Last month I was introduced to Julep Nail Polish. I really liked all of their fun nail polish colors and the unique long, square bottle it comes in. They are fun. And I like things that are fun and unique.
Admittedly, I am not someone who collects nail polishes in all sort of different colors. But when I do find a color I like, I hold onto it and use it repeatedly because I like to stick to the same colors when it comes to doing my nails. I never saw myself as signing up for a Nail Polish monthly service, but the Julep Maven box piqued my interest in the same way I was initially drawn to Birchbox. I took their Nail & Beauty Quiz to find out what my style preference was and I got Classic with a Twist. Yup, that actually sounds a lot like me!
The Julep Monthly Maven Box costs $19.99 a month. I used the code FREEBOX and got my first box for free (and you can too if you use that code. Click here for more info). But the box was not entirely free. I did have to pay $3.99 for shipping of my box and I also had to give Julep my credit card number. So if I decide not to keep moving forward with the monthly subscription, I am going to need to remember to cancel right away.
One of the nail polish colors that was recommended to me in my Julep Nail Polish box was the Red Myrtle color. It's a really pretty red and it's the color my latest manicure is in. I really like it. The nail polish gives a nice coverage too – my nails have been this color for over 24 hours now and I have no chips. This is a big deal for me, people. With how active I am, I normally can barely keep a manicure without it chipping for a couple hours. So I'm very happy with how well my manicure has stayed nice even while I am active.
Overall I am not someone who gets really excited about nail polish but I really enjoy the Julep colors and it is something I thought would be fun to try out. The next one I have my eye on is a mint color, and I am hoping I can request certain colors in my box for next month. Even if I can't, it is still fun and worth the surprise. I enjoyed my Julep Maven Welcome box and will likely get one more that I pay the full $19.99 price for just to see if I continue to like it. From there I will let you know if I continue as a Monthly Maven Member.
If you are interested in getting your first Julep Maven Box for free , click here and enter FREEBOX at checkout. Note that you will have to pay $3.99 for shipping.
What about you? Have you heard of Julep? Have you used them? Post in the comments and let us know.
**Disclosure: This post contains affiliate links. I purchased my own Julep Maven box (well, only the $3.99 for shipping) and am reviewing my experience.
Looks like a really pretty red!
I have a lot of OPI, Essie, and Butter London polishes but haven't taken the time to pain my nails since Nov/Dec.
I just received my first (and Free) Julep Maven box but have yet to try the colors. My only concern is that when I called to cancel my subscription the gentleman I spoke with said that their colors work best on top of their own base coat. Something about the concentration of chemicals in other polishes can eat away at their colors, causing them not to look as good. I'm curious if anyone that has already tried their polishes, with some other brands base/top coats, has had any complications/issues. Thanks!
PS I got the Halloween box, with a Red/Orange (Boris & Nicole Bombshell), Shimmer Purple (Queen Anne – It Girl) and Black (Jet – It Girl). <3 the colors so far & the bottle shapes.


We recently discovered some serious issues when trying to perform SAP software upgrades using SL Toolset 1.0 at support package stack 11 or higher on POWER8 hardware with IBM i 7.1. The problems did not happen when running on older hardware, or when running on POWER8 with IBM i 7.2. The problem could also happen when running an SAP application server Java with a recent patch level of SAPJVM.
PTF 5770999-MF59648 was provided and marked "HIPER" (High Impact/Pervasive) by IBM to solve these problems.
Before attempting any SAP upgrade with IBM POWER8 and IBM i 7.1, it is critical to load and apply PTF 5770999-MF59648. No special action is necessary if you are running IBM i 7.2. As always, prior to making any major changes in your SAP environment, we recommend updating PTF levels to what is found in the SAP info apar for your IBM i release level.
Thank you very much for your vital hint and very important input.
Could we please also have some detail about the error message and SUM phase?
the "error message" was a hard system crash with system reference code (SRC) B600 0103. Because of that it was difficult to identify the SUM phase, but I guess it happens very early in the upgrade.


Supporting the development of effective food and drug laws. The scope of our research includes food, drugs, biologics, and tobacco.
Examining the role of international law in protecting and promoting positive health outcomes at a global level, in particular driving towards a Framework Convention on Global Health.
Focusing on legal, regulatory, and policy responses to HIV, tuberculosis, and malaria. This area includes the development and implementation of legal preparedness instruments, such as the World Health Organization's International Health Regulations.
Exploring the relevance of law to non-communicable diseases, which are now the leading cause of morbidity and mortality in the world.
Advancing a public health approach to substance use disorders, including the opioid epidemic, through policies, practices, and regulations that promote evidence based treatment and recovery.


67 Desirable Kitchen Island Decor Ideas & Color Schemes . Kitchen Island Decor .. Your kitchen island is one of the main focal points of the entire room, serving as both a functional and a decorative piece. There are so many kitchen island decor ideas to consider-- a variety of styles and designs. Depending on your preferences as well as the available room in your kitchen, the ideas are endless. Best 25+ Kitchen Island Decor Ideas On Pinterest | Island ... Find and save ideas about Kitchen island decor on Pinterest. | See more ideas about Island lighting, Kitchen Island Lighting and Decorating kitchen.


