Prospects for U.S. agriculture continue to be strong with record income in 2011 and a strong balance sheet.
EDITOR'S NOTE —The following comments were made Feb. 23rd by Joseph W. Glauber, chief economist, USDA during the opening session of the Agricultural Outlook Forum in Washington.
Thanks, Madam Secretary. I too would like to welcome everyone to USDA's 88th annual Agricultural Outlook Forum.
I will briefly give an overview of the major economic trends affecting U.S. agriculture and offer a few thoughts about 2012.
2011 was a very good year for much of U.S. agriculture. We saw record prices for many commodities, record agricultural exports and record farm income. Not surprising, record prices have prompted record production for many commodities and as we saw over the last half of 2011, prices for grains, oilseeds and cotton have come down, reflecting strong production levels.
World wheat and cotton stocks have rebounded and while supplies still remain tight for feed grains, slowing growth in biofuels and a return to trend yields should result in a rebound in corn stocks.
This should help relieve some of the volatility that have roiled markets over the past 5 years and improve prospects for future livestock expansion.
The global economic recovery has slowed in 2012 with negative GDP growth forecast in Europe as a result of the sovereign debt crisis. Yet despite slower growth, 2012 should be another good year for US agricultural exports.
The lower dollar will more than compensate for the expectations of slower world growth. With a slow economic recovery in the United States, U.S. agricultural products will likely remain competitively priced in global markets over the next few years.
FY 2012 U.S. agricultural exports are forecast at $131 billion, down $1 billion from the November forecast, but are still forecast to be the second highest on record in both nominal and real terms.
The decline from record exports in FY 2011 reflects record global crop production which has weakened prices and export volumes.
Imports are projected at $106.5 billion for FY 2012, up $12 billion from FY 2011 levels. The net trade balance for FY 2012 is forecast at $24.5 billion. This compares with a trade surplus of near $43 billion in FY 2011.
China was the largest destination for U.S. agricultural exports in FY 2011, importing just shy of $20 billion. Just five years ago they were our 5th largest destination after Canada, Mexico, Japan and the EU.
Exports to China are expected to fall by 15 percent this year reflecting the concentration of trade in bulk commodities like soybeans and cotton which accounted for 75 percent of total US agricultural exports to China in 2011.
Yet while U.S. exports to China are anticipated to fall in 2012, China import demand is expected to remain strong in 2012, accounting for over 60 percent of total world soybean imports and over 50 percent of world cotton imports.
Rather than going through the individual balance sheets, I will briefly touch on what I see are some of the main drivers in the current supply and demand outlook.
Record world crops. Record prices in late 2010 and through the first half of 2011 resulted in increased plantings and record production for grains and cotton. Soybean production, while off last year's record, was still the third highest on record.
Global demand has largely kept pace with production.
Total wheat consumption topped 680 million metric tons, total corn use was over 867 million metric tons, and total rice use was 480 million tons, milled basis. All of these figures were records.
At 258 million metric tons, global soybean use was also a record in 2012. Unlike grains and oilseeds, demand for world cotton declined last year, reflecting sluggish world growth, particularly in the developed economies.
Ethanol production slows as blend wall constrains expansion. After increasing by almost 700 million bushels per year over 2005-10, corn use for ethanol has flattened and is projected to fall by 21 million bushels in 2011/12.
Under the 2007 Energy Act, the maximum amount of conventional biofuels that may be applied towards the Renewable Fuel Standard (RFS) is 13.2 billion gallons in 2012. Current ethanol production capacity is estimated at 14.75 billion gallons.
The expiration of the Volumetric Ethanol Excise Tax Credit (VEETC) and the other duty and charges (ODC) on imported ethanol on Dec. 31, 2011 has meant that corn-based ethanol produced beyond the 13.2-billion- gallon mandate will have to be attractively priced to be profitably blended with gasoline.
Weekly ethanol production in December 2011 was running close to capacity as ethanol producers increased production just prior to expiration of the VEETC and ODC. Ethanol production levels have dropped about 4 percent since January 1, but still remain at almost 14.2 billion gallons, on an annualized basis.
Margins for ethanol producers have fallen as well in recent weeks, reflecting the drop in ethanol prices.
The longer run issue for corn-based ethanol is how much ethanol can be absorbed in the domestic gasoline supply — the so-called blend wall. At the time the Energy Act of 2007 was passed, forecasts by the Energy Information Administration for gasoline consumption implied almost 150 billion gallons of blended gasoline by 2013.
With the recession and subsequent sluggish economic recovery, however, forecasts for transportation fuel demand have been revised downward. Current EIA forecasts of blended gasoline fuel consumption in 2013 suggest less than 134 billion gallons, 16 billion less than forecasts made in 2007.
The current penetration rate of ethanol at roughly 10 percent implies a blend wall of about 13.5 billion gallons. Ethanol produced in excess of 13.5 billion must be held as stocks or exported.
U.S. ethanol exports hit record levels in 2011. An estimated 909 million gallons of denatured ethanol was exported 2011, about 43 percent going to Brazil. With world sugar prices falling, exports to Brazil will likely fall this year. Because of the expected decline in ethanol exports, corn use for ethanol is expected to fall by 50 million bushels in 2012/13 to 4.95 billion bushels.
In the short-run, growth in corn use for ethanol will be driven principally by the mandated levels under the RFS and the blend wall.
Over the longer-term, further expansion will largely be determined by relative attractiveness of ethanol prices to gasoline prices and the ability to market ethanol blends of more than 10 percent.
Dry weather conditions persist in the Southern United States. Devastating drought conditions prevailed over much of the Southern Plains causing poor yields and high abandonment rates in 2011/12.
Unfortunately, dry conditions have persisted in the region and worsened in the Southeast. It is still premature to conclude much concerning yield prospects for 2012.crops and much can happen between now and planting time. Nonetheless, weather will be a key concern this year, particularly in Texas.
Expected returns for soybeans and corn are again historically high reflecting strong new-crop futures and cash forward prices.
CRP enrollments are also down again for 2012/13 with total CRP area projected at 30 million acres, 6.8 million acres lower than at its peak enrollment in 2007/08. Corn plantings are estimated at 94 million acres. If realized, this would be the largest plantings since 1944.
Soybeans are projected at 75 million acres, unchanged from 2011, but down 1.6 million from last year's intentions which were not achieved partly due to excessive moisture during planting, especially in the Upper Midwest.
Wheat acreage is expected to increase 3.6 million acres to 58 million. Winter wheat area at 41.9 million acres, is up 1.3 million from last year. Spring wheat plantings should rebound from last year's levels when excessive spring and early summer wetness limited seedings.
Lower prices will likely result in a decline in upland cotton area to 13 million acres. Rice plantings will likely increase 2.3 percent to 2.8 million acres. Most of the increase will occur in long-grain rice in the Delta where farmers were prevented from planting substantial intended acreage by early season flooding.
Farm prices for most field crops will be lower, reflecting larger world and domestic supplies. A return to trend yields will likely push corn prices down significantly as stock levels rebuild.
Corn prices are forecast to average $5 per bushel in 2012/13, down almost 20 percent from 2011/12's record levels.
Cotton prices are expected to decline by more than 10 percent to 80 cents per pound for 2012/13, reflecting larger supplies worldwide.
Rice prices are anticipated to remain strong, in part reflecting strong world demand which will likely boost US rice exports in 2012/13.
Livestock and dairy producers have faced tight margins for most of the past 5 years. Despite higher product prices, little expansion has occurred.
The January 1 cattle inventory was at its lowest level since 1952. Most of the modest hog expansion seen in 2011 has been due to productivity gains rather than increased farrowings.
Feed price ratios have been low for the past 5 years for livestock, dairy and poultry, reflecting high feed costs. Lower prices for corn, wheat and soybeans will help moderate feed prices, particularly when 2012 crops are harvested. Margins are expected to improve somewhat, particularly by the fourth quarter of 2012.
Per capita domestic disappearance for meat and poultry has declined over the past 5 years. Some of the decline is due to higher prices, but consumption has also been affected by the weak economy as well as changing demographics.
Exports have become a key driver in producer returns. Beef, pork and broiler exports were at record levels in 2011. Export outlook should be strong in 2012 as well, with the major constraint being tight supplies.
Prices for livestock, dairy and poultry were either at record levels in 2011 or expected to hit record levels in 2012. The all milk price is expected to decline by almost 9 percent as record high prices have resulted in increased milk production. Prices are expected to fall in the first quarter but should rise throughout the second half of the year.
Food prices were closely watched in 2011 as year-over-year inflation rates for all food rose from 1.8 percent in January 2011 to 4.7 percent in November. Food at home inflation peaked at 6.2 percent, year-over-year, in October 2011.
Inflation estimates for January 2012 suggest food prices have begun to moderate. Year-over- year inflation rates for all food were estimated by BLS at 4.4 percent and for food-at-home at 5.0 percent.
ERS currently is forecasting inflation rates for all food and food at home to be between 2.5 and 3.5 percent for 2012.
Agriculture's strong performance is projected to ease in 2012. Net cash income for 2012 is forecast at $96.3 billion, down 11.5 percent from 2011, but still the second highest in nominal terms on record. Cash receipts for 2012 are forecast at $364.1 billion, a record high in nominal terms. Total expenses are projected to increase $12.5 billion.
Farm asset values are likely to increase by more than 5 percent for the third consecutive year. Debt is expected to rise 3.8 percent. The inflation-adjusted value of the farm sector's equity is expected to establish a new record high.
It is gratifying for an economist to watch markets follow the basic laws of supply and demand. High prices have prompted a global production response for most commodities.
As a result of increased plantings and generally favorable yields, record production levels have been reached this year which have helped moderate prices for most crop prices.
Slowing demand for ethanol means that corn stocks will likely increase in 2012/12 assuming a return to trend yields. This should help moderate record feed grain prices.
Livestock markets should see increasing margins towards the end of 2012 as the new crop is harvested bringing down feed costs.
There are still a number of key uncertainties starting with the size of the South American corn and soybean crops and the persistent dry areas of the Southern U.S.
Nonetheless, prospects for U.S. agriculture continue to be strong with record income in 2011 and a strong balance sheet.


