a wealthy nation with unhealthy lifestyles, little interest in preventive medicine, and expectations of limitless, top-notch specialist care would empower its health-care system to accommodate these preferences

his very first patient shocked him by refusing the moderately expensive but effective treatment he prescribed for her cancer—a choice that turns out to be common among patients in Singapore, who like to pass the money in their government-mandated health-care savings accounts on to their children

“value-based care,” which rewards providers who keep costs down while achieving good outcomes, is not going well

John Robert, a microbiologist in New Mexico did an experiment on whether the beard contained bacteria. Results from the experiment that beards contain a lot of bacteria as dirty as a toilet. That’s a lot of bacteria and it’s a bit unsettling. He advised men with a beard should wash hands frequently and wash beard if they want to have a clean and healthy beard. Also, take care not to get food on your beard when you eating. If you exercise outside for a long time under the hot weather, there will be massive secretion of oil and have a lot of dust in your beard. If you haven’t clean your beard in the time it’s very easy to damage your sink. In particular, the bacteria on the surface of the face will take advantage of this, causes folliculitis and sebaceous adenitis, even cause swelling of the lips and face.

The HMO Act of 1973 changed that premise. It authorized for-profit IPA-HMOs in which HMOs may contract with independent practice associations (IPAs) that, in turn, contract with individual physicians for services and compensation. By the late 1990s, 80 percent of MCOs were for-profit organizations, and only 68 percent or less of insurance premiums went toward medical care.

Nixon signed into law, the Health Maintenance Organization Act of 1973, in which medical insurance agencies, hospitals, clinics and even doctors, could begin functioning as for-profit business entities instead of the service organizations they were intended to be. 

a group of teachers created a program through Baylor University Hospital where they would agree to pre-pay for future medical services (up to 21 days in advance). The resulting organization was not-for-profit and only covered hospital services. It was essentially the precursor to Blue Cross.

Since U.S. businesses were prohibited from offering higher salaries, they began looking for other ways to recruit new employees as well as incentivizing existing ones to stay. Their solution was the foundation of employer-sponsored health insurance as we know it today.

Because health benefits could be considered part of compensation but did not count as income, workers did not have to pay income tax or payroll taxes on those benefits. Thus, by 1943, employers had an increased incentive to make health insurance arrangements for their workers, and the modern era of employer-sponsored health insurance began

have the knowledge and skills to help navigate the hospital system, explain your diagnosis in detail, and explain potential outcomes.  We are also here to help decipher the information from doctor visits, set up meetings with care teams, and organize home care, and medications

Initial resistance to the hospitalist movement among physicians often focused on the unavoidable discontinuity in care created by the model and the potential loss of information across the hospital threshold.45,49-52 Effective hospitalist programs have created mechanisms to mitigate the impact of this discontinuity, including calling primary care physicians on admission and discharge, faxing daily progress notes, and encouraging primary care physicians to visit or call their hospitalized patients. Though some concerns about information transfer linger, 2 recent surveys suggest that most physicians now accept the hospitalist model. In a national telephone survey of 400 internists, 51% (204) thought hospitalists might provide better care and 46% (184) thought patients might get more cost-effective care. Although 73% were concerned about the impact of hospitalists on continuity, physicians with hospitalists in their community were more approving.10 In a survey of 524 California primary care physicians, physicians perceived hospitalists as increasing (41%) or not changing (44%) the overall quality of care and most (55%) thought that hospitalists increase inpatient efficiency.11 In both surveys, primary care physicians stated their belief that patients generally preferred to be cared for in the hospital by their regular physician. Surveys of both generalists and specialists at Park Nicollet showed high levels of physician satisfaction several years after the implementation of a hospitalist program.28

A major early concern was that patients accustomed to having their primary physician as their inpatient attending would not accept hospitalists.45 In general, however, surveys of patients who were cared for by hospitalists show high levels of satisfaction, no lower than that of similar patients cared for by their own primary physicians28,31,32 or by traditional academic ward attendings.18,21 We have postulated that patients may be willing to trade off the familiarity of their regular physician for the availability of the hospitalist.45

And while hospitalists have already moved into post-acute-care settings, Dr. Bessler says that will become an even bigger focus in the next 20 years of the specialty. “It’s not generally been the psyche of the hospitalist in the past to feel accountable beyond the walls of the hospital,” he says. “But between episodic care [and] bundled payments … you can’t just wash your hands of it. You have to understand your next site-of-care decision. You need to make sure care happens at the right location.”

