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Healthy Communities: New Partnerships for the Future of Public Health (1996)
Chapter: Public Health and Managed Care
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Suggested Citation:"Public Health and Managed Care." Institute of Medicine. 1996. Healthy Communities: New Partnerships for the Future of Public Health. Washington, DC: The National Academies Press. doi: 10.17226/5475.
Public Health and Managed Care In the past decade, there has been substantial growth in organized health care delivery systems in most parts of the United States. Managed care organizations, the most common form of these systems, can be defined as "any system that is under the management of a single entity that (1 ) insures members-either by itself or through an intermediary, (2) furnishes covered benefits through a defined network of participating providers, and (3) manages the health care practices of participating providers" (Rosenbaum and Richards, 1996~. Public health practice is sometimes thought of as separate from, or complementary to, the delivery of personal health services. A more helpful distinction is between personal health services and community interventions. Personal health services involve a one-to-one interaction between a provider and a patient (IOM, 1993~. Personal health services are delivered primarily by private- sector organizations, but in many communities, governmental health departments provide many of these services, especially for disadvantaged populations. Community interventions aim to alter the social or physical environment to change one or more health-related behaviors or to directly reduce the risk of causing a health problem. Community-based services are usually carried out by public health agencies, other government agencies, or community-based voluntary organizations. The provision of personal health services per se, even if they are delivered in the community rather than in health care settings, is not a community intervention. Outreach or community-based activities intended to improve access to personal health services or their utilization, however, are included. Public health agencies are often challenged to provide both types of services, but community organizations frequently help the public health agency 13
14 HEALTHY COMMUNITIES achieve a public heal objective In a community (Box 1~. Private heal service organizations sometimes sponsor outreach activities such as mass screening arid heals fairs (at times win commercial Interests), with and without a public heals agency's involvement. BOX 1. Overcoming Barriers to Immunization: An Example for Public Health In 1992 the 16,000 members of the Florida District of Kiwanis International formed a partnership with the Department of Health and Rehabilitative Services' (HRS's) State Health Office Immunization Program to help increase immunization levels in the preschool population. As part of their "Young Children: Priority One" major initiative, the Florida District Kiwanis made an eight-year commitment to be lead volunteer agency assisting in implementing Florida's Immunization Action Plan. This flare provides objectives to raise the immunization rates of Florida's two-year-olds to 90% by the year 2000. At the time of the formation of the partnership, only 63% of Florida's two-year- olds were up to date with their immunizations. Since the HRS-Kiwar~is partnership was formed four years ago, the immunization levels have increased by 27%. The Kiwanis have donated many thousands of volunteer hours in immunization clinics and have organized coalitions, recruited other community groups, and purchased computer equipment, vans, and educational materials. With the Kiwanis's help, Florida's 67 county public health units have increased their clinic hours, opened new clinic sites, extended service times and added locations, arranged transportation services for low- income clients, and coordinated services with other agencies to reach more children. Because of this partnership, more of Florida's young children are protected against vaccine-preventable diseases now than at any other time in the state's history. The 1995 Survey of Immunization Levels in the two-year-old population indicated that an unprecedented 80% of Florida's two-year-olds are immunized. Much of the increase can be attributed to the Kiwanis's leadership in volunteer efforts. This partnership has helped reduce the dangers that exist when society fails to immunize its children. For example, the number of measles cases in Florida had nearly doubled, from 322 cases in 1989 to 603 cases in 1990. Two of the cases occurred among unvaccinated preschool children. In 1995, there were 14 confirmed measles cases in Florida. Through this partnership, the Kiwanis, the county public health units, and the immunization program office have set an example that demonstrates the positive benefits that result when a community-based partnership works together to donate time, energy, and resources to improve the health of Florida's children. SOURCE: Based on information provided by Charles Mahan, Dean of the University of South Florida College of Public Health (former director, Florida State Department of Health and Rehabilitative Services), 1996.
PUBLIC HEALTH AND MANAGED CARE 15 An estimated 90 million insured Americans are enrolled in managed care plans, including more than 25% of Medicaid beneficiaries and 10% of Medicare beneficiaries (Rosenbaum and Richards, 19961. Most of the growth in enrollment has occurred in recent years. Between 1988 and 1993, the percentage of employees enrolled in a managed care plan increased from 29% to 51% (Gabel et al., 1994~. In the Medicaid program, the growth has been even more dramatic as states have requested waivers from the Health Care Financing Administration (HCFA) to shift their Medicaid populations into managed care arrangements. Between 1993 and 1994, the number of Medicaid beneficiaries in managed care increased by 63%, from 4.8 million to 7.8 million (Kaiser Commission, 1995~. The factors contributing to the growth in managed care are the rising costs of personal health care and an interest among employers to find ways to control providers and, therefore, to control costs (Rosenbaum and Richards, 1996~. States have also used managed care arrangements as a way of containing spiraling costs in the Medicaid program and of trying to improve access to care (Kaiser Commission, 1995~. STRENGTHS AND WEAKNESSES OF MANAGED CARE FOR PUBLIC HEALTH Managed care offers opportunities for public health (CDC and GHAA, n.d.; Baker et al., 1994; HRSA, n.d.) but it also poses challenges. In the discussions initiated by the Public Health Committee, proponents of managed care have argued that its goals and tools are consistent with public health. Many public health professionals, on the other hand, have also indicated concern about managed care organizations' motives and ability to deliver on Heir promises. The committee's view, as developed in this section, is that if the proper kinds of partnerships between managed care organizations and governmental public health departments are developed, managed care can indeed make an important contribution to improving the health of the public. Accountability, Responsibility, and Quality Because it is responsible for delivering care to a defined group of enrollees, managed care makes possible, for the first time, accountability in terms of quality of care for populations, including access to care and heals outcomes. This is possible because managed care organizations can monitor the health outcomes of enrollees and examine their use of services. However, this is not regularly done. Some managed care organizations, especially large staff-model managed care organizations, are using their data systems to track the health oftheir enrollees, but
16 HEALTHY COMMUNITIES many managed care organizations do not collect the types of information needed for surveillance and epidemiologic studies. There have been a number of attempts to assess the quality of care offered by managed care organizations. The National Committee for Quality Assurance (NCQA), which accredits managed care organizations, has developed the Health Plan Employer Data and Information Set (HEDIS), a set of performance measures for managed care organizations designed to meet employers' and government purchasers' needs for information about the value of services they purchase and to systematize the measurement process (NCQA, 19939. The data systems maintained by some managed care organizations are an important tool for improving performance and maintaining accountability, and simply by having performance monitoring systems, these organizations compare favorably with fee-for-service delivery systems or indemnity insurance companies that typically have no data with which to monitor performance. The committee heard of instances in which a managed care organization's performance in terms of provision of preventive services, for example was criticized based on the organization's own data, with the implicit assumption that other providers do better. Such assumptions may well be incorrect and are unfair because they cannot be checked unless the other providers have appropriate data systems. Experience suggests that performance monitoring as a basis for punishing those who are not producing as expected is not an effective way to alter behavior and improve outcomes. Rather, performance monitoring should be used to encourage productive action and broad collaboration (Berwick, 1989; IOM, in press). Population Orientation and Prevention Managed care's responsibility for a defined population gives it an interest in promoting health and preventing disease in that population, which is the mission of public health. Both managed care organizations and governmental public health agencies have a philosophical emphasis on promoting health and preventing disease. Both address prevention and health promotion in a defined population. However, in actual practice, some managed care organizations seem more concerned about efficiency and controlling short-run costs than about prevention or the health status of their members. Governmental public health agencies have a geographic perspective and are accountable to the people within their jurisdiction while many managed care organizations focus on their current enrollees, an ever- changing group, who may only be a subset of the population. Committee discussions suggested that in the long term, it is important for managed care organizations to think more broadly and to promote health in the whole community because anyone may be their enrollee in the future (Box 2~. In a
P UBLIC HEAL TH AND At4NA GED CARE 17 capitated system with limited turnover, some prevention activities might result In larger filture profit margins. Unlike public heals agencies, managed care organizations are primarily accountable to purchasers, subscribing employers, large groups of payers, and ultimately weir stockholders or trustees. As managed care organizations respond to public demands for accountability, more should find ways to measure the quality of services Hey provide. A focus on heal outcomes and prevention objectives, as some organizations which have adopted HEDIS and other performance measures have done, would help. BOX 2. Group Health Cooperative of Puget Sound Group Health Cooperative of Puget Sound is a large, nonprofit health maintenance organization (HMO) that was established in 1947. It has approximately 540,000 enrollees, of whom about 80,00090,000 are enrolled in the Medicare and Medicaid Basic Health Plan. The cooperative has been involved in community-based health for more than 50 years. Its public health focus grew out of 10 years of involvement with public health in community issues and priorities such as AIDS prevention. In 1992, Group Health adopted a vision statement that calls for delivery of quality health care to the whole community, not just its enrolled population. They also adopted a set of community service principles to recognize the work that Group Health had been doing in the community in the area of health promotion and disease prevention. They currently focus their attention on four areas: (1) childhood immunization, (2) the reduction of infant mortality, (3) health care for homeless families, and (4) the reduction and prevention of interpersonal violence. In their community-based programs, Group Health has gone beyond just providing immunization and preventive clinical services to issues that deal with changing social norms, such as violence and alcohol abuse. Group Health is also working with the State of Washington on surveillance issues to improve their performance measurements and develop more integrated information systems. Group Health considered several factors in implementing its community programs. Improving community health in general is expected to lead to improved health for the members of Group Health as well. Involvement in community-based programs also helps Group Health compete for contracts with large employer groups and with Medicaid and Medicare populations. In addition, community service programs help to encourage innovative approaches to providing services to the patient population. SOURCE: Based on a presentation by William Berry, director, Center for Health Promotion, Group Health Cooperative of Puget Sound, at the February 22, 1996, meeting of the Public Health Committee.
18 HEALTHY COMMUNITIES Personal Health Services for Vulnerable Populations As managed care organizations enroll increasing numbers of people from disadvantaged groups, the biggest challenge for public health agencies is in the area of providing personal health services for poor and vulnerable populations. Public health agencies, primarily at the local level, have played an important role in providing health care services to both Medicaid-eligible and uninsured and underinsured population groups. For example, they provide maternal and child health services, sexually transmitted disease (STD) services, and tuberculosis services. For certain services, issues of expertise or confidentiality would suggest that public health agencies are the appropriate entities to continue to provide these services (Frieden et al., 1995; IOM 1996), so local public health agencies must maintain this capacity. As more states shift their Medicaid enrollees into managed care, public health agencies have the option of trying to obtain contracts with managed care organizations, but many are ill-equipped to compete for and negotiate with health plans (Lipson and Naierman, 1996~. Many issues of language, culture, tradition, class, race, and ethnicity need to be taken into account when providing services to especially vulnerable populations. Perhaps the most serious aspect of this problem is providing services to those who are covered by neither insurance nor Medicaid and who are especially vulnerable. As many cities and counties move to privatize public hospitals, which have traditionally served vulnerable populations, they will have to consider whether and how managed care organizations fill this role and how the delivery of care to the underinsured and uninsured will continue. Individuals who are eligible for Medicaid but unfamiliar with managed care organizations may not understand how to access needed services. A strategy of partnering with both governmental public health agencies and community-based organizations, which have the skills and experience needed to work effectively with these vulnerable populations, could strengthen the entire health system's response to the needs of these special populations. Many state Medicaid agencies do not have the management skills to monitor the performance of managed care organizations or to write appropriate contracts with these organizations (Box 3~. Competitive cost-cutting pressures coupled with vulnerable populations may result in opportunities for health care plans or providers to take advantage of poor patients. The problem of turnover of patient population as enrollees lose and regain their eligibility for Medicaid also contributes to serious problems of continuity of care.
