CEO of a major hospital:We are going to be buying up GP practices, cardiologists and orthopaedic surgeons and other specialists. We then make sure that the GPs perform enough unnecessary tests and procedures or by admitting patients who do not need a hospital stay. There is no better time to make money as people are worried about their health.
Q: Why are you buying the specialists.
A: Because there is a shortage and these doctors are proud of what they can do. Just look at in flight magazine and they list all these top specialists around the US. Pride! Pride! Pride! This way we can control the fees for our own patients and charge the government or other insurers whatever fee we like.
Q: Some examples?
A: Colonoscopy is now three time what it used to be.
Laser eye surgery, $738 when performed by a hospital-employed doctor, compared with $389 when done by an unaffiliated doctor.
EKG:$319, versus $143
Q: What about hospital admissions?
A: For our own patients, doctor gets $5000 bonus if they are not admitted for more than 3 days and for the ones we charge other insurers or government, $5000 deducted if patient is not admitted. Q:What about long term. A: By having nearly all or most of the doctors, the others will eventually join us like with Kaiser Permenante. We then can control the total cost but still make money from the government.
Q: What if nurses whistle-blow on us?
A: Sacked on the spot.
CEO: Doctors are now the hottest commodity. Our life is in their hands so to speak and the sooner we control them the better. They are now enjoying a good salary, some with performance bonuses and the administration headaches we take care of. The best money though is government money, be it Medicare or Medicaid. By controlling hospitals and doctors, the government will have to go along with our price structure. We are money experts. We know what we do. We let the doctors treat (on our terms).
For decades, doctors in picturesqueBoise,Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.
The New Way
But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.
Today,Boiseis a medical battleground.
A little more than half of the 1,400 doctors in southwesternIdahoare employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.
Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit. In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.
Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe increasing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.
Pumping Up Admissions: in reality!
According to two emergency room doctors who worked atCarlisleRegionalMedicalCenterin southernPennsylvania, the message could not have been clearer: more patients needed to be admitted.
The doctors were employed by EmCare, whose parent companywas later acquiredby the private equity firm Clayton, Dubilier & Rice in 2011 as part of a $3.2 billion deal. EmCare, in turn, was under contract to provide emergency room doctors for the hospital, which is owned by Health Management Associates. In interviews, doctors said that hospital administrators created targets for how many patients they should admit. More admissions translated into more dollars for the hospital.
Dr. Jean-Paul Romes, one of the physicians, recalled getting phone calls in the middle of the night questioning why he had not admitted an older patient whose hospitalization he could easily have justified. “The pressure to admit was so high,” he said. Dr. Romes left the hospital last year.
After another physician, Dr. Cloyd B. Gatrell, raised concerns that the hospital had too few nurses to keep patients safe, an EmCare executive warned him to “back off,” according to a lawsuit Dr. Gatrell filed last year. EmCare later fired him atCarlisle’s request, according to the suit. Dr. Gatrell’s wife, Kathryn, a nurse atCarlisle, had been fired earlier and also filed a lawsuit. Both Gatrells maintained they were fired for bringing up patient safety concerns, according to Dr. Gatrell’s lawsuit.
The side effect of the New NHS HSC Act with all the CCGs is that it would no longer matter if Foundation Trusts are private or not. Before long most specialists would only offer their expert services via private organisations. Why else are the Private Health Organisations hovering around!!! My reading is that the CCGs owned by Privateers will be doing what I suspected a long time ago:direct cases to their hospitals.
Chris Ham"May I add something briefly? The big question is not whether GP commissioners need expert advice or patient input or other sources of information. The big problem that we have had over the past 20 years, in successive attempts to apply market principles in the NHS, has been the fundamental weakness of commissioning, whether done by managers or GPs, and whether it has been fundholding or total purchasing."
“………The barriers include government policies that risk further fragmenting care rather than supporting closer integration. Particularly important in this respect are NHS Foundation Trusts based on acute hospitals only, the system of payment by results that rewards additional hospital activity, and practice based commissioning that, in the wrong hands, could accentuate instead of reduce divisions between primary and secondary care.”
