A Socialized Health Care System Requires Population Control and Impeccable Registries

In a nationalized health care system, you need to know who is who – otherwise the system could never be able determine who is entitled. The structure depends on how the system is created and designed, but with a nationalized health care system you will be tracked by the state where you reside and how you move in a manner that is unseen in America. The nationalized health care system becomes a vehicle for population control.

If you leave the United States and are no longer a resident of the state, even if you are a citizen and might maintain a driving license, you will have to report immediately if you want to avoid the 13% health care tax. I use the number 13% as it is in Sweden to exemplify the actual tax pressure that is laid upon you for the nationalized health care.

Let’s say you moved and you do not want to pay the 13% tax for services you do not receive, can receive, or want to taken out from the tax roll. The mammoth entity has no interest to let you go so easy. You will end up having to reveal your private life – partner, dwellings, travel, money, and job to prove your case that you have the right to leave the public health care system and do not need to pay the tax. If you have to seek an appeal, your information could be a part of administrative court documents that are open and public documents. As soon as you return to the United States, you will be automatically enrolled again and the taxes start to pile up.

Public universal health care has no interest in protecting your privacy. They want their tax money and, to fight for your rights, you will have to prove that you meet the requirements to not be taxable. In that process, your private life is up for display.

The national ID-card and national population registry that includes your medical information is a foundation of the nationalized health care system. You can see where this is going – population control and ability to use the law and health care access to map your whole private life in public searchable databases owned and operated by the government.

By operating an impeccable population registry that tracks where you live, who you live with, when you move and your citizen status including residency the Swedes can separate who can receive universal health care from those not entitled. The Swedish authorities will know if you have a Swedish social security number, with the tap of the keyboard, more information about yourself than you can remember. The Swedish government has taken sharing of information between agencies to a new level. The reason is very simple – to collect health care tax and suppress any tax evasion.

It is heavily centralized and only the central administration can change the registered information in the data. So if you want to change your name, even the slightest change, you have to file an application at a national agency that processes your paperwork. This centralized population registry makes it possible to determine who is who under all circumstances and it is necessary for the national health care system. Otherwise, any person could claim to be entitled.

To implement that in the United States requires a completely new doctrine for population registry and control. In an American context that would require that every existing driving license had to be voided and reapplied under stricter identification rules that would match not only data from Internal Revenue Service, state government, municipal government, Social Security Administration, and Department of Homeland Security but almost any agency that provides services to the general public. The reason why a new population registry would be needed in the United States is the fact that lax rules dating back to the 1940s up until the War on Terrorism, and stricter identification criteria following 9/11, has made a significant percentage of personal information about individuals questionable.

If America instead neglects maintaining secure records, determining eligibility for public health care would not be possible and the floodgates for fraud would open and rampant misuse of the system would prevail. This would eventually bring down the system.

It is financially impossible to create a universal health care system without clearly knowing who is entitled and not. The system needs to have limits of its entitlement. A social security number would not be enough as these numbers have been handed out through decades to temporary residents that might not even live in the United States or might today be out of status as illegal immigrants.

The Congress has investigated the cost of many of the “public options”, but still we have no clear picture of the actual realm of the group that would be entitled and under which conditions. The risk is political. It is very easy for political reasons to extend the entitlement. Politicians would have a hard time being firm on illegal immigrants’ entitlement, as that would put the politicians on a collision course with mainly the Hispanic community as they represent a significant part of the illegal immigrants. So the easy sell is then that everyone that is a legal resident alien or citizen can join according to one fee plan and then the illegal immigrants can join according to a different fee structure. That assumes that they actually pay the fee which is a wild guess as they are likely to be able to get access to service without having to state that they are illegal immigrants.

It would work politically – but again – without an impeccable population registry and control over who is who on a national level, this is unlikely to succeed. The system would be predestined to fail because of lack of funds. If you design a system to provide the health care needs for a population and then increase that population without any additional funds – then naturally it would lead to a lower level of service, declined quality, and waiting lists for complex procedures. In real terms, American health care goes from being a first world system to a third world system.

Thousands, if not a million, American residents live as any other American citizen but they are still not in good standing with their immigration even if they have been here for ten or fifteen years. A universal health care system will raise issues about who is entitled and who is not.

The alternative is for an American universal health care system to surrender to the fact that there is no order in the population registry and just provide health care for everyone who shows up. If that is done, costs will dramatically increase at some level depending on who will pick up the bill – the state government, the federal government, or the public health care system.

Illegal immigrants that have arrived within the last years and make up a significant population would create an enormous pressure on a universal health care, if implemented, in states like Texas and California. If they are given universal health care, it would be a pure loss for the system as they mostly work for cash. They will never be payees into the universal health care system as it is based on salary taxes, and they do not file taxes.

The difference is that Sweden has almost no illegal immigrants compared to the United States. The Swedes do not provide health care services for illegal immigrants and the illegal immigrants can be arrested and deported if they require public service without good legal standing.

This firm and uniform standpoint towards illegal immigration is necessary to avoid a universal health care system from crumbling down and to maintain a sustainable ratio between those who pay into the system and those who benefit from it.

The working middle class that would be the backbone to pay into the system would not only face that their existing health care is halved in its service value – but most likely face higher cost of health care as they will be the ones to pick up the bill.

The universal health care system would have maybe 60 million to 70 million “free riders” if based on wage taxes, and maybe half if based on fees, that will not pay anything into the system. We already know that approximately 60 million Americans pay no taxes as adults add to that the estimated 10-15 million illegal immigrants.

There is no way that a universal health care system can be viably implemented unless America creates a population registry that can identify the entitlements for each individual and that would have to be designed from scratch to a high degree as we can not rely on driver’s license data as the quality would be too low – too many errors.

Many illegal immigrants have both social security numbers and driver’s licenses as these were issued without rigorous control of status before 9/11. The alternative is that you had to show a US passport or a valid foreign passport with a green card to be able to register.

Another problematic task is the number of points of registration. If the registration is done by hospitals – and not a federal agency – then it is highly likely that registration fraud would be rampant. It would be very easy to trespass the control of eligibility if it is registered and determined by a hospital clerk. This supports that the eligibility has to be determined by a central administration that has a vast access to data and information about our lives, income, and medical history. If one single registration at a health care provider or hospital would guarantee you free health care for life and there is no rigorous and audited process – then it is a given that corruption, bribery, and fraud would be synonymous with the system.

This requires a significant level of political strength to confront and set the limits for who is entitled – and here comes the real problem – selling out health care to get the votes of the free riders. It is apparent that the political power of the “free” health care promise is extremely high.

A promise that can not alienate anyone as a tighter population registry would upset the Hispanic population, as many of the illegal immigrants are Hispanics – and many Hispanics might be citizens by birth but their elderly parents are not. Would the voting power of the younger Hispanics act to put pressure to extend health care to elderly that are not citizens? Yes, naturally, as every group tries to maximize its own self-interest.

The risk is, even with an enhanced population registry, that the group of entitled would expand and put additional burden on the system beyond what it was designed for. That could come though political wheeling and dealing, sheer inability from an administrative standpoint to identify groups, or systematic fraud within the system itself.

We can speculate about the outcome but the challenges are clear. This also represents a new threat to the privacy and respect for the private sphere of the citizenry as an increased population registration and control empowers the government with more accurate information about our lives and the way we live our lives. Historically, has any government when given the opportunity to get power taken that opportunity and given that power back to the people after the initial objective was reached? Governments like to stick to power.

To ensure the universal health care system is designed to function as intended it, would require procedures that would limit fraud, amass a significant amount of personal information, have access to all your medical data, and also determine who you are beyond any doubt. Just to be able to determine if you are entitled or not and, track the expenditures you generate.

The aggregation of these data could also open the floodgates for any data mining within these data under the pure excuse that it would help the universal health care system to better “serve you” and lower the costs.

To lower the costs also means to identify which procedures should not be done on which type of patients as it is not viable based on the government’s interest to optimize your productivity under your life cycle. The collection of data has a tendency to look inviting and good when we start to collect it but aggregated data and personal information creates a deep intrusion in our privacy.