For the seventh year in a row, I served as Curator of Performance Art for the annual Collaborative Concepts Farm Project. This year, I called the program "Something for Everyone, " because I selected a very diverse line-up of performers. From live painting and poetry readings to modern dance and one-on-one interactions, the performances reflected the variety and energy of this contemporary form of expression.


Are school trips too expensive? That's the concern one mum had after her daughter's school arranged a trip she can't afford prompting a big reaction across the country.
Louise Worrell was outraged when her child's school organised a trip to South Africa with an asking price of more than an eye-watering £1,800, branding the move "divisive".
Speaking to The Mirror, she said the savings-busting trip is well out of her budget.
"It is ridiculous and my daughter is going to be left out," she said.
Louise, 32, lives in Croydon, South London, added her friends of daughter Nevaeh, 13, in year nine at Woodcote High School, were excited about the ten-day trip next Easter, piling the pressure on her being able to stump up the cash.
Ms Worrell said: "We were only told about the trip last month and they want the money by February.
"If I had longer to pay, I think I could have scraped the cash together – it is really unfair.
Has your child's school arranged trips that are too expensive?
"I know other parents are struggling to pay and some are putting it on credit cards.
"This is not a private school, it is a state school with a catchment area that includes a lot of children from poor or struggling families.
Another parent said: "Ski trip was £600.
"These are for less than a week.
Another added that by not paying for the trips, it then upsets and embarrasses their children, saying: "When a trip says 'voluntary' contribution, the teachers hassle the children saying they can't go and embarrassing them because we have chosen not to pay.
The school said its trips to South Africa had been running since 2008 and had numerous educational benefits.
However, research by teaching union NASUWT, found more than one in six parents were unable to let their child go on an educational trip or visit in the past year due to costs of up to £3,000.


Oil painting allows me to focus intently on the endless possibilities presented by simple organic forms.
Monrüd W. Becker earned a Bachelor of Fine Arts Degree from Suffolk University and an Associates Degree from New England School of Art And Design. He has shown in the Boston area since 1991. One of Monrüd's art pieces was selected to represent the New England School of Art and Design in the 1992 New England Book Components (NEBA) Calendar. This calendar presented work by a select group of NESAD students and was distributed to regional advertising agencies, graphic designers, illustrator, and related industries. Work by Monrüd is in more than 50 private collections.
Monrüd is a member of the SOWA Artists Guild.


The Flying Phantom ESSENTIEL is an 18' versatile catamaran easy to use and able to fly in a wide range of conditions. The foil configuration makes the boat more user friendly and less physically demanding for the crew.
The FP ESSENTIEL was first launched in December 2016 after several years of experience pioneering foiling catamarans. It is designed to deliver pure foiling pleasure to a broad spectrum of sailors wishing to move on and enjoy a new way of sailing.
The FP ESSENTIEL can reach 20 knots in 10 knots of wind, with top speed over 25 knots. Get ready for take-off!
Nothing sounds like a foiling boat. Forget about the noise of the waves crashing on the carbon hulls. You'll just hear the vibration of appendages, and the wind, just the wind, with a unique feeling of speed and freedom.


JMW Professional Engineers, PC provides engineering consulting and design services for mechanical, electrical and plumbing (MEP) systems to commercial, industrial and institutional clients. Based in Irvington, Virginia, JMW offers multi-disciplinary facility expertise that includes specialized services to optimize energy conservation, improve indoor air quality and reduce building humidity levels.
"For example, with Design Master Plumbing I no longer have to worry about drawing isometrics and getting them just right. Design Master draws the isometric for me right from the plan view with a couple of mouse clicks. If the floor plan changes, I can redraw the isometric in seconds. That is a huge benefit to me.
"For example, before I got Design Master HVAC I used another program to do cooling load calculations. I had to enter all the building data into that other program. Now I can do those calculations much quicker and more easily, right in AutoCAD.
"Design Master saves me time every day, so I can work more efficiently and accomplish more with less effort," asserts Mr. West. "It also eliminates a lot of the busy-work. If you do any design work at all, a Design Master subscription is money well spent—especially as you use more of the tools it makes available to you.
"Doing what I do wouldn't be as much fun without Design Master, I can tell you that," Mr. West concludes.


