A Call For a New Primary Care Society

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.

Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.

These impacts have been catastrophic not only for primary care physicians, but for patients, who are routinely exposed to unnecessary medical risks, and for purchasers, who for decades have borne an unnecessarily onerous economic burden. It seems unlikely that these groups’ prospects can improve without a meaningful change in the strategy pursued by primary care’s leading organizations.

The State of Primary Care

Primary care is a demoralized medical specialty. Recent Medscape data show that, on average, generalists make about half what their specialist colleagues do. Other surveys are more pronounced. A 2010 Graham Center study calculated a $3.5 million career income difference between primary care and specialist physicians.

None of this is lost on medical students. Faced with skyrocketing training debt, few now opt to make significantly less, so the percentage selecting primary care has plummeted. Between 1990 and 2007, the percentage of internal medicine residents becoming generalists dropped by 80%.

Then there’s office visit duration. Lower reimbursements and changing health status dynamics have translated to significantly shorter visits with more complex patients. Complicated patients who warrant thorough work-ups will often require more time than is allocated, meaning that they may cost more than they generate. This at least partly explains why specialty referrals have doubled in the last decade. Traditional primary care patients have increasingly become specialty cases, exposed to excessive specialty visits, diagnostics and procedures.

The growing inability of primary care physicians to succeed in private practice has precipitated a wholesale flight to health systems, where many doctors become “feeders” for outpatient and inpatient services. In 2010 the Medical Group Management Association reported that the share of practices owned by physicians had dropped from two-thirds to half in only three years. That trend continues.

Many of these dynamics are rooted in the relationship between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association’s specialist-dominated Relative Value Scale Update Committee (RUC), which formulates recommendations for the value of medical services. This controversial and opaque process – former CMS Administrator Tom Scully recently described it as “highly politicized” and “not objective” – has overvalued specialty services at primary care’s expense, and inhibited primary care’s ability to hold specialty care accountable. Still, despite the RUC’s ongoing disregard for primary care’s interests and value, primary care societies continue to argue that “being at the table” means having a say.

The Need for A New Organization
Primary care’s second rate status in the US results from organizational structures that are not constituted to cope with American health policy’s power dynamics. Generalists stand no chance against a far larger, wealthier and more influential health care industry that can field billions of dollars to promote ever-increasing health care spending.

At the same time, no single organization represents primary care professionals’ overarching interests. Nor is there one that aggregates their many groups (and their collective influence) to effect policy change that values primary care as medicine’s foundation. Generalists have diluted their modest influence, which derives from about 30 percent of American physicians, by scattering loyalties among six different medical societies. Several of these societies also advocate for sub-specialist interests that, contrary to their protests, may conflict with those of primary care.

Nor does primary care’s policy agenda meaningfully acknowledge that it isn’t only about them. Within health care, primary care’s competitors are the rest of the health care industry, comprising nearly one-fifth of the US economy. But outside the industry, one group, non-health care business, makes up the other four-fifths. Much larger and more influential than health care, non-health care business has suffered significant harm from American health care’s egregious inflation and waste. It should be primary care’s most powerful ally.

A new primary care society could reinvigorate the debate about what kind of health system our children will inherit. It could broaden primary care’s power base by being inclusive, acknowledging non-physician professionals and other groups in service to primary care’s larger missions, unifying it as a specialty, and embracing a 21st century vision of what medicine can be. Support from non-health care businesses and institutions could extend that power base further, re-establishing primary care in policy as the basis of a medical system built around evidence, appropriateness, efficiency, quality, safety and value.

A new primary care organization would not replace existing medical societies. Instead, it would become strong by convening and emphasizing other societies’ most positive attributes, providing a counterweight to the sub-specialists’ perspective. Ironically, the exemplar for this approach is the American Medical Association, which brought together all medical societies in its House of Delegates, then evolved to advocate against primary care and for specialists. This fact is evidenced by its insistence on disproportionate sub-specialist voting representation on the RUC, American health care’s most influential federal financial advisory panel.