Who’s Paying For Health Care?

America spent 17.3% of its gross domestic product on health care in 2009 (1). If you break that down on an individual level, we spend $7,129 per person each year on health care…more than any other country in the world (2). With 17 cents of every dollar Americans spent keeping our country healthy, it’s no wonder the government is determined to reform the system. Despite the overwhelming attention health care is getting in the media, we know very little about where that money comes from or how it makes its way into the system (and rightfully so…the way we pay for health care is insanely complex, to say the least). This convoluted system is the unfortunate result of a series of programs that attempt to control spending layered on top of one another. What follows is a systematic attempt to peel away those layers, helping you become an informed health care consumer and an incontrovertible debater when discussing “Health Care Reform.”

Who’s paying the bill?

The “bill payers” fall into three distinct buckets: individuals paying out-of-pocket, private insurance companies, and the government. We can look at these payors in two different ways: 1) How much do they pay and 2) How many people do they pay for?

The majority of individuals in America are insured by private insurance companies via their employers, followed second by the government. These two sources of payment combined account for close to 80% of the funding for health care. The “Out-of-Pocket” payers fall into the uninsured as they have chosen to carry the risk of medical expense independently. When we look at the amount of money each of these groups spends on health care annually, the pie shifts dramatically.

The government currently pays for 46% of national health care expenditures. How is that possible? This will make much more sense when we examine each of the payors individually.

Understanding the Payors

Out-of-Pocket

A select portion of the population chooses to carry the risk of medical expenses themselves rather than buying into an insurance plan. This group tends to be younger and healthier than insured patients and, as such, accesses medical care much less frequently. Because this group has to pay for all incurred costs, they also tend to be much more discriminating in how they access the system. The result is that patients (now more appropriately termed “consumers”) comparison shop for tests and elective procedures and wait longer before seeking medical attention. The payment method for this group is simple: the doctors and hospitals charge set fees for their services and the patient pays that amount directly to the doctor/hospital.

Private Insurance

This is where the whole system gets a lot more complicated. Private insurance is purchased either individually or is provided by employers (most people get it through their employer as we mentioned). When it comes to private insurance, there are two main types: Fee-for-Service insurers and Managed Care insurers. These two groups approach paying for care very differently.

Fee-for-Service:

This group makes it relatively simple (believe it or not). The employer or individual buys a health plan from a private insurance company with a defined set of benefits. This benefit package will also have what is called a deductible (an amount the patient/individual must pay for their health care services before their insurance pays anything). Once the deductible amount is met, the health plan pays the fees for services provided throughout the health care system. Often, they will pay a maximum fee for a service (say $100 for an x-ray). The plan will require the individual to pay a copayment (a sharing of the cost between the health plan and the individual). A typical industry standard is an 80/20 split of the payment, so in the case of the $100 x-ray, the health plan would pay $80 and the patient would pay $20…remember those annoying medical bills stating your insurance did not cover all the charges? This is where they come from. Another downside of this model is that health care providers are both financially incentivized and legally bound to perform more tests and procedures as they are paid additional fees for each of these or are held legally accountable for not ordering the tests when things go wrong (called “CYA or “Cover You’re A**” medicine). If ordering more tests provided you with more legal protection and more compensation, wouldn’t you order anything justifiable? Can we say misalignment of incentives?

Managed Care:

Now it gets crazy. Managed care insurers pay for care while also “managing” the care they pay for (very clever name, right). Managed care is defined as “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care prior to its provision” (2). Yep, insurers make medical decisions on your behalf (sound as scary to you as it does to us?). The original idea was driven by a desire by employers, insurance companies, and the public to control soaring health care costs. Doesn’t seem to be working quite yet. Managed care groups either provide medical care directly or contract with a select group of health care providers. These insurers are further subdivided based on their own personal management styles. You may be familiar with many of these sub-types as you’ve had to choose between then when selecting your insurance.

Preferred Provider Organization (PPO) / Exclusive Provider Organization (EPO):This is the closet managed care gets to the Fee-for-Service model with many of the same characteristics as a Fee-for-Service plan like deductibles and copayments. PPO’s & EPO’s contract with a set list of providers (we’re all familiar with these lists) with whom they have negotiated set (read discounted) fees for care. Yes, individual doctors have to charge less for their services if they want to see patients with these insurance plans. An EPO has a smaller and more strictly regulated list of physicians than a PPO but are otherwise the same. PPO’s control costs by requiring preauthorization for many services and second opinions for major procedures. All of this aside, many consumers feel that they have the greatest amount of autonomy and flexibility with PPO’s.
Health Management Organization (HMO): HMO’s combine insurance with health care delivery. This model will not have deductibles but will have copayments. In an HMO, the organization hires doctors to provide care and either builds its own hospital or contracts for the services of a hospital within the community. In this model the doctor works for the insurance provider directly (aka a Staff Model HMO). Kaiser Permanente is an example of a very large HMO that we’ve heard mentioned frequently during the recent debates. Since the company paying the bill is also providing the care, HMO’s heavily emphasize preventive medicine and primary care (enter the Kaiser “Thrive” campaign). The healthier you are, the more money the HMO saves. The HMO’s emphasis on keeping patients healthy is commendable as this is the only model to do so, however, with complex, lifelong, or advanced diseases, they are incentivized to provide the minimum amount of care necessary to reduce costs. It is with these conditions that we hear the horror stories of insufficient care. This being said, physicians in HMO settings continue to practice medicine as they feel is needed to best care for their patients despite the incentives to reduce costs inherent in the system (recall that physicians are often salaried in HMO’s and have no incentive to order more or less tests).

The Government

The U.S. Government pays for health care in a variety of ways depending on whom they are paying for. The government, through a number of different programs, provides insurance to individuals over 65 years of age, people of any age with permanent kidney failure, certain disabled people under 65, the military, military veterans, federal employees, children of low-income families, and, most interestingly, prisoners. It also has the same characteristics as a Fee-for-Service plan, with deductibles and copayments. As you would imagine, the majority of these populations are very expensive to cover medically. While the government only insures 28% of the American population, they are paying for 46% of all care provided. The populations covered by the government are amongst the sickest and most medically needy in America resulting in this discrepancy between number of individuals insured and cost of care.

The largest and most well-known government programs are Medicare and Medicaid. Let’s take a look at these individually:

Medicare:

The Medicare program currently covers 42.5 million Americans. To qualify for Medicare you must meet one of the following criteria:

Over 65 years of age
Permanent kidney failure
Meet certain disability requirements

So you meet the criteria…what do you get? Medicare comes in 4 parts (Part A-D), some of which are free and some of which you have to pay for. You’ve probably heard of the various parts over the years thanks to CNN (remember the commotion about the Part D drug benefits during the Bush administration?) but we’ll give you a quick refresher just in case.

Part A (Hospital Insurance): This part of Medicare is free and covers any inpatient and outpatient hospital care the patient may need (only for a set number of days, however, with the added bonus of copayments and deductibles…apparently there really is no such thing as a free lunch).
Part B (Medical Insurance): This part, which you must purchase, covers physicians’ services, and selected other health care services and supplies that are not covered by Part A. What does it cost? The Part B premium for 2009 ranged from $96.40 to $308.30 per month depending on your household income.
Part C (Managed Care): This part, called Medicare Advantage, is a private insurance plan that provides all of the coverage provided in Parts A and B and must cover medically necessary services. Part C replaces Parts A & B. All private insurers that want to provide Part C coverage must meet certain criteria set forth by the government. Your care will also be managed much like the HMO plans previously discussed.
Part D (Prescription Drug Plans): Part D covers prescription drugs and costs $20 to $40 per month for those who chose to enroll.

Ok, now how does Medicare pay for everything? Hospitals are paid predetermined amounts of money per admission or per outpatient procedure for services provided to Medicare patients. These predetermined amounts are based upon over 470 diagnosis-related groups (DRGs) or Ambulatory Payment Classifications (APC’s) rather than the actual cost of the care rendered (interesting way to peg hospital reimbursement…especially when the Harvard economist who developed the DRG system openly disagrees with its use for this purpose). The cherry on top of the irrational reimbursement system is that the amount of money assigned to each DRG is not the same for each hospital. Totally logical (can you sense our sarcasm?). The figure is based on a formula that takes into account the type of service, the type of hospital, and the location of the hospital. This may sound logical but often times this system fails.