text:
Journal of General Internal Medicine
April 2017 , Volume 32, Issue 4, pp 475–482 | Cite as
The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis
Michelle P. Salyers
Kelsey A. Bonfils
Lauren Luther
Ruth L. Firmin
Dominique A. White
Erin L. Adams
Angela L. Rollins
Review Paper
First Online: 26 October 2016
Healthcare provider burnout is considered a factor in quality of care, yet little is known about the consistency and magnitude of this relationship. This meta-analysis examined relationships between provider burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and the quality (perceived quality, patient satisfaction) and safety of healthcare.
Publications were identified through targeted literature searches in Ovid MEDLINE, PsycINFO, Web of Science, CINAHL, and ProQuest Dissertations & Theses through March of 2015. Two coders extracted data to calculate effect sizes and potential moderators. We calculated Pearson's r for all independent relationships between burnout and quality measures, using a random effects model. Data were assessed for potential impact of study rigor, outliers, and publication bias.
Eighty-two studies including 210,669 healthcare providers were included. Statistically significant negative relationships emerged between burnout and quality (r = −0.26, 95 % CI [−0.29, −0.23]) and safety (r = −0.23, 95 % CI [−0.28, −0.17]). In both cases, the negative relationship implied that greater burnout among healthcare providers was associated with poorer-quality healthcare and reduced safety for patients. Moderators for the quality relationship included dimension of burnout, unit of analysis, and quality data source. Moderators for the relationship between burnout and safety were safety indicator type, population, and country. Rigor of the study was not a significant moderator.
This is the first study to systematically, quantitatively analyze the links between healthcare provider burnout and healthcare quality and safety across disciplines. Provider burnout shows consistent negative relationships with perceived quality (including patient satisfaction), quality indicators, and perceptions of safety. Though the effects are small to medium, the findings highlight the importance of effective burnout interventions for healthcare providers. Moderator analyses suggest contextual factors to consider for future study.
burnout quality of care healthcare outcomes meta-analysis
Professional burnout is characterized by high levels of emotional exhaustion, cynical attitudes, and a diminished sense of personal accomplishment at work.1 A number of reviews have highlighted the problematic nature of burnout for a variety of healthcare professions, including medical residents,2 nurses,3 and mental health workers.4 , 5 Recent changes in healthcare delivery have also raised concerns that provider burnout may worsen if increased patient care and administrative demands outpace resources.6 Indeed, a recent national study found significant increases in burnout among physicians compared to the general population.7
Burnout is associated with a number of problems, not only for individual providers, but also for their employer organizations, patients, and the healthcare system as a whole. Workers with burnout often experience physical health problems (e.g., insomnia, headaches, poor overall health), relationship problems, reduced job satisfaction, and increased mental health problems (e.g., depression, anxiety, substance abuse).8 – 15 Burnout has also been negatively associated with organizational functioning, including excessive employee absences, tardiness, frequent breaks, reduced job commitment, and in some studies, poor job performance and increased turnover.11 , 13 , 16 , 17
Burnout can impact healthcare quality and safety in a number of ways. According to the job demands-resources model of burnout,18 – 21 job demands (e.g., interacting with patients with intensive service needs, balancing competing priorities) require effort over time and can result in costs to the healthcare provider (e.g., emotional exhaustion), particularly when resources are low. As providers become exhausted, they withdraw emotional energy from work, leading to depersonalization. This conservation of resources20 can also lead to providers spending less time with patients, and potentially becoming more directive than collaborative and patient-centered. Furthermore, burnout has been associated with cognitive impairments, including attention deficits,22 which can lead to errors. Williams and colleagues23 describe a cyclical model whereby burnout negatively affects the quality of the patient encounter, leading to dissatisfied patients, poor adherence, and worse health outcomes, which can cause additional provider burnout.
While links between burnout and quality of care have been theorized since the term burnout was introduced,24 research empirically linking burnout to quality of care has varied widely across healthcare specialties and types of quality domains (e.g., patient satisfaction, self-reported quality, errors). Some studies have reviewed aspects of these relationships, but none has attempted a comprehensive, quantitative review across disciplines and domains. For example, the relationship between burnout and job performance was summarized,25 but this meta-analysis included only 16 studies, was not restricted to healthcare settings, and included limited measures of performance. Within healthcare, Lee and colleagues26 studied correlates of burnout, but the sample was restricted to physicians, and few studies assessed quality. Another review27 took a broader approach, including a variety of healthcare professionals, but restricted studies to hospital settings, and because it was a narrative review, the authors were unable to quantify relationships or assess other contributing variables.
The objective of the current study was to systematically review and quantify empirical studies linking healthcare provider burnout to quality and safety in order to better understand the magnitude and consistency of these relationships. We explored potential moderators to examine whether the relationships would vary as a function of the aspect of burnout or quality being studied. Given the importance of multidisciplinary teams in patient-centered care,28 , 29 we included a variety of healthcare providers, and explored possible differences among provider types (e.g., nurses vs. physicians) and settings (inpatient vs. outpatient). We hypothesized that there would be negative relationships between each aspect of burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and quality and safety. We further hypothesized that the effects would be largest for provider perceptions, compared to more objective indicators of quality (e.g., observation or medical records). Other relationships were considered exploratory.
Data Sources and Searches
We followed guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).30 A systematic literature search of Ovid MEDLINE, PsycINFO, Web of Science, CINAHL, and ProQuest Dissertations & Theses was conducted to identify all studies involving health professionals, burnout, and quality of care through March 2015. The full electronic search string used for PsycINFO included the following: ((DE "occupational stress") AND (SU "burnout")) AND ((DE "quality of care") OR (DE "quality of services") OR (DE "satisfaction") OR (DE "client satisfaction") OR (DE "safety") OR (DE "perceived quality")). Similar search strategies were used for the other databases. All search strategies and the coding protocol are available from the authors.
We included published and unpublished studies of any design (e.g., cross-sectional surveys, intervention studies), as long as empirical data was used to assess the relationship between burnout and quality (including patient satisfaction) and/or safety; if these variables were assessed but the bivariate association was not reported, the authors were contacted to gather additional data for analyses. Attempts were made to contact 63 authors, of whom 21 provided usable data, 6 responded that data did not meet inclusion criteria or could not be obtained, 3 could not be located, and 33 did not respond. Although review articles were not included in our analyses, we examined reference sections of review articles to identify primary studies for inclusion.
We retained articles that specifically examined burnout. The Maslach31 three-dimensional scale of burnout (emotional exhaustion, depersonalization or cynicism, and reduced personal accomplishment) was used most often, although any study measuring at least one dimension of burnout or a global burnout score was included. We focused on healthcare providers and excluded studies of burnout in other occupations (e.g., education, probation officers, vocational rehabilitation). We categorized quality of care along two dimensions: perceived quality (rating scales or items reflecting provider's perception, patient satisfaction) and safety (perceived safety, adverse events, "near misses," medical errors). Included studies are briefly summarized in Table 1 of the supplemental online material.
Data Extraction and Quality Assessment
Articles were coded independently by a pair of coders (from a group of six coders comprising a clinical psychologist and five doctoral students). To maintain consistency and ensure reliability, coders met to review and come to consensus for each independent sample. We extracted information on burnout type and measure(s) used, quality and safety indicators, provider type (nurses, physicians, interdisciplinary), setting (outpatient, inpatient, or mixed inpatient/outpatient), and country (coded by region: North America, South America, Europe, Asia, Australia, Africa). Where available, we coded provider characteristics (age, gender, experience/length of time in the field) and patient characteristics (age, gender). We extracted information on potential methods-related moderators including study year, unit of analysis (individual, dyad, service unit, hospital/organization), and quality or safety data source (provider, patient, observer, medical records).
We rated the quality of each study to account for bias in individual studies (see Table 2 of the supplemental online material). Because quality rubrics commonly recommended for meta-analyses32 , 33 include items not relevant for correlational designs (e.g., blinding, allocation of intervention), we created items based on common sources of bias in observational studies.34 , 35 We tested and refined the initial rating system on several studies before rating the full sample. Two raters independently coded each study; disagreements were resolved through discussion. Measures of central tendency highlighted the presence of eight items as a potentially valuable cutpoint (mean = 8.12, median and mode = 8). Following other meta-analyses that examined subgroups based on quality ratings,36 – 38 we used quality rating as a moderator, examining the effect sizes for those with high quality (8 or above) compared to effect sizes of studies scoring below 8.
Data Synthesis and Analysis
We extracted effect size information at the level of burnout and quality (or safety) relationship. All associations were first converted into Pearson's correlations; Fisher's Z-transformation was conducted to adjust for the non-normal distribution of Pearson's r. When a study reported multiple measures of the same construct, we averaged the effect sizes and weighted them by sample size in order to maintain statistical independence.39 We calculated an overall relationship, with one effect size per independent sample, to describe the relationships between burnout and perceived quality and safety. We conducted separate meta-analyses to examine the relationships aggregated at the level of predictor (burnout type) and aggregated at the level of the quality indicator (perceived quality and safety). We conducted moderator analyses for perceived quality and safety.
We used a random effects model to calculate the mean effect sizes using Comprehensive Meta-Analysis (CMA) software, version 2.40 At the aggregate level, Z-scores and confidence intervals were examined to determine the statistical significance of each association. The strength of the mean effect sizes were interpreted in light of Cohen's41 recommendation for correlations, where 0.10 is small, 0.30 is medium, and 0.50 is large. We conducted one-study-removed sensitivity analyses to determine whether any single sample unduly influenced the results (indicating a potential outlier); because the point estimate of the mean effect size did not change substantially upon removal of any study, we performed the remainder of the analyses with the full sample.
We examined heterogeneity with the Q-statistic and the I 2 index; a significant Q-statistic informs whether moderation may be present, and the I 2 index informs the extent of the heterogeneity, ranging from 0 to 100 %, with higher values indicating greater heterogeneity.42 – 44 Although I 2 is of value in determining the need for moderation analyses, it does not speak to the source of heterogeneity or dispersion of effects.45 We used I 2 values of 25 % or more as a cutoff to examine the presence of moderators, as this suggests that between-study variability in effect size is greater than expected by chance.43 To document dispersion of effects, we report 95 % confidence intervals for each effect size.