PUBLIC HEALTHAND MANAGED CARE 19 BOX 3. Medicaid Managed Care The move toward managed care for Medicaid patients offers promise for improving health outcomes arid solving potential problems. The promise is due to the shift inherent in managed care toward interest in the health of defined populations. This facilitates the use of public health assessment tools (e.g., epidemiology), strategic thinking about efficient ways to improve the health of populations, and opportunities to undertake activities focused on disease prevention. Problems that may occur during this transition to Medicaid managed care include (1) personal health services traditionally carried out by public health departments (i.e., prenatal care, immunization services, family planning arid sexually transmitted disease [STD] clinics, and Early and Periodic Screening, Diagnosis, arid Treatment [EPSDT]) will not be completely transferred to a managed care organization; (2) poor people who are eligible for Medicaid but are unfamiliar with managed care organizations may not understand how to access needed service; (3) marry state Medicaid agencies do not have the management skills to monitor the performance of managed care organizations or to write appropriate contracts with them; and (4) competitive cost-cutting pressures coupled with vulnerable populations and weak oversight may result in some unscrupulous health care providers talking advantage of poor patients. There is a growing realization that managed care organizations need the expertise and authority of public health agencies to undertake community-based interventions arid perform outreach services that are necessary for maintaining the health of the populations for which they are responsible. Public health services are also necessary in cases in which confidentiality is art issue, such as at STD or family planning clinics. Many public health professionals now provide personal health services, often in community-based categorical public health clinics. Such services are the type that managed care organizations should be able to handle, and therefore, once they are trasfemed, there will be less of a need for health professionals with the same skills in public health departments. There will be art increased need in both public health departments and managed care organizations for people with public health assessment skills arid health care management skills. SOURCE: Presentations to the Institute of Medicine (IOM) Board on Health Promotion arid Disease Prevention alla the National Research Council/IOM Board on Children arid Families in joint session on June 15, 1995. DEFINING ROLES AND RESPONSIBILITIES Given the challenges involved in the transition to managed care, it will be important for each community to define the roles and responsibilities of governmental public health agencies and managed care organizations in improving health. Depending on local conditions, public health agencies can play a variety of roles, from serving in an advisory or regulatory capacity to obtaining contracts to
20 HEALTHY COMMUNITIES provide services. Managed care organizations can play a role In heal promotion and disease prevention, disease surveillance, and promoting quality. The IOM report The Hidden Epidemic: Confronting Sexually Transmitted Diseases (~1996~), illustrates He opportunities and problems In He relationship between heals department and managed care organizations in one area (Box 4~. Two recent reports (CDC and GHAA, n.d.; Joint Council, 1996) identify a varietal of approaches to collaboration. More generally, a new joint initiative of He American Medical Association and the American Public Heals Association is exploring new ways Hat medicine and public health can collaborate to Improve health and heals care In the United States (Reiser, 1996~. BOX 4. IOM Committee on the Prevention and Control of Sexually Transmitted Diseases (STDs) The Institute of Medicine (IOM) Committee on the Prevention and Control of STDs held a workshop on November 8, 1995, to examine the role of managed care in STD prevention and control. The national movement toward managed care coupled with limited public funds for health programs will have a significant impact on the delivery of services provided by public health agencies, especially those that involve many providers and intervention points such as STD prevention and control. There are many opportunities and challenges for managed care to address STD issues effectively. Strengths of managed care organizations that are particularly appropriate for this role include (1) a population-based focus (i.e., group and staff models track disease and health trends for a population), (2) the ability to coordinate and integrate STD services into primary care, and (3) accountability to purchasers of health services. Increasingly, managed care organizations are enrolling Medicaid populations whose health care used to be provided by local public health departments. In some states, Medicaid revenues have been a major source of funding for public health clinical services. The absence of the revenues becomes a problem for local health departments as well as for community-based health clinics that have been providing services. Nevertheless, local health departments report that many persons with health insurance continue to use public health clinics, local health department STD clinics, or other clinics outside of their health plan for STD-related services. ! OURCE: Presentation by Richard Brown, member of He IOM Committee on the Prevention and Control of STDs, at the February 22, 1996, meeting of the Public Health Committee; IOM (1996).
PUBLIC HEALTH AND MANAGED CARE Roles for Public Health Agencies 21 With their potentially extensive knowledge of the community and its depth and breadth of experience in fields such as epidemiology and injury prevention, governmental public health agencies can play an important role with managed care organizations. The Future of Public Healths analysis implies that public health departments should work with managed care organizations, in the public interest, as part of their assessment and assurance mandate. Their role can include everything from offering advice about data and information systems, to developing training and education programs, even to fostering an advocacy role (Box 5~. In particular, governmental public health agencies can: · provide information about the health status, risks, and determinants of communities served by managed care organizations, which is vital for raising awareness and setting priorities even if the jurisdictions of the health agencies do not correspond exactly to the population covered by the managed care organizations; · participate with managed care organizations in planning and policy development related to voluntary collaborative actions or regulatory policy development; · provide services, such as case management and enabling services, to managed care clients; and · assist managed care organizations with assurance and oversight when working with state agencies with regulatory responsibility. In carrying out the assessment function, governmental public health agencies have a responsibility to monitor the health status of managed care enrollees, just as for others in their communities. Similarly, governmental agencies must ensure that members of managed care plans have access to quality health care, and assessment results provide relevant information to carry out this function. In conjunction with managed care, these two functions are clearly interrelated and have undeniable costs. Managed care organizations can and should participate in data preparation and analysis, and their data systems can facilitate these activities. If there are to be independent checks on managed care plans' performance, these functions must, at some level, involve public health or other governmental agencies.
22 HEALTHY COMMUNITIES BOX 5. Minnesota Department of Health Minnesota has a relatively mature managed care market and has been licensing health maintenance organizations (HMOs) since the early 1970s. Most of the employer- insured population is enrolled in an HMO, except in rural areas. In 1994, approximately 80% of the Twin Cities population of 2.6 million was enrolled in HMOs, Preferred Provider Organizations, and self-funded employer plans. The State of Minnesota is a large employer that began coordinating health services for its employees in 1989 and joined the Buyers' Health Care Action Group (BHCAG) in 1995. BHCAG is a coalition of 23 area employers that developed a plan to provide direct contracting with competing health systems to develop health care systems that offer a full continuum of services; shared financial risk with purchasers; clinical and fiscal accountability; competition on the basis of quality, cost, and service; and commitment to community-wide quality improvement. In addition, Minnesota is in the process of transferring its Medicaid enrollees and Aid to Families with Dependent Children recipients into HMOs. It plans in the event that Congress enacts legislation that creates a block grant system for Medicaid to take a portion of Medicaid funds and set it aside for the public health infrastructure. Minnesota requires all HMOs to file annual action and collaboration plans. Action plans provide information to consumers, purchasers, and the community, as a first step toward greater accountability of health plan companies. This is intended to encourage local discussions of the health needs of the community. The Minnesota Department of Health is responsible for ensuring that the action plans submitted by managed care organizations are available for review by local organizations. Collaboration plans describe the actions that managed care organizations intend to take to achieve public health goals for their service areas. Action plan are to be jointly developed in collaboration with community health boards, regional coordinating boards, and other community organizations providing health services within the service area of the managed care organization. Managed care organizations are required to cover services out of network in the area of STDs, AIDS, tuberculosis, and family planning. Minnesota has a Community Health Services Act that provides the framework for state and local partnerships in that the state delegates most core public health functions to the local level. Community health boards submit a plan every year based upon the community's assessment of its needs. Funds are provided from the state to the community, based upon its needs assessment. Federal preventive health block grants are used to hold capacity-building conferences in specific areas such as immunization, STDs, alcohol and tobacco use, prenatal care, and violence. These conferences bring together representatives from local public health agencies, community health providers, managed care organizations, and other health service providers to analyze the community's needs assessment data. | OURCES: Based on a presentation by Anne Barry, commissioner of health of| Minnesota, at the February 22, 1996 meeting of the Public Health Committee; National Health Policy Forum, 1995; Minnesota Department of Health, 1 995a,b.
PUBLIC HEALTH AND Al4NAGED CARE Roles for Managed Care Organizations 23 Managed care organizations can also take a more active role in improving the public's health. They can strengthen their health promotion and disease prevention activities by integrating public health programs and services with their primary health care activities and collaborating with public health agencies. With public health agencies and others, managed care organizations can advocate for measures to improve the public's health in the community. Managed care organizations can also develop their data systems to be useful for surveillance and epidemiologic research. Furthermore, they can continue to pave the way for improving the quality of health care (Box 6~. Showstack and colleagues (1996) have argued that managed care organizations have a social responsibility to "broaden their missions from the care of enrolled populations to include contributions to the health of the communities in which they serve." To guide managed care organizations and judge whether they are responsible, accountable, and responsive contributors to the community's health, Showstack and colleagues offer the following eight attributes of a socially responsible managed care system: enrolls a representative segment of the general population living in the system's geographic service area; 2. identifies and acts on opportunities for community health improvement; 3. participates in community-wide data networking and sharing; 4. publishes information regarding its financial performance and contribu- tions to its community; 5. includes the community, broadly defined, in the governance and advisory structures of the managed care system; 6. participates actively in health professions education programs; 7. collaborates meaningfully with academic health centers, health depart- ments, and other components ofthe public health infrastructure; and 8. advocates publicly for community health promotion and disease prevent . . . Ion pot .lcles. Local health deparDnents can organize as managed care providers and compete with private care plans for payer contracts or they can contract with managed care plans to provide specific services. Public health agencies can also assert their assurance function. They can play a strong regulatory role by setting standards, through licensing, and by monitoring the quality of services (Box 7~. These roles, while important, will take time, skill, and initiative to develop. Furthermore, some challenges will arise. For example, there is a potential conflict of interest if public health departments have managed care contracts and are also