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Radical Passions
A Memoir of Revolution and Healing
Sharon Spring Cabin
Read published reviews about Radical Passions:
Reviews on Amazon.com
Bitch Magazine: Feminist Response to Pop Culture, Issue 43
Rapid River review, by Beth Gossett
Right Arm, Left Wing, New Age, by Pat Stone
Destination: Revolution, by Clare Moen, War Resisters League.
Asheville Citizen-Times reviews Radical Passions, by Rob Neufeld. October 19, 2008. (Requires Adobe Acrobat to read)
They Call Me the Seeker, by Ron Jacobs. June 22, 2008.
Sixties Rebel Undaunted (Maybe Just a Little Daunted), by Paul Buhle July 16, 2008.
Radical Passions and the Stuff of Thought, by Alli Marshall, Mountain Xpress, Sept. 04, 2008.
From Martha Rogers, November, 2009
Dear Kendall,
I loved your book. You write beautifully. Among many things what I loved was your honesty and undiminished passion. You brought us along in the adventure like good friends wholeheartedly invited. I continually wondered how you could remember such vivid details that brought it all to life. I can see why you needed to write the book. Your experience is so varied and full of history that is not written in any usual books. It really is a one-of-a-kind slice of life in this country from several layers beneath the surface sheen. It takes so much work to really promote a publication. I'm so glad I was able to attend while you were in Boston. It was a wonderful gathering.
From Susan Freireich:
I don't know why I have waited so long before telling you how much I loved your book!! I started it a few days after seeing you and Steve at Rachel's and really could not put it down. I felt like I was there with you. It was your story, told in your own style, but it was so easy to relate to, so much of it was my story, too. I've always believed that the more personal and individual the story is, the more universal. And your writing proves it.
I love your honesty and vulnerability in this work. It's a great book. And it's wonderful that you got it together to print it. I am totally impressed.
Susan Freireich
From Sherri, April, 2009:
I read your book and have passed it on to many friends including the women in my book club. We all admired your candor, humor, and wonderful writing to bring it alive. What an amazing life you are leading–it is quite inspiring. I am so glad you have shared it with the world…more of your gifts to those around you.
From Elizabeth, March 15, 2009:
Well, I finally got to read your book, "Radical Passions." I just wanted to let you know how much I enjoyed reading it. You really created a vivid picture of the wild 60's and beyond. I couldn't put it down. I, myself, was only on the fringes of the movements, always aware, but busy raising children in a relatively safe, semi-traditional world. I longed so to be part of everything but that was not my destiny. I could only fantasize about it. Instead, I was drawn to the spiritual world, reading, learning, and then teaching whatever I had learned. I became the center of radical change on another level – a change in consciousness.
This challenged my traditional world, and the people in it, perhaps as much as you did. Someday, I'd love to talk more with you. I so admire your energy, your perseverance, and your courage. I hope you realize that you too, in your own way, fulfilled your soul's purpose by doing what you did. And even now continue to do so.
Now, with Obama as our president, and as consciousness continues to expand, perhaps finally the world will become what you worked so hard for.
Congratulations to you and to Steve for all that you've done and all that you are. Right on!
From Jessie:
Kendall!
I read your book early last fall after Moriah gave it to me. I had of course intended to write to you about it as soon as I finished it, but then life ran away and took me with it, you know that same old story. But I for sure read it, and felt very engaged by it and felt like it opened up a lot for me about you as an individual and about Moriah and how being your daughter has shaped her. It also got me thinking about women who feel called to do justice work in the world and what kind of ability we have to manifest our ideas and our ideals in whatever way we want to.
One of the things that I found compelling about your story was/is your ability to move from one entry point to another in an effort to actualize your radical passions. Not only was there an ongoing shift in what movements you attached yourself to, but a very clear distinction in what parts of your body, your artistic expression/medium, the location of your motivation you were moving out from. I found/find it inspiring that though your priorities and consciousness of the kind of risks you were willing to take personally shifted, you continued and continue to search for ways to act out your commitment to justice and wholeness in ways that work for you. I think this ability to shift, to watch something you have thrown your whole self into fall apart or fade away, and then to get up, dust yourself off and move forward with a little more wisdom or a different tenor to your strength and effort, is the great lesson of the book. You were and are clearly hungry for so much, and those hungers have changed as you have gotten older, but they still seem to burn with the same curiosity, investment, and passion. Your story made me feel safer about my own path, and knowing that it will shift hundreds of time before the work of my life is done. And that to stay close to my core values and my core strength is what is important.
Bitch Magazine: Feminist Response to Pop Culture, bitch magazine, Issue 43
In a time when the word "revolution" is used to sell everything from yogurt to laptops, it's instructive to remember that it was not so long ago that plenty of activists in the United States believed that a real revolution-the kind that involves seizing state power-was possible and worth dying for.
Kendall Hale was one of them. Driven by an ambition to be "written into history," she has crafted and self-published a memoir that chronicles a gutsy and adventurous life, from her revolutionary days at the University of Wisconsin to her middle-aged exploration of various spiritual philosophies. Radical Passions: A Memoir of Revolution and Healing is evenly split between the two halves of its subtitle. The first half, which covers Hale's activist career, is filled with valuable observations of the movements of the 1960's and '70's. The second half, which covers Hale's psychic transformations, is loosely written and at times reads like a catalog of international spiritual practices, from sweat lodge ceremonies to rebirthing rites.