We tested study-level moderators for both quality and safety, including year, type of report, provider type and setting, region, and quality of study. Additional moderators for burnout and perceived quality included burnout type, quality source, and unit of analysis. Additional moderator analysis for safety compared perceived safety (e.g., questionnaires) versus events (e.g., reported adverse events, near misses). For categorical moderators, we used an analysis of variance (ANOVA) analog. To test continuous moderator variables, we conducted random effects meta-regressions using unrestricted maximum likelihood estimation. Because meta-regressions use list-wise deletion, each moderator was examined independently to maximize the number of studies included in the analysis. Continuous moderators were considered significant if beta weights were significant and I 2 decreased. We interpreted statistical tests at p < 0.05. All moderator analyses were conducted in CMA, version 2.40
Finally, we assessed the potential influence of publication bias by examining funnel plots and testing for asymmetry using Egger's46 regression approach. Although Egger's test may be prone to bias in low-power situations, our sample size was well beyond the recommended minimum of ten samples.47 In addition, Failsafe N was not appropriate because of the high level of study heterogeneity and the random effects model used.39
The search yielded 1674 citations, resulting in 102 studies with 82 unique samples of healthcare providers (see Fig. 1 for PRISMA flow diagram30). A summary description of the included studies appears in Table 1, and a detailed table showing each study including individual effect sizes is presented in Table 1 of the supplemental online material. A total of 210,669 healthcare providers were included, from 32 countries on 6 continents. The majority of studies measured at least the emotional exhaustion component of burnout; about half studied depersonalization and reduced personal accomplishment. Some (19.5 %) included a total or global measure of burnout. Most assessed perceived quality, and about half assessed safety. Most studies took place in a setting that included both inpatient and outpatient care. Nurses were the most frequent target populations.
PRISMA flow chart of article identification and exclusion.
Summary of Study Characteristics Across Independent Samples (k = 82)
Sample characteristics
Median year (range)
2010 (1982 to 2015)
Mean sample size (SD)
2569.1 (8021.0)
Median sample size (range)
454 (30 to 68,724)
Country grouping of study
Burnout type measured*
Emotional exhaustion
Depersonalization
Reduced personal accomplishment
Total/Global
Quality indicator*
Interdisciplinary sample
Mean provider age (k = 57)
Sex (mean % female; k = 60)
Education (mean % doctoral; k = 39)
Mean years in the field (k = 41)
*Percentages add to greater than 100 %, as some samples used more than one burnout predictor and/or quality indicator
The meta-analysis of the relationship between burnout and perceived quality including 63 independent samples resulted in a significant negative relationship (r = −0.26), with 95 % CI ranging from −0.29 to −0.23. The Q-statistic of the overall effect was significant, with a large amount of heterogeneity (I 2 = 93 %). A second meta-analysis was conducted between burnout and safety, including 40 independent samples, which also yielded a significant negative relationship (r = −0.23) and 95 % CI ranging from −0.28 to −0.17. The burnout–safety relationship also demonstrated high levels of heterogeneity (I 2 = 97 %). Forest plots for the meta-analyses of perceived quality and safety are shown in Tables 3 and 4 of the supplemental online material.
Moderator analyses for the relationship between burnout and perceived quality are shown in Table 2. Three categorical moderators were significant: type of burnout, unit of analysis, and source of quality rating. The relationship between burnout and perceived quality was strongest for emotional exhaustion (r = −0.27) or overall burnout (r = −0.25), whereas effects for depersonalization (r = −0.21) and reduced personal accomplishment (r = −0.20) were weaker but still significant. Effect sizes were significantly stronger when examining individuals (r = −0.27) compared to service units (r = −0.12). Effect sizes were significantly stronger for provider report (r = −0.28) compared with patient reports of quality (i.e., patient satisfaction, r = −0.17). No continuous moderators were significant predictors.
Moderator Analyses of the Relationship Between Professional Burnout and Quality
k*
95 % CI
Burnout type
−0.27
Reduced pers. acc.
Quality indicator source
Patient (satisfaction)
Study-level moderators
Study quality rating
Lower-quality studies
High-quality studies
Country grouping
Continuous study level moderators
Provider age
Provider sex (percent female)
Time in the field
*k = number of studies; r = correlation; 95 % CI = 95 % confidence interval; Q b = Q-statistic comparing heterogeneity between groups; Q w = Q-statistic showing heterogeneity within groups; I 2 = degree of heterogeneity within the category; B = beta weight in regression for continuous moderators; Z = test of significance of the predictor
Moderators for the safety meta-analyses are shown in Table 3. None of the continuous moderators were significant, but three categorical moderators were identified: safety indicator, study population, and the country in which the study was conducted. Though both types of safety indicators were statistically significant, burnout had a stronger relationship with perceptions of safety (r = −0.28) than events (r = −0.16). In terms of discipline, the strongest relationship was for nurses (r = −0.27), followed by interdisciplinary samples (r = −0.24) and physicians (r = −0.15). Regarding country, effect sizes were stronger in studies from Europe (r = −0.36) than in those from North America (r = −0.18). Discipline, however, was confounded with location. Most European studies with safety outcomes consisted of nursing samples (78 %), whereas only 26 % of North American studies focused on nursing samples. Follow-up analyses to parse the overlap in these results indicated that in North American studies, nurses (r = −0.22) and physicians (r = −0.15) did not differ in relationships between burnout and safety (Q = 0.59, df = 1, p = 0.44). There were not enough studies of physicians within the European sample to conduct a parallel analysis.
Moderator Analyses of the Relationship Between Professional Burnout and Safety
Safety indicator type
Safety events
Safety perceptions
Study level moderators
Lower quality studies
High quality studies
−.022
Provider sex (% female)
We created a funnel plot, displaying overall study effect as a function of precision (calculated as 1/SE; see Figures 1 and 2 in supplemental online material). Egger's test of the intercept was not significant for either perceived quality (t = 1.13, p = 0.26) or safety (t = 0.72, p = 0.48). As both meta-analyses had substantially more than the recommended minimum number of ten samples,47 , 48 the lack of significance suggests that publication bias did not influence these findings.
Summarizing all available empirical literature on healthcare provider burnout, we found small to medium-sized relationships between burnout and both decreased quality of care and decreased safety. For perceived quality, the effect size of r = −0.26 translates into approximately 7 % of variance accounted for by provider burnout. For safety, the effect size of r = −0.23 translates into approximately 5 % of the variance in safety being attributable to provider burnout. These relationships were robust to potential publication bias and ratings of study rigor, which increases confidence in the findings. Given the increasing rates of burnout, particularly among physicians,7 these findings could have important ramifications.
Of the burnout components, emotional exhaustion had the strongest relationship with quality, followed by depersonalization and reduced personal accomplishment. These findings parallel a meta-analysis of burnout and objective job performance in other service industries.25 Together, these findings suggest that emotional exhaustion may be the most critical element of burnout to address. Earlier conceptualizations of burnout also posit a primary role for emotional exhaustion—that it may be the driving element that leads to other aspects of burnout.49
In terms of quality, burnout had a medium-sized relationship with lower perceived (provider-reported) quality and a weaker, but still significant, relationship with reduced patient satisfaction. This is important, given the increasing role of satisfaction as a benchmark for performance evaluations. Medicare payments are now tied to performance outcomes, which began with, and still include, patient satisfaction.50 In addition, satisfaction has important implications for retaining patients in competitive markets and for engaging patients in good self-care strategies, both of which could impact patient outcomes over the long term. For example, relationship variables such as working alliance51 and perceptions of patient-centered care52 , 53 have important associations with improved patient outcomes. In an era of increasing attention to collaborative care, burnout may be interfering with the provision of optimal care.
The relationship between burnout and safety risk is of particular concern. Similar to quality, the relationships were stronger for self-reported perceptions of safety (all provider-reported), yet a significant negative correlation (−0.18) was still found for safety events (i.e., errors and adverse events), some of which included external sources of data such as medical records or observer ratings. Although the effect size translates into about 3 % of the variance, these findings represent an instance where small statistical effects are still noteworthy;54 provider burnout may contribute in part to real-world outcomes for patients, putting them at higher risk of an error or adverse event. In addition to the obvious implications for patient health and well-being, a greater number of errors also leads to greater liability for healthcare organizations.
Moderator analyses for safety suggest that the impact of burnout might be greater for nurses than for physicians or mixed provider samples. This finding is consistent with research showing that nursing care is more predictive of patient ratings of quality than physician care.55 As noted by Leiter and colleagues56 in one of the first studies linking nurse burnout with patient satisfaction, nurses have more direct patient contact and perform more of the daily care activities than other healthcare professionals such as physicians, which may have a more central impact on patients. Alternatively, there may be a reporting bias, as nurses have been shown to report more minor errors and safety events than physicians.57 However, subsequent analyses suggest that geographic location might be the driving factor. European samples, which were predominantly based on studies of nurses, showed stronger relationships between burnout and safety than those conducted in North America. It is possible that systemic differences across countries in how healthcare services are provided or experienced could affect the relationship between provider burnout and safety. For example, Aiken and colleagues58 found wide variability in nurse- and patient-reported safety and quality across 12 countries, and those samples were included in our study. More research is needed to clarify which explanation is most accurate.