It's no secret that factory farms use unconscionable amounts of antibiotics when fattening up animals for market. In Germany, however, veterinarians play a crucial role in the abuse. Many are getting rich in the process, but the risks to both human and animals are many. They had sold huge quantities of drugs, some of which were not approved, and dispensed dozers of liters of medications to animals to which they should never have been administered. Investigators with the public prosecutor's office in the western city of Wiesbaden called the operation a "pharmacy on wheels." Antibiotics were allegedly stored on pallets. A former employee told investigators at the time that the veterinary clinic was essentially a mail-order operation for drugs, and that the pharmaceutical industry had expressed its gratitude by giving the clinic huge discounts.
"Some veterinarians' profit margins are bigger than those of cocaine dealers," says Nicki Schirm, who has been a veterinarian in the state of Hesse for more than 25 years. When a veterinarian finds a sick chick among 20,000 other chicks, he treats the discovery as justification to preventively treat the entire flock with antibiotics, says Rupert Ebner, a veterinarian from the Bavarian city of Ingolstadt. "Nowadays, flock or herd health monitoring is the code name for the generous administration of drugs," says Ebner. In many cases, he adds, fake diagnoses are used to provide a justification for the use of antibiotics.
In large veterinary practices, profits from the sale of drugs can account for up to 80 percent of revenues. This is mainly due to the volume discounts offered by the pharmaceutical industry and the sweet privilege known as the right to dispense -- a special provision for the pharmaceutical monopoly. For more than 150 years, veterinarians have been allowed to both prescribe and sell medications -- with almost no supervision whatsoever.
But this could change. Veterinarians have come into the political firing line after testing of animal populations in the western states of Lower Saxony and North Rhine-Westphalia revealed the large-scale presence of antibiotics. In North Rhine-Westphalia, Green Party Environment Minister Johannes Remmel ordered the testing of 182 flocks on commercial chicken farms. More than 90 percent of the animals had been treated with antibiotics, many multiple times, so that they were essentially being fed a constant diet of drugs. Others were given the medications for only one or two days, which isn't long enough and is in violation of the conditions for licensing the drugs. Such results raise suspicions that the drugs were being used to guarantee the success of the poultry fattening operation rather than to fight disease.
Both farmers and veterinarians are now under suspicion, prompting Agriculture Minister Ilse Aigner to push for a tightening of Germany's Pharmaceutical Products Act and a "careful review" of veterinarians' right to dispense drugs. Scale: Some 900 tons of antibiotics were fed to animals in Germany in 2010. This is 116 tons more than in 2005, and more than three times as much as the entire German population takes annually. Pharmaceutical producers were required to report their 2011 sales of veterinary drugs by the end of March. A number of companies did not comply, prompting the Federal Office of Consumer Protection and Food Safety to request the information in writing.
Even though there are fewer than 5 million pigs in the UK, and over 33million sheep, it is worth noting that according official figures pig farmingaccounts for approximately 60% of all UK farm antibiotic use, and sheepfarming for less than 0.3% This means that use per animal is about 1,500times higher in pig farming than it is in sheep farming. Although sheep andpigs are not directly comparable these statistics help to illustrate the factthat even though the use of some antibiotics on farms has now beenbanned many producers have simply switched to others and overallantibiotic use remains very high.
Although the use of antibiotics for growth promotion has now been bannedin all EU countries, many of the antibiotics still used as growth promoters inpigs in the US (such as tetracycline, penicillin and tylosin) remain availableas feed additives for prophylactic use in the UK at growth promoting rates,as long as a veterinary prescription is obtained.
There aren’t many operas that manage to kill off all the principal characters by the end (although many have a good stab at it). But that’s what happens inTosca– and wonderfully too with one knifing, one firing squad and a sudden suicidal leap. Of the many explanations given about why it has become one of the most loved and watched of all operas, the appeal of the story must be a major one.
Execution in Tosca, ROH Photo
It is arguably one of the best known of Puccini and of all operas. I may have a preference for Turandot or Boheme, but that is entirely personal.
Sadly, I am reminded of the same tactics used for the privatization of the NHS.
However, the privatisation debate has now been reignited by revelations about section 75 of the act and the associated statutory instruments(SI 257 regulations) making their way through parliament. The regulations are aimed at making competitive tendering compulsory for clinical commissioning groups (CCGs), except in emergencies. At a stroke, they inject competition into the NHS and enable the market to decide how services are provided. Thus the reassurances ministers gave about clinicians and local people having control of how services are commissioned look set to be overturned. Private providers will gain rights under EU competition law, which will make it virtually impossible to stop them encroaching into the NHS market.