24 HEALTHY COMMUNITIES BOX 6. U.S. Healthcare U.S. Healthcare is a large, for-profit company that operates in the northeastern, middle Atlantic, and southeastern United States. It was founded 22 years ago in Pennsylvania and uses an independent physician association model, which means that each physician has a private practice and agrees by contract to accept U.S. Healthcare members. U.S. Healthcare has approximately 2.5 million members, of which 130,000 are Medicare members, 87,000 are Medicaid members, and 10,000 are covered under an uninsured children's program. Each year about 26% of the Medicaid population disenrolls. Only 3.6% of the Medicare population disenrolls, which makes it the most stable group. U.S. Healthcare's responsibility for public health cuts across many of its programs. These programs include women's health, domestic violence, primary care, and a program that incorporates nutritional screening and interventions into medical practice. Health educators at U.S. Healthcare developed off~ce-based programs to assist physicians working with patients who are enrolled in programs such as smoking cessation. For patient outreach, there are preventive care and immunization programs. Other public health programs include (1) Challenge 1996 to immunize the Medicare population against pneumococcal pneumonia; (2) cancer screening; (3) Medicaid's Early and Periodic Screening, Diagnosis, and Treatment; (4) an uninsured children's program; and (5) health education programs such as Healthy Breathing for smoking cessation, Healthy Lifestyles to decrease stress, Healthy Eating to assist in establishing healthy eating patterns, as well as avoiding obesity, and a fitness program. Case management is also a part of their health care plan. Teams of nurse case managers and social work case managers are formed depending upon the patient population. Health plan accountability is a major issue for the company, because its management believes it is important to make available performance measurement information that assesses the health plan's effectiveness in providing services and to identify areas for improvement. U.S. Healthcare has been involved in developing the Heath Plan Employer Data and Information Set (HEDIS) and has a representative serving on the Medicaid HEDIS committee and the Medicare HEDIS subcommittee. The Medicare Quality report card was developed by U.S. Healthcare in collaboration with its division, U.S. Quality Algorithms, because the Medicare HEDIS was still being developed at the time and there were no measurements that they could use for their Medicare beneficiary patient population. SOURCE: Based on a presentation by Sandy Harmon-Weiss, senior vice president and medical director, U.S. Healthcare, at the February 22, 1996, meeting of the Public Health Committee.
PUBLIC HEALTH AND MANAGED CARE 25 BOX 7. San Diego and Los Angeles Counties' Experience with Public Health and Managed Care SAN DIEGO COUNTY DEPARTMENT OF HEALTH SERVICES The San Diego County Health Department established a Medi-Cal (California's Medicaid program) managed care system that integrates public health functions and services of a local health department with private-sector health plans. The Medi-Cal managed care contract stipulates that health plans will provide services to the Medicaid population and that the health department will administer the Medi-Cal program. The San Diego County Health Department will be responsible for oversight and enrollment of the program. The State Health Department will be responsible for setting local standards and requirements in the Medi-Cal managed care contracts with managed care organizations. The San Diego County Health Department will certify physicians who provide public health services for selected communicable diseases and early intervention for children and pregnant women. It will also determine eligibility, will inform patients of their rights and responsibilities in using health care resources, and will enroll people into health plans. The County Health Department will also select performance standards and provide oversight for quality improvement. Local monitoring of health indicators calculated from reports on all health care encounters will be performed for the Medi-Cal population. The County Health Department is also involved with providing public health services (immunizations, home visitation, and teaching responsible parenting) to a new child abuse center (administered by the Social Services Agency). The County Health Department has created partnerships with representatives of San Diego community organizations (e.g., the San Diego Chamber of Commerce, the San Diego Taxpayers Association, the Medical Society, the Hospital Council, the Welfare Rights Organization, and the Legal Aid Society). Representatives of these organizations meet with the health department staff about public health policies and programs for the community. In this way, the community is involved in the planning process of all new public health programs. LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES The Los Angeles County Department of Health Services is also in the process of implementing California's Medi-Cal managed care program. The department developed a memoranda of understanding (MOW) between the Public Health Programs and Services (PHPS) and the Personal Health Services (PHS) branches of the department regarding provision of clinical preventive services and other services provided by PHS that have or could have public health significance. The department also developed MOUs as a basis of negotiation between PHPS and the health maintenance organizations in Los Angeles County intending to participate in the state's Medi-Cal managed care program. The Continued
26 BOX 7. Continued HEALTHY COMMUNITIES MOUs cover both administrative issues and program areas detailing specific tasks and responsibilities. The program areas included in the MOUs are family planning services, sexually transmitted diseases, HIV counseling and testing services, immunizations, children with special health care needs, prenatal care, child health and disability prevention programs, arid tuberculosis. SOURCES: Based on a presentation by Paul Simms, deputy director, Department of Health Services, Sari Diego County, at the February 22, 1996, meeting of the Public Health Committee; and on a presentation by James Haughton, senior health services policy advisor, County of Los Angeles Department of Health Services, at the October 27, 1995. meeting of the Public Health Committee. playing a regulatory role with managed care organizations. Despite these challenges, many state and local public health departments have moved forward to develop their abilities in the managed care marketplace. CONCLUSIONS There has been substantial growth in organized health care delivery systems (which include managed care organizations) in recent years, and these developments have important implications for the health of the public. In the discussions initiated by the Committee on Public Health, proponents of managed care have argued that its goals and tools are consistent with public health. Many public health professionals, on the other hand, have also indicated concerns about managed care organizations' motives and ability to deliver on their promises. The committee's view, as developed in this section, is that if the proper kinds of partnerships between managed care organizations and governmental public health depar~nents are developed, managed care can indeed make an important contribution to improving the health of the public. The proliferation of organized health care delivery systems, which continue to provide care for an increasing number of Americans, has made it possible in some locales for governmental public health agencies to assure the provision of personal health services entirely within the private sector. How many elements of public health services private organizations can or should subsume remains unclear, but they can be considerable. Providing care for the uninsured, however, remains a challenge; governmental public health departments will be ill prepared and inadequately funded to do so if no other personal services are being provided.
PUBLIC HEALTHAND MANAGED CARE 27 To ensure that partnerships between governmental public health agencies and managed care organizations work effectively toward improving the health of the public, the committee reiterates The Future of Public Health recommendation that the function of local public health agencies should include "assurance that high-quality services, including personal health services, needed for the protection of public health in the community are available and accessible to all persons...." This assurance function can be carried out "by encouraging other entities (private or public sector), by requiring such actions through regulation, or by providing services directly." Public health agencies can only exercise this responsibility if they are adequately staffed, equipped, and funded for this complex and demanding task and have appropriate relationships with health service providers. These activities should not be undertaken at the expense of existing essential public health services. Particular concerns arise when health departments have a dual role: direct provision of personal health services to some people and regulating private entities providing similar services to others. To improve the efficiency of all health systems, health agencies and organized health delivery systems, in conjunction with other community stakeholders, must reach agreement on their proper roles and responsibilities, which will vary by locale. Successful models of the integration of public health and managed care and of joint approaches to policy development do exist and need to be studied and tested more broadly. Most public health agencies do not currently have the full statutory and regulatory authority to ensure the accountability of the organized health delivery systems to the public. In the current regulatory structure, health care delivery systems are open regulated by insurance commissions that focus on fiscal integrity rather than health. State Medicaid agencies, usually separate from public health departments, also typically focus on fiscal rather than medical accountability dimensions. Recognizing the clear need for financial oversight, governmental public health agencies should increase their ability to oversee health care providers, with the goal of becoming coequal partners with insurance regulators and state Medicaid agencies, to ensure that the public's health is addressed in the regulation of public and private health care delivery systems (see Box 8~. In many states, additional legislative authority will be needed before public health agencies can take on this role. This approach requires population- based health outcome and performance standards that can be monitored, and public health agencies should participate in the development and monitoring of these standards. The functions described in this report cannot be undertaken without properly trained professionals available to all communities. Thus, public health professionals and students enrolled in schools of public health should be trained to work with health services organizations to ensure quality personal
28 HEALTHY COMMUNITIES health services in a community, as an essential element in providing for the health of the public. In addition, public health agencies should actively participate with organizations such as state health professions boards, medical schools, accrediting bodies in planning and policy development. BOX 8. Maryland's Alliance Between the Health Department and the Insurance Commissioner: An Example for Public Health Health care reform is not a new concept for the State of Maryland. Maryland's "all- payor system" ensures equity among financing mechanism and has not only held down hospital rates to far less than the national average, but has also maintained the high quality of Maryland's privatized hospital delivery system. For more than 20 years, Maryland's rate increases consistently have been less than the national average. In 1993, HB 1359 created a special insurance program for small businesses that presaged the current Kennedy-Kassebaum bill recently signed into law by President Clinton. Furthermore, Maryland's experience with managed care is vast, with penetration rates being third highest in the nation. With pride in its health care policy formulations, Maryland recognized the importance of creating a working relationship among the critical agencies that affect the statewide system. With statutory relationships defined in the general HMO statute (between the insurance commissioner and the secretary of the Department of Health and Mental Hygiene) early in 1995, a Memorandum of Agreement was signed by the insurance commissioner, the secretary, and the governor-appointed chairmen of the three major commissions responsible for health care regulations (Planning, Hospital Rate Review, and Ambulatory Care Rate and Information System). This memorandum designed a working relationship and led to the development of the Maryland Health Care Principles to which each of the organizations subscribe: · Ensure every Marylander financial and clinical access to health care. · Provide services at a reasonable cost. · Maintain the high quality of Maryland's health care system. · Improve the health status of individuals, families, and communities through an emphasis on prevention and early intervention services. · Ensure public accountability through use of reporting criteria, such as health status outcomes and financial reports. · Promote the sharing of public responsibility costs equitably. · Ensure long-term financial viability. · Promote equity among purchasers. In addition, during the 1996 legislative session, the relationship between the insurance commissioner and the health secretary was further strengthened by def~ninginterdependent roles for oversight of the Managed Care Organizations (MCOs) that will be responsible for providing care under the Medicaid waiver reform program.
PUBLIC HEALTH AND MANAGED CARE 29 Applications prepared by the MCOs will be jointly reviewed. The Department of Health will assist the insurance commissioner in reviewing solvency claims for the new organizations and the commissioner will review the secretary's capitation rates for payment. A mechanism for joint review of complaints has also been established and a separate Memorandum of Understanding was signed in July 1996 to ensure a continuing relationship between the two organizations. It is precisely because Maryland understands the evolving health care system that this strategic alliance between public health and the insurance administration has been created. The need for common oversight to assure the organizational integrity from both the fiscal and quality of health services delivery perspective is necessary to assure optimal health care services delivery while maintaining the quality of the evolving health care enterprises for Maryland's employers and taxpayers. SOURCE: Based on information provided by Martin Wasserman, Secretary of the Maryland Department of Health and Mental Hygiene, 1996.
Next: Public Health and the Community »
Healthy Communities: New Partnerships for the Future of Public Health Get This Book
The Future of Public Health, issued in 1988, set forth a vision of public health and a specific role for the governmental public health agency within that vision, including the mission and content of public health, and an organizational framework. In the eight years since the report was released, there has been a significant strengthening of practice in governmental public health agencies and other settings. Substantial social, demographic, and technological changes in recent years, however, have made it necessary to reexamine governmental public health agencies' efforts to improve the public's health. Drawing on the activities and discussions initiated by the Institute of Medicine (IOM) Committee on Public Health, the current report addresses two critical public health issues that can greatly influence the opportunity for our public to be healthy as the United States enters a new century-(1) the relationship between public health agencies and managed care organizations, and (2) the role of the public health agency in the community-and their implications for the broader issues raised in The Future of Public Health.
Executive Summary 1–6
Introduction 7–12
Public Health and Managed Care 13–30
Public Health and the Community 31–42
Revisiting the Future of Public Health 43–50
Appendix A 57–66
Appendix B 67–74
Appendix C 75–81