As a meta-analysis, this study is limited by some of the same constraints as the primary studies examined. Studies were predominantly cross-sectional. Thus, while the consistent negative relationships between burnout and both quality and safety indicators suggest that provider burnout may be negatively impacting healthcare, we cannot rule out the possibility that poor quality itself could contribute to increased burnout, or that other factors (e.g., negative organizational culture) may be causing both burnout and poor quality. Cross-sectional studies may also limit our ability to detect delayed consequences of burnout, such as a gradual erosion of quality or safety over time, or the impact of burnout on staff turnover that subsequently impacts quality and safety in clinical settings. Studies were predominantly based on self-reports, and few used objective indicators of quality. At the same time, the findings regarding patient satisfaction and some studies of safety events did include external sources of data. The fact that these were still significantly related to burnout suggests that the relationships go beyond common method variance. Furthermore, the majority of studies were at the level of the individual provider, despite the fact that team-based care models are the norm. More research is needed on the impact of burnout within a team. For example, it is possible that the impact of one team member with burnout on the total delivery of care would not be enough to affect outcomes; alternatively, burnout may be subject to a "contagion effect,"59 in which one or a few burned-out team members could negatively impact the whole team. Finally, meta-analyses were characterized by high levels of heterogeneity; in most moderator analyses, I 2 values remained above 25 %, indicating likely additional moderators. Future studies should continue to investigate relationships between burnout and healthcare quality and safety, including potential moderators not examined here. Similarly, the overall effects accounted for less than 10 % of the variance in quality and safety. Clearly, provider burnout is not the primary factor in these outcomes. However, our findings do suggest a consistent role, perhaps as an important contextual variable, in addition to other predictors of quality and safety (e.g., organizational policies, staffing ratios, communication).
Despite limitations, this study has several notable strengths. It is the first to systematically, quantitatively analyze the links between healthcare provider burnout and healthcare quality and safety across disciplines. We aggregated findings from a large number of independent samples; analyses suggested that publication bias and study rigor were not important factors in our findings. In addition, the studies spanned 6 continents and 33 countries, enhancing the generalizability of the results. Taken together, our findings suggest that healthcare provider burnout is an important area for future research and a target for intervention that could have benefits for providers, patients, and the healthcare system at large.
We would like to thank Heidi Hedrick for assisting with this project.
No funding was received in support of this work.
Prior Presentations
This work has not been presented at any conference.
The authors declare no conflicts of interest.
Maslach C. Burnout: a multidimensional perspective. In: Schaufeli WB, Maslach C, Marek T, eds. Professional burnout: recent developments in theory and research. Washington: Taylor & Francis; 1993:19–32.Google Scholar
Thomas NK. Resident Burnout. JAMA. 2004;292:2880–9. doi: 10.1001/jama.292.23.2880.CrossRefPubMedGoogle Scholar
Khamisa N, Peltzer K, Oldenburg B. Burnout in relation to specific contributing factors and health outcomes among nurses: a systematic review. Int J Environ Res Public Health. 2013;10:2214–40. doi: 10.3390/ijerph10062214.CrossRefPubMedPubMedCentralGoogle Scholar
Morse G, Salyers M, Rollins A, Monroe-DeVita M, Pfahler C. Burnout in Mental Health Services: A Review of the Problem and Its Remediation. Admin Pol Ment Health. 2012;39:341–52. doi: 10.1007/s10488-011-0352-1.CrossRefGoogle Scholar
Paris M Jr, Hoge MA. Burnout in the mental health workforce: a review. J Behav Health Serv Res. 2010;37:519–28. doi: 10.1007/s11414-009-9202-2.CrossRefPubMedGoogle Scholar
Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011;305:2009–10. doi: 10.1001/jama.2011.652.PubMedGoogle Scholar
Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–13. doi: 10.1016/j.mayocp.2015.08.023.CrossRefPubMedGoogle Scholar
Carson J, Cavagin J, Bunclark J, Maal S, Gournay K, Kuipers E, et al. Effective communication in mental health nurses: did social support save the psychiatric nurse? Nurs Times Res. 1999;4:31–42. doi: 10.1177/136140969900400105.CrossRefGoogle Scholar
Heaney CC, Price RH, Rafferty J. The caregiver support program: an intervention to increase employee coping resources and enhance mental health. In: Murphy LR, Hurrell JJJ, eds. Job stress interventions. Washington: American Psychological Association; 1995:93–108.CrossRefGoogle Scholar
Rohland BM. A survey of burnout among mental health center directors in a rural state. Admin Pol Ment Health. 2000;27:221–37. doi: 10.1023/A:1021361419155.CrossRefGoogle Scholar
Stalker C, Harvey C. Professional Burnout: A Review of Theory, Research, and Prevention. Wilfrid Laurier University; 2002.Google Scholar
Long CG, Blackwell CC, Midgley M. An evaluation of two systems of in-patient care in a general hospital psychiatric unit II: measure of staff and patient performance. J Adv Nurs. 1990;15:1436–42. doi: 10.1111/j.1365-2648.1990.tb01786.x.CrossRefPubMedGoogle Scholar
Smoot SL, Gonzolas JL. Cost-effective communication skills training for state hospital employees. Psychiatr Serv. 1995;46:819–22. doi: 10.1176/ps.46.8.819.CrossRefPubMedGoogle Scholar
Killian KD. Helping till it hurts? A multimethod study of compassion fatigue, burnout, and self-care in clinicians working with trauma survivors. Traumatology. 2008;14:32–44. doi: 10.1177/1534765608319083.CrossRefGoogle Scholar
Perrone KM, Aegisdottir S, Webb LK, Blalock RH. Work-family interface: commitment, conflict, coping and satisfaction. J Career Dev. 2006;32:286–300. doi: 10.1177/0894845305283002.CrossRefGoogle Scholar
Burke RJ, Richardsen AM. Psychological burnout in organizations. In: Golembiewski RT, ed. Handbook of organizational behavior. New York: Marcel Dekker; 1993.Google Scholar
Schwab RL, Jackson SE, Schuler RS. Educator burnout: sources and consequences. Educ Res Q. 1986;10:15–30.Google Scholar
Boyd CM, Bakker AB, Pignata S, Winefield AH, Gillespie N, Stough C. A longitudinal test of the job demands‐resources model among Australian university academics. Appl Psychol Int Rev. 2011;60:112–40. doi: 10.1111/j.1464-0597.2010.00429.x.CrossRefGoogle Scholar
Hakanen JJ, Schaufeli WB, Ahola K. The Job Demands-Resources model: a three-year cross-lagged study of burnout, depression, commitment, and work engagement. Work and Stress. 2008;22:224–41. doi: 10.1080/02678370802379432.CrossRefGoogle Scholar
Hobfoll SE. Conservation of resources: a new attempt at conceptualizing stress. Am Psychol. 1989;44:513–24. doi: 10.1037/0003-066X.44.3.513.CrossRefPubMedGoogle Scholar
Van den Broeck A, Vansteenkiste M, De Witte H, Lens W. Explaining the relationships between job characteristics, burnout, and engagement: the role of basic psychological need satisfaction. Work and Stress. 2008;22:277–94. doi: 10.1080/02678370802393672.CrossRefGoogle Scholar
van der Linden D, Keijsers GPJ, Eling P, van Schaijk R. Work stress and attentional difficulties: an initial study on burnout and cognitive failures. Work and Stress. 2005;19:23–36. doi: 10.1080/02678370500065275.CrossRefGoogle Scholar
Williams ES, Savage GT, Linzer M. A proposed physician-patient cycle model. Stress Health. 2006;22:131–7. doi: 10.1002/smi.1088.CrossRefGoogle Scholar
Freudenberger HJ. Staff burn‐out. J Soc Issues. 1974;30:159–65. doi: 10.1111/j.1540-4560.1974.tb00706.x.CrossRefGoogle Scholar
Taris TW. Is there a relationship between burnout and objective performance? A critical review of 16 studies. Work and Stress. 2006;20:316–34. doi: 10.1080/02678370601065893.CrossRefGoogle Scholar
Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: a meta-analysis. Hum Resour Health. 2013;11:48. doi: 10.1186/1478-4491-11-48.CrossRefPubMedPubMedCentralGoogle Scholar
Humphries N, Morgan K, Catherine Conry M, McGowan Y, Montgomery A, McGee H. Quality of care and health professional burnout: narrative literature review. Int J Health Care Qual Assur. 2014;27:293–307. doi: 10.1108/IJHCQA-08-2012-0087.CrossRefPubMedGoogle Scholar
Cronholm PF, Shea JA, Werner RM, Miller-Day M, Tufano J, Crabtree BF, et al. The patient centered medical home: mental models and practice culture driving the transformation process. J Gen Intern Med. 2013;28:1195–201. doi: 10.1007/s11606-013-2415-3.CrossRefPubMedPubMedCentralGoogle Scholar
Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291:1246–51. doi: 10.1001/jama.291.10.1246.CrossRefPubMedGoogle Scholar
Moher D, Liberati A, Tetzlaff J, Altman DG, Grp P. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. 2009;6:e1000097. doi: 10.1371/journal.pmed.1000097.CrossRefPubMedPubMedCentralGoogle Scholar
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto: Consulting Psychologists Press; 1996.Google Scholar
Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343. doi: 10.1136/bmj.d5928.
National Collaborating Centre for Methods and Tools. Quality Assessment Tool for Quantitative Studies. Hamilton: McMaster University; 2008.Google Scholar
Hammer GP, du Prel J-B, Blettner M. Avoiding bias in observational studies: part 8 in a series of articles on evaluation of scientific publications. Dtsch Ärztebl Int. 2009;106:664–8. doi: 10.3238/arztebl.2009.0664.PubMedPubMedCentralGoogle Scholar
Sanderson S, Tatt ID, Higgins JP. Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography. Int J Epidemiol. 2007;36:666–76. doi: 10.1093/ije/dym018.CrossRefPubMedGoogle Scholar
Clair C, Cohen MJ, Eichler F, Selby KJ, Rigotti NA. The effect of cigarette smoking on diabetic peripheral neuropathy: a systematic review and meta-analysis. J Gen Intern Med. 2015;30:1193–203. doi: 10.1007/s11606-015-3354-y.CrossRefPubMedPubMedCentralGoogle Scholar
Faragher EB, Cass M, Cooper CL. The relationship between job satisfaction and health: a meta-analysis. Occup Environ Med. 2005;62:105–12.CrossRefPubMedPubMedCentralGoogle Scholar
Huang R-Y, Huang C-C, Hu FB, Chavarro JE. Vegetarian diets and weight reduction: a meta-analysis of randomized controlled trials. J Gen Intern Med. 2016;31:109–16. doi: 10.1007/s11606-015-3390-7.CrossRefPubMedGoogle Scholar
Card NA. Applied meta-analysis for social science research. New York: Guilford Press; 2012.Google Scholar
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Comprehensive Meta-Analysis (Version 2). Englewood: Biostat; 2011.Google Scholar
Cohen J. A power primer. Psychol Bull. 1992;112:155–9. doi: 10.1037/0033-2909.112.1.155.CrossRefPubMedGoogle Scholar
Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21:1539–58. doi: 10.1002/sim.1186.CrossRefPubMedGoogle Scholar
Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11:193–206. doi: 10.1037/1082-989X.11.2.193.CrossRefPubMedGoogle Scholar
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60.CrossRefPubMedPubMedCentralGoogle Scholar
Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to Meta-Analysis. Chippenham, Wiltshire, UK: John Wiley & Sons, Ltd; 2009.CrossRefGoogle Scholar
Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–34. doi: 10.1136/bmj.315.7109.629.CrossRefPubMedPubMedCentralGoogle Scholar
Kepes S, Banks GC, McDaniel M, Whetzel DL. Publication bias in the organizational sciences. Organ Res Methods. 2012;15:624–62. doi: 10.1177/1094428112452760.CrossRefGoogle Scholar
Sterne JA, Sutton AJ, Ioannidis J, Terrin N, Jones DR, Lau J, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011;343. doi: 10.1136/bmj.d4002.
Leiter MP, Schaufeli WB, Maslach C, Marek T. Burnout as a developmental process: consideration of models. In: Schaufeli WB, Maslach C, Marek T, eds. Professional burnout: recent developments in theory and research. Philadelphia: Taylor & Francis; 1993:237–50.Google Scholar
CMS. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/. Accessed September 20 2016.
Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: a meta-analysis. J Couns Psychol. 1991;38:139. doi: 10.1037/0022-0167.38.2.139.CrossRefGoogle Scholar
Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45:340–9. doi: 10.1097/01.mlr.0000254516.04961.d5.CrossRefPubMedGoogle Scholar
Stewart M, Brown JB, Donner A, Mc Whinney IR, Oates J, Weston WW. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49:796–804.PubMedGoogle Scholar
Prentice DA, Miller DT. When small effects are impressive. Psychol Bull. 1992;112:160. doi: 10.1037/0033-2909.112.1.160.CrossRefGoogle Scholar
Carey RG, Seibert JH. A patient survey system to measure quality improvement: questionnaire reliability and validity. Medical Care. 1993;834–45. doi: 10.1097/00005650-199309000-00008.
Leiter MP, Harvie P, Frizzel C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med. 1998;47:1611–7. doi: 10.1016/S0277-9536(98)00207-X.CrossRefPubMedGoogle Scholar
Sarvadikar A, Prescott G, Williams D. Attitudes to reporting medication error among differing healthcare professionals. Eur J Clin Pharmacol. 2010;66:843–53. doi: 10.1007/s00228-010-0838-x.CrossRefPubMedGoogle Scholar
Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344, e1717. doi: 10.1136/bmj.e1717.CrossRefPubMedPubMedCentralGoogle Scholar
Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs. 2005;51:276–87. doi: 10.1111/j.1365-2648.2005.03494.x.CrossRefPubMedGoogle Scholar
© Society of General Internal Medicine 2016
1.Department of PsychologyIndiana University-Purdue University IndianapolisIndianapolisUSA
2.ACT Center of IndianaIndianapolisUSA
3.VA HSR&D Center for Health Information and CommunicationRichard L. Roudebush VAMCIndianapolisUSA
Salyers, M.P., Bonfils, K.A., Luther, L. et al. J GEN INTERN MED (2017) 32: 475. https://doi.org/10.1007/s11606-016-3886-9
Received 31 March 2016
Revised 02 September 2016
First Online 26 October 2016
Society of General Internal Medicine