As a youth, Hale's politics quickly surpassed those of her principled parents, who took their children to the 1963 March on Washington and encouraged critical thinking while maintaining a stable Midwestern household. By the end of her sophomore year of college, Hale was swept up in a flurry of militant activism. She wrote to her parents in 1970, "Unfortunately, since you are members of the middle class and the silent majority, our People's Army will have to fight anyone who stands in our way..I will not be coming home this summer." By then Hale was a full-time revolutionary, protesting the war, working in solidarity with Black Panthers, and participating in women's consciousness-raising sessions. Galvanized by Robin Morgan's seminal work, Sisterhood is Powerful, Hale helped organize a women's collective that performed skits intended to provoke conversations about sexism, racism, and imperialism.
The bombing of Madison's Army Math Research Center, as well as her own rape at the hands of three men, left Hale scarred and exhausted. She retreated temporarily from the movement, finished school, and moved east. There she became a rank-and-file organizer, first in nonunion female-dominated electronics factories, including Cambion and Unitrode; and then as a welder at General Dynamics, which was, according to Hale, the largest shipyard in New England. These are two of the most politically instructive chapters in the book, filled with thoughtful discussions of the complicated dynamics of workplace organizing.
Beginning in 1978, Hale's life journey turned international. She met with Palestinian, Russian, and Cuban workers in Havana; confronted the reality of the Cultural Revolution in China; and helped to build a health clinic in the Sandinista village of Esteli, Nicaragua. Finally, exhausted from politics and the responsibilities of parenthood, she traveled to Peru and India seeking spiritual transformation. Radical Passions is a volume of boundless energy. It offers a thoughtful firsthand account of some important movements of recent history. But the book is not without flaws: It's poorly edited, and at their worst, the accounts of Hale's later-life spiritual undertakings lapse into incoherence, as when she describes a 20th wedding anniversary hike with her husband: "I'm in a trance vibrating in earth energy. Yesterday's hike seemed womb-like, tunneling into earth's core where the water falls. Today we pass an incredible phallic mushroom. What a plant signature!" Still, in a time when consumer choice masquerades as political action, Hale's story potently reminds us that it is the actions of groups, not individuals, that change the world. —Chloe Tribich
Kendall Hale presents her memoir Radical Passions in stark and passionate prose. It reads a lot like Margaret Atwood's stunning Cat's Eye (1989). Like Atwood's self reflection, Hale shows how outside events and people in her past have shaped the woman who she is today. Her life's journey takes her to Castro's Cuba, Mao's China, and Nicaragua during the Contra War and to her life as wife, mother and veteran of a fractured marriage.
This powerful and moving story is made all the more fascinating because it is a true account of one woman's life, her struggles and triumphs that move the reader through the pages. The book's only real flaw is the cover. It fails in capturing the beauty of Hale's work. A peace sign inside a broken heart would have done the job.
Reviewed by Beth Gossett, Rapid River Magazine
Right Arm, Left Wing, New Age
A review of Kendall Hale's Memoir, Radical Passions. By Pat Stone
Whew–this is going to be tough.
What are the two most controversial topics people talk about? Politics and religion, right? Well, Fairview's very own massage therapist/yoga instructor/political activist, Kendall Hale, has recently self-published a personal memoir, Radical Passions . . . and what is the book mainly about? Politics and religion! Specifically, left-wing politics and New Age religion!
We all have our own (probably strong) opinions about those topics. So how do I review Kendall's book? Do I just describe it–tell you what it's about? Or do I react to it, which would necessarily entail my own political/religious opinions?
Out of respect for Hale and fairness to you, readers, I've decided to describe it. (If you want to learn about my own reactions, though, see the sidebar, "Is God a Salad Bar?")
One of the reasons Kendall wrote her memoir is so people can learn the history of what really happened in the left-wing political movement of the 1960's. But she discovered that recording her life in print was also a very therapeutic experience.
In a way, Hale has done in print something she once actually did in real life: relive the past. As she recalls in Radical Passions, "My fiftieth birthday party evolved into a ceremonial playback theatre, a life review I created to make sense of a half century of seemingly unconnected random events that brought me to the doorstep of cronehood. It was a life in four acts, the maiden, the rebel, the wife/mother, and the overt spiritual seeker . . . The four acts lasted four hours with a grand finale of me spinning under a tunnel of outstretched midwife hands that birthed me into the spring green sunshine of the adjacent yard."
Hale's book mainly focuses on two of those four acts: the roughly 20 years she lived in the midwest and northeast as a radical activist and the almost 20 years since that she has lived in this area, focusing more on personal spiritual growth. (See? Politics and religion!) It's a fascinating, somewhat episodic story that may leave you spinning as much as Kendall–like watching a homemade documentary filmed with a handheld camera. Hale was part of much of the tumult of the '60s. Student protests. Marches on Washington. She journeyed to Cuba, Nicaragua, even to China, trying to find a socialist utopia. She sang in a feminist women's singing group, The New Harmony Sisterhood Band. She worked seven years at factory or other blue-collar jobs (including two as a shipyard welder!) trying to organize worker unions. Kendall went through a free-love phase, a lesbian phase, a drug phase, a co-op living phase, and an anti-male phase ("Go struggle with your sexism!" she yells at one boyfriend.) At one point, she writes her parents from school, "Our People's Army will have to fight anyone who stands in our way. This means I could be face to face with you and have no choice but to shoot." ("I will not be coming home this summer," she adds.)