The pie charts compare the amount of electricity produced using five different sources of fuel in two countries over two separate years.
Total electricity production increased dramatically from 1980 to 2000 in both Australia and France. While the totals for both countries were similar, there were big differences in the fuel sources used.
Coal was used to produce 50 of the total 100 units of electricity in Australia in 1980, rising to 130 out of 170 units in 2000. By contrast, nuclear power became the most important fuel source in France in 2000, producing almost 75% of the country's electricity.
Australia depended on hydro power for just under 25% of its electricity in both years, but the amount of electricity produced using this type of power fell from 5 to only 2 units in France. Oil, on the other hand, remained a relatively important fuel source in France, but its use declined in Australia. Both countries relied on natural gas for electricity production significantly more in 1980 than in 2000.
雅思备考之雅思口语Part 3问题What's the difference between men and women in their reading habits?


So there we were, two very middle-aged women climbing the steps of the Bronx County Courthouse on a beautiful August day. Our driver, Orlando, could hardly contain his curiosity about our mission, but contented himself in wishing us well as we went to pick up our "big bag of money." Well, hardly.


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DecodeDCInternational
Streak ends: US men's basketball falls to Australia, 98-94
First international loss in almost 13 years
Eric Gay
United States' DeAndre Jordan (6) pulls in a rebound against Serbia during the men's gold medal basketball game at the 2016 Summer Olympics in Rio de Janeiro, Brazil, Sunday, Aug. 21, 2016. (AP Photo/Eric Gay)
MELBOURNE, Australia (AP) — The World Cup is a week away, and the United States is no lock for gold.
Australia delivered that message to the world on Saturday.
For the first time in nearly 13 years, a U.S. roster of NBA players played an international game — and lost. Patty Mills scored 30 points, and Australia rallied from a 10-point deficit in the second half to stun the Americans 98-94 and snap a 78-game U.S. winning streak that started with the bronze-medal game at the 2006 world championships.
"They wanted it more than us tonight," U.S. guard Kemba Walker said. "Lesson learned for us."
It was the first loss for the U.S. in a major international tournament or exhibition since the 2006 world championship semifinals against Greece. The Americans won the bronze there, then were unbeaten through the cycles for the 2007 FIBA Americas, 2008 Olympics, 2010 World Cup, 2012 Olympics, 2014 World Cup and 2016 Olympics.
Add all that up, along with wins over Spain and Australia with this team, and it was a 78-game winning streak for the U.S. — the longest in program history.
And it's now over.
"It was awesome," Mills said.
Australia had never beaten the Americans, and the U.S. national team had been 30-0 all-time in Australia.
"Some of it is expected with a new group that's trying to learn about each other and learn a system," U.S. coach Gregg Popovich said. "So it's not surprising. But the Aussies gave us a great lesson as far as where we want to be and how you have to play in this kind of a competition."
A World Cup where Serbia has already made very clear it expects to win gold, where NBA MVP Giannis Antetokounmpo will lead Greece, where France figures to have a medal shot and now with the Australians absolutely knowing they can beat the U.S., will begin next week with no shortage of realistic title hopefuls.
USA Basketball is No. 1 in FIBA's world rankings, but so far in the run-up to this World Cup — with most of the top NBA stars deciding to not play this summer — the Americans have not looked like a lock for more gold. They beat Spain by nine in Anaheim, California on Aug. 16, needed a big second half to defeat Australia by 16 on Thursday, and then let a sizable second-half lead slip away Saturday.
"Obviously, this was a great step for us," Australia guard Joe Ingles said.
Mills plays for San Antonio, so ordinarily Popovich — the longtime Spurs coach — would enjoy seeing what the veteran guard did down the stretch. Mills scored Australia's last 10 points, doing it all from banking in 3-pointers to slicing through for a layup that put the hosts up by six with 1:50 remaining.
"As I told you all after the last game, Patty's a pain," Popovich said.
Walker scored 22 points for the U.S., and Harrison Barnes had 20. Donovan Mitchell's 3-pointer with 1:05 left got the U.S. within 97-94, the Americans forced a stop on the ensuing possession and had two chances to tie — but Mitchell's 3-pointer was off, Joe Harris missed a corner 3 a few seconds later and Mills iced the game with a free throw.
Aron Baynes left the floor with his head back, screaming in celebration as he slapped hands with delirious countrymen. Ingles and Andrew Bogut grabbed their kids and brought them on the floor for a look.
Bogut scored 16 points, Ingles had 15 and Baynes scored 13 for the Australians.
Baynes powered in for a score that put Australia up 82-76 with 8:25 remaining, just before Barnes answered with a three-point play for the U.S. to start an 8-0 run that put the Americans back on top. There were four lead changes in the final quarter, the last coming when Ingles made a step-back 3 with 3:35 left for an 88-87 lead.
Mills did the rest.
He banked in a long 3 for a four-point lead, added a layup to put his country up six with 1:50 left and clinched it with the last free throw.
The U.S. led by one at the half and went up 68-58 midway through the third on a dunk by Jayson Tatum, but the Australians got right back into the game. Mills scored eight points in 45 seconds, including a pair of 3-pointers, to get Australia within one with 2:40 left in the third.
"That's a great team and they've been together a long time," Barnes said. "They play a great style of basketball."