redpajama_set_name: RedPajamaCommonCrawl


text:
China, food/ nutrition, forest conservation, renewable energy, tropical forests, vegetation cover, wind erosion, women
(-) food/ nutrition (50)
(-) renewable energy (32)
(-) wind erosion (3)
(-) tropical forests (1)
(-) forest conservation (1)
INDC's shed light on the need to address sustainable bioenergy in Africa: Rwanda at the forefront
In a recent review, FAO identified that 41 out of 54 countries in Africa included at least one policy or measure on more sustainable use of bioenergy in their Intended Nationally Determined Contributions (INDCs). Considering the critical role of sustainable bioenergy in sub-Saharan Africa, FAO's…
SDG Knowledge Weekly: Renewable Energy and Linkages Across SDGs
Twenty-seven policy briefs were authored for the Global Preparatory Meeting for Review of SDG 7. IRENA released two reports, on renewable energy market analysis for Southeast Asia and prospects for the EU. A joint report by Bloomberg New Energy Finance and Facebook looks at options for bridging the…
European Commission launches Knowledge Centre to boost food quality and step up the fight against food fraud
Responding to consumer concerns about food quality and fraudulent practices concerning food, on 13 March 2018, the European Commission is launching a Knowledge Centre for Food Fraud and Quality, operated by the JRC.
Can Strategic Spatial Planning Contribute to Land Degradation Reduction in Urban Regions? State of the Art and Future Research
Land degradation is becoming a serious environmental issue threatening fertile agricultural soils and other natural resources. There are many driving forces behind land degradation. The expansion of artificial surfaces due to various economic activities, such as housing, industry, and transport…
ATONU web-based "Nutrition-Sensitive Intervention (NSI) Selection Tool"
The Food, Agriculture and Natural Resources Policy Analysis Network (FANRPAN) and partners are pleased to share an updated version of the web-based tool "ATONU's Nutrition-Sensitive Intervention (NSI) Selection Tool". The tool assists development practitioners working in the agriculture sector to…
Relationship between food waste, diet quality, and environmental sustainability
This analysis finds that US consumers wasted 422g of food per person daily, with 30 million acres of cropland used to produce this food every year. This accounts for 30% of daily calories available for consumption, one-quarter of daily food (by weight) available for consumption, and 7% of annual…
These 20 Water-Stressed Countries Have the Most Solar and Wind Potential
Most power generation consumes water, whether to cool steam in thermoelectric plants or power turbines for hydropower. And the global demand for both water and electricity will continue to increase substantially in the coming decades. Although growth is generally a good thing for the economy, it…
Foodsource-A free and evolving resource to empower informed discussion on sustainable food systems.
A free and evolving resource to empower informed discussion on sustainable food systems.
The economic impact of reducing food waste in Germany, Poland and Spain
A new study has quantified the economic impact of reducing avoidable food waste in Germany, Poland and Spain. The researchers modelled impacts on production, GDP and employment. The results show that reducing food waste from households has the greatest impact, although policy measures should be…
TEEB for Agriculture & Food: Scientific and Economic Foundations report
Communities across the world are becoming more interested in eating a healthy, nutritious, and low-footprint diet. But there remains a big disconnect between consumers, producers, and the impact current production and consumption patterns have on the environment and climate. What can you do? The…
Renewables 2018 Global Status Report
Transformation is picking up speed in the power sector, but urgent action is required in heating, cooling and transport This year's Renewables 2018 Global Status Report GSR reveals two realities: one in which a revolution in the power sector is driving rapid change towards a renewable energy future…
Powerful New Policy Options to Scale Up Renewables in New IRENA, IEA, REN21 Report
A new report by the International Renewable Energy Agency (IRENA), the International Energy Agency (IEA), and the Renewable Energy Policy Network for the 21st Century (REN21), Renewable Energy Policies in a Time of Transition, is an unprecedented collaboration that sheds new light on the policy…
Global land use implications of dietary trends
Global food security and agricultural land management represent two urgent and intimately related challenges that humans must face. The authors quantify the changes in the global agricultural land footprint if the world were to adhere to the dietary guidelines put forth by the United States…
Clean energy can provide 100% of electricity
All the electricity the world needs can come from clean energy, reliably and throughout the year, British researchers say, at any time of day or night.
New IRENA report: 'Hydrogen from Renewable Power'
Launched during IRENA's Innovation Week, the agency's latest technology outlook 'Hydrogen from Renewable Power' outlines the potentially pivotal role hydrogen may play in a deeper energy transition. And, while hydrogen is already widely used in facilities such as chemicals plants and refineries, by…
Global hunger continues to rise, new UN report says
821 million people now hungry and over 150 million children stunted, putting hunger eradication goal at risk