Medicaid:

Medicaid is a jointly funded (funded by both federal and state governments) health insurance program for low-income families. Eligibility rules vary from state to state and factors in age, pregnancy, disability, income and resources. Poverty alone does not qualify an individual for Medicaid (there is currently no government-provided insurance for the American poor…despite the fact that almost all first world countries have such a system…enter the current health care debate) but is a significant factor in Medicaid eligibility. Each state operates its own Medicaid program but must adhere to certain federal guidelines to receive matching federal funds (you may be familiar with California’s MediCal, Massachusetts’ MassHealth and Oregon’s Oregon Health Plan due to their recent media coverage). Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States.

How are the bills paid?

We now understand who is paying the bill but we have yet to cover how those bills are paid. There are two broad divisions of arrangements for paying for and delivering health care: fee-for-service care and prepaid care.

Fee-for-Service

As we mentioned briefly while discussing PPO’s, in a fee-for-service structure, consumers select a provider, receive care (a.k.a. “service”) from the provider, and incur expenses (a.k.a. “a fee”) for the care. Deductibles and copayments are also required as previously discussed. Pretty simple. The physician is then reimbursed for their services in part by the insurer (i.e. a private insurance company or the government) and in part by the patient, who is responsible for the balance unpaid by the insurer (the return of the unanticipated medical bill despite your overpriced insurance). Again, the major downfall of the fee-for-service approach is that medical professionals are incentivized to provide services (and by this we mean any and all services they can legally request or must request to be protected legally), some of which may be nonessential, to increase their revenue and/or “C.Y.A.” (revenue that has steadily decreased as insurance companies continue to lower the amount they pay medical professionals for their services).

Fee Schedule

A fee schedule operates in the same way that Fee-for-Service does with one exception: instead of using the “usual, customary, and reasonable” amount to reimburse medical professionals, states set fees to be paid for specific procedures and services. The reimbursement is very low ($.10-.15 on the dollar) and barely covers the actual direct cost of providing the care. Physicians may chose to opt into the plan or not (starting to see why a doctor might not be so excited about this plan?). Would you sign up to be paid 10 cents for every dollar you charged for your work? Try the insurance reimbursement approach next time you go out to eat. We’ll come bail you out of the Big House if things go awry. What happens when the insurance system does this? You get the Wal-Mart approach to medicine (high volume, low quality). Not the kind of heath care we recommend.

Pre-Paid

Pre-paid health care? Like a phone card? Not exactly–but close. The pre-paid system evolved out of the insurance company’s desire to share its risk ( a.k.a “pooled risk”) with health care providers. Essentially, they wanted the doctors to have some skin in the game. In the pre-paid system, insurers make arrangements with health care providers to provide agreed-upon covered health care services to a given population of consumers for a (usually discounted) set price-the per-person premium fee-over a particular time period. What does that mean? It means that Dr. Bob gets paid, say, $30 per month to take care of Joe the Plumber including his blood work and x-rays. If Dr. Bob spends less than that caring for Joe, he makes money. If Joe is sick every month and needs lots of tests and follow-up visits, Dr. Bob could lose money caring for Joe. The set monthly fee paid to the doctor for taking care of a patient is set up on a per-member, per-month (PMPM) rate called a “capitated fee.” The provider receives the capitated fee per enrollee regardless of whether the enrollee uses health care services and regardless of the quality of services provided (not a good thing in our book). Theoretically, providers should become more prudent and subsequently provide services in a more cost effective manner because they are bearing some of the risk. Often times, however, less care is provided than is needed in hopes of saving money and increasing profits. In addition, physicians are incentivized to cherry pick the youngest and healthiest patients because these patients typically require less care (i.e. they are cheaper to keep healthy). We like that doctors are encouraged to keep patients healthy but we have to worry about the ways in which they are being encouraged to reduce costs (as little care as possible?). Again, the incentive system falls short and encourages providers to act unethically.

The Take Home Message:

Health Care in the United States today is complex and messy at best. The layers on top of layers of failed attempts to correct the system continue to encourage the wrong behavior in both patients (out of fear of medical bills) and providers (out of fear of bankruptcy). We have yet to provide every American citizen with medical care (something that goes without saying in most 1st World countries…even Cuba has it!). We spend more money on caring for our citizens than any country in the world yet we continue to lag behind in terms of national health outcomes. We think it’s safe to say that we’re not getting the best bang for our buck. The ultimate solution? We wish we knew. Only time will tell where the system goes from here. Our goal: to help you better understand the system as it stands today in hopes of developing a more effective, efficient, and comprehensive system for the future. Are you with us?

Hospital Leadership, Strategy, And Culture In The Age of Health Care Reform

With just eleven months to go before the Value-Based Purchasing component of the Affordable Care Act is scheduled to go into effect, it is an auspicious time to consider how health care providers, and hospitals specifically, plan to successfully navigate the adaptive change to come. The delivery of health care is unique, complex, and currently fragmented. Over the past thirty years, no other industry has experienced such a massive infusion of technological advances while at the same time functioning within a culture that has slowly and methodically evolved over the past century. The evolutionary pace of health care culture is about to be shocked into a mandated reality. One that will inevitably require health care leadership to adopt a new, innovative perspective into the delivery of their services in order to meet the emerging requirements.

First, a bit on the details of the coming changes. The concept of Value-Based Purchasing is that the buyers of health care services (i.e. Medicare, Medicaid, and inevitably following the government’s lead, private insurers) hold the providers of health care services accountable for both cost and quality of care. While this may sound practical, pragmatic, and sensible, it effectively shifts the entire reimbursement landscape from diagnosis/procedure driven compensation to one that includes quality measures in five key areas of patient care. To support and drive this unprecedented change, the Department of Health and Human Services (HHS), is also incentivizing the voluntary formation of Accountable Care Organizations to reward providers that, through coordination, collaboration, and communication, cost-effectively deliver optimum patient outcomes throughout the continuum of the health care delivery system.

The proposed reimbursement system would hold providers accountable for both cost and quality of care from three days prior to hospital admittance to ninety days post hospital discharge. To get an idea of the complexity of variables, in terms of patient handoffs to the next responsible party in the continuum of care, I process mapped a patient entering a hospital for a surgical procedure. It is not atypical for a patient to be tested, diagnosed, nursed, supported, and cared for by as many as thirty individual, functional units both within and outside of the hospital. Units that function and communicate both internally and externally with teams of professionals focused on optimizing care. With each handoff and with each individual in each team or unit, variables of care and communication are introduced to the system.

Historically, quality systems from other industries (i.e. Six Sigma, Total Quality Management) have focused on wringing out the potential for variability within their value creation process. The fewer variables that can affect consistency, the greater the quality of outcomes. While this approach has proven effective in manufacturing industries, health care presents a collection of challenges that go well beyond such controlled environments. Health care also introduces the single most unpredictable variable of them all; each individual patient.

Another critical factor that cannot be ignored is the highly charged emotional landscape in which health care is delivered. The implications of failure go well beyond missing a quarterly sales quota or a monthly shipping target, and clinicians carry this heavy, emotional burden of responsibility with them, day-in and day-out. Add to this the chronic nursing shortage (which has been exacerbated by layoffs during the recession), the anxiety that comes with the ambiguity of unprecedented change, the layering of one new technology over another (which creates more information and the need for more monitoring), and an industry culture that has deep roots in a bygone era and the challenge before us comes into greater focus.

Which brings us to the question; what approach should leadership adopt in order to successfully migrate the delivery system through the inflection point where quality of care and cost containment intersect? How will this collection of independent contractors and institutions coordinate care and meet the new quality metrics proposed by HHS? The fact of the matter is, health care is the most human of our national industries and reforming it to meet the shifting demographic needs and economic constraints of our society may prompt leadership to revisit how they choose to engage and integrate the human element within the system.