Kendall's political-activist decades were clearly intense, her dedication to social justice deep, her anger almost blazing. But she doesn't sugarcoat the experience. Instead, she's almost brutally honest. She readily admits how often her left-wing efforts against "the capitalist corporate enemy" failed. One factory union drive "imploded" because her group of organizers couldn't organize themselves. Another time, the Steering Committee of the Boston communist party sends her a "Dear Comrade" letter. ("My friends. I had been fired by my friends.") Her visits to foreign socialist utopias prove disillusioning. (She writes from China, "Once again my idealism is knocked flat.")
As harshly as Kendall sometimes criticizes her fellow leftists, though, she is always hardest on herself. Occasionally she's humorous. At her very first protest, against 2,000 National Guardsmen at the University of Wisconsin in 1968, she sees people raising their right fists and yelling, "Power to the People! Right On!" Kendall throws up her fist and shouts, "Power to the People! Right Arm!" At other times, her self-criticism is almost painful to read. She calls herself "toxic," "too-blunt"–even "a car wreck on two wheels."
In 1992, Kendall and her family move to Asheville to try co-housing, a chance at living "our socialist dream" on a personal level. It doesn't work out, but then she and husband Steve Norris move to a lovely piece of land in Fairview, and Kendall's focus shifts more to inner work than outer–namely, massage therapy and New Age spirituality. Kendall jumps into the latter with both feet. She meets people who see elves jump out of bushes and Jesus walk across a swimming pool. Ones who carry lizards on their body and let sows sleep on the sofa. She attends the Harmonic Convergence in Hawaii and the Pachamama Ceremony in Peru. She sets up prayer flags in India and builds sweat lodges in Fairview. Kendall is dubious of many of these "New Age wannabies," but she does find some moments–in sweat lodges, the beautiful outdoors, therapeutic massage, and a few peak experiences–that feel deep and authentic to her.
By the end of the book, it seems like Kendall has tried just about every new thing there is. What does she conclude? "Formulas and dogmas belong permanently under deleted messages," she decides, with the skepticism of experience. Still, she dreams that the future will hold a better socialism. And she concludes with, "I do know it is possible to find moments of personal peace like those Buddha found sitting under the Bo tree . . . I can promise you that."
I very much enjoyed reading Radical Passions. It's a fascinating saga, sometimes positive, sometimes painful, that makes you think about your own life choices. And I commend Kendall for how courageously she's worked at finding purpose in life and how open she is about what she's found.
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Love those colours….
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I keep coming across twenty-somethings who've tested positive then had either 'no symptoms' or a couple of days cough. When I ask those if it was like the flu, they reply it was more like 'a cold'. Different for different age-groups of course, but there's undoubtedly a high number of those who've had the virus but haven't been recorded as such. We are rapidly heading for endemic stage. Boosters will evolve to strain specificity, such as Pfizer's 'Omicron booster' currently in the works. Treatments for the 'illness' will also evolve and improve. Putting aside the inexplicable attitude toward vaccines by some (a fractional percentage in Australia, thankfully), and the developed world's greed-fuelled neglect of vulnerable countries, the global response to this pandemic is remarkable. Far from what it could be obviously, but compared to its obvious precedent, the Spanish Flu, remarkable nonetheless. All we need do now is redirect our vocational values system toward health and community (hospital staff on garbage wages are currently being slaughtered), and away from its frank obsession with 'wealth accumulation', and the future's looking bright.
Great stuff….would love to see a pic of it in situ. 👌
Last two in the triptych are underway….
Merry Christmas Demonland
Webber replied to Wrecker46's topic in Melbourne Demons
Watch the GF played over Kings College carols………appropriately divine.
two front teeth
You're very close dpositive. Very! Stay tuned….
They are. My print-makers are way until mid January, so after then. Just enough time to get the other two of the triptych underway and ready before season's start. Planning to make them available as a pair……for the completists 😉.
Great news ucanchoose…..the designed and the desired effect.
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Sounds great W11, will give it a listen.
For the sole reason that a delayed return usually indicates a problematic knee. That is, the return date is not by choice. The vast majority of the delays I've treated are caused by joint-surface trauma issues, not the graft, thus a compromised future. We discussed the article a bit at work when it came out, and noted the lack of commentary on this, but then again, that would need another study!). American Football is inherently hard to analyse because it is positionally based, meaning some field-positions will have very high incidence, others very low. I'm loathe to even compare the two.
There's always doubt, and there's always tinkering/improvising on existing protocols. Otherwise known as trial and error. Ask David Schwarz. The women's issue is troubling, and complicated. At the moment, their rate of ACL rupture is somewhere between 2 and 3 times that of men. There's a number of theories as to why, none of which dominate. Anatomical differences (thigh to lower leg angle, narrower notch at the bottom of the femur that's more likely to 'cut' the ACL in rotational activities), hormonal consequences (monthly ligamentous softening), developmental differences - are girls/women coming to the sport later less bodily 'attuned' or familiar with its bio-mechanical specifics? Current thinking is that it's likely a combination of all these factors. The industry is trying to find screening measures (being doing this for decades) to assess the likelihood of ACL injury, and specific training to lessen likelihood, but I suspect nothing will change until the women's game is made of girls/women who've all been playing from 'birth', like the men, and the ACL vulnerable are weeded out before they get to adult status. Even then, incidence will be higher. Do you then alter rules, etc to mitigate incidence, and how? Complicated. No, soccer doesn't have the same joint forces through the knee. Less game time = less running = less load. Less body contact (no tackling), less spiking joint forces (jumping, landing), and arguably less rotational repetition. Australian Football is unique in its lower limb demands, all of which makes it a perfect storm for the poor old knee.