redpajama_set_name: RedPajamaCommonCrawl


text:
J. S. Bach's Chamber Music, Vogt
Works Composers Movements
Page 1 of 3 | | | |
Popularity Date Title Composer Last Name First Name Duration Op. Number Catalog Age Nationality
All (45) Duo (20) Flute Sonata (6) Solo (21) Trio (4) Trio Sonata (4) Violin Sonata (14)
Detail Summary
Show Movements
Cello Suite No. 1 in G major, BWV 1007 (for solo cello)
c. 1720 (age 34-35), 18 minutes
Cello Suite No. 3 in C major, BWV 1009 (for solo cello)
Sonata No. 6 in G major, BWV 1019 (for obbligato harpsichord and violin)
1717-1723 (age 31-38), 17 minutes
Sonata No. 5 in f minor, BWV 1018 (for obbligato harpsichord and violin)
Sonata No. 4 in c minor, BWV 1017 (for obbligato harpsichord and violin)
Sonata No. 3 in E major, BWV 1016 (for obbligato harpsichord and violin)
Sonata No. 2 in A major, BWV 1015 (for obbligato harpsichord and violin)
Sonata No. 1 in b minor, BWV 1014 (for obbligato harpsichord and violin)
Partita [Sonata] in a minor, BWV 1013 (for solo flute)
1722-(?) 1723 (age 36-38), 14 minutes
Sonata in G major, BWV 1027 (for bass viol and harpsichord)
before 1741 (age 55-56), 13 minutes
Sonata in b minor, BWV 1030 (for flute and harpsichord)
Cello Suite No. 4 in E-flat major, BWV 1010 (for solo cello)
Cello Suite No. 6 in D major, BWV 1012 (for solo cello)
Cello Suite No. 5 in c minor, BWV 1011 (for solo cello)
Cello Suite No. 2 in d minor, BWV 1008 (for solo cello)
[Trio] Sonata in c minor, BWV 1079, (from Das Musikalisches Opfer) [The Musical Offering] (for flute, violin and continuo)
1747 (age 61-62), 18 minutes
Violin Sonata No. 3 in C major, BWV 1005 (for solo violin)
Violin Sonata No. 2 in a minor, BWV 1003 (for solo violin)
Violin Sonata No. 1 in g minor, BWV 1001 (for solo violin)
Sonata in g minor, BWV 1029 (for bass viol and harpsichord)


text:
Eugenio Camillo Costamagna  (né en 1864 à San Michele Mondovì et mort en 1918 à Milan) est un journaliste italien qui fut l'un des fondateurs du quotidien sportif italien La Gazzetta dello Sport.

Biographie

Liens externes

Naissance à San Michele Mondovì
Journaliste italien du XXe siècle
Journaliste sportif italien
Naissance en 1864
Décès en 1918
Décès à Milan

redpajama_set_name: RedPajamaWikipedia


text:
Why Did The Church Want To Spread Christianity In Europe?
1 Why did Christianity spread in Europe?
2 What are the reasons Christianity spread?
3 Why did Christianity spread throughout Europe during the Byzantine Empire?
4 Who started Christianity in Europe?
5 What role did Christianity play in Europe?
6 How did Christianity spread in Germany?
7 Who first spread Christianity?
8 What is the toleration of Christianity?
9 How did the religion of Christianity develop and change over time?
10 Who was responsible for spreading Christianity throughout Europe?
11 Why did Christianity decline in Europe?
12 What was the Byzantine Empire's most famous form of artwork?
13 What is the most religious country in Europe?
14 Which country is most Catholic?
15 What was the last pagan country in Europe?
Why did Christianity spread in Europe?
What are the reasons Christianity spread?
Why did Christianity spread throughout Europe during the Byzantine Empire?
Why did Christianity spread throughout Europe during the Byzantine Empire? Byzantine leaders refused to employ non- Christians in government. Christianity became the state-sponsored religion of the Byzantine Empire. Byzantine leaders did not punish crimes perpetrated against Jews and Muslims.
You might be interested: Question: Who Was The Early Missionary Who Spread The Word Of Christianity?
Who started Christianity in Europe?
It was under the reign of Constantine I (306-337) where Christianity became an official religion of the empire. Constantine himself had been introduced to the religion by his mother Helena, and according to Christian sources, he himself witnessed a miraculous cross in the sky before a battle.
What role did Christianity play in Europe?
Europe has a rich Christian culture, especially as numerous saints and martyrs and almost all the popes were European themselves. All of the Roman Catholic popes from 741 to 2013 were from Europe. Europe brought together many of the Christian holy sites and heritage and religious centers.
How did Christianity spread in Germany?
It was introduced to the area of modern Germany by 300 AD, while parts of that area belonged to the Roman Empire, and later, when Franks and other Germanic tribes converted to Christianity from the 5th century onwards. The area became fully Christianized by the time of Charlemagne in the 8th and 9th centuries.
Who first spread Christianity?
Beginning with the son of a Jewish carpenter, the religion was spread around the world first by Jesus's disciples, then by emperors, kings, and missionaries. Through crusades, conquests, and simple word of mouth, Christianity has had a profound influence on the last 2,000 years of world history.
What is the toleration of Christianity?
An edict of toleration is a declaration, made by a government or ruler, and states that members of a given religion will not be persecuted for engaging in their religious practices and traditions. The edict implies tacit acceptance of the religion rather than its endorsement by the ruling power.
You might be interested: Readers ask: What Was Not A Reason That Christianity Spread Throughout The Roman Empire?
How did the religion of Christianity develop and change over time?
The Roman Empire did not become Christianized overnight. Roman religious beliefs changed slowly over time. At the time the Western Roman Empire fell in 476 CE, Christianity was still spreading. Christianity grew out of Jewish traditions and was shaped by Roman cultural and political structures for several centuries.
Who was responsible for spreading Christianity throughout Europe?
Why did Christianity decline in Europe?
Starting in 1880 and accelerating after the Second World War, the major religions began to decline among the Dutch, while Islam began to increase. During the 1960s and 1970s, pillarization began to weaken and the population became less religious.
What was the Byzantine Empire's most famous form of artwork?
Mosaic art flourished in the Byzantine Empire from the sixth to the fifteenth centuries. Whereas in Antiquity, walls were usually decorated with less-expensive painted scenes, the Byzantine aesthetic favored the more sumptuous, glittering effect of mosaic decoration.
What is the most religious country in Europe?
The most religious countries are Romania (1% non-believers) and Malta (2% non-believers). Religiosity.
"I believe there is a God"
"I believe there is some sort of spirit or life force"
"I don't believe there is any sort of spirit, God or life force"
"Declined to answer"
You might be interested: FAQ: Christianity First Spread Through Which Type Of Diffusion?
Which country is most Catholic?
According to the CIA Factbook and the Pew Research Center, the five countries with the largest number of Catholics are, in decreasing order of Catholic population, Brazil, Mexico, the Philippines, the United States, and Italy.
What was the last pagan country in Europe?
In fact, Lithuania was the last pagan state in Europe. Almost 1,000 years after the official conversion of the Roman Empire facilitated the gradual spread of Christianity, the Lithuanians continued to perform their ancient animist rituals and worship their gods in sacred groves.


