There's a lot of factors that you can attribute to the underperformance, ... it becomes harder and harder to show top-line revenue growth as your customer base gets bigger and bigger.

It's been a little too easy to attribute it to managed care. There are a number of factors here that could explain overcrowding and increases in the numbers of people in certain periods going to the emergency room.

It's been a difficult record and it's like sometimes the harder something is, then the more valuable it becomes,

I'll admit it's a little surprising, but all the factors were enough to push New Jersey into the top five this year. The economy is the bulk of the state's strength, but New Jersey has other factors going for it, such as a 95 percent graduation rate among high school seniors.

As it gets harder and harder to break through with messaging, what becomes important is the realness of a message in terms of being relevant and having impact on someone's purchasing.

With all these factors in play, scale becomes important in order to compete with these large marketplaces.