Two problems with this. Australian Rules Football produces more ACL ruptures per playing hour per player than any football sport in the world. The reason rehab has been pushed from 9 to 12 months is not to reduce the risk of graft failure (it doesn't), but to lessen the incidence of general joint irritability on return to the game (which has to do with lingering joint surface trauma suffered during the injury that ruptured the ligament). It has done that. As I've said, there are surgeons who push more aggressive returns. I don't know who did Tommo's knee, but if he comes back 'early', I've got more than a fair idea.
Haven't seen or heard of it for ~ 5 years.
He wasn't doing full contact. Used to be 9 months turnaround (surgery to full match ready) for ACL recons, but the last few years we've been standardising full rehab 12 months, predominantly to avoid incidence of 'joint irritability'. Different surgeons have different ideas, but the vast majority now go with a 12 month protocol. Dispute it as you will, but if Tommo plays Round 1, it will be against trend.


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May 2013 New models of integrated health care management in nephrology
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Nefrología al Día
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Nefrología (English Edition)
Nefrología is the official publication of the Spanish Society of Nephrology. The Journal publishes articles on basic or clinical research relating to nephrology, arterial hypertension, dialysis and kidney transplants. It is governed by the peer review system and all original papers are subject to internal assessment and external reviews. The journal accepts submissions of articles in English and in Spanish languages. Nefrología follows the publication requirements of the International Committee of Medical Journal Editors (ICMJE) and the Committee on Publication Ethics (COPE).
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Vol. 33. Issue. 3.May 2013
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DOI: 10.3265/Nefrologia.pre2013.Feb.11638
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New models of integrated health care management in nephrology
Nuevos modelos de gestión de asistencia integral en nefrología
Rosa Ramosa, Manolo Molinab
a Fresenius Medical Care, Nephrocare España, Madrid,
b Servicio de Nefrología, Hospital Universitario Santa Lucía, Cartagena, Murcia,
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La enfermedad renal crónica (ERC) representa uno de los principales problemas de salud pública debido a los altos costes sociales y económicos tanto por su elevada prevalencia como por la morbimortalidad cardiovascular asociada. Existen suficientes evidencias que demuestran que la implementación de modelos de prevención y de seguimiento mejora la evolución y frena la progresión de la ERC reduciendo los costes al mismo tiempo que mejora o se mantiene la calidad en la atención. Se requieren, por tanto, nuevos modelos que manejen de forma integral todos los niveles de la ERC. Aunque existen diferentes modelos de reembolso por parte de las aseguradoras o los gobiernos, tradicionalmente el pago por servicios ha sido el utilizado en los centros de diálisis concertados pagándose por sesiones de diálisis y unos requerimientos mínimos de calidad. Este modelo comporta el riesgo de favorecer la sobreutilización e inducción a la demanda. Sin embargo, cuando se acerca el estadio final de la ERC (inicio de la diálisis), el manejo integral mediante una tarifa comprensiva ofrece ventajas basadas en un principio de equidad, calidad y sostenibilidad. El reembolso se realiza a través de un pago único y completo de un paquete asistencial que cubre los servicios que se han definido previamente. La tarifa se estima con base en la utilización previa de recursos, sin tener en cuenta la prevalencia de la enfermedad. Un tercer modelo es la capitación. Esta ofrece a los proveedores una cantidad fija de dinero para proporcionar servicios a una determinada población durante un tiempo determinado teniendo en cuenta la prevalencia e independientemente del volumen de los servicios consumidos de forma individual. Para evitar la asignación incorrecta de los servicios y productos inducida por incentivos en contención de costes, se establecen requisitos mínimos de calidad de servicio. En nuestra opinión, el modelo de tarifa integral significa una tendencia hacia una mejor coordinación de los servicios concertados en la ERC estadio 5, siendo la financiación capitativa uno de los pilares para fomentar la integración de proveedores y la articulación entre niveles asistenciales.
Sistemas de reembolso
Enfermedad renal crónica
Chronic kidney disease (CKD) is becoming a worldwide major public health problem that is rapidly approaching epidemic proportions due to its high prevalence, as well as the associated increase of cardiovascular morbidity and mortality in these patients. Early detection and prevention may have an impact on both slowing the progression of CKD and reducing cardiovascular morbidity and mortality. CKD prevention programmes can be more cost-efficient over time without negative impacts on quality of care. Until now, reimbursement in CKD has been segmented and usually focused on the end of the process (dialysis) when cost is higher, whereas new models focused on provider integration, while balancing quality and costs, are needed to respond to today's challenges. Traditionally, "pay for services" has been used in state-assisted dialysis centres, but this model has the risk of inducing an increase in demand. Integrated management would respond to this challenge with comprehensive solutions that manage kidney disease at all levels of health care risk. It is based on a comprehensive model that typically includes several products and services, often including pharmacological treatments. The rate of reimbursement directly depends on the achievement of previously defined quality control parameters. The third model is based on a "capitation" model that consists of the provider receiving a set amount of resources per population for a particular time regardless of the volume of services provided. The complexity and the progressive nature of CKD along with the associated morbidity rates in these patients force us to consider a global approach rather than a sum of different services. In our opinion, the first method of reimbursement in CKD that should be considered is a bundle rate, and when this model has been consolidated, tending toward a global capitation model.