Previous promise was not kept:
In the face of public and professional opposition to Lansley's bill, coalition MPs and peers eventually passed the legislation only after receiving reassurances from senior ministers that there would be no NHS privatisation, anda focus on integration of services rather than competition.
But the bill went through and with the emphasis on competition from the private providers, the already stressed NHS hospitals will indeed fail and those that did not will have to cut back on services to support those that failed. In fact the PFI scheme is indeed one of the main reason for financial failures. Centrally imposed targets were the cause of clinical and patient care failures.
We may indeed forget that whether private or public, for now they will be the same doctors until of course most of the NHS consultants decide to give up the much degraded NHS.
The Cockroach Catcher felt that a number of people made what appeared to be strong views against the dismantling of our beloved NHS; that they did so knowing that these protestations may satisfy the public, remembering that in the Markets of old, fake customers would be there to lure real ones.
To me the same people are making noises that will I am sure have no impact on S75.
Many have protested about this broken promise. Lib Dem MPs Norman Lamb and Andrew George have raised serious concerns in the Commons. The Conservative MP Dr Sarah Wollaston has asked for it to be referred to the health select committee. The Labour party iscalling for an early day motionand has Lib Dem support. …..EvenDr Michael Dixonof NHSAlliance, who was one of Lansley's key allies in helping to get the bill to royal assent, hascome out against these new regulations.
So people like Sir Terence Stephenson (leader of the Paediatricians) should have listened to the likes of Clare Gerada (leader of the GPs) rather than now telling Tories/Rich Men what they should do. It makes me very sad that people of the intelligence of Sir Terence trusted the Government to protect the NHS. He was utterly naive in this. I return to work, doing the last 2 months of my career, to a service that I have worked in for 38 years without any break, to see it gradually falling apart. No amount of wailing from Sir Terence-like people or the absurd Dr Michael Dixon will undo the damage they have helped usher in.
Dr Michael Dixonwas the medical director of The Prince's Foundation for Integrated Health, which closed in 2010 after its finance director was arrested for stealing £253,000 from the organisation.Dixonis a director of theCollegeofMedicinewhich opened in 2010. He has been criticised by professor of complementary medicine and alternative medicine campaigner Edzard Ernst for advocating the use of complementary medicine. Ernst said that the stance of the NHSAllianceon complementary medicine was "misleading to the degree of being irresponsible." Wikipedia
He was not born yesterday!
Tosca got a written promise of a faked execution of her love one by agreeing to sexual favours but had the wisdom to kill the one who signed the order just in case. In the end the fake execution was real and she committed suicide.
A seven-week-old baby with a suspected respiratory infection died in November after repeated calls to the service over several days, during which it is alleged to have failed to follow protocols in key areas. Sources with knowledge of the case say they fear a four-hour wait for a doctor to see the baby at a Harmoni-run clinic at the Whittington hospital inLondonon the Saturday he died may have contributed to the tragedy.
Harmoni, which has contracts covering 8 million patients across large areas of London and southern England, is also alleged to have manipulated its performance data, masking delays in seeing patients and other missed targets.
One fellow blogger ( Dr No)wrote asking how the NHS could be modeled on The Mayo Clinic. That got me thinking.
No apologies for re-printing the posting.
It is of course always easier to criticise and my goodness we bloggers have and for good reasons. We loved the principles of our NHS.
My fellow blogger was right, sooner or later we have to come up with an alternative model.
I will quote from my letter back to him:
My view after studying Mayo and also Kaiser Permanente is that these two organisations avoided some of the major pitfalls that have gradually eroded a once great health care provider in the world: The NHS.
Those amongst readers that were trained in this country may not realise that we from Hong Kong would come over to the UK for specialist training. It was for a long time the only way to become a consultant or senior lecturer/professor in Hong Kong. This was despite the weather, yes the weather!!! We indeed were very well trained. Even when we started to have our local specialist training in our teaching hospitals many would still prefer to come over here. Training here gives them an edge so to speak. The US is the other obvious destination but often the ones that went over there stayed there. I stayed in England for the rich culture this country have: opera, concerts, theatres and museum. Major hospitals here are world famous and they were truly the crown jewels. Foundation Trust approach is seen by many as selling off such treasures.