Primary care is in decline because it is fragmented, inwardly focused, and structurally incapable of protecting its mission and value in the face of far larger forces. Within the ferocious world of influence, a new society would seek to drive policy that invests in America by investing in primary care’s capabilities.

Success will require primary care to amass much more power, pooling its resources, aligning with other more powerful groups and developing a unified voice under the umbrella of a new society. Only then could primary care’s value be feasibly reestablished within American health care.

Brian Klepper, PhD, is an independent health care analyst, Chief Development Officer for WeCare TLC Onsite Clinics and the editor of Care & Cost. His website, Replace the RUC, provides extensive background on the issue.

23 replies »

  1. Primary care MDs are logical allies with doctors of chiropractic, who provide another aspect of primary care, also underfunded and under-respected by the system. But primary care MDs, acting against their own best interests, more typically align politically with specialist MDs.

  2. “not being able to take a salary for up to 6 weeks while CMS sorts out congress’s foolishness.”

    “The ever increasing pre-authorization hurdles (multiple faxes and 30 min phone calls to get a $4 drug approved).”

    “The threat of an RAC/Medicaid audit is always there – they can ruin you over intrepretation of coding that even government coders have been shown to be unable to agree on”

    “I get blamed for what ultimately is the result of the policies of the insurance they carry. I see this getting worse moving forward, not better.”

    Why don’t you go all cash? Here is an example of one doc in Apex NC.

    If you want you can hear his second interview on America Public Media Show – The Story, with Dick Gorden. You can lsten to a Podcast here: http://thestory.org/archive/The_Story_7212.mp3/view

    He takes cash as well as a monthy fee if his patient prefers. Posts all his prices and makes a good living. Even insured go to him and submit their own claim.

  3. I have to agree with Brian here- the primary care societies have been left in the dust when it comes to advocating for the success of its members- especially as that success relates to financial gain and job satisfaction. The RUC is just one example of how our leadership failed to (and continues to fail to) identify a critical flaw in driving fair reimbursement.
    As a primary care doc who too left his extremely busy practice due to increasing demands and growing headwinds that made success simply untenable, I read the posts from Dr. Mike with a sad affirming nod of agreement.
    The lion-share of reform goals have primary care at the center. It is a shame that our ranks have so badly atrophied just when the industry is beginning to realize their value. It’ll take years for primary care to regain its past leadership role in the care delivery value chain. Lets hope the new enthusiasm for family physicians and general internists will be enough to turn things around.
    I agree with Brian, perhaps the best approach is to start with a brand new society with fresh and bold leadership such that it is obvious we are not in for more of the same.

  4. Thanks. You said I expect more than a few patients to lose employer sponsored insurance and in the long run I believe that is correct. That’s part of Dr. Goldsmith’s optimism — that when the consumer becomes the individual patient rather than the company for which he works the dynamic driving both health care and insurance will be changed as a result.

    One long-standing policy aim of most experts (which nobody wants to speak aloud) is the goal of uncoupling health care from employment.
    One of the arguments against ACA has been that employers whose employees are not insured will be obliged to shell out $2000 each — the famous fee/ fine/ tax/ charge (take your pick) — which is seen as a “disincentive” to furnish group insurance. (Well, hello! Like the high and rising premiums are not already a disincentive?) The argument is that it would be cheaper to “pay the tax” and drop group insurance.


    That may or may not be a valid argument, since that “fine” only applies if the employee (a)refuses to get any insurance at all and (b) earns less than 130% of FPL.

    In any case two points drive the uncoupling of employment and health care.
    1. American companies saddled with even a portion of the group insurance burden are at a competitive disadvantage in a global economy in which other countries furnish universal health care — even if it is inferior it is not a drain on business.
    2. When individuals have more skin in the game than token co-pays and lower premiums tax-advantaged for the employer, they will become more conscientious about health insurance. Plus, individual insurance is not an employment handcuff. Many people are locked into jobs because they are terrified of losing their insurance.


    The open questions are 1) Will there be states that refuse to expand Medicaid? 2) Will younger patients chose to pay the penalty and remain uninsured?