The Unbelievably Easy Knit Dishcloth is a great pattern for beginner knitters who want to work up a fun and practical pattern. Choose either black or blue to create a great knit dishcloth you will reach for again and again. If you have a loved one who recently moved, a set of these knitted dishcloths would make a perfect housewarming gift. This is the perfect beginner knit pattern to keep your fingers busy without needing to follow a pattern or if you simply want to practice your skills. You can use this cloth for dishes or bathing and the scrubby is made from polyester, so it washes easily by machine and dries quickly.
NotesGAUGE: 16 sts = 4" [10 cm]; 34 rows = 4" [10 cm] in Garter stitch.
Knit every row until Dishcloth measures 7½" [19 cm] from beginning.
Oh my goodness! I love novelty yarns! This is the perfect dish cloth to add a pop of color and decorate the kitchen for the holidays. There are so many different colors (27 from the red heart website) that matching them up with a holiday shouldn't be difficult at all. I bet the texture will help get the dishes clean too!
I love this yarn. I make simple scrubbies holding a strand of cotton yarn with the scrubby yarn. Also, I prefer a smaller size...4x4". The cotton is great for absorbing dish soap and wiping down counters and they wash and dry perfectly .
Love the scrubby look of the yarn - like it was made just to knit dishcloths. Could also use it for a washcloth in the bath, or to wash the dog. Sometimes simply knitting a dishcloth is te perfect way to de-stress.
I love this scrubby yarn. I ordered two skeins of it and that will make a lotta dishcloths.
Really? I have 2 skeins here, but each skein is just 92 yards,is it possible to get larger balls somewhere? I made 1 dishcloth with a different pattern and I barely had enough to finish it. I'd love to know what size of these balls make alot of dishcloths.
You can never have too many dishcloths and this pattern looks incredibly easy.
These would make the perfect rags. We always seem to be losing those at my house. Now, I can just knit them up myself. Thanks!


text:
Palmarès

Giocatore

Flamengo: 1974

Sport: 1980

Allenatore

Desportiva: 1992

Flamengo: 2013

Flamengo: 2014

Collegamenti esterni

Calciatori della Nazionale brasiliana
Allenatori di calcio brasiliani


Last fall, my partners and I all attended the McGuireWoods Healthcare Private Equity Conference here in Charlotte. While most of the southeast was still battling the remnants of what was Hurricane Irma, we had an opportunity to listen to sector experts as they tried to navigate the swirling winds of the healthcare industry. Make no mistake – healthcare is hot. There is a lot of opportunity, but it doesn't come without an equal amount of risk.
Overall activity has been very robust over the last several years. 2016 saw $270MM additional invested over prior year, and 89% of funds raising capital hit their targets – an all-time high. This has resulted in a very favorable environment for sellers. Buyers, on the other hand, find themselves in a highly competitive market, which leads some to consider newer sectors where there is still much consolidation to occur. Healthcare is one of those general sectors, but specific markets with a lot of highly fragmented opportunities are: behavioral health; physical therapy (including staffing); dentistry and dental practice management; and healthcare technology. All of this forecasts coming trends of consolidation with a high degree of certainty.
The year 2016 saw record highs for overall M&A activity in terms of both total capital and total number of deals. While 2017 has seen higher dollar amounts, there have actually been fewer numbers of transactions completed. This year we have seen an overall Debt:EBITDA multiple around 5.9X and a valuation multiple around 10.5X (EBITDA). Key takeaways are: robust access to capital; multiples continue to remain high; it's a seller's market; and it's a very competitive scenario for buyers.
I always find it fascinating to listen to panel discussions when the question is asked: "What do you look for or consider when you're evaluating businesses?" Sometimes you never know what kind of answers you'll get. Thankfully the panel in Charlotte was willing to share a lot with the audience.
Be realistic about whether you're growth-oriented versus value-oriented. PE is almost always focused on growth-oriented opportunities because initial valuation matters less as long as it meets with (growth strategy) return requirements. The goal is to double or triple the size of business in 4 to 6 years.
Can founders articulate a vision for the next 3-5 years? And what are the strategic moves you need to make to get there? If you say you're growth-oriented, but you can't clearly communicate your vision or how you intend to make it a reality, then you may not have many investors who are interested in your business.
Are you aggregating for aggregation's sake? Or are you aggregating to operate (and build a platform)? When it comes to being growth-oriented, you have to be disciplined in your approach. And after you open new locations or acquire existing ones, you have to prove that you have the ability to operate those businesses effectively.
Many entrepreneurs take on debt to fuel growth, but be wary of using too much leverage to get a deal done. Don't let your debt load constrain your ability to operate the business. You should be able to model these scenarios quantitatively.
Your clinical providers are the key to your growth and production. Do you have a strategy to attract clinicians to join you? And what is your turnover rate compared to industry norms?
What is your formal operating structure for your business? Do you have monthly reporting, quarterly board meetings, etc.? Or are you running your empire as if it were still a start up?
Is your house in order from a regulatory compliance standpoint? And do you have established, documented and monitored procedures in place to handle everything from a patient complaint to a state audit for billing fraud?
Is your leadership team consistent or do you have turnover at the C suite level? The PEG wants to know what kind of leadership turnover should they expect over the 4-6 years of their investment.
How fragmented is your ownership structure overall? Do you have 100 owners each owning 1% of the business or is equity concentrated in fewer individuals? Is decision-making based on simple majority or unanimous vote? This has a dramatic impact on how quickly decisions can get settled on major issues, but it also has an impact on smaller, day-to-day aspects as well. In short, who really cares about cost-cutting initiatives if they only own an inconsequential piece of the pie?
As an aside, if you're an Emerging DSO (2-8 locations) and are struggling with any of these points above, we cover all of them in varying detail during our full-day "deep dive" sessions with our clients. Contact us for more details or download our Overview of Services here.
Look for a partner with an industry focus in your space. Yes, they're going to buy your business, but they're going to want you to stay on to help grow and operate it, so you want a partner who can bring some experience to the table.
Ask PE firm for their references. You should want to talk with those who have gone down your path and are "on the other side" now.
The closing process is never smooth. Be ready for an emotional roller coaster that takes twice as long as what you expect. Pick a trusted advisor to guide you through that process.
Ask about the day-to-day life with a PE partner after closing the deal. What's it going to be like? What's their playbook for the first 100 days after closing? Do they operate in a very formal manner or are there more loose constraints? And can you function under that structure?
I think the most important aspects of the conference for me were that so many people remain so bullish and optimistic about the healthcare industry and specifically the dental sector. However, that continued optimism is borne out of the ability to establish, grow and operate successful group dental practices. Excitement abounds, but this is not a case of a rising tide lifting boats with holes in them. The ability to execute is more important than ever. Operational details matter now and at the closing table.
As always, if you'd like to discuss these topics or any others related to trends in our industry, please feel free to contact me at Perrin@TUSK-Partners.com. TUSK provides industry-leading resources for Group Dental Practices and DSOs. We help our clients START, GROW and SELL their DSO or Group Dental Practice. For more details, download our Overview of Services or visit our website HERE.
TUSK will be a featured presenter at the 1-800 DENTIST DSO Leadership Summit in Los Angeles, CA on March 16th where we will share "5 Things to Know if You're Going to Use the Bank's Money to Grow." We hope to see you there as well!
Special thanks to Bart Walker and all of the great people at McGuireWoods for hosting us in Charlotte. We look forward to seeing everyone at their Chicago conference in a few weeks.


text:
University School of Nashville Cafeteria
MZA designed a 7500 s.f. renovation and 2000 s.f. LEED Gold expansion of USN's food services and cafeteria. The project includes a full redesign of the kitchen equipment and food storage, a new concessions area for athletic events, supplemental accommodations for the after school program, and seating for an additional 60 students.
The new space is designed to encourage upper school students to use the cafeteria for lunch by creating a mezzanine level with tiered, casual seating and a connection to the 2nd floor music and dance studios. Clad in 1' x 4' flat lock copper shingles, the first piece of modern architecture on USN's 98 year old campus gives the school an "architectural identity" at the corner of a major Nashville intersection, and allows the personality of USN to be distinct from the adjacent Vanderbilt University buildings.
Client: University School of Nashville
Online: usn.org
Copyright © 2020 Manuel Zeitlin Architects. All rights reserved.
Connect with us on Instagram, Twitter, or Facebook


Lifestyle membership has been designed for discriminating clientele living and working in California's mid-Peninsula community. Rosewood Sand Hill provides an exclusive membership with an emphasis on personal health and wellbeing. Lifestyle members enjoy luxurious amenities and services throughout the hotel that will enhance their lifestyle as a whole. These limited memberships also include personalized attention to health and fitness needs at an intimate, state-of-the-art fitness center and Menlo Park's finest day spa.
Lifestyle members may opt to enjoy select services or take full advantage of membership at Rosewood Sand Hill. Whether members frequent the fitness center, pool, Sense Spa, the signature restaurant, Madera, or simply enjoy the ease of having signing privileges throughout the Bay Area hotel, Rosewood Sand Hill feels like a second home. In addition, a personal lifestyle coordinator will ensure that specific needs are taken care of.
Given the exclusivity and level of service, there are only a limited number of Lifestyle Memberships available. If all available memberships are in use, a wait list will go into effect.
For further information, please contact Sunita Goldstein at +1 (650) 561 1571 or sunita.goldstein@rosewoodhotels.com.


Title: A poem in khafif metre on the dates of birth and death and the burial places of the Fourteen Immaculates.
Not in Morley Printed Catalogue. Bound with 4 (1), 4 (1B), 4 (2), 4 (3). Red heading and red lines dividing sections.


Display this We Welcome New Patients at your check in counter to make everyone aware that you are always ready to provide care to newcomers.
2" x 8" or 2" x 10"
Front Office Right Sign | 3" x 10"
Custom Text Tent Sign | 2" x 8"
Please Pay Here Desk Plate | 2" x 8"
Make sure you place this "we welcome new patients" desk plate at the front desk of your healthcare facility or medical office. Choose your size of 2" x 8" or 2" x 10" in a number of background colors, engraved with We Welcome New Patients. Holder included in your choice of color of black, silver, gold or rose gold. Make sure incomers know that you offer help to new patients.