The meeting commenced at 2.04 pm.
Apologies were received from Jim Wells MLA; Brian Moreland, Head of Internal Audit; and Dr Gareth McGrath, Director of Parliamentary Services, who is currently on secondment. SARC members again sent their best wishes to Brian.
Minutes of the previous meeting held on 31 January 2018 were approved without amendment.
It was noted that both action points have been completed, with the draft Internal Audit Plan for 2018-19 on the agenda.
Eddie Kelly gave SARC members an overview of the Internal Audit Reports and Follow-up Reports which had been issued since April 2017, focusing on the reports that had issued since the SARC meeting on 31 January 2018.
The recommendations were in relation to Parliament Buildings Access; Control Room Key Database; Compliance with Lost Property Policy; VMS – Post-Contract Evaluation; Upper Car Park Permits issued to Assembly Members; and Operational Planning (Room Booking App).
The assurance rating for this audit is Satisfactory.
The final report on the Review of the Roof Project was issued on 21 March 2018 with three recommendations. Recommendations were made in respect of convening a Project Board meeting to formally close the project following the Defects Liability Period; recording Project Board approval in any instance where project methodology deviates from the requirements defined in the PID; and ensuring that all of the records relating to the roof project are systematically filed in order to provide a comprehensive management trail of the entire project.
The assurance rating for this audit is Satisfactory. SARC members stressed the importance of documentation being systematically filed and readily acknowledged that the Roof Project was a good project, delivered on time and within budget.
The follow-up report on the Review of Northern Ireland Assembly Commission Support to Politics Plus was issued on 12 February 2018. The successful implementation of the original recommendation resulted in the assurance level being raised to Substantial.
The follow-up report on the Voluntary Early Severance (VES) Scheme Administration was issued on 14 February 2018. Successful implementation of both recommendations resulted in the assurance level being raised to Substantial.
The follow-up report on the Review of Risk Management was issued on 7 February 2018. Successful implementation of the original recommendation resulted in the assurance level remaining Substantial.
The follow-up report on the review of iTrent (HR) was issued on 24 April 2018. Internal Audit noted successful implementation of 17 of the 18 original recommendations. As regards the remaining recommendation (risk rating 1), Internal Audit agreed an alternative approach proposed by management to control the risk of unauthorised HR staff access to recruitment scheme records. It was noted that procedures have been amended to reflect the new procedures; however, this cannot be demonstrated until the next relevant recruitment competition is held. The assurance level remains Satisfactory.
In relation to audits in progress, Eddie advised SARC that work on the review of Secretariat Travel has been completed. Internal Audit is in the process of clarifying several issues prior to publication of the draft report.
Fieldwork on the review of PECOS (purchase to pay system) has been completed. The draft report is at quality assurance stage and will be published following this stage.
The Review of Members' Expenses has commenced, and testing has just been completed at constituency offices. Eddie confirmed to SARC that this is based on a 25% sample of Members, with all Members being audited at least once within the mandate.
Eddie reported that, in addition to the planned assurance and control-related consultancy activity carried out during the year, the Head of Internal Audit and Audit Manager provided assistance to the Houses of the Oireachtas during Quarter 3 of 2017-18 in respect of Internal Audit quality assessment and risk based planning.
An outturn of planned versus actual days for the 2017-18 Internal Audit plan was tabled, and it was noted that this did not include time spent concluding the 2016-17 plan or unplanned direct activity such as the provision of control-related consultancy services, and attendance at corporate groups and project boards. Other factors affecting the outturn for 2017-18 included the provision of assistance to the Houses of the Oireachtas, the temporary redeployment of a member of the audit team (since the beginning of January), and the impact of long-term leave on the unit. The SARC Chairperson noted that the budgeted days for 2017-18 appeared low for the number of staff in the unit and that while some progress had been on a resource plan he would like to see more.
A 2018/19 plan has been agreed by the Secretariat Management Group and tabled as a separate agenda item.
The Audit Manager informed SARC that the overall level of assurance for the period 1 April 2017 to 31 March 2018 is Satisfactory.
SARC members were pleased to note that there were no Audit Reports in 2017-18 resulting in Limited or Unacceptable assurance ratings.
No whistleblowing cases have been reported to Internal Audit to date this year, and no new cases of fraud have been identified by or reported to Internal Audit since the last SARC meeting.
The next meeting of the inter-parliamentary Head of Internal Audit group is due to be held in the National Assembly for Wales in late June 2018.
The Assembly's Internal Audit function was rated as fully compliant in all aspects of the standards during its last Quality Assurance and Improvement Review (follow-up report dated September 2014). These reviews are required at least every five years. As previously reported, the Heads of Internal Audit of the Scottish and Welsh legislatures have agreed in principle that the three bodies engage in a review arrangement that would facilitate the requirements of the standards in a cost-effective manner. In preparation for the next external review, some planned time has been set aside for the current year to conduct an internal quality assessment of the Internal Audit function.
All members of the Internal Audit team monitor compliance with the Continuing Professional Education requirements of the Institute in order to maintain their certified status. Progress is discussed at team meetings throughout the year.
Rodney Allen noted that the Assembly Commission was continuing to use the Substantial assurance rating, and that this was contrary to the approach adopted by the Northern Ireland Civil Service and wider public sector. It was confirmed that SARC had made the conscious decision to retain the Substantial rating to provide an incentive to staff to achieve better than Satisfactory.
Eddie Kelly tabled the 2018-19 Internal Audit & Resource Plan, as agreed by SMG on 25 April 2018. The plan has been based on the final year of the current Internal Audit Strategy. Formulation of the plan has also included discussions with the Clerk/Chief Executive and members of SMG; discussions with Heads of Business, including the Head of Finance and the Head of IS; review of the Corporate Risk Register; consideration of the results of previous audits; assessment of the efficiency of delivery of assurance; and the identification of areas carried over from the 2017-18 periodic plan.
Rodney Allen highlighted that the audit of Business Continuity had been deferred from 2017-18 and queried why it was not on the 2018-19 plan. Eddie explained that resources were being prioritised in the current circumstances. Lesley advised that she had recently initiated a strategic review of business continuity with the Assembly Commission which would change current arrangements and that auditing current arrangements was likely to be of limited benefit.
Eddie presented the accompanying Resource Plan and outlined the resource pressures currently being experienced in Internal Audit as a result of staff absence and staff temporary redeployment. Eddie explained that the Resource Plan presented resource days for two scenarios, one based on a complement of 2.8 FTE staff which would enable the full plan to be delivered and a second scenario based on a complement of 1.9 FTE reflecting current resources in the unit. The inherent risk in limiting the scope of planned internal audit activity will be a consequently limited audit opinion at year end.
The SARC Independent Member requested that the Audit Manager critically look at the proposed audits and the time allocated to ensure that the Assembly Commission avoided a limited audit opinion at the end of the year. Lesley Hogg advised that SMG had already planned to consider resources when more clarity was received regarding the scope of the audits included in the plan and that resources may need to be reprioritised at that stage.
Action: 2018-19 Internal Audit & Resource Plan to be revisited once scope of planned audits has been considered.
SARC members acknowledged that a flow of activity and audit reports was needed to avoid a limited audit opinion. SARC members noted that the Audit Manager is to make recommendations to SMG at the end of June in relation to how best the plan can be delivered. SARC members welcomed the further development of Internal Audit resource planning as helpful and useful.
SARC members considered the updates and noted the continuing high level of implementation of accepted Audit recommendations, with 13 recommendations currently "in progress". SARC members continue to view implementation as very important and were pleased with the good progress that had been made and maintained in this area.
Rodney Allen informed SARC that no significant matters had arisen in NIAO's interim audit work and that the final audit of the Financial Statements is to commence on 21 May 2018.
Rodney thanked the Assembly Secretariat for facilitating an NIAO intern as part of the audit process.
Paula McClintock apologised for the late circulation of the draft accounts the previous evening and explained that the timescale for preparation was extremely tight. She also acknowledged that SARC members would not have had sufficient time to read them in detail and indicated that comments could be provided up to the end of the week. Paula gave SARC members an overview of the draft Accounts and set out the background of Spring Supplementary Estimate assumptions that had resulted in underspends in the Resource and Capital outturns.
The SARC Chairperson and the Clerk/Chief Executive congratulated the Finance Office on the timely production and significant effort that had gone into the preparation of the draft Accounts, and the Head of Finance thanked her team for all their hard work.
Action: SARC members to contact the Head of Finance, by 18 May 2018, with any further comments or queries on the draft Accounts or Governance Statement.
SARC members considered the contents of the Directorate Risk Registers and acknowledged the quality of the documents and the usefulness of reviewing them annually at SARC. Directors gave brief overviews of the key risks identified. All present recognised the need for the registers to be living documents with input from staff at all levels.
SARC members noted the changes made to the contents of the Corporate Risk Register since the January 2018 SARC meeting and the excellent correlation with the Directorate Risk Registers. The SARC Chairperson also noted that while the Assembly Commission had a number of high risks SMG actively amended the residual risk scores to reflect the mitigations put in place.
SARC members noted the contents of the Stewardship Statements as at 31 March 2018. SARC members found the statements to be a valuable discipline in strengthening accountability and a useful resource for Internal Audit.
SARC members sought and received assurance on the Assembly Commission's preparedness for the introduction of the General Data Protection Regulation (GDPR) on 25 May 2018. It was noted that an Information Commissioner's Office seminar had been held for MLAs and Party staff and that a comprehensive information note had been provided. The SARC Independent Member stated that he was very impressed with the Assembly Commission's work on GDPR.
SARC members were content with the contents of the SARC Annual Report and the very positive self-assessment, subject to minor additions to the concluding paragraph of the report, and for the Annual Report to be presented to the Assembly Commission. The SARC Chairperson stated that the Secretariat had shown great strength and resilience in a very difficult year.
Action: David Johnston to circulate revised wording, by 18 May 2018, to reflect the overall Internal Audit Satisfactory assurance rating; the Substantial ratings achieved; and the fact that there had been no Limited or Unacceptable ratings during 2017-18.
The Governance Officer advised SARC that the National Audit Office's good practice guide "Cyber Security and Information Risk Guidance for Audit Committees" checklist had been completed in January 2018 and an action plan put in place to improve and strengthen a small number of areas where potential weaknesses were identified. SARC members noted the high level of implementation to date.
The Governance Officer informed SARC that the Northern Ireland Audit Office's Managing Fraud Risk Self-assessment Checklist and the British Standards Institution's Anti-bribery Self-assessment Questionnaire were completed in September 2017, confirming a very high level of compliance. An action plan was put in place to improve and strengthen a small number of areas where potential weaknesses were identified. SARC members noted the latest implementation position.
The Governance Officer advised SARC members that the Northern Ireland Audit Office's "Managing the Risk of Bribery and Corruption: A Good Practice Guide for the Northern Ireland Public Sector" organisation checklist had been completed in January 2018 and the assessment had confirmed a very high level of compliance. A short Action Log to further enhance compliance had been compiled. SARC members noted the latest implementation position.
In relation to fraud prevention and detection, it was confirmed to SARC members that the Assembly Secretariat participates in the National Fraud Initiative.
SARC members thanked the Governance Officer for the considerable amount of work that had gone into completing and monitoring the various checklists throughout 2017-18.
SARC members noted the three DAO letters and three FD letters that had been issued by the Department of Finance since the January 2018 SARC meeting.
The Governance Officer informed SARC that the Department of Finance had issued its Audit and Risk Assurance Committee Handbook (NI) 2018 on 30 March 2018. The contents are almost identical to those of the HM Treasury Audit and Risk Assurance Committee Guidance, issued in April 2016, but without the full HM Treasury annexes on Whistleblowing and Cyber Security. A Gap Analysis has been carried out and this has confirmed a high level of compliance within the NI Assembly Secretariat.
SARC members were grateful for the analysis and were pleased to note the high level of compliance.
The date of the next meeting is Wednesday 20 June 2018.
The meeting ended at 3.35 pm.


text:
Die in Markneukirchen ansässige Firma Hermann Schmidt Metallblasinstrumente (kurz: HSM) zählt zu den wenigen überlebenden traditionellen Instrumentenbaubetrieben des Vogtlands, die bis heute in Handarbeit Musikinstrumente herstellen. Sie wurde nach eigenen Angaben 1978 von Hermann Schmidt zunächst als reiner Reparaturbetrieb für Blechblasinstrumente gegründet. Schmidts Vorfahren waren als Mundstückdreher 1896 aus Franken ins Vogtland übersiedelt.

Zur Produktpalette zählen Trompeten, Flügelhörner, Kornette, Posaunen, Jagdhörner, Tenorhörner, Baritone und Tuben.

HSM leistete 2002/03 einen entscheidenden Beitrag zur Entwicklung einer modernen Ophikleide.

Für eine Basstrompete in C erhielt HSM 2011 den Deutschen Musikinstrumentenpreis. Zur Entwicklung einer Doppeltuba, die umschaltbar eine Basstuba in F und eine Kontrabasstuba in B in einem Profiinstrument vereint, erhielt HSM 2011 eine Förderung vom Bundesministerium für Wirtschaft und Technologie in Höhe von rund 27.000 Euro.