    Good questions. Bobby Jendal already said Louisiana wasn’t gonna plarticipate. His people will wonder where the federal dollars are next time that state has a disaster, and many will figure out sooner than that that he’s cutting off THEIR noses to spite HIS face.

    As for the other, Ezra Klein said in March…

    the Affordable Care Act doesn’t include an actual enforcement mechanism for the individual mandate. If you refuse to pay it, the IRS can’t throw you in jail, dock your wages or really do anything at all. This leads to one of the secrets of Obamacare: Perhaps the best deal in the bill is to pay the mandate penalty year after year and only purchase insurance once you get sick. To knowingly free ride, in other words. In that world, the mandate acts as an option to purchase insurance at a low price when you need it. For that reason, when health-policy experts worry about the mandate, they don’t worry that it is too coercive. They worry it isn’t coercive enough.

  5. Happy to respond
    -Patients seem to like the Medicare Advantage plans – they are signing up in droves. They are surprised however when they start having to deal with pre-authorizations and denials. It seems most of the patients end up on the same companies Part D plan as well and suffer the consequences of a severely restricted formulary – seemingly more restricted than stand alone part D plans. I really have no idea as to whether all of this translates into savings or expense for Medicare – but there clearly is some rationing going on just as in most managed commercial plans. I can see at least some of the policies on the exchanges looking a lot like an advantage plan, and paying about the same as well.
    -Yes Exchanges will be commercial plans but I highly doubt they will be offered to docs under existing contracts – the companies will come round with new contract to sign and you can count on the rates being lower than the policies they replace. Replace as in I expect more than a few patients to lose employer sponsored insurance. The minimum standards are the problem – they are too generous IMHO. Generous benefits combined with government price controls equals pressure on the one remaining weak spot – the contract with the docs.
    Employers have started to ask for and receive better value from both their insurers and the docs the insurers contract with. I am not aware of any significant impact from the individual market – all the movement is in employer sponsored insurance and the employers themselves seem to be the ones driving this – but I could be wrong as it is not something I monitor closely. Whether such initiatives continue into the exchanges will probably vary state by state depending on how forward thinking the custodian of the exchange is. But improvements in outcomes and costs can still translate into pressure on the docs to accept less, although maybe there will be in some places attempts to bribe the docs into better behavior, although the history of such endeavors would suggest to me that over time the bribes disappear but the good behavior (and extra work) is expected to remain. But keep in mind I tend to be a cynic.
    -I too wonder what outfits like Qliance are thinking about now. I suspect this also will be a state by state thing with some states doing a better job of getting everyone onto the insurance they need and thus fewer cash paying patients remaining. The open questions are 1) Will there be states that refuse to expand Medicaid? 2) Will younger patients chose to pay the penalty and remain uninsured? No one knows yet. It will be sad if we lose the very real benefits of the direct pay model just as we are learning how to make the model more applicable to a greater variety of patients – patients who are on the whole extremely satisfied with the care they receive in direct pay practices. Containing costs will be more difficult if this model is lost.
    -Stage 2 final rule is not out. Preliminary info suggests that stage 1 requirements continue but are more stringent (higher percent needed for each item and optional items are now mandatory). Stage 2 adds things like you must have received and responded to email from patients, patients must have downloaded information from your portal, more quality measures to report, more security requirements, more electronic exchange of information between incompatible systems, more decision support pop-ups, etc. Each item has merit in and of itself, but without a change in the coding and billing system we labor under now, the sum total of the requirements is untenable for small practices who cannot asorb the cost of hiring the staff necessary to achieve compliance.

  6. Thanks for your candor. It seems you have found a better alternative anyway which is in a much-need area. (From what I’ve heard, be careful of burnout. The substance abuse people can be to medicine what fast food and social work are to their respective fields. Lots more young workers because of burnout.)

    I have some general questions and since you won’t be grinding an ax your opinion is valuable.

    ►What difference(s) do you see between traditional Medicare and Medicare Advantage (which is entirely non-governmental)?