In contemplating this approach, a canvasing of the peer-reviewed research into both quality of care and cost containment issues points to a possible solution; the cultivation of emotional intelligence in health care workers. After reviewing more than three dozen published studies, all of which confirmed the positive impact cultivating emotional intelligence has in clinical settings, I believe contemplating this approach warrants further exploration.

Emotional intelligence is a skill as much as an attribute. It is comprised by a set of competencies in Self-Awareness, Self Management, Social Awareness, and Relationship Management, all leading to Self Mastery. Fortunately, these are skills that can be developed and enhanced over the course of one’s lifetime.

Keeping the number of handoffs and individuals involved in delivering the continuum of care, let’s examine how emotional intelligence factors into the proposed quality measures the Department of Health and Human Services will be using come October, 2012:

1.) Patient/Caregiver Experience of Care – This factor really comes down to a patient’s perception of care. Perceptions of care are heavily shaded by emotions. Patients consistently rate less skilled surgeons that have a greater bedside manner as better than maestro surgeons that lack, or choose not to display, these softer skills. Additional research into why people sue over malpractice also indicates how perceptions of care are formed. People don’t sue over a medical mistake in and of itself. People sue because of how they felt they were treated after the error occurred. From the patient’s perspective (and often their family’s) there’s a difference between being cured and being healed. The difference often can be found in the expression of authentic empathy through healthy, professional boundaries.

This is a key driver in patient decision-making as well. Patients tend to choose a hospital based upon one or two criteria; the recommendation of their primary care physician (with whom they have an established relationship) and/or upon the recommendations from family members or friends that have experienced care in a particular hospital or an individual surgeon. A quick look into the field of Applied Behavioral Economics supports this finding. Economic decision making is 70% emotionally driven with the remaining 30% based in rational thought. In many instances, it would appear that a lot of hospital marketing initiatives don’t seem to reflect an understanding of this phenomena. Waiting room times in Emergency Rooms have little to do with why patients choose a hospital, yet we see billboards everywhere that have the actual E.R. wait times electronically flashing along the roadside.

A patient’s experience (and perception) of care can be highly impacted at the handoff points within the continuum of care. Any new model of care will require exceptional cross-organizational communications to emerge. This requires a high level of engagement and commitment to the new vision at every patient touch-point.

This metric also addresses the caregivers’ experience of care. This speaks largely to the experience of nurses that are delivering that care. The research related to the impact of cultivating emotional intelligence in nurses clearly demonstrates a reduction in stress, improved communication skills, improved leadership and retention, the ability to quickly connect and engage patients, as well as a reduction in nurse burnout (which leads to turnover and additional stress amongst the remaining staff).

2.) Care Co-ordination – Again, this will require optimal engagement and pro-active communication intra-organizationally and cross-organizationally. Each handoff introduces opportunities for variable care to emerge that must be seamlessly co-ordinated. Poor co-ordination also introduces the risk of eroding the quality of the patient’s experience.

3.) Patient Safety – Research shows that the cultivation of emotional intelligence competencies in nursing contributes to positive patient outcomes, lowers the risk of adverse events, lowers costs at discharge, and reduces medication errors, all while lowering nurse stress, burnout, and turnover. Each time a nurse resigns it adds to the nursing shortage on the floor, requires additional hours from other nurses, and costs the hospital approximately $64,000, on average, to backfill the open position. Improving how an institution cares for its nurses improves the level of patient care and safety as well. In many institutions, this will require a shift in leadership’s perspective in order to support a culture that embraces and values the critical role nurses play in maintaining patient safety.

4.) Preventive Health – Elevating Self-Awareness and Social Awareness in clinicians helps them quickly connect and effectively communicate with patients. Subtle, non-verbal cues become more readily apparent, helping clinicians understand the fears and emotions of their patients. Self Management and Relationship Management helps clinicians communicate appropriately and supports the expression of authentic empathy through healthy, professional boundaries. All of these factors come into play when speaking with patients about lifestyle choices, course of treatment, and preventive health care.

From our own personal lives we’ve all learned we cannot “fix” other peoples’ behaviors. We can, however, be in relationship and help support healthy changes they’re ready to embrace. Pro-actively moving to improve preventive health will require deeper, more authentic relationships to emerge between front-line health care providers and patients.

5.) At-Risk Population/Frail Elderly Health – Like preventive health, being measured on the care of the community’s at-risk population and elderly will require an innovative approach to community outreach and pro-active communication. These are not populations that can be easily reached via Facebook or Twitter. Building effective relationships with these demographics will require trustful, human contact and deep engagement with each population, both of which are supported through the development of a mindful approach (i.e. emotionally intelligent) to the challenges at hand.

It will be interesting to see how reform unfolds and how leadership within the health care delivery system chooses to respond to the challenges that lie ahead. Systems and hospitals that choose to take an honest, evidence-based look at how they choose to lead, how they create and execute strategy, and the organizational culture they’re cultivating will be well served in preparing to successfully navigate this unprecedented change.

© 2011, Terry Murray.

Terry Murray is a professional coach and business executive with twenty-five years of progressive experience in strategic development, executive leadership, and the deployment of highly profitable business teams. His executive leadership with Fortune 1000 and start-up companies has directly contributed more than $1 billion in market capitalization growth throughout his career.

Terry is the founder and president of Performance Transformation, LLC a Professional Coaching and Strategic Development firm focused on igniting breakthrough performance through the authentic engagement and development of human talent. The company’s evidence-based programs and philosophical approach employs their proprietary Adaptive Coaching Process. The organization’s engagements align the clients’ human capital with their strategic imperatives driving tangible results, delivering a sustainable competitive advantage and an exceptional Return on Investment.

Patient Abandonment – Home Health Care

Elements of the Cause of Action for Abandonment

Each of the following five elements must be present for a patient to have a proper civil cause of action for the tort of abandonment:

1. Health care treatment was unreasonably discontinued.

2. The termination of health care was contrary to the patient’s will or without the patient’s knowledge.

3. The health care provider failed to arrange for care by another appropriate skilled health care provider.

4. The health care provider should have reasonably foreseen that harm to the patient would arise from the termination of the care (proximate cause).

5. The patient actually suffered harm or loss as a result of the discontinuance of care.

Physicians, nurses, and other health care professionals have an ethical, as well as a legal, duty to avoid abandonment of patients. The health care professional has a duty to give his or her patient all necessary attention as long as the case required it and should not leave the patient in a critical stage without giving reasonable notice or making suitable arrangements for the attendance of another. [2]

Abandonment by the Physician

When a physician undertakes treatment of a patient, treatment must continue until the patient’s circumstances no longer warrant the treatment, the physician and the patient mutually consent to end the treatment by that physician, or the patient discharges the physician. Moreover, the physician may unilaterally terminate the relationship and withdraw from treating that patient only if he or she provides the patient proper notice of his or her intent to withdraw and an opportunity to obtain proper substitute care.

In the home health setting, the physician-patient relationship does not terminate merely because a patient’s care shifts in its location from the hospital to the home. If the patient continues to need medical services, supervised health care, therapy, or other home health services, the attending physician should ensure that he or she was properly discharged his or her-duties to the patient. Virtually every situation ‘in which home care is approved by Medicare, Medicaid, or an insurer will be one in which the patient’s ‘needs for care have continued. The physician-patient relationship that existed in the hospital will continue unless it has been formally terminated by notice to the patient and a reasonable attempt to refer the patient to another appropriate physician. Otherwise, the physician will retain his or her duty toward the patient when the patient is discharged from the hospital to the home. Failure to follow through on the part of the physician will constitute the tort of abandonment if the patient is injured as a result. This abandonment may expose the physician, the hospital, and the home health agency to liability for the tort of abandonment.

The attending physician in the hospital should ensure that a proper referral is made to a physician who will be responsible for the home health patient’s care while it is being delivered by the home health provider, unless the physician intends to continue to supervise that home care personally. Even more important, if the hospital-based physician arranges to have the patient’s care assumed by another physician, the patient must fully understand this change, and it should be carefully documented.