Five years ago, it was accountable care organizations and value-based purchasing that SHM glommed on to as programs to be embraced as heralding the future. Now it’s the Bundled Payments for Care Improvement initiative (BCPI), introduced by the Center for Medicare & Medicaid Innovation (CMMI) at the Centers for Medicare & Medicaid Services (CMS) back in 2011 and now compiling its first data sets for the next frontier of payments for episodic care. BCPI was mandated by the Patient Protection and Affordable Care Act (ACA) of 2009, which included a provision that the government establish a five-year pilot program by 2013 that bundled payments for inpatient care, according to the American Hospital Association. BCPI now has more than 650 participating organizations, not including thousands of physicians who then partner with those groups, over four models. The initiative covers 48 defined episodes of care, both medical and surgical, that could begin three days prior to admission and stretch 30, 60, or 90 days post-discharge. <img class="file media-element file-medstat-image-flush-right" height="220" width="220" alt="Dr. Weiner" typeof="foaf:Image" src="https://www.the-hospitalist.org/sites/default/files/styles/medium/public/images/weinerweb.jpg" title="" />Dr. Weiner “The reason this is so special is that it is one of the few CMS programs that allows providers to be in the driver’s seat,” says Kerry Weiner, MD, chief medical officer of acute and post-acute services at TeamHealth-‎IPC. “They have the opportunity to be accountable and to actually be the designers of reengineering care. The other programs that you just mentioned, like value-based purchasing, largely originate from health systems or the federal government and dictate the principles and the metrics that as a provider you’re going to be evaluated upon. “The bundled model [BCPI] gives us the flexibility, scale, and brackets of risk that we want to accept and thereby gives us a lot more control over what physicians and physician groups can manage successfully.”

“If we can’t build what I think of as a pyramid of care with one doctor and many, many other people supporting a broad group of patients, I don’t think we’re going to be able to find the scale to take care of the aging population that’s coming at us,” she says. Caring for patients once they are discharged means including home nurses, pharmacists, physical therapists, dietitians, hired caregivers, and others in the process, Dr. Gorman says. But that doesn’t mean overburdening the wrong people with the wrong tasks. The same way no one would think to allow a social worker to prescribe medication is the same way that a hospitalist shouldn’t be the one checking up on a patient to make sure there is food in that person’s fridge. And while the hospitalist can work in concert with others and run many things from the hospital, maybe hospital-based physicians aren’t always the best physicians for the task. “There are certain things that only the doctor can do, of course, but there are a lot more things that somebody else can do,” Dr. Gorman says, adding, “some of the times, you’re going to need the physician, it’s going to be escalated to a medication change, but sometimes maybe you need to escalate to a dietary visit or you need to escalate to three physical therapy visits. “The nitty-gritty of taking care of people outside of the hospital is so complex and problematic, and most of the solutions are not really medical, but you need the medical part of the dynamic. So rather [than a hospitalist running cases], it’s a super-talented social worker, nurse, or physical therapist. I don’t know, but somebody who can make sure that all of that works and it’s a process that can be leveraged.” Whoever it is, the gravitation beyond the walls of the hospital has been tied to a growing sea change in how healthcare will compensate providers. Medicare has been migrating from fee-for-service to payments based on the totality of care for decades. The names change, of course. In the early 1980s, it was an “inpatient prospective payment system.”

Hospitalists are often referred to as the quarterbacks of the hospital. But even the best QB needs a good team to succeed. For HMGs, that roster increasingly includes nurse practitioners (NPs) and physician assistants (PAs).

“The day is upon us where we need to strongly consider nurse practitioners and physician assistants as equal in the field,” he says. “We’re going to find a much better continuity of care for all our patients at various institutions with hospital medicine and … a nurse practitioner who is at the top of their license.”

“The role of the hospitalist often is to take recommendations from a lot of different specialties and come up with the best plan for the patient,” says Tejal Gandhi, MD, MPH, CPPS, president and CEO of the National Patient Safety Foundation. “They’re the true patient advocate who is getting the cardiologist’s opinion, the rheumatologist’s opinion, and the surgeon’s opinion, and they come up with the best plan for the patient.”