    ►You indicated that the Exchanges were going to be different from the commercial policies. My impression is that the Exchanges will be commercial policies but will have to meet minimum standards being formulated even now, but in compliance with the new legislation.

    I took time, believe it or not, to listen to the Jeff Goldsmith talk (posted by Matthew Holt) and he seems to be of the opinion that the future of private insurance will be better due to becoming more consumer-driven. Joe Flower, a couple of posts before, is also optimistic. These guys make a strong case that the present is a muddle but the future will be better — with or without ACA — with improvements in both outcomes and costs. Do you see any merit in either of these opinions? And if not, where are they wrong?

    ►You mentioned cash patients paying Medicaid rates. Will ACA in effect kidnap them from you? Or is there a subset of the population who may continue to pay cash, either because they may be unaware of their eligibility, don’t want the hassle or just “don’t want to be on welfare”?

    ►I appreciate that this is a limited forum, but can you explain briefly the difference between Stage 1 and Stage 2 of Meaningful Use?

    If you don’t care to mess with any of this, I understand. Thanks again for a thorough reply.

  7. It is a matter of being worn down in private practice from the usual suspects – The nearly annual SGR debacle – not being able to take a salary for up to 6 weeks while CMS sorts out congress’s foolishness. The ever increasing pre-authorization hurdles (multiple faxes and 30 min phone calls to get a $4 drug approved). The process of going through meaningful use has been illuminating – stage 1 is a piece of cake compared to what I see coming in stage 2, and it is obvious to me that I cannot sustain even stage 1 meaningful use year after year and will face the penalties instead (up to 5%). My profit margin is too thin to tolerate a 5% cut. The threat of an RAC/Medicaid audit is always there – they can ruin you over intrepretation of coding that even government coders have been shown to be unable to agree on.
    It can still be rewarding working with patients but increasingly I get blamed for what ultimately is the result of the policies of the insurance they carry. I see this getting worse moving forward, not better. And I just don’t see how the insurance policies offered on the exchanges can pay as well as the commercial policies and cash payments they will replace. I charge cash patients essentially medicaid rates but benefit from the lack of overhead insurance causes. Many of these patients will get medicaid now – good for them, not so good for me. I survive in practice only because I have enough commercial payers that pay higher than CMS rates – I see the delta shrinking over time, and not because CMS rates are going up.
    No one can deny that these are some of the reasons driving small practices into the arms of large organizations like hospital systems. Some even celebrate this transition, seemingly unaware of the consequences that arise from monolithic health care. I personally cannot see my self working for a large system. I see so few that truly understand primary care – it’s the specialists that pay their bills afterall. I have thought about an ideal micro practice (google it) but the uncertainty of the next two to three years makes it seem foolish to make a committment to starting such a transformation.
    So, what am I doing instead? I have stumbled into working for a mental health clinic doing basic psychotropic management and have recently started doing substance abuse treatment including suboxone detox. It has been extremely rewarding to see the transformed lives. I now have an opportunity to join another mental health clinic doing the same thing. At both locations I am a contract employee – I have zero overhead, the hourly wage is more than what I can make at my FP clinic. I have also been approached by a FQHC to purchase my practice and it seems likely that if that works out I will do some contract work with them in pain management and substance abuse treatment. My 20 years in family practice may be coming to an end. I will work less for about the same pay in a practice style that I can sustain for many more years.
    Oh and I am not anti-NP. I employ two right now. It is just that I see a disturbing trend in that unexperienced new RN grads are going straight into NP programs. The programs haven’t changed – but there is a world of difference between an NP with 10 years prior experience in the ER or ICU and one with zero years of experience. You can’t tell me you know how to treat out-patient pneumonia until you have seen the pneumonia patient in the ICU. Woe to the patients who have as their providers people who don’t know what they don’t know.

  8. “But I was misled and betrayed by the society I had hoped to serve.”

    Maybe you can be more specific about the misleading betrayal?

  9. What a painful comment. And even more painful conclusion. (I’m presuming that FP means family practice, not financial planner — though that may not be a bad alternative.)