As supported by case law, the types of actions that will lead to liability for abandonment of a patient will include:

• premature discharge of the patient by the physician

• failure of the physician to provide proper instructions before discharging the patient

• the statement by the physician to the patient that the physician will no longer treat the patient

• refusal of the physician to respond to calls or to further attend the patient

• the physician’s leaving the patient after surgery or failing to follow up on postsurgical care. [3]

Generally, abandonment does not occur if the physician responsible for the patient arranges for a substitute physician to take his or her place. This change may occur because of vacations, relocation of the physician, illness, distance from the patient’s home, or retirement of the physician. As long as care by an appropriately trained physician, sufficiently knowledgeable of the patient’s special conditions, if any, has been arranged, the courts will usually not find that abandonment has occurred. [4] Even where a patient refuses to pay for the care or is unable to pay for the care, the physician is not at liberty to terminate the relationship unilaterally. The physician must still take steps to have the patient’s care assumed by another [5] or to give a sufficiently reasonable period of time to locate another prior to ceasing to provide care.

Although most of the cases discussed concern the physician-patient relationship, as pointed out previously, the same principles apply to all health care providers. Furthermore, because the care rendered by the home health agency is provided pursuant to a physician’s plan of care, even if the patient sued the physician for abandonment because of the actions (or inactions of the home health agency’s staff), the physician may seek indemnification from the home health provider. [6]

ABANDONMENT BY THE NURSE OR HOME HEALTH AGENCY

Similar principles to those that apply to physicians apply to the home health professional and the home health provider. A home health agency, as the direct provider of care to the homebound patient, may be held to the same legal obligation and duty to deliver care that addresses the patient’s needs as is the physician. Furthermore, there may be both a legal and an ethical obligation to continue delivering care, if the patient has no alternatives. An ethical obligation may still exist to the patient even though the home health provider has fulfilled all legal obligations. [7]

When a home health provider furnishes treatment to a patient, the duty to continue providing care to the patient is a duty owed by the agency itself and not by the individual professional who may be the employee or the contractor of the agency. The home health provider does not have a duty to continue providing the same nurse, therapist, or aide to the patient throughout the course of treatment, so long as the provider continues to use appropriate, competent personnel to administer the course of treatment consistently with the plan of care. From the perspective of patient satisfaction and continuity of care, it may be in the best interests of the home health provider to attempt to provide the same individual practitioner to the patient. The development of a personal relationship with the provider’s personnel may improve communications and a greater degree of trust and compliance on the part of the patient. It should help to alleviate many of the problems that arise in the health care’ setting.

If the patient requests replacement of a particular nurse, therapist, technician, or home health aide, the home health provider still has a duty to provide care to the patient, unless the patient also specifically states he or she no longer desires the provider’s service. Home health agency supervisors should always follow up on such patient requests to determine the reasons regarding the dismissal, to detect “problem” employees, and to ensure no incident has taken place that might give rise to liability. The home health agency should continue providing care to the patient until definitively told not to do so by the patient.

COPING WITH THE ABUSIVE PATIENT

Home health provider personnel may occasionally encounter an abusive patient. This abuse mayor may not be a result of the medical condition for which the care is being provided. Personal safety of the individual health care provider should be paramount. Should the patient pose a physical danger to the individual, he or she should leave the premises immediately. The provider should document in the medical record the facts surrounding the inability to complete the treatment for that visit as objectively as possible. Management personnel should inform supervisory personnel at the home health provider and should complete an internal incident report. If it appears that a criminal act has taken place, such as a physical assault, attempted rape, or other such act, this act should be reported immediately to local law enforcement agencies. The home care provider should also immediately notify both the patient and the physician that the provider will terminate its relationship with the patient and that an alternative provider for these services should be obtained.

Other less serious circumstances may, nevertheless, lead the home health provider to determine that it should terminate its relationship with a particular patient. Examples may include particularly abusive patients, patients who solicit -the home health provider professional to break the law (for example, by providing illegal drugs or providing non-covered services and equipment and billing them as something else), or consistently noncompliant patients. Once treatment is undertaken, however, the home health provider is usually obliged to continue providing services until the patient has had a reasonable opportunity to obtain a substitute provider. The same principles apply to failure of a patient to pay for the services or equipment provided.

As health care professionals, HHA personnel should have training on how to handle the difficult patient responsibly. Arguments or emotional comments should be avoided. If it becomes clear that a certain provider and patient are not likely to be compatible, a substitute provider should be tried. Should it appear that the problem lies with the patient and that it is necessary for the HHA to terminate its relationship with the patient, the following seven steps should be taken:

1. The circumstances should be documented in the patient’s record.

2. The home health provider should give or send a letter to the patient explaining the circumstances surrounding the termination of care.

3. The letter should be sent by certified mail, return receipt requested, or other measures to document patient receipt of the letter. A copy of the letter should be placed in the patient’s record.

4. If possible, the patient should be given a certain period of time to obtain replacement care. Usually 30 days is sufficient.

5. If the patient has a life-threatening condition or a medical condition that might deteriorate in the absence of continuing care, this condition should be clearly stated in the letter. The necessity of the patient’s obtaining replacement home health care should be emphasized.

6. The patient should be informed of the location of the nearest hospital emergency department. The patient should be told to either go to the nearest hospital emergency department in case of a medical emergency or to call the local emergency number for ambulance transportation.

7. A copy of the letter should be sent to the patient’s attending physician via certified mail, return receipt requested.

These steps should not be undertaken lightly. Before such steps are taken, the patient’s case should be thoroughly discussed with the home health provider’s risk manager, legal counsel, medical director, and the patient’s attending physician.

The inappropriate discharge of a patient from health care coverage by the home health provider, whether because of termination of entitlement, inability to pay, or other reasons, may also lead to liability for the tort of abandonment. [8]

Nurses who passively stand by and observe negligence by a physician or anyone else will personally become accountable to the patient who is injured as a result of that negligence… [H]ealthcare facilities and their nursing staff owe an independent duty to patients beyond the duty owed by physicians. When a physician’s order to discharge is inappropriate, the nurses will be help liable for following an order that they knew or should know is below the standard of care. [9]

Similar principles may apply to make the home health provider vicariously liable, as well.

Liability to the patient for the tort of abandonment may also result from the home health care professional’s failure to observe, examine, assess, or monitor a patient’s condition. [10] Liability for abandonment may arise from failing to take timely action, as well as failing to summon a physician when a physician is needed. [11] Failing to provide adequate staff to meet the patient’s needs may also constitute abandonment on the part of the HHA. [12] Ignoring a patient’s complaints and failing to follow a physician’s orders may likewise constitute a tort of abandonment for a nurse or other professional staff member.

1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).

2. Kattsetos v. Nolan, 368 A.2d 172 (Conn. 1976).

3. 61 AM. Jur. 2d, Physicians and Surgeons § 237 (1981).

4. See, e.g., Tripp v. Pate, 271 S.E.2d 407 (N.C. App. 1980).

5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).

6. M.D. Nathanson, Home Healthcare Answer Book: Legal Issues for Providers 212 (1995).

7. See, generally, E.P. Burnzeig, The Nurse’s Liability for Malpractice (1981).

8. Sheryl Feutz-Harter, Nursing Caselaw Update: In appropriate Discharging of Patients, 2 J. Nursing L. 49 (1995).

9. Id., 53.

10. See, e.g., Pisel v. Stamford Hosp., 430 A.2d1 (Conn. 1980) (nurses were held liable for failing to monitor the condition of a patient).

11. See, e.g., Sanchez v. Bay General Hosp., 172 Cal. Rptr. 342 (Cal. App. 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Tex. 1982).

12. Czubinsky v. Doctors Hosp., 188 CAl. Rptr. 685 (1983).

Health Care Reform – Busting The 3 Biggest Myths Of ObamaCare

Why are Americans so worked up about health care reform? Statements such as “don’t touch my Medicare” or “everyone should have access to state of the art health care irrespective of cost” are in my opinion uninformed and visceral responses that indicate a poor understanding of our health care system’s history, its current and future resources and the funding challenges that America faces going forward. While we all wonder how the health care system has reached what some refer to as a crisis stage. Let’s try to take some of the emotion out of the debate by briefly examining how health care in this country emerged and how that has formed our thinking and culture about health care. With that as a foundation let’s look at the pros and cons of the Obama administration health care reform proposals and let’s look at the concepts put forth by the Republicans?