Why, though, do we not romanticize our preservation? The same matter of chance, of the fleeting nature of fate exists on the other side of the coin. What would have happened if we were better rested, if our energy was better preserved, if we managed our time and said what we really mean? Rarely do we approach whether we get eight hours of sleep with the same guilt as we do whether or not we attended a party, even when, according to sleep expert Matthew Walker, sleep deprivation prevents the brain from remembering information, creating new memories, and sustaining emotional well-being.

Despite the hospitalist field’s unprecedented growth, there have been challenges. The model is based on the premise that the benefits of inpatient specializa-tion and full-time hospital pres-ence outweigh the disadvantages of a purposeful discontinuity of care. Although hospitalists have been leaders in developing sys-tems (e.g., handoff protocols and post-discharge phone calls to pa-tients) to mitigate harm from dis-continuity, it remains the model’s Achilles’ heel.

Finally, financial penalties for readmis-sions have led many hospitalists to staff post–acute care facilities to improve coordination with col-leagues at acute care hospitals.

Conversely, some traditional programs may develophospitalist tracks that emphasize acquisition of theskills most relevant to inpatient practice. If suchtracks are developed, it will be important not to re-duce training in ambulatory care too aggressively,since the competent hospitalist will need a full un-derstanding of what can — and cannot — be donein the outpatient setting

As with anymajor transition, the medical community must con-tinually reevaluate the new approach to ensure thatany possible discontinuity in care is outweighed byimproved clinical outcomes, lower costs, better edu-cation for physicians, and greater satisfaction on thepart of patients.

Equally pressing is the question of value, definedas the quality of care divided by its cost.10

Two of the principles underlying generalism,whether in the form of internal medicine, pediatrics,or family medicine, have been comprehensivenessand continuity.7,8 Ideally, the primary care physicianwould provide all aspects of care, ranging from pre-ventive care to the care of critically ill hospitalizedpatients. This approach, argued the purists, wouldresult in medical care that was more holistic, less frag-mented, and less expensive.9 To its proponents, thenotion was so attractive — the general internist ad-mits the patient to the hospital, directs the inpatientworkup, and arranges for a seamless transition backto the outpatient setting — that questioning it wouldhave seemed sacrilegious merely a few years ago

Polls show that doctors are trusted by the public more than politicians, which means it’s hard for public policy to shape the healthcare system unless medical associations sign off on it.

“It’s about embracing the inscrutable nature of human interactions,” says Chang. Evidence-based medicine was a massive improvement over intuition-based medicine, he says, but it only covers traditionally quantifiable data, or those things that are easy to measure. But we’re now quantifying information that was considered qualitative a generation ago.

“Our biggest opportunity is leaning into that. It’s either embracing the qualitative nature of that and designing systems that can act just on the qualitative nature of their experience, or figuring how to quantitate some of those qualitative measures,” says Chang. “That’ll get us much further, because the real value in health care systems is in the human interactions. My relationship with you as a doctor and a patient is far more valuable than the evidence that some trial suggests.”

Duffy points to the increase in health care interactions online and adds that he would like to see a pervasive culture of in-person care as last resort. “If every organizational decision, technology decision, process decision — assuming all the payment stuff, that’s kind of ticket of entry, transpires — if you view in-person as last resort, that will help pull systems across the country to a more consumer-forward Uber-like experience,” he says

As with other forms of value-based health care, patient-centered care requires a shift in the way provider practices and health systems are designed, managed, and reimbursed. In keeping with the tenets of patient-centeredness, this shift neither happens in a vacuum, it driven by traditional hierarchies in which providers or clinicians are the lone authority. Everyone, from the parking valet and environmental services staff to c-suite members, are engaged in the process, which impacts hiring, training, leadership style, and organizational culture. Patient-centered care also represents a shift in the traditional roles of patients and their families from one of passive “order taker” to one of active “team member.” One of the country’s leading proponents of patient-centered care, Dr. James Rickert, has stated that one of the basic tenets of patient-centered care is that “patients know best how well their health providers are meeting their needs.” To that end, many providers are implementing patient satisfaction surveys, patient and family advisory councils, and focus groups, and using the resulting information to continuously improve the way health care facilities and provider practices are designed, managed, and maintained from both a physical and operational perspective so they become centered more on the individual person than on a checklist of services provided. As the popularity of patient- and family-centered health care increases, it is expected that patients will become more engaged and satisfied with the delivery of their care, and evidence of its clinical efficacy should continue to mount.