    So what is your Plan B? I’m only a bystander and it’s none of my business, but since this is a public forum you must find it okay to have a conversation about that. Without giving away any secrets, perhaps you can give out a list of alternatives. One that comes to mind is teaching (medical topics, of course — more NPs, nurses, techs). Another is “hospitalist” or other institutional employee not burdened with so many of the non-medical burdens of a smaller practice.

    I have seen other comments from you and you have a lot to contribute.

  10. It’s bye bye primary care for this FP doc. I could have done so many different things with my life – I was better at the educational system than most of my peers – but I chose FP even before I finished college because I thought that being involved in the health of the whole person and their family would make a difference. But I was misled and betrayed by the society I had hoped to serve. I’ll still be in health care but with a narrower focus and a fraction of the headaches. AAFP and AMA can go to you know where. I’m sure my patients will do just fine with their NPs (they have 400 hours of FP clinic experience after all – I’m sure my 12,000 hours of clinical training were just overkill).

  11. Rope-a-doped by dopes?
    Does ‘health care’ oppression = ‘voodoo’ magic justice?
    Look harder my dear friends. If you were a previous attorney, now president, wouldn’t you create a whole new ‘health care’ market for all of your colleagues to practice in if you could? Or, God forbid, let guns walk and chaotic bills increase if it grew your business? This isn’t rocket science. These are legal malpractice issues. Oppressive corruption at it’s ‘finest.’
    The attorney clan will now forever benefit from the recent Supreme Court Health care decision, and remain hidden behind our judiciary and big greedy corporation/banks/etc.. And we the people will forever pay for it all, and forever suffer from it all. Or else risk going to jail.

    Congress can Constitutionally REDRESS anything. Yet, they choose to magically ‘Repeal’ so that they don’t have to get their slothful hands dirty.

    The bad seeds have become the head of America, and officials have let we the people become the tail. They produce nothing, but feed off of our production. In fact, they exploit our production for their own benefit. Remember the ‘Ants’ movie. We’re the ants, they are the big bad locusts feeding off of us.
    They are the 0.3%-ers hidden behind each 1%-er. We the people are the 98.7%-ers squashed by the 1.3%-ers!
    WE THE PEOPLE with Upright U.S.A. and citizens for scientific justice are now fighting against corruption, vanity & greed with a new deceleration of independence and the fear of God. (discriminated parents, minorities and inmates are welcome to join us.)
    (See THE REAL HEAD OF GOVERNMENT at uprightusa.org under the link: LEGAL DEVELOPMENTS and then the link THE REAL THREE BRANCHES OF GOVERNMENT.)

  12. Yes, yes and yes. Therefore, we absolutely cannot let matters of this magnitude be governed by professional politicians (mostly manipulators.) Why not scientific studies of these issues properly that could only resolve these problems in a win-all solution? Even variable solutions if need be. Not deadbeat ‘laws’ in a deadbeat system governed by a deadbeat practice. It’s stupid for accepting that people who bear false witness for a living have any control over those who have to suffer for them. Therein lies the answers. It can really come for no other place less deceptive & inexperienced. Issues of this magnitude that effects everything and everyone needs right voice. Not deceptions games.

  13. I agree, wholeheartedly.

    There are so many issues to address here, but I will point to what I think is the basic topic. This is obviously seen from the outside (Europe), but I worked ten years with hospitals, doctors and patients in the US.

    Discussing the verdict in the Supreme Court is like giving Tylenol to patient with a severe pneumonia.

    What is so hard to understand for the other Western countries, is the fact that in the US you use an enormous amount of money on medical care (18.2 of the GDP) because the basically privatized health care system. (All other Western countries use between 9 and 12 %) The prizes of fairly simple procedures are in the US extremely more expensive than in the rest of the world. The physicians, the “Hospitals” and the insurance companies all get rich and the poor gets poorer. And, at the same time, 46.2 million of the populace are without any kind of medical insurance.

    So, what do you do about it?