Access to state of the art health care services is something we can all agree would be a good thing for this country. Experiencing a serious illness is one of life’s major challenges and to face it without the means to pay for it is positively frightening. But as we shall see, once we know the facts, we will find that achieving this goal will not be easy without our individual contribution.

These are the themes I will touch on to try to make some sense out of what is happening to American health care and the steps we can personally take to make things better.

A recent history of American health care – what has driven the costs so high?
Key elements of the Obama health care plan
The Republican view of health care – free market competition
Universal access to state of the art health care – a worthy goal but not easy to achieve
what can we do?

First, let’s get a little historical perspective on American health care. This is not intended to be an exhausted look into that history but it will give us an appreciation of how the health care system and our expectations for it developed. What drove costs higher and higher?

To begin, let’s turn to the American civil war. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause ghastly results. Not generally known is that most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace and this caused severe delays in treating the wounded. Secondly, many wounds were subjected to wound care, related surgeries and/or amputations of the affected limbs and this often resulted in the onset of massive infection. So you might survive a battle wound only to die at the hands of medical care providers who although well-intentioned, their interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!

Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and increasingly attempt risky surgeries (now largely performed in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.

This very basic review of American medical history helps us to understand that until quite recently (around the 1950’s) we had virtually no technologies with which to treat serious or even minor ailments. Here is a critical point we need to understand; “nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in such a scenario costs are curtailed. The simple fact is that there was little for doctors to offer and therefore virtually nothing to drive health care spending. A second factor holding down costs was that medical treatments that were provided were paid for out-of-pocket, meaning by way of an individuals personal resources. There was no such thing as health insurance and certainly not health insurance paid by an employer. Except for the very destitute who were lucky to find their way into a charity hospital, health care costs were the responsibility of the individual.

What does health care insurance have to do with health care costs? Its impact on health care costs has been, and remains to this day, absolutely enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight a great pool of money became available to pay for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. More Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare and Medicaid (1965). In addition funding became available for expanded veterans health care benefits. Finding a cure for almost anything has consequently become very lucrative. This is also the primary reason for the vast array of treatments we have available today.

I do not wish to convey that medical innovations are a bad thing. Think of the tens of millions of lives that have been saved, extended, enhanced and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor’s offer and most of us demand and get access to the latest available health care technology in the form of pharmaceuticals, medical devices, diagnostic tools and surgical procedures. So the result is that there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). Add an insatiable and unrealistic public demand for access and treatment and we have the “perfect storm” for higher and higher health care costs. And by and large the storm is only intensifying.

At this point, let’s turn to the key questions that will lead us into a review and hopefully a better understanding of the health care reform proposals in the news today. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? When we add politics and an election year to the debate, information to help us answer these questions become critical. We need to spend some effort in understanding health care and sorting out how we think about it. Properly armed we can more intelligently determine whether certain health care proposals might solve or worsen some of these problems. What can be done about the challenges? How can we as individuals contribute to the solutions?

The Obama health care plan is complex for sure – I have never seen a health care plan that isn’t. But through a variety of programs his plan attempts to deal with a) increasing the number of American that are covered by adequate insurance (almost 50 million are not), and b) managing costs in such a manner that quality and our access to health care is not adversely affected. Republicans seek to achieve these same basic and broad goals, but their approach is proposed as being more market driven than government driven. Let’s look at what the Obama plan does to accomplish the two objectives above. Remember, by the way, that his plan was passed by congress, and begins to seriously kick-in starting in 2014. So this is the direction we are currently taking as we attempt to reform health care.

Through insurance exchanges and an expansion of Medicaid,the Obama plan dramatically expands the number of Americans that will be covered by health insurance.

To cover the cost of this expansion the plan requires everyone to have health insurance with a penalty to be paid if we don’t comply. It will purportedly send money to the states to cover those individuals added to state-based Medicaid programs.

To cover the added costs there were a number of new taxes introduced, one being a 2.5% tax on new medical technologies and another increases taxes on interest and dividend income for wealthier Americans.

The Obama plan also uses concepts such as evidence-based medicine, accountable care organizations, comparative effectiveness research and reduced reimbursement to health care providers (doctors and hospitals) to control costs.

The insurance mandate covered by points 1 and 2 above is a worthy goal and most industrialized countries outside of the U.S. provide “free” (paid for by rather high individual and corporate taxes) health care to most if not all of their citizens. It is important to note, however, that there are a number of restrictions for which many Americans would be culturally unprepared. Here is the primary controversial aspect of the Obama plan, the insurance mandate. The U.S. Supreme Court recently decided to hear arguments as to the constitutionality of the health insurance mandate as a result of a petition by 26 states attorney’s general that congress exceeded its authority under the commerce clause of the U.S. constitution by passing this element of the plan. The problem is that if the Supreme Court should rule against the mandate, it is generally believed that the Obama plan as we know it is doomed. This is because its major goal of providing health insurance to all would be severely limited if not terminated altogether by such a decision.

As you would guess, the taxes covered by point 3 above are rather unpopular with those entities and individuals that have to pay them. Medical device companies, pharmaceutical companies, hospitals, doctors and insurance companies all had to “give up” something that would either create new revenue or would reduce costs within their spheres of control. As an example, Stryker Corporation, a large medical device company, recently announced at least a 1,000 employee reduction in part to cover these new fees. This is being experienced by other medical device companies and pharmaceutical companies as well. The reduction in good paying jobs in these sectors and in the hospital sector may rise as former cost structures will have to be dealt with in order to accommodate the reduced rate of reimbursement to hospitals. Over the next ten years some estimates put the cost reductions to hospitals and physicians at half a trillion dollars and this will flow directly to and affect the companies that supply hospitals and doctors with the latest medical technologies. None of this is to say that efficiencies will not be realized by these changes or that other jobs will in turn be created but this will represent painful change for a while. It helps us to understand that health care reform does have an effect both positive and negative.

Finally, the Obama plan seeks to change the way medical decisions are made. While clinical and basic research underpins almost everything done in medicine today, doctors are creatures of habit like the rest of us and their training and day-to-day experiences dictate to a great extent how they go about diagnosing and treating our conditions. Enter the concept of evidence-based medicine and comparative effectiveness research. Both of these seek to develop and utilize data bases from electronic health records and other sources to give better and more timely information and feedback to physicians as to the outcomes and costs of the treatments they are providing. There is great waste in health care today, estimated at perhaps a third of an over 2 trillion dollar health care spend annually. Imagine the savings that are possible from a reduction in unnecessary test and procedures that do not compare favorably with health care interventions that are better documented as effective. Now the Republicans and others don’t generally like these ideas as they tend to characterize them as “big government control” of your and my health care. But to be fair, regardless of their political persuasions, most people who understand health care at all, know that better data for the purposes described above will be crucial to getting health care efficiencies, patient safety and costs headed in the right direction.

A brief review of how Republicans and more conservative individuals think about health care reform. I believe they would agree that costs must come under control and that more, not fewer Americans should have access to health care regardless of their ability to pay. But the main difference is that these folks see market forces and competition as the way to creating the cost reductions and efficiencies we need. There are a number of ideas with regard to driving more competition among health insurance companies and health care providers (doctors and hospitals) so that the consumer would begin to drive cost down by the choices we make. This works in many sectors of our economy but this formula has shown that improvements are illusive when applied to health care. Primarily the problem is that health care choices are difficult even for those who understand it and are connected. The general population, however, is not so informed and besides we have all been brought up to “go to the doctor” when we feel it is necessary and we also have a cultural heritage that has engendered within most of us the feeling that health care is something that is just there and there really isn’t any reason not to access it for whatever the reason and worse we all feel that there is nothing we can do to affect its costs to insure its availability to those with serious problems.