The concept of patient-centered care extends to the treatments and therapies clinicians provide. Not only are care plans customized, but medications are often customized as well. A patient’s individual genetics, metabolism, biomarkers, immune system, and other “signatures” can now be harnessed in many disease states — especially cancer — to create personalized medications and therapies, as well as companion diagnostics that help clinicians better predict the best drug for each patient.

Strict visiting hours and visitor restrictions are a thing of the past in a patient-centered care model. Patients are given the authority to identify who can visit and when. Family members (as defined by the patient and not limited to blood relations) are invited to visit during rounding and shift changes so they can be part of the care team, participating in discussions and care decisions. When not in the room with the patient, they are kept informed of their loved one’s progress through direct and timely updates. A patient-centered care hospital’s infrastructure encourages family collaboration through a home-like environment that not only meets the needs of the patient, but also meets the needs of family members. For example, maternity wards are being redesigned with family-friendly postpartum rooms that can accommodate the mom, new baby, and family members, who are encouraged to spend up to 24 hours a day together in the room to foster family bonding.

The primary goal and benefit of patient-centered care is to improve individual health outcomes, not just population health outcomes, although population outcomes may also improve. Not only do patients benefit, but providers and health care systems benefit as well, through: Improved satisfaction scores among patients and their families. Enhanced reputation of providers among health care consumers. Better morale and productivity among clinicians and ancillary staff. Improved resource allocation. Reduced expenses and increased financial margins throughout the continuum of care.

Patient- and family-centered care encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan. Most definitions of patient-centered care have several common elements that affect the way health systems and facilities are designed and managed, and the way care is delivered: The health care system’s mission, vision, values, leadership, and quality-improvement drivers are aligned to patient-centered goals. Care is collaborative, coordinated, and accessible. The right care is provided at the right time and the right place. Care focuses on physical comfort as well as emotional well-being. Patient and family preferences, values, cultural traditions, and socioeconomic conditions are respected. Patients and their families are an expected part of the care team and play a role in decisions at the patient and system level. The presence of family members in the care setting is encouraged and facilitated. Information is shared fully and in a timely manner so that patients and their family members can make informed decisions.

In patient-centered care, an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements. Patients are partners with their health care providers, and providers treat patients not only from a clinical perspective, but also from an emotional, mental, spiritual, social, and financial perspective.

Koh et al. (11) detailed a cycle of crisis care elaborating the nature of high medical costs, possibly resulting from fear and denial. First, an individual is in need of medical help, so he or she goes to a physician's office where the staff asks the individual to fill out a complex and confusing form. The physician examines the patient and explains the condition and treatment options using medical jargon. Numerous prescriptions, laboratory tests, and referrals are given without confirmation of the patient's comprehension. The staff sends the patient home with complicated instructions. Inevitably, the patient may consume medication incorrectly or miss follow-up appointments, and his or her condition worsens. Eventually, the patient presents to the emergency department, and the hospital staff develops a new treatment plan. Again, no one confirms the patient's understanding. When the patient is discharged, he or she is likely to get sick again and repeat the cycle (11)

CARE Framework

Making Child Care More Accessible and Affordable

We want better children—but not by turning procreation into manufacture or by altering their brains to gain them an edge over their peers. We want to perform better in the activities of life—but not by becoming mere creatures of our chemists or by turning ourselves into tools designed to win or achieve in inhuman ways. We want longer lives—but not at the cost of living carelessly or shallowly with diminished aspiration for living well, and not by becoming people so obsessed with our own longevity that we care little about the next generations. We want to be happy—but not because of a drug that gives us happy feelings without the real loves, attachments, and achievements that are essential for true human flourishing.

medical care

child care

Child and elder care

Anomie (/ˈænəˌmi/) is a "condition in which society provides little moral guidance to individuals".[1] It is the breakdown of social bonds between an individual and the community, e.g., under unruly scenarios resulting in fragmentation of social identity and rejection of self-regulatory values.