Fußnoten

Weblinks
 Internet-Präsenz von HSM

Blasinstrumentenhersteller
Produzierendes Unternehmen (Vogtlandkreis)
Organisation (Markneukirchen)
Produzierendes Unternehmen (DDR)
Gegründet 1978
Musikinstrumentenbauunternehmen (Deutschland)

redpajama_set_name: RedPajamaWikipedia


text:
Chapter 3745-555 - Solid Waste Transfer Facilities
Ohio Admin. Code 3745-555-610 - Operation of a solid waste transfer facility - general requirements
The owner or operator of a solid waste transfer facility shall do the following:
(A) Conduct all operations at a transfer facility in compliance with the transfer facility license, the contingency plan, and the permit to install for those transfer facilities with an approved permit to install.
(B) Have available at the transfer facility copies of the authorizing documents and the contingency plan.
For a transfer facility that consists solely of portable containers and does not have a waste handling floor, the owner or operator shall make the authorizing documents and contingency plan available for inspection by the licensing authority or Ohio EPA during normal operating hours.
(C) Prepare a contingency plan.
(1) The contingency plan shall detail the emergency procedures, equipment, material, and services at or available to the facility to address the following:
(a) Discovery of unauthorized wastes.
(b) Burning or dusty material.
(c) Fire, explosion, and spills.
(d) Equipment failure.
(e) If operations in all or part of the transfer facility cannot be conducted in compliance with the authorizing documents:
(i) The handling, removal, and disposal of solid wastes.
(ii) The written notification of the solid waste management district in which the transfer facility is located, the appropriate Ohio EPA district office, and the local health district.
(iii) If the transfer facility is unable to accept waste, the general notification of the service area and customers.
(f) Storage and disposal of leachate in the event that collected leachate cannot be managed in accordance with normal operating procedures.
(g) The disposal facility where waste from the transfer facility is normally taken can no longer accept waste.
(2) The contingency plan shall be prepared within the following time frames:
(a) For a transfer facility established prior to the effective date of this rule, not later than one hundred eighty days after the effective date of this rule.
[Comment: Unless the owner or operator of a transfer facility who holds a permit to install successfully alters the permit to remove or replace the contingency plan contained therein, the owner or operator is obligated to comply with both contingency plans, the pre-existing plan and the newly prepared plan, in accordance with rule 3745-500-35 of the Administrative Code.]
(b) For a transfer facility with an approved permit to install issued pursuant to Chapter 3734. of the Revised Code to establish a new facility after the effective date of this rule, prior to waste acceptance.
(D) Prior to waste acceptance, execute and fund a financial assurance instrument pursuant to rule 3745-503-05 of the Administrative Code for an amount not less than the current closure cost estimate established in the approved permit to install issued pursuant to Chapter 3734. of the Revised Code. If the closure cost estimate is five thousand five hundred dollars or less, no financial assurance is required.
(E) For a transfer facility without an approved permit to install issued pursuant to Chapter 3734. of the Revised Code, execute and fund a financial assurance instrument pursuant to rule 3745-503-05 of the Administrative Code for an amount not less than the current closure cost estimate to include the following:
(1) The cost of removal and disposal of solid waste. The volume of solid waste shall be based on the maximum amount of waste that can be stored in the waste handling area and stored in containers within the facility boundary.
(2) The cost of removal and disposal of leachate.
(3) The cost of compliance with the closure requirements in rule 3745-555-700 of the Administrative Code.
(F) Ensure that at least one operator is on site at all times when the facility is in operation. This paragraph does not apply to a transfer facility that consists solely of portable containers and does not have a waste handling floor.
(G) Not cause or allow the transfer facility to create a nuisance or health hazard due to dust, odors, or the attraction or breeding of birds, insects, rodents, or other vectors.
(H) Employ all reasonable measures at the transfer facility to collect, properly contain, and dispose of scattered litter, including frequent policing of the area and the use of wind screens where necessary.
(I) Manage the transfer facility in such a manner that the attraction, breeding, and emergence of birds, insects, rodents, and other vectors are strictly controlled.
(J) Maintain the waste handling floor to prevent the infiltration of leachate into the ground.
(K) Clean the waste handling floor to prevent odors and nuisances.
(L) Manage and dispose of leachate in accordance with all applicable regulations.
(M) Have available at or near the transfer facility adequate fire control equipment, material, and services which shall be employed immediately to extinguish any fire at the transfer facility.
(N) Maintain the integrity and effectiveness of the engineered components of the solid waste transfer facility. If damage to or failure of an engineered component occurs after Ohio EPA has concurred with the construction certification report for that engineered component, the owner or operator shall comply with rules 3745-512-60 and 3745-555-500 to 3745-555-599 of the Administrative Code.
(O) Annually review and make appropriate revisions to the closure cost estimate and to the financial assurance instrument when the closure cost estimate is over five thousand five hundred dollars. At a minimum, the review shall include an adjustment of the closure cost estimate for inflation using an inflation factor derived from the annual implicit price deflator for gross domestic product as published by the U.S. department of commerce in the February issue of "Survey of Current Business" as described in rule 3745-500-03 of the Administrative Code. The inflation factor is the result of dividing the latest published annual deflator by the annual deflator for the previous year. After the closure cost estimate is reviewed and increased, the owner or operator shall submit the revised closure cost estimate and appropriate increase to the financial assurance instrument to the director.
Ohio Admin. Code 3745-555-610
Effective: 4/1/2017
Five Year Review (FYR) Dates: 04/01/2022
Promulgated Under: 119.03
Statutory Authority: 3734.02
Rule Amplifies: 3734.02
§ 3745-555-610. Operation of a solid waste transfer facility - general requirements
(Effective: 4/1/2017 Five Year Review (FYR) Dates: 04/01/2022 Promulgated Under: 119.03 Statutory Authority: 3734.02 Rule Amplifies: 3734.02)


This Maxiheat Corner hearth is suitable for corner installations and will complement most make and models of wood heaters sold at Barbeques Galore. Australian safety standards require a hearth be installed on combustible material floors. This full hearth is also available in gloss black.


text:
Bevin asks Congress to get rid of Obamacare and, if Medicaid expansion continues, limit it to those who are in poverty
By melissa_patrick	Published January 26, 2017 YOUR HEALTH
By Melissa Patrick
Gov. Matt Bevin has taken a stronger stance against Obamacare than his fellow Republican governors, urging Congress to repeal it "in its entirety" and saying that if Medicaid expansion under the reform law must continue, then only those under the federal poverty line (FPL) should get it.
Gov. Matt Bevin
"Medicaid was always intended to be a poverty program, and anyone above FPL should be eligible for gradually decreasing subsidies to the extent Congress decides to keep premium subsidies and cost-sharing reductions," Bevin wrote House Republicans in a letter dated Jan. 6.
The FPL is $11,880 for an individual and $24,300 for a family of four. The Medicaid expansion is for those who earn up to 138 percent of the FPL: $16,394 for an individual and $33,534 for a family of four. Before the expansion of Medicaid, only people in households with incomes of 69 percent or less of the FPL were eligible for Medicaid in Kentucky.
Kentucky is one of the states that has benefited most from the expansion, with its uninsured rate dropping by more than half from 2013 to 2015, from 14.3 percent to 6 percent respectively. The state has about 1.3 million Kentuckians on Medicaid, with about 430,000 qualifying through the expansion.
Bevin said the expansion is "unaffordable and harmful, threatening to eat up the state's budget and undermine Kentucky's ability to provide care for the poorest residents." The federal government paid the full expansion cost through last year; this year states are paying 5 percent of it, an amount that would rise in annual steps to the law's limit of 10 percent if that provision is not repealed. Bevin estimates Kentucky's cost at $1.2 billion over the next five years.
"We need a more sustainable solution, focused less on mere enrollment and more on actually improving health outcomes," Bevin wrote. "At a minimum, the Medicaid expansion population should be converted to a block grant program, possibly encompassing the Children's Health Insurance Program "in order to promote family coverage across those who are at or below the poverty line."
As a candidate in the 2015 primary, Bevin pledged to end the expansion and other elements of Obamacare, but backed off that as the Republican nominee, and as governor has only asked for a waiver from federal rules that would allow the state to charge income-based premiums and require able-bodied recipients who aren't primary caregivers to work or prepare for work. The Lexington Herald-Leader said in an editorial that "emails to Bevin's spokespeople, asking whether he still supports his Medicaid plan . . . or again wants to repeal the expansion produced no replies Wednesday," Jan. 25.
Bevin's comments contrasted with those of other GOP governors, such as Ohio's John Kasich, who said Congress should preserve Medicaid expansion, as well as several consumer protections in the law, Deirdre Shesgreen reports for USA Today. Bevin also asked for "maximum flexibility" for states to create their own plans.
Several governors urged simultaneous repeal and replacement of the law, but Bevin did not, Shesgreen notes. The letters came in response to House Majority Leader Kevin McCarthy's request for governors to offer input about the ACA and their suggestions for replacement.
Tags: children children's health Congress governor health insurance Medicaid obamacare Patient Protection and Affordable Care Act poverty
Previous ArticleEastern Kentucky has some of the nation's highest cancer mortality rates, study finds
Next ArticleRepublicans want to block-grant Medicaid but can't agree on how
obamacare children obesity rural health schools smoking ban children's health politics drug abuse legislature nutrition state government hospitals Patient Protection and Affordable Care Act research tobacco legislation Affordable Care Act health reform insurance exchange Medicaid prescription drug abuse smoking health insurance General Assembly