    Why is it so impossible to realize that the only way to secure a just health care system that will secure everybody what they need, is through a program administered by the US

    Whether you are a busdriver or the CEO of a major bank, in most countries you will get what you need, even a new hart or a bypass or heavy treatment for cancer. Not so in the US. Only those with the most expensive insurance will get that.

    So, the Super Power may not be as Super as they think they are…….. Spending enourmus sums on completely hopeless wars, 15.3 % of the populace lives under UN’s level of poverty, the lowest score on illitaricy etc etc

    That may seem out of order, but there is a point here. Why do the American people accept the money spent and the suffering of those wars, when at the same time accept that sick people are not treated and there are a lot of premature deaths…….

    Do the American people accept that poverty as such legitimize this appaling situation?

  14. If the Supreme Court has decided the Obama Care is really a tax, then isn’t the law null and void, because it did not pass by a 2/3 majority, as required for all new taxes? It was funny watching President Obama’s interview chastising the interviewer for looking up the definition of tax in the Miriam Webster dictionary, and accusing him of stretching it. It was like watching President Clinton saying, “it depends on what your definition of “is” is.”

  15. One of the reasons primary care is not supported politically is that the benefits of prevention and early intervention are not included in the Congressional Budget Office’s calculations. Every politician worships at the alter of CBO scoring. Primary care lobbyists need to pressinng why CBO scoring is misguided and misleading. For example, the 30% of funding to be allocated to prevention under ACA only includes the cost of prevention programs not the offsetting cost reductions. Also, there was no projected cost increases under ACA is we never address childhood obesity. CBO just does not work when it comes to health care and primary care is its victim..

  16. I would agree with J Irvine that the onslaught of potential patients tied to the diminished number of primary providers is an arithmetic nightmare. Going even further, reimbursing primary docs based on value, outcomes satisfaction and quality demands more time and effort per patient which further impedes access.

    It is going to take a total re-engineering of how we deliver primary care with an increased use of nurses, mid-level providers, wellness practitioners etc. acting as frontline care givers (as is done in many countries). Such will leave the higher trained physicians to manage complex conditions, population health and specialized work-up + referrals.

    I stil contend that the value of any one physician (specialist, primary etc.) is equal with regard to benefit, intellect etc. and that reimbursement should be based on work-hours, call hours, risk and total length of training.

  17. Interesting post. I’ve followed your campaign with interest over the last year. If anything the changes under the first round of health reform look as though they will put even more pressure on primary care docs (add twenty million new patients to the system – many of whom have lived outside the health care box for years – expect a serious, serious set of problems that haven’t been talked about much as the system transitions. ) I’m guessing a lot of docs will agree with you …

  18. …primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues.

    This is the clearest statement of the core challenge to health care as I have read. The sooner primary care returns to the driver’s seat the quicker most of the other challenges will diminish — starting with costs, otherwise known as health care inflation.

  19. Here’s the major hidden problem:

    Does ‘health care’ oppression = ‘voodoo’ magic?

    Look harder my dear friends. If you were a previous attorney, now president, wouldn’t you create a whole new ‘health care’ market for all of your colleagues to practice in if you could? Or, God forbid, let guns walk if it increased your market share and market value? This isn’t a political issue. Politics has become a deceptive rouse. These are legal malpractice issues. Oppressive corruption at it’s ‘finest.’

    The attorney clan will forever benefit from the recent Supreme Court Health care decision. And we the people will forever pay for it all, and suffer from it all. Or else risk going to jail. Or else Doctors fighting with insurance companies. Or else insurance companies & doctors fighting with patients. (Which all helps their judicial business.) A win-all for them. But a loose-all for the rest of us. They have become the head, we have let ourselves become the tail. They produce nothing, but feed off of our productions. In fact, they exploit our production for their own gain.

    0.3%-ers controlling 99.7% of the rest of the population before and after any election. Whatever it takes to make them a buck or a big ego I guess?! Does one man’s ego = we the people’s pain?

    Citizens for an Upright U.S.A. fight against corruption.

    (See the real Head of Government at uprightusa.org under the link: LEGAL DEVELOPMENTS and then the link THE REAL THREE BRANCHES OF GOVERNMENT.)