The technical and theoretical details underlying clinical informatics are beyond the scope of this chapter. What follows is a concise introduction to topics and resources of general interest in this field, presented to help clinicians use information technology for the benefit of patient care.

Satisfaction with cost to you88.93

Convenience of location for you84.17

Friendliness and courtesy of the staff78.63 High

Accuracy and completeness in filling out reports73.66

Skill and competency of medical staff

Speed in completing examination and reports

There are many resources available to help you and your health care proxy develop a care plan. These are merely suggestions to get you thinking about possible scenarios and topics to discuss. I hope you found this blog informative, and urge you to share it with anyone who does not have a health care proxy. We always think it will never happen to us, but what if it does? It's best to be prepared!

Further, a doctor, medical center, hospital, EMT, and even assisted living staff can make decisions regarding your healthcare, treatment methods and type of medical care to provide you if you are not married, over 18 years old, and do not have a health care proxy in place

Who would decide what was best for you? Who would advocate on your behalf?

Health care proxy: An advance medical directive in the form of a legal document that designates another person (a proxy) to make health care decisions in case a person is rendered incapable of making his or her wishes known.

The question each proxy should ask when making decisions on behalf of others is, who am I truly serving — the patient or myself?

When the patient is unwilling or unable to make medical decisions, the health care proxy is activated and he or she is obligated to make all health choices on behalf of the patient. These may be related to withdrawing or withholding life support, instituting artificial liquid feeding, attempting resuscitation and even whether or not to participate in autopsy and organ donation.

First, the industry is demanding it. Those who are paying for healthcare—the government, employers, patients, commercial health plans—want more value for their healthcare dollar. The transaction-driven, fee-for-service model has helped contribute to a fragmented healthcare system that has led to major challenges in healthcare. This fee-for-service model is simply not sustainable.

reliability and accessibility of big data will help facilitate increased reliance upon outcomes-based contracting and alternative payment models.

fee-for-service payment models to value-based care

He calls for more thoughtful engagement with the notion not so much of making things, but of fixing them, repurposing them in their diminishment and dismantlement—not of making new, but of making do, and of thereby engaging what he calls ‘an ethics of mutual care’—with each other, the world around us, and with the (quite literal) objects of our affection (Jackson, 2013, p. 231). This is a source, he says, of ‘resilience and hope’ and it’s a way of being in space and time that has deep feminist roots (Jackson, 2013, p. 237).

‘I don’t care about me.’

Section 139A of the Internal Revenue Code of 1986 is amended by adding at the end the following new sentence: “This section shall not be taken into account for purposes of determining whether any deduction is allowable with respect to any cost taken into account in determining such payment.”.

Es handelt sich um eine Politik ohne Zwang, die biopolitische Interessen in die Individuen hineinverlagert. Der gesellschaftliche Zugriff auf den weiblichen Körper bleibt bestehen, es sieht aber nach Freiheit aus, argumentiert wird mit "optimalen Gesundheitsentscheiden" oder "Risikominimierung". Dieser individualisierte Optimierungsimperativ macht es letztendlich schwierig zu erkennen, dass Kinderbekommen kein privates Ereignis ist, sondern auch Teil von gesellschaftspolitischen Dynamiken. Auf diese Weise wird auch das große Thema Care-Arbeit ausgeblendet.

The science of variation like the clinical gaze was believed to unearth all sides of truth and was therefore effectively applied as a form of industrial management in order to cope with population growth.

that doesn't mean the drugs can't be immensely profitable. Treanda is an orphan drug but also Teva's second-best seller, racking up $740 million in sales last year, according to Teva's annual report.

Is Google Making Us Stupid?

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Or more plainly: attention on social media both compensates for and is the logical endpoint of commoditized care work.

The disaggregation of news in the Internet age has inverted this relationship, and made news outlets hypersensitive to the interests of their readers. This is a positive development. It’s good that the media covers stories that its constituents are interested in and want to read about. It’s good when news outlets are connected to the communities they serve.

we feel friendly to those who have treated us well, either ourselves or those we care for, whether on a large scale, or readily, or at some particular crisis; provided it was for our own sake.