chief economist Tom Stinson. He has the facts to prove it and they aren't pretty. No one expects the President of the U.S. to admit to a national recession, so the fact that Stinson will do it makes us wonder why. And what can we do about it if anything.

2007 BOOKS THAT MAKE A DIFFERENCE
The one that will change your thinking as it is changing policy-makers, is The Omnivore's Dilemna by Berkeley Journalism professor Michael Pollan. Agriculture, trade, health, energy, land use, and environmental policy are all impacted by this intriguing trip from farm to farm across America.

For those who wonder why change, vision, leadership, experience and all these character traits take precedence over programs and plans in the primary elections, I recommend Ron Brownstein's Second Civil War. A Pulitzer finalist in 1996 and 2004 for his election coverage from the LA Times, Brownstein is a likely winner this year for this penetrating analysis.

If I am right about the economy driving public opinion this year and policy-making next year, Supercapitalism, by former Clinton Labor Secretary and current Berkeley professor Robert Reich explains, in a way traditional liberals cannot, what's gone wrong with capitalism and democracy and what can be done to strengthen both.

No less an authority than David Leonhardt of the New York Times says that New America Foundation's Shannon Brownlee may have written the best "must read" book on the American healthcare "system." Overtreated: Why too much medicine is making us sicker and poorer and its author is apparently playing to packed houses at it did at the UST Opus College of Business in November.

In 2008 those of us into health policy reform should expect to read former Senate Leader Tom Daschle's Critical: What We Can Do about the Health Care Crisis; former cabinet secretary (in more administrations than anyone) George Schultz will publish Putting Our House in Order: A Guide to Social Security and Health Care Reform, his first effort at health policy reform, in April; Harvard's Clayton Christianson, whose academic specialty has become "disruptive technology," will apply his expertise to the health care system in what is likely to be the "must read/must hear/must pay" book of the year.

"When the tide goes out, you find out who was swimming naked and who dumped garbage on the beach."
- Alex Stenbach, Minneapolis mortgage banker and blogger, in reference to most economic crises caused by failures in financial markets. The tide is not predictable and when it goes, it goes fast. The swimmers and the garbage dumpers are caught "with their pants down," so to speak. Ocean tides are much slower. Their detritus more predictable. Sea shells being the best example. So the social implications of new financial markets and "new" economies.

"People are looking for a presidential candidate who reminds them more of the guy they work with rather than the guy that laid them off."
- Mike Huckabee, on The Tonight Show with Jay Leno

"You have a woman running to break the highest and hardest glass ceiling. I don't think either of us wants to inject race or gender in this campaign. We're running as individuals."
- Senator Hillary Clinton to Tim Russert, January 12, 2008.

"The interesting split (between Clinton and Obama) is not between the feminist and civil rights Old Bulls, its between the establishments of both movements, who emphasize top-down change, and the younger dissenters who don't. This dispute is going to be settled by the rising, and so far ignored, minority group. For all the current fighting, it'll be Latinos who end up determining who gets the nomination. At last, a bridge to the 21st century."
- David Brooks, New York Times, January 15, 2008

"For the last six years, the economy has been growing at a pretty healthy clip. The problem now isn't the level of growth, but how little of it is filtering down to the middle class. In today's economy, middle-class incomes have almost no margin for error. For much of the last 35 years, the incomes of most workers have been growing far more slowly than they once did. In the current expansion, which started in 2001, the median weekly paycheck of workers actually fell 1 percent, once inflation is taken into account, according to the Labor Department. Keep in mind that middle class families have received not only modest raises in recent years; they have also received smaller reductions in their overall federal tax rates than high-income families have."
- David Leonhardt, New York Times, January 16, 2008

Tick, Tock - Tick, Tock
"At the breakfast table several years ago, one of my children asked what was the longest day in the year. I assumed school was teaching about the seasons, including the summer solstice, and that he was trying out his new knowledge.

I said, 'June 21.' 'Nope...the day before Christmas!' And so the holiday associated with the winter solstice, the shortest day, becomes the longest.

It's that way with time, isn't it? The hands of the clock tell us very little about our experience of time, except that it continues to fly and that for us, time is not in infinite supply.

Yet even when time seems to drag, the time of our lives is moving swiftly. Let us, therefore, pour ourselves into our time even as Christ emptied himself into time, the outset of which event we celebrate at Christmas.

May the ongoing relevance of that event in time mark every day of our lives."

- By the Rev. Donald Meisel, D.D., Ph.D., Seeing Through The Cross

"Her response to happenings and circumstances is always so wonderfully apt...Of course, she enjoys the inestimable advantage of never looking at TV, listening to radio, or reading the newspapers, and so can have a clear notion of what is really going on in the world; the siren- voice of consensus does not reach her."
- Malcolm Muggeridge on Mother Teresa in his "A Spiritual Pilgrimage' written in 1987, three years before his death at age 87

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