Reimbursement systems
Our health system is currently facing a crisis. This would appear unlikely when taking into account the extensive efforts made by health care professionals in many different aspects, such as genomic medicine, regenerative medicine, and evidence-based medicine. However, costs continue to rise rapidly, primarily due to demographic changes in the form of a progressively aging population and an increase in the prevalence of chronic diseases, while new technologies and treatments are constantly being developed and put into practice.
One of the circumstances that have provoked this change in the medical care has been the growing incidence of chronic diseases and their impacts. Currently, chronic diseases are responsible for 60% of the 58 million deaths per year worldwide, representing a significant economic cost to society.1 This means that approximately 80% of health care resources in developed nations are used for fulfilling the needs of patients with chronic diseases.2
In Spain, it has been more than two decades since experts foresaw coming issues within the National Health System, and a commission was established to evaluate these problems and elaborate possible solutions.3 The general objectives of this commission were4:
A progressive introduction of the separation of funding and acquisition of health services (public), and of the functions of health care management and provision (public and private).
Replacement of the concept of comprehensive health care for one based on the functions of health care authorities and functions based on services provided, with collaboration with the private sector.
Increased flexibility among health care personnel, that is, a modification of the current regulatory framework that determines employee conditions (respecting worker's rights).
Approval of a new legal framework that would allow for certain hospitals and other health care institutions to become state-governed societies with financial and property autonomy subject to private law.
Only a few of these goals have been put into practice during the last two decades, and studies examining this issue have predicted that the current system will become unsustainable by the year 2015 if new models are not established and adopted.5
In this article, we sought to discuss the different models proposed for comprehensive health care for patients with chronic kidney disease (CKD) that attempt to establish a balance between quality of services provided and costs incurred.
CKD represents one of the main public health issues in modern society, both due to its high prevalence and the important associated cardiovascular morbidity and mortality rates, with all of the social and economic costs that this implies.
In 2008, the United States spent 23 billion dollars in the treatment of advanced CKD (ACKD), which represents 7.4% of that country's health care budget, yet is applicable to only 1.1% of the population.6,7 In 2010, more than 48,000 individuals in our country were on renal replacement therapy (RRT), a statistic that has continued to grow during the last decade due to a progressively aging population and an increase in the prevalence of other chronic diseases, such as diabetes mellitus. The treatment of CKD (0.1% of the population) consumes 2.5% of the Spanish National Health System budget.8 This staggering value has generated widespread doubts about the long-term sustainability of RRT,8-10 as well as a proliferation of articles concerning the costs incurred by different modalities of dialysis.8,10-12 Our group carried out one study13 in patients on haemodialysis that resulted in a mean cost surpassing 40,000 Euros per patient per year.
However, we must keep in mind that CKD is a progressive and irreversible disease in which the patient passes through different phases, RRT constituting the final stage only reached by a small proportion of patients with CKD. However, a large percentage of patients do not reach the stage of RRT, primarily due to cardiovascular mortality.14
With this in mind, CKD represents an ideal scenario for the creation of an integrated health care management plan involving models for the comprehensive treatment of all stages of CKD in the at-risk population.
Such a plan has the potential to act upon different risk levels which are represented graphically in the following figures adapted from Theodore F. Hatch (Figure 1 and Figure 2).
Why is an integrated health care model necessary?
There are several different reasons why integrated health care management is particularly suited for the case of CKD: 1) multiple sources of comorbidity in this population require improved coordination of health care and specific plans for controlling diabetes and cardiovascular disease, 2) high rates of hospitalisation and mortality, which could be reduced with improved outpatient care and prevention-oriented medicine, 3) numerous health care techniques and processes have demonstrated improved clinical results for these patients, and 4) the disproportionately high health care costs for the relatively small population with CKD.15
Several different strategies have been proposed for reducing health care costs in these patients, but options are usually considered individually due to the impacts derived from social barriers,16-18 in addition to the fact that ACKD has traditionally been treated in a segmented and fragmented manner, particularly in end stages, when the risk of high usage of available health care resources is maximum. In order to face the current challenge presented to the provision of health care in our country, we must adopt a comprehensive approach that cares for patients of all three risk levels while achieving an appropriate balance between quality and costs.19 This process must also integrate the entire spectrum of health care provided to patients with kidney disease, ranging from prevention to the management of patients in late stages of disease development.20
Sufficient evidence already exists to demonstrate that the implementation of prevention and follow-up strategies achieves a slower progression of CKD and cost reduction,16,18,21,22 while the quality of health care provided is maintained or even improved. In order to achieve these positive changes, our efforts must be directed towards changing the management and treatment strategies applied to these pathologies.23
Palmer et al.24 demonstrated that a yearly screening programme applied in primary care for the early detection of nephropathies in hypertensive patients with type II diabetes mellitus, based on determining microalbuminuria rates using semiquantitative rapid strip tests, followed by early treatment with nephroprotective drugs (angiotensin receptor blockers) for patients diagnosed with nephropathies, yields improved long-term clinical results in exchange for a minimal initial economic cost.