OK, this article was not intended to be an exhaustive study as I needed to keep it short in an attempt to hold my audience’s attention and to leave some room for discussing what we can do contribute mightily to solving some of the problems. First we must understand that the dollars available for health care are not limitless. Any changes that are put in place to provide better insurance coverage and access to care will cost more. And somehow we have to find the revenues to pay for these changes. At the same time we have to pay less for medical treatments and procedures and do something to restrict the availability of unproven or poorly documented treatments as we are the highest cost health care system in the world and don’t necessarily have the best results in terms of longevity or avoiding chronic diseases much earlier than necessary.

I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens – health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don’t need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.

Let’s go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don’t exercise but we offer a lot of excuses. We don’t eat right but we offer a lot of excuses. We smoke and/or we drink alcohol to excess and we offer a lot of excuses as to why we can’t do anything about managing these known to be destructive personal health habits. We don’t take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because “health care is there” and somehow we think we have no responsibility for reducing our demand on it.

It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.

There are a huge number of free web sites available that can steer us to a more healthful life style. A soon as you can, “Google” “preventive health care strategies”, look up your local hospital’s web site and you will find more than enough help to get you started. Finally, there is a lot to think about here and I have tried to outline the challenges but also the very powerful effect we could have on preserving the best of America’s health care system now and into the future. I am anxious to hear from you and until then – take charge and increase your chances for good health while making sure that health care is there when we need it.

Delicious Modern Rice Noodles

The Noodles is not a modern food item it is eaten from 4000 years ago in China and then it is slowly spread to Northern America and rest of the world. At first Noodles were made only by millets. In Northern America Noodles are made by Wheat & Rice. The communication develops all people made Noodles as per their taste with using items like Wheat, Rice, Millets etc.

A Noodles is a delicious dish and also it is a item of fast food. Noodles were invented 4000 years ago in China. Mainly Noodles are made from Wheat, Millets etc. Wheat & Millets are high contents of carbohydrates, proteins etc therefore Noodles also high contents of carbohydrates, proteins & other nutrients. Noodles are made faster in cheap rate. This shows that eating Noodles is a cheap and good for Health also. The native dishes derived from Malaysia and Indonesia take full advantage of vegetables.

Rice noodles are noodles that are made from rice. Their principal ingredients are rice flour and water. Rice noodles are most commonly used in the cuisines of East and Southeast Asia, and are available fresh, frozen, or dried, in various shapes and thicknesses. This is a good salad for a hot day.

N- Noodle

O- Omni (in all ways)

O- Optimal (best)

D- Delicious and

L- Loved

E- Everyone.

Noodle is Omni Optimal with Delicious and Loved by Everyone
Rice noodles [http://indomunch.com/Rice-Noodles.html] is a very simple dish. Rice noodles are lovely to use and very light and easy to digest, take care not to leave in the boiling water too long otherwise they over cook. Vegetable rice noodles is a very flavor and very tasty and preparation is very easy. There are a few different kinds of rice noodles. The ones referred to here are flat, dried and about the width of linguine. Please purchase online [http://www.indomunch.com] in NewYork city.

How to Move With Children and With Pets

Moving Day can be tough, no question about that. While getting a fresh start in a new home can be invigorating, it can also be incredibly frustrating. The moving process gives you a million and one things to do, and to ensure a successful move, you have to handle every one of these tasks with care.

But believe it or not, the moving process shouldn’t even be your biggest concern. It should be helping the little ones cope with your upcoming move.

The little ones I refer to are your children and your pets. Remember, as hard as your move may be on you, they are much worse off.

They may not be pressured with many (or any) moving responsibilities, but they aren’t the ones who called the shots, either. It wasn’t them who decided to move. Thus, they feel helpless, depressed, troubled, and maybe even a bit scared. And guess what? It’s your job to relieve them of those negative emotions, make sure they have a comfortable trip, and ease their transition to your new location.

Of course, you’re going to have to put in more effort to get these done. Listed below are some of the additional responsibilities you must take on when moving with kids and pets.

For your kids:

-Tell them about the move several months in advance.
-Show them around your new neighborhood, if possible.
-Give them a chance to properly say good-bye to your old neighborhood and the people in it.
-Look for good schools in your new place and enroll your kids. Let them see the place themselves, if possible.

For your pets:

-Buy comfortable pet carriers and pet IDs.
-Talk to their vet about your move, and get the necessary meds and certificates of health.
-If you’re traveling by road, make reservations (in advance) at pet friendly hotels along the way.
-If you’re traveling by air, make the necessary bureaucratic arrangements that will allow your pets to be safely transported to your destination.
-When Moving Day arrives, keep them away from the packing process, as it will surely terrify them.

For both:

Consult a dependable moving company and ask its experts for more tips and information on how to move with children and with pets. Listen attentively to what these professionals have to say, and follow their advice as best you can. Also check and see if they have any specific services that can help you out (like pet moving services, for example), and avail of them. You can’t go wrong with the guidance and assistance of licensed professionals.

If you don’t know where to begin looking for a mover you can trust, try finding one online. A first-rate mover may be closer than you think.

Max Cohen was born in Brooklyn. Now lives in the Soho and is the owner of Mover New York

5 Good Oral Hygiene Practices You Should Do More Often

There are many things you can do to ensure the health of your teeth and gums such as practicing good hygiene. Regular visits to a dental care professional are recommended, but you can also improve their results by using some of the suggestions below:

1. Changing your toothbrush in regular intervals

If you use a toothbrush until all the bristles are worn out then you are making a mistake. There is the inclination to think why fix it if it is not broken when it comes to toothbrush purchases. However, this can lead to complications for several reasons. One, toothbrushes provide a good breeding ground for bacteria. After prolonged use colonies form and these increase the chance of an infection. Two, in most cases the bacteria in your mouth is transferred to your toothbrush, especially after you have been sick. The best practice is replacing your toothbrush every three months.

2. Visiting a dentist

There is an inclination to wait until you have a dental complication before visiting a dentist. The reality is; that as with any medical care, you should receive it on a regular basis since prevention is better than treatment. A visit to the dentist can enable them to diagnose a dental complication in its early stage. This allows them to treat it with better results than simply repairing damage to the surrounding areas. For example, dental decay takes a long time to get to cavities. When detected early the tooth can be saved. A good practice is to visit a dentist at least semi-annual basis.

3. Flossing

Dental flossing tends to be reserved for special occasions. Dentists even surmise that majority of patients do it just before they visit them. Flossing is more important for dental health than even brushing. This is because it removes detritus lodged in hard to reach parts of the teeth such as the proximal area between two teeth. Dentists recommend that you use soft flossing wire made from silk or plastic. Best practice is to floss on a daily basis, especially immediately after meals.

4. Drinking milk

Milk contains calcium. Calcium is part of the mineral substance that forms the covering of the tooth. This covering, called enamel is constantly eroded due to friction between teeth when chewing, talking, and other activities. Furthermore, the bacteria in the mouth produce lactic acid due to anaerobic respiration. Drinking milk provides calcium for the re-mineralization process of the teeth. This keeps the enamel strong by ensuring the hard tissue layer covering the crown is constantly re-grown. Best practice is having at least a glass of milk on a daily basis.

5. Cleaning the tongue

Conventional brushing techniques for the teeth tend to focus on the teeth. This means there is a tendency of ignoring the tongue which is bad for oral hygiene. The tongue has a large surface area which can be covered in food particles and therefore bacteria. Best practice is to use a tongue scraper to thoroughly clean the tongue. New toothbrushes come with tongue scrapers built into them.

Isabel Caro Is A Brave Young Woman – Her 13 Year Struggle With Anorexia May Save Lives

Is it enough to go to such extremes as having a poster campaign, which was launched in Italy on Monday, September 24th 007, in the campaign for awareness of Anorexia? Will it have the right impact on society?

With the death of three models over the run of one year, the Fashion world stood up and took action against the disease. (a recap is listed below)

Girls starving themselves to point of their organs failing, in order to have a glam career is what it’s come to in the Fashion World. But, anorexia has been around a long time, and it affects people all over the world. Eating disorders like anorexia can kill, and unfortunately it’s not the type of disease that can be easily fixable. There are no pills, there is no direct treatment that works for everyone, there is no physical reason for it to develop. Other than what’s in the mind of the anorexic, or bulimic.