In his book Men of Courage, Dr. Larry Crabb writes that there are two kind of men: inauthentic and authentic.
Last week, I mentioned some of the characteristics of each. For an inauthentic man, these included being controlling, destructive, and selfish. An authentic man is quite different. He an active man who is more concerned with developing a strength others can enjoy rather than achieving power and control for himself. He is a gentle man and lives with purpose.
This week, we are going to begin looking at the characteristics of an inauthentic man that represent the battles going on deep inside his soul. The first is that a inauthentic man feels powerless. For those who feel this way, they like things to be predictable. Unfortunately, life is not predictable. So, men who feel powerless are haunted by the possibility of something happening that they cannot handle. This becomes prevalent in their personal relationships, which is one area that cannot be effectively controlled. Getting close to their wives, feeling respected by their children, having healthy friendships: these are the kinds of areas that have the power to make men feel weak.
To hide their weakness, powerless men find something they can control, something they can handle well, and avoid what they fear. This may be as simple as keeping a car clean or as wrong as seducing another woman. Powerless men spend their lives controlling some outcome and deceiving themselves into thinking it matters.
Now, an authentic man knows he is strong, not powerless. He is not an aggressive man, he is an active man, involved in offering quality relationships to others, more committed to developing a strength that others can enjoy than to achieving for himself a sense of power and control.
So, which kind of man are you: inauthentic or authentic? You see, you can't move from inauthenticity to authenticity by yourself. It requires surrender to God and having someone to walk along side of you. Who is that person in your life?


Nadeem pretends not to care about money.
Rick doesn't appear to be nervous.
Emily told me I was like a son to him.
Lana told me he used to be married.
Do you think Murthy is innocent?
Louise is sending me unsolicited love letters.
Peggy happened to have the day off on Malloy's birthday.
Sangho has never done anything like this before.
I have some questions I'd like to ask Stanly.
Micah's colleague has just received another prize for his research.
Jamie thought that Charley would ask her to the prom, but he asked someone else.
Jason never seems to be very happy.
What's Darin doing here again?
Jean's brother looks just like him.
Let's see what Tahsin left us.
Ti is going to the mall.
Erwin forgot to renew his passport.
That gave Teri an idea.
Do you want to know my first impression of Dominic?
I'm still trying to a hold of Ilya.
Ahmet knows when he's supposed to be here.
Paola unlocked his office door.
Felix will probably say no.
Spock asked me to make sure you understood what you needed to do.
I think we shouldn't tell Sjouke about what happened.
Butler is anticipating his trip to China.


"Vivienne Parry takes her diagnoses of literary heroines into the 20th century and the age of Freud, the Great War and the explosion of the 'sciences of the mind' focusing on three great works of fiction, mixing contemporary psychiatric and literary insight.
How did modern literary and psychiatric ideas meet and how did each shape the other? Do these heroines show literature of the period to be a critical – and even emancipating – force…or is fiction really medicine's stooge? Novels on the couch include Scott Fitzgerald's Tender is the Night and Virginia Woolf's Mrs Dalloway….interestingly with both novels there's a tendency to base the heroines on real people – Nicole Diver is based on the case history of Fitzgerald's own wife Zelda, whereas Woolf's Mrs.Dalloway comes very close in literary terms to what Freud calls 'self-analysis' – one difference is that Woolf sometimes believed 'madness' was necessary to be creative, while Scott Fitzgerald depicted it as disastrous drain on creativity (ie. his). And both novels have the dynamic and lucrative new industry of psychotherapy in their sights. Vivienne compares fiction in the age of Freud to literary ideas of mental health in the Victorian age and in Dickens specifically, using Great Expectations' Miss Havisham as a case study.
The programme is broadcast again on March 31 at 2330 and is also currently available on iPlayer.


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Create your home
Develop your land
Buy your dream new home in Durham
02.08.2021 | Hester McQueen ACIM
Trinity Mews now on sale.
Custom Build Homes (CBH), in partnership with Durham County Council (DCC), today (Monday 2 August) announced the launch of Trinity Mews, Durham's first custom build community in the much sought-after postcode – DH1. Trinity Mews is a collection of nine 3 to 5-bedroom bespoke homes, offering new homeowners the opportunity to design and create a house they will love and want to live in every day.
Viewing days are confirmed for Friday 6 August, 2pm to 4pm, and Saturday 7 August, 9am to 11am giving potential custom homebuyers an opportunity to explore the area. These days are beneficial for potential purchasers as they can speak directly to custom build experts, to understand the technical process of building a bespoke home and design & planning packages, to financing their custom build.
"We're really excited to launch the development to market. Trinity Mews offers people in Durham the unique opportunity of creating a new home exactly as they wish it to be while being supported by the experts at Custom Build Homes", says Tom Connor, Founder of Custom Build Homes.
Features and benefits of Trinity Mews include:
Detached homes with garages giving homebuyers privacy and space.
Interested parties will be taken on a complimentary design discovery to create a home that works, by understanding how they want to live.
New homeowners will create their homes digitally for a fixed cost (includes design, planning and technical design).
Purchasers will have more choice when creating living spaces that enable them to live in an amazing home that works for them including reaching their desired aspirations, for example, an environmentally friendly home.
They will have the opportunity to design their house with the award-winning Chartered Architect and Homebuilding & Renovating Magazine Expert, CBH Head of Architecture, Allan Corfield.
Trinity Mews is now available at custombuildhomes.co.uk, plots starting from £180,000. For more information on Trinity Mews, visit custombuildhomes.co.uk/plotstore/sites/trinity-mews/
CBH supported DCC to understand the demand in their area, CBH demand data was used to shape the Trinity Mews site. The public helped shape the new custom build development. This scheme has been created for the people who want to purchase a home at Trinity Mews and by those who live alongside. The public can continue helping shape custom build developments by signing up to the CBH Custom Build Register.
CBH is on a mission to make it possible for everyone to custom build their own home, to enable them to live in a home they love. Their Long Four Acres development won the 2019 Best Custom Build Development Build It Award.
HESTER MCQUEEN
Custom Build Homes
Hester.McQueen@custombuildhomes.co.uk
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You made a RelateIQ approved app!
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Skiing In The Shower: We DID it! We skied the Great One!
Then we booted up fairly firm snow to the middle pinch, hiked across the talus field, and then I kicked in the steps for the second half, up the steep top pitch of the couloir. (Lesson 6: don't move your feet if your ice axe is moving. Don't move your ice axe if your feet are moving.) It was really fun to boot up something so steep, and I was psyched to be breaking trail. I needed to pace myself a bit slower, I was slowing down at the top, but I felt SO much better than the last bootpack I did!
The interval training, week of rest, and steep hiking has helped! We had a nice lunch at the top with a couple of guys that came up the long way "Wow, are you guys in training, or something?" was the question as we climbed out of the couloir and onto the top.
The boys took off, and we followed a bit after, Angela let me ski it first, which was pretty fun, the snow was firm, and not rocky, I didn't feel like I needed to do any survival skiing, I could actually kind of get after it in there, and THAT was an awesome feeling!
At the bottom, we took our skis off to hike across the talus, and, of course, as I'm standing there looking at them, I think, "I should either turn those over or pick them up." and off they go. Bouncing down the rocks. That was a nice little extra detour. Angela was just totally laughing, until her laugh started HER skis down, but she caught them.
We skied the second pitch with a bit more verve, the snow was still fantastic, and we tipped em over a bit more on this pitch. We were going to give the line across the basin a go, we watched a snowboarder come down it and it looked super fun, but it was getting late, and TODAY is my little sister's birthday, so we did a mini hike up the bowl and skied down to our shoes.
YES, I must admit, there is INDEED a Kate Faceplant in this story, really, what back country adventure would BE complete without me landing on my face? ONCE AGAIN, when it was very nearly flat, my ski hung up on something, got pulled behind me, and I was very suddenly on my face. So much so that my nose was jammed full of snow. And, of course, rather than blowing it out, I snorted it in. Immediate result: brain freeze of doom. Angela was looking at me like I'd grown horns. "What happened?" Who knows? Too sporty on a low angle with rocks and twigs sticking out of it. AGAIN. Maybe I'll learn that lesson one day.
ANNNNYHOOO, not important. The climbing was awesome. (I had a perfect moment climbing UP! That's happening more and more on the climbing part, which is exciting, because it used to just be painful, like PLEASE GOD let the ridge be CLOSER, my lungs are DYING!) The skiing was awesome. There is still a ton of snow up there.
The hike out was serene, and a bit damp (we had a little tropical storm to cool us off as we headed for the car.) There are so many great lines to explore up there, and the snow is just right! Thanks for another super fun day, Angela! See you in September!