In addition to obtaining beneficial results for the cost-effectiveness of treatment of diabetic patients, these screening programmes should be applied to hypertensive and elderly patients as well.23,25,26
It is equally important to integrate the patients themselves into the process of managing the progression of their pathology with education and training. Wingard et al.17 observed how the application of a structured programme involving educational strategies for incident patients on haemodialysis, along with an exhaustive effort on the part of health care personnel during the first three months that the patient is on RRT in various specific areas of clinical care, such as control of anaemia, adequate dialysis dosage, nutrition, reduced catheter use, review of medicines prescribed, logistic support, and psychosocial evaluation with appropriate referral to social services, resulted in a significant improvement in rates of hospitalisation and reduced mortality.
Another point of emphasis is the advantages derived from early referral of these patients to a nephrologist. The majority of the results reported from early referrals to nephrologists are based on retrospective studies, with little evidence available based on prospective studies due to the possible ethical conflicts, and yet a systematic review found that inferior results were produced in terms of mortality and length of hospitalisation in patients who were referred to nephrology later in the progression of their disease.27 McLaughlin et al.28 evaluated the economic impacts of early referral (patient creatinine clearance rate = 20ml/min) as compared to late referral using a decision tree (Markov model), observing that early referral resulted in decreased costs, improved survival, a longer interval of life free of RRT, and reduced duration of hospitalisation.
Several different reimbursement models for medical services are used by insurance providers and governments. Table 1 summarises the basic differences between them.
Payment for services is a variable method that assigns resources to the provider based on the amount of services or medical interventions provided. This method may generate incentives for increasing the number of interventions or services provided in order for the provider to receive a greater economic compensation, thus risking over-use of medical resources and over-induction of demand.29 To date, this has been the most common method applied in dialysis centres. Health care authorities pay the provider for the health care services provided, in this case based on the number of dialysis sessions, under minimal quality requirements.
However, in public hospitals, reimbursements generally form only part of the annual budget, which is primarily based on an analysis of budgets from previous years and that, although it can be adjusted based on indicators such as increased prices of goods and services, tends to remain fairly stable and does not allow for a reassignment of resources among different categories of health care services.
A capitation model, in contrast, offers providers a fixed quantity of economic resources based on the provision of services to a predetermined population during a fixed time period, regardless of the volume of services/goods consumed by individual patients. The definition of the different components related to treatment and quality requirements can vary widely.
The capitation model is based on three crucial elements:
Payments are linked directly to the inhabitants for whom each institution is responsible, that is to say, the money follows the patient.
Services are paid for in advance; as such, the capitation model is a prospective method of reimbursing the provider.
The health care provider who receives payments under the capitation model may enter into a situation of financial risk if expenses surpass payments, and as such, providers are influenced by incentives to promote thrifty management of health care resources.
This mechanism shifts the economic responsibility of controlling the provision of services within the system to the provider, thus facilitating improved efficiency throughout the fiscal period and fostering preventative measures, improved continuity of health care provided, and a lower consumption of available resources.30
Evidently, the capitation model can be considered as a cost-reducing strategy, thus maximising the profit-based feasibility of the provider business model, although it has the potential for negatively impacting the quality of health care provided. In order to avoid the inappropriate assignment of health care goods and services induced by this incentive, reimbursement models tend to define quality requirements and adopt one of the two following options: fines and punishments applied to institutions that do not comply with quality requirements, or a direct correlation of reimbursement quantities with treatment results.
As such, prospective capitation models strongly promote the following health care policy objectives31:
Increased participation and coordination among health care service providers in the elaboration of clinical strategies, shared referral protocols, and allocation of resources among the different levels of health care.
Improved coordination of services provided among primary, secondary, and tertiary levels of the National Health System.
Increased access to health care and greater freedom of choice among different providers for the consumer, while restricting doctor shopping, which has the potential to produce an excessive demand in terms of doctor visits, tests, and prescriptions.
Increased professional and economic satisfaction for health care providers.
Increased cost-efficiency in the health care sector.
In the final stages of CKD, when RRT become necessary, integrated health care management based on a comprehensive fee system could offer major advantages based on three basic principles:
Principle of equality
The patient should be free to choose the modality of RRT preferred, within the context of a consensus between the patient and health care professionals (nephrologists, nursing staff, psychologists, and social workers). We have shown how the incorporation of a specific consultation for ACKD into our gamut of health services has contributed notably to facilitating freedom of choice for the patient, with a resulting increase in the rate of patients' choosing home techniques both in the incident and prevalent population. In this context, the model facilitates state support not just of haemodialysis, but also of any home dialysis technique that the patient might choose.
The nephrologist in charge of the patient will be responsible for giving advice regarding the optimal technique for each particular situation, taking into account both clinical and social factors. In this manner, the patient is free to choose between manual and automated peritoneal dialysis, or from any one of the various haemodialysis options available (low-flux, high-flux, haemodiafiltration, etc.), accompanied by a signed informed consent form. It is common for this effort to be made in hospital care, but this is not always the case for state-assisted patients in real-life situations.