Being educated in what’s going on in the world about anorexia is what this article is all about. Informing people of who is taking action, and why. Maybe other countries will join them, maybe even your own.

So, for the curious reader, the ones who want to learn about the disease, and how certain places are making it known that it won’t be tolerated any longer, I have tallied up some facts for you, about Italy, and Milan in particular. I love Models, I love Fashion Tv, and I write a lot of articles for Models because I think they should have a healthy and fabulous career. They deserve it, and the rest of the world deserves to be have healthy, strong viable youths. And it certainly seems to be on the horizon.

Here’s a recap of some of the facts:

Isabel Caro, an anorexic for over 13 years, posed nude for a series of photographs that are being displayed on billboards, and in a centerfold picture for a popular news paper in Italy.

Italian photographer Oliviero Toscani, known for his disturbing photographs of aids victims, was the most appropriate choice for this sensitive issue. Isabel Caro is a young French woman, and she weighs just over 31 kilos, (68.2 lbs) as Milan’s Fashion Star, to promote the dangers of the disease of anorexia.

No Anorexia it states, No-l-ita.

The Fashion World has applauded the campaign sponsored by Italian clothing company Flash & Partners to publicize their fashion brand targeting young women.

The reactions from such a naked truth about the disease runs extreme in both directions. Some health professionals are worried that envy from those suffering the disease may increase the competition anorexic’s often fall prey to. “This model should be in a hospital, not on a billboard, was reported to the BBC News in the UK, by Health Professionals in Italy.

Giorgio Armani called the imagery shocking, and he thought it was “opportune” as a way of making people face up to the dangers of anorexia, which he said had little to do with models on catwalks. “Anorexia has reasons which are not linked to fashion. Even people who take no notice of fashion get anorexic,” he said.

Giorgio Armani has a distinct point. Unless you are a fashion guru, have time to fly to Milan, Paris and New York, for fashion shows, you aren’t really going to notice a runway Model, or even be able to name the ‘It’ girl of the week. Media such as television and magazine models all don’t necessarily walk the runways of the modeling industry. In fact, the weight loss pressures seen on television, and exaggerated stats on obesity in certain countries also do factor in on how the general public perceive the acceptable size of a beautiful woman. For this disease to be combated, everyone needs to take a piece of the responsibility.

Toscani himself (the controversial photographer) concluded that the disease of anorexia was not the fault of fashion, he was quoted to say. “It’s a much wider phenomenon, involving all the media and TV in particular. Television offers young women absurd models for success”.

Riccardo Dalle Grave, head of an Italian association dealing with eating disorders, wasn’t impressed by the use of an anorexic model for a publicity stunt.

“You can die from this disease,” he said. “If they really want to prevent it, it would be better to help young women accept a variety of body measurements and understand that beauty comes in all sizes”.

Dalle Grave admitted the campaign’s alarming images are getting the public talking, but said talking about anorexia with likely victims often wasn’t helpful. It could even spark “self-destructive behavior,” he said.

Fabiola De Clercq, leader of the ABA association for research into Anorexia and Bulimia, had reportedly referred to Toscani’s scandalous photo as “excessively crude”. She was quoted to have concerns about the impact having the right effect on girls suffering from the illness. “They could feel envious of the anorexic model photographed in an ad and think that they too can get thinner. Done this way, this campaign has no sense,” she said.

Corriere della Sera, a popular Italian newspaper refused to publish the crude photos, and it was picked up by their competition La Repubblica.

On the other side of the fence, there was reportedly a supporting statement for the anorexia awareness campaign from the Italian health ministry. The alarming image of Isabelle Caro could “open an original channel for communication” and “encourage people to shoulder their responsibilities in the area of anorexia,” said Minister Livia Turco.

The billboard was released to the public a week prior to the Fashion Show Week in Milan. It had the streets buzzing with curiosity, and in some cases praise for such an impacting statement in a single photograph.

Isabelle Caro, the star Model for Milan’s fashion week, was interviewed by Vanity Fair, where she openly discusses her silent struggles with anorexia. She expressed her reasoning for exposing her body in such a manner as ‘psychologically useful’.

She was quoted to say, “I’ve hidden myself and covered myself for too long. Now I want to show myself fearlessly, even though I know my body arouses repugnance”.

She certainly was brave to willingly be so utterly exposed, but with Toscani’s vision in control of the camera, a quality respectable and impacting statement was certain to be created. As long as people keep talking about the disease, and countries such as Italy show they care about young women, hopefully the disease will decrease in numbers among women.

It was a shocking day in Italy, when the naked truth was exposed about the disease anorexia, the buzz on the street however, was supportive, receptive, and just like Milan, leading in the fashion trends, and standing strong for what they believe in!

5 Things You Must Know Before Running A Marathon

1. Proper preparation prevents poor performance
One of the biggest mistakes you can make before running a marathon is to assume that ‘it’ll be alright on the day’; ‘The crowd and adrenalin will get me round’; ‘How hard can it be to run 26.2 miles?’ Make no mistake, it is a very long way and people can seriously damage their health by underestimating the challenge. Proper preparation involves doing some consistent training and following a recommended programme set out by an expert. It also involves investing a little bit of money in good running shoes and other equipment.

2. Running a marathon requires a lifestyle change (sorry, it just does!)
If you are serious about running a marathon well it will require three major lifestyle changes, at least for most of us it will.

o You need to sort out your nutrition. What I mean is that no serious runner will put junk into their body and expect to perform well. I’m afraid that means MacDonalds and their likes need to be shelved for the duration of training and your intake of fruit and vegetables needs to increase dramatically.

o You need to sort out your hydration. Most of us are actually permanently dehydrated through a lack of water. Whilst training for a marathon drink much more water than normal and severely cut back on your alcohol intake. I’m afraid that alcohol is poison to a runner.

o You need to rest much more than you used to.

3. Your pre-race preparation can make all the difference between success and failure.
The worst thing you can do is just swan up to the start line and start running. It won’t be long until you’re a dying swan if you do that! Without proper pre-race preparation your race can be over before it begins. Here are a few vital things to get right before the race begins:

o Think carefully about what you will wear on the day. Don’t wear anything new but only what you’ve already trained in.

o Don’t get freaked out by the starting procedure. Give yourself plenty of time and take some warm stuff in case you are held up. A bin bag is always good in case it’s cold. Warm up properly so that you don’t get any pulled muscles.

4. Get your mind sorted out for the actual race

o Prepare your mind. Visualize the course as much as you can.

o Visualize finishing and celebrating.

o Everyone has negative thoughts. When they occur just push them away and remind yourself of the good training days.

o Apply lubricant to areas that will chafe.

o As you warm up check that you don’t need a last minute toilet break.
During the Race….

o Do not “race” during the first 20 miles of the marathon. Start slowly!

o Do not panic if the pace seems wrong. Many things can happen, it’s a long race and there will be plenty of time to make up early slow splits.

o If it’s windy stay behind other runners and shelter from direct head winds.

o Do not race through the water stations. Stop if necessary. Finally, and most important, HAVE FUN!

5. A good after-race strategy is crucial if you want a quick recovery.
Many runners find themselves in great pain after a race. So much so that it puts them off ever running another race. Here are a few tips to help you get back to normal living as soon as possible.

o Immediately after finishing you should try to keep walking for 5-10 minutes to allow your legs to cool down. If the weather is cold, windy, or wet make an effort to get inside or back into warm clothing. Keep drinking small amounts of water or sports drink if your stomach will allow it, even when you feel you no longer need to. My personal favourite is ‘Complete’ from the Juice Plus+ organization. www.juiceplus.co.uk/+mm026962

o Ice any sore spots immediately.

o As soon as you feel like eating, begin with small amounts of easily digestible food that you know will agree with your stomach. Although carbohydrate replacement is vital, protein is important for rebuilding damaged muscle tissue immediately following the race and for the next few days. Drink a lot of water for 48 hours.