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20 of the world's most amazing aquariums
Photo: Angelo De Santis
Albie Hartshill
IF YOU'VE EVER OWNED A PERSONAL AQUARIUM, you know how hard it can be to maintain. You've got to keep the water clean, you've got to make sure it has the right level of saltiness, and you need to ensure the fish you put into it won't eat each other. I once made the mistake of putting a goldfish into a tank with a Siamese fighting fish (also known as a betta). When I woke up the next morning, the betta was gone, and my goldfish was incredibly fat. Even if the pet-store clerk hadn't led me astray, it was not the outcome I would have expected for that fight.
So naturally, it's infinitely more impressive when major aquariums put together million-gallon tanks with thousands of fish and hundreds of different species. It's a feat of planning we typically don't recognize, beyond looking at the fish and saying, "Oooh, that's pretty!"
And with our oceans in the state they are, these aquariums are often hubs for research and conservation projects, spearheading the movements to save our seas — while others may be mistreating their animals or obtaining them through sketchy means. The list below includes both.
The Monterey Bay Aquarium in California does a huge amount of marine research, and was the first aquarium to successfully keep a great white shark in captivity. It's also one of the few places where you can see an ocean sunfish.
Hotel Atlantis Dubai
The Hotel Atlantis in Dubai offers these "underwater" rooms built right up against huge aquarium tanks. It's a cool view, but I'd be terrified of it breaking in my sleep...
Photo: Werner Bayer
Okinawa Churaumi
The Kuroshio Sea is the main tank at the Okinawa Churaumi Aquarium in Japan. It held the record of the world's largest tank when it opened in 2002, but has since been surpassed by the Georgia Aquarium.
Photo: Sonotoki
21 amazing images of the new Seven Wonders of the World
Kate Siobhan Mulligan
The New England Aquarium in Boston also doubles as a whale watching spot because of its location near the harbor, and many of its staff participate in marine animal rescue operations.
Photo: Theresa
L'Oceanogràfic
L'Oceanogràfic is in Valencia, Spain, and has a total capacity of up to 11 million gallons of water in all of its tanks. It also happens to be a particularly beautiful building.
Photo: Nickolay Pirogov
Aquarium of Genoa
The Aquarium of Genoa is the largest in Italy, and has a number of different marine habitats, including North Atlantic, Caribbean, and Ligurian Sea tanks.
Photo: Castgen
Chimelong Ocean Kingdom
The Chimelong Ocean Kingdom in Hengqin, China, broke five world records—including largest aquarium—when it opened earlier this year. Unfortunately, it's come under a lot of criticism for its methods of obtaining the animals.
Photo: Sina
13 gorgeous images of Norway's fjord region in winter
Jacqueline Kehoe
Deep Aquarium
The Deep is an aquarium in Hull, England, that is the world's only "submarium." It also functions as a charity and a research center, and happens to be pretty beautiful from the outside as well.
Photo: Adrian S Jones
AquaDom Berlin
The AquaDom is a cylindrical, 25-meter-tall aquarium in the Radisson Blu Hotel in Berlin. Inside the cylinder is a glass elevator.
Photo: Jamie Mead
Probably the most (in)famous aquarium in the world, SeaWorld is known for its shows with marine animals, particularly killer whales. It came under a ton of criticism for its treatment of those whales recently, thanks to the documentary Blackfish.
Photo: Chris A
Hilton Maldives Undersea Restaurant
The Hilton in the Maldives has both underwater suites and an underwater restaurant. The Maldives is actually at risk of sinking into the sea, due to climate change and sea level rise, so this might be the way the whole country is going.
Photo: Christian Jensen
13 amazing sights that prove Iran is a stunning destination
Angelo Zinna
uShaka Marine World
The uShaka Marine World in Durban, South Africa, is the largest aquarium on the African continent. It's also connected to a water park and has SeaWorld-like shows.
Photo: Cat
The aquarium bed
Okay, so it's not the largest by any measure, but I would've killed as a five-year-old to fall asleep with fish swimming over my head. And the sound of the aquarium must be insanely soothing.
Photo: Wicker Paradise
TurkuaZoo
The TurkuaZoo in Istanbul, Turkey, has the largest aquarium in Europe. It also allows visitors to go diving with sharks.
Photo: Pixage
The Shedd Aquarium has been in Chicago since 1930, and for a long time it was the largest aquarium in the world, though it has since been dwarfed by a lot of these other spots.
Photo: Smart Destinations
The Georgia Aquarium in Atlanta was the largest in the world when it opened in 2005, and it remains the largest in the United States. It's home to 500 different species and holds a total of 10 million gallons of water.
Photo: Melvin "Buddy" Baker
The Newport Aquarium in Northern Kentucky is probably best known for its shark petting exhibits.
Photo: Ken Colwell
Dubai Mall Aquarium
The largest mall in the world also has one of the largest aquariums in the world—the Dubai Mall Aquarium has a single tank with 33,000 animals in it.
Photo: Salis
Shanghai Ocean Aquarium
The Shanghai Ocean Aquarium has one of the longest underwater tunnels in the world, and is located right next to the Oriental Pearl skyscraper in Pudong.
Photo: Aapo Haapanen
National Aquarium Baltimore
The beautiful National Aquarium in Baltimore Harbor is technically partnered with the National Aquarium in Washington DC, but Baltimore's aquarium is significantly cooler. It's home to 750 species and can hold 2.2 million gallons of water.
Photo: Jeff Kubina
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Farmivirta ("Farm Power"), the winner of the annual Ilmastoteko Climate Award 2014, is genuine local energy generated by Finnish small-scale producers. Electricity is generated for the producers' own needs by using micro and small-scale power plants and renewable raw materials. Surplus electricity not used by the producer is sold to the grid and is available as Farmivirta.
Farmivirta is different from traditional electricity contracts in one important thing: every producer can set the price of electricity they generate and sell to the grid.
Producers of Farmivirta are committed to the use of renewable sources of energy, such as wood, hydroelectric power, wind power and solar power. The metering, calculation and tracking procedures used in the production of Farm Power are certified by external experts. Farm Power is certifiably non-polluting, clean local energy.
Locally produced. Farmivirta is generated using micro and small-scale power plants on Finnish farms near the consumers.
Renewable. Based on renewable sources of energy. The energy is produced using 100% renewable raw materials.
Sustainable. Distributed production of energy increases domestic generation capacity in a sustainable way and ensures availability of Finnish electricity also in the future.
CO2 neutral. As wood binds an amount of carbon dioxide equal to the amount that is released when its is burned for energy, electricity generated using wood-based fuels causes no CO2 emissions. Solar power, wind power and hydroelectric power produce no CO2 emissions at all.
The winner of the annual Ilmastoteko Climate Award 2014. Genuine local energy generated by Finnish small-scale producers.
Farmivirta (Farm Power) is genuine local energy generated by Finnish small-scale producers. Read more about the producers.


2000 square foot ranch home sits on 1 acre owned by original family since 1959. Owners just installed brand new furnace, oil tank, hot water heater and had CT Basement install full water elimination basement system with a 15 year warranty on basement system that will pass to new owner. Also, Very important to note: that this house is a definite rehab or flip project but it's in a great location on a very nice lot. House has underground oil tank in front yard, owner is not willing to remove. Will need new kitchen and bathrooms. Not in the flood zone.


Before going to university, when asked what I wanted to do, I would glibly say I'd probably go do a Computer Science degree and end up working for IBM. This wasn't my life's dream, it was just the easy reply to the question. I don't remember why I picked IBM - I guess it was a big company that surely did interesting and worthwhile things that people would have heard of.
In my final year at uni, getting to stage when I had to think about a job, companies were starting to run recruitment events. Having collected all the free pens, desk toys and post-it pads from the myriad of financial services and consulting companies eager for my soul, I decided it was time to dip my toe in the water and actually apply for something. Despite the freebies, I had little interest in what they had to offer by way of employment, so when IBM came along I thought it was worth a try. As did a dozen or so others from my course.
After passing the aptitude and programming tests, I found myself headed to a two-day assessment centre in Hampshire with a group of my course-mates. It was a fun couple of days doing team exercises, a presentation and formal interview at the end of which we were told we'd hear within the next couple weeks. We headed for the train back to uni.
About 10 minutes into the journey, one of the guys phone rang. It was the IBM recruiter offering him the job. The call lasted a couple minutes at the end of which he hung up and we all congratulated him. Then his phone rang again. Quickly answering it, we saw him look around to us all and say "Yes, they are travelling back with me". He then passed his phone over to one of the other guys, who was then duly offered a job.
Anyone who has travelled north of Winchester on a train and tried to use a mobile phone will know what happened next. The signal cut out. We had entered the mobile black hole of Hampshire - a zone that has barely improved since.
Another nervous 10 minutes later and finally his phone rang again. One by one, it got passed around to each of us and we were all offered a job.
And with that, I was employed by IBM.
Fast-forward to September 3rd 2001 and I found myself turning up for my first day of work. 10 years ago today.
In that time, I've tested our Storage Virtualisation product, worked with customers in its beta program, travelled to the US twice (San Jose both times, with an added weekend customer visit to rural Arkansas) and Germany once. I've lead the Pervasive messaging team, worked on MicroBroker and MQTT, spent a couple of hours pretty much every Thursday afternoon on interminable status calls with the US and helped mind-control taxi's for TV.
For what was always the easy reply to the question of what I wanted to do, I've done quite a lot.
My current role in the Emerging Technologies team, which I started in July, holds the promise of doing even more varied and interesting things.
But I do have the nagging feeling that I'm still here because it's the easy option. I came close to taking a year-off last year to do interesting things with the now sadly gone Tinker. But then my son arrived and it wasn't the right time to be doing something like that.
Will I still be here in another 10 years? I don't know. If I am, I hope it isn't because it was the easy option.


After the success achieved in previous editions, Andalusian wines and extra virgin olive oils will again have a prominent presence in the Wine and Olive Oil Halls of Andalucía Sabor, respectively. These areas will give the exhibiting companies the opportunity to share the organoleptic qualities of their wines and extra virgin olive oils, launch new products and consolidate the success of their best wines and extra virgin olive oils.
In the Halls, wines and extra virgin olive oils will be displayed accompanied by a factsheet with their most significant characteristics as well as the company producing them also indicating the exhibition booth number. This space will be permanently attended by expert tasters and sommeliers to ensure the proper development of the Halls and the suitability of the products for tasting. These two free tastings exhibitions will target professional visitors.