In 2004,32 in the Region of Murcia, reimbursement for using special techniques was granted for the first time (on-line haemodiafiltration and frequent haemodialysis) in state-assisted patients (as many as 20% of all patients). Other autonomous communities followed suit, generating enormous differences in treatments provided between the different geographic regions of Spain.
The new model guarantees the eligibility of all possible treatment options in 100% of cases, both in terms of the type of technique applied and the frequency and number of sessions, thus eliminating any differences between hospital dialysis and dialysis in state-assisted centres in terms of equal access.
Principle of quality
The Cartagena model33 incorporates several novel aspects in terms of traditional dialysis regimens, such as the participation of public nephrologists in state-supported health care and the creation of an oversight committee that will evaluate compliance with each of the established protocols on a trimester basis. This committee is composed of representatives from the Murcia health department, the hospital, the contractor, and the patient association (Association for the Assistance of Renal Patients).
The group of quality indicators includes two components with major impact on vascular access points, one of the biggest issues in modern nephrology. Recently, major differences (52.7%-82.6%) were reported among the different autonomous communities in terms of the percentage of state-assisted patients with an autologous fistula.34 In the current treatment model, the contractor has committed to ensuring that more than 80% of patients on haemodialysis have an autologous or heterologous fistula at any given moment.
In this same manner, a commitment has been made to ensure that 95% of all patients should have a definitive access point within a maximum deadline of 15 days.
Principle of sustainability
The new model35 utilises a fixed cost per patient for each modality of dialysis, with no hidden fees or other surprises for the individual who pays for the health care services, incorporating financial penalties in the case of non-compliance with quality indicators, especially in cases of the greatest economic impact, which can lead to a cessation of the state-assisted health care agreement in the case of recurrent or particularly severe non-compliance.
The final goal is a responsible health care system throughout the entire process, introducing the concept of economic responsibility in the management of all contractors involved. In this manner, compliance with the previously mentioned quality indicators regarding vascular access points would reduce the number of patients who start RRT with a temporary catheter, as well as the global number of catheters placed, with substantial impacts in terms of reducing indirect costs and morbidity/mortality rates.36,37 In health care partnerships in which the contractor assumes the responsibility of the vascular access point, the recommendation should be made, based on national and international guidelines, that the patient be referred by the hospital in stage 4 CKD (glomerular filtration rate: 20-30ml/min) in order to ensure sufficient time for establishing and maturing the vascular access (4-6 months prior to inclusion in a haemodialysis programme in the case of an autologous arteriovenous fistula, and 4-6 weeks for prosthetic fistulas).38
The combination of all of these elements of equality, quality, and sustainability define the Cartagena model of integrated health care, under the concept shared with De Francisco9 that efficiency cannot be prioritised at the expense of quality in the health care provided.
To conclude, we need imaginative responses for dealing with the double threat facing the public health care system in the form of the economic crisis and increasing prevalence of chronic diseases that consume large quantities of health care resources. We should search for strategies for early detection and prevention of CKD, as well as secondary prevention measures for progression towards advanced chronic kidney disease, since both processes would have considerable economic impacts on the budget available for health care. In this article, we have reviewed some of the public-private collaboration models that can be applied to the situation of CKD and RRT, which in our opinion do not contradict with, but rather provide an opportunity for collaboration with other initiatives for improving the quality of health care services provided, such as clinical management models that demand efficiency among health care professionals. In the first stage of implementation, the integrated Cartagena model of reimbursements could signify a tendency towards improved coordination among health care partnerships responsible for treating stage 5 CKD. After this process yields an appropriate framework for improved collaboration, the capitation financial model could come to constitute an optimal regulatory pillar for the development of integrated services from health care providers and coordination between the various levels of the health care system.
The authors declare that they have no conflicts of interest related to the contents of this article.
Table 1. Differences between the different models of reimbursement for medical services
Figure 1. Level of severity/degree of costs
Figure 2. Level of severity/type of intervention/degree of costs
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Dr. Jacob completed a Geriatric psychiatry post- doctoral fellowship program from Division of Geriatric Psychiatry and Neuropsychiatry at Johns Hopkins University School of Medicine, Baltimore in Maryland in 2013. He completed a residency in psychiatry from University of Miami Miller School of Medicine & Jackson memorial Hospital. Prior to his training in psychiatry he completed a residency in general internal medicine and practiced as an internist in India.
Dr. Jacob is available by appointment for psychiatric consultation for second opinions for psychiatric medications, psychotherapy and additional treatment approaches to formulate a treatment plan. We also perform chart reviews, assessing testamentary capacity and answer clinical questions related to psychiatric diagnostic formulation. Our evaluation is usually a one- time consultation with recommendations for primary care providers.
Our goal is to encourage practice of personalized medicine directed to address uniqueness of every individual. Referral from primary care provider is required in addition to bringing all available medical records including lab work up and imaging results from last 2years. An ongoing primary care provider for medications and therapist or counselor is recommended to address needs such as individual or group psychotherapy. We welcome research opportunities in mental health, psychiatry and behavioral medicine.
Dr. Jacob is practicing Psychiatry in SWFL since 2008. He is board certified in sub-specialty of geriatric psychiatry and specialty of adult psychiatry by American board of Psychiatry and Neurology. Dr. Jacob is also board certified in Addiction Medicine by American board of Addiction Medicine. He is a fellow of American Psychiatric Association and a member of American Psychiatric Association and Florida Psychiatric Society.
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