There were principles of the Mayo Model that was the NHS model of old.
An Egalitarian Culture.
Similar to Mayo, in the NHS, consultant pay peaked after a few years and then there was only the Distinction Awards (or equivalent) to look forward to. If we ignore private income for now, all disciplines are paid the same and it allows for a fairly nice and attractive prospect for new doctors to enter whichever specialty. Currently some specialty such as psychiatry is struggling and chances are private providers will be the norm. I hate to think that it will be the repeat of OOH service with poorly qualified doctors providing inferior care. There may be regulators but what good are they after the event.
In health care, death is irreversible.
No doubt the pay at Mayo is much better but not to the level of others in California or New York. Interestingly in Maine many doctors want to be salaried paid (more women doctors: children, holiday, insurance etc).
The internal market has its advantages but the pitfalls are more than its worth. If reform is about better patient care then it is definitely the wrong way as it encourages distortion of good and efficient healthcare.
Mayo did well without it and we could as well. In fact we used to. Such a perverse system has caused a rift between primary and secondary care and is not helpful.
Many argued that it was there to pave the way for partial privatisation. I cannot honestly provide any counter argument. Why waste so much effort for so little return.
The only other possibility is that it is a covert form of rationing and soon not so covert but it would be done by your trusted family doctors, the GPs. It is the shifting of blame.
It has also been argued by those that promote privately controlled consortia that GPs stand to make lots of money. This could be directly from the total health budget or through some financial wizardry on the Stock Market. Remember Four Seasons, Qatar and RBS (our money) buy back?
The Royal Bank ofScotland, the biggest debt provider in a lending syndicate of more than 100, has agreed along with other senior lenders to cut the debts of the embattled Four Seasons by more than 50pc to £780m.
So primary care tried to save money and secondary care, for survival tried to extract as much as they could. Patients lose out in the process. It also encourages gross distortion of service at the hospital end and if allowed to continue leads to unholy “gaming” strategies.
On the other hand it is also very easy for some hospitals to fail and be gobbled up by privateers whose interest would be that of the money making specialties and not those that cannot be nicely packaged.
Patients come first:
A friend’s wife consulted me for a second opinion about her cardiac condition as her doctor husband has passed away a few years back. I am no cardiologist so I wrote to my cardiologist classmates (two in Hong Kong and one in the US) and within hours I had three very useful answers: all free. In our new NHS such consultations would have to be paid for. Sad really.
Mayo cross consult bottom to top and top to bottom as well. Who knows the bright young things might really be bright young things (quoted in one of my blogs).
Virtually all Mayo employees are salaried with no incentive payments, separating the number of patients seen or procedures performed from personal gain. That was how it was in our NHS hospitals. Payment for performance encourages gaming.
This sound perverse and is very much against the bonus culture. But remember such culture saw the collapse of the US financial system and ours and a few other EU countries including France.
The NHS of old was plagued by a covert two tier system that led to unjustified waiting lists and I do not have a quick answer except to say that paying a better salary is one and the other is a complete separation of private and public health. A limit of 10% if well monitored may work as well as close scrutiny of common waiting time.
My fellow blogger pointed out that we may need to keep that as a safety valve and I would agree.
How else could we have a fully integrated system unless we do away with competition and the internal market and indeed private providers? The difficulty is that some of the private providers are already “in”. There is little doubt that in the long term we would be paying over the odds for what they provide and if not they will abandon what they do. Business is business.
Too Big: we cannot run the whole NHS as one Mayo Clinic.
I do not dispute that.
The solution is to regionalise the NHS. We did not have many Child & Adolescent Inpatient Units in the country and the two I used to run (one for children and one for adolescent) accepted referrals from three counties in the south of England.
Regionalisation is therefore the way forward and there is no doubt that given our small country it is better to have major centres of excellence run on the Mayo, Cleveland and even the Kaiser model.
Like Mayo Clinic, our NHS could have a seamless health care with no artificial obstacle on referral to hospital consultants or admission or to specialised treatment.
“The best interest of the patient is the only interest to be considered.”
If he is honest, he hasn’t read every line himself. Instead, he suggests you consider one core question:why is the Secretary of State so determined to remove his duty to provide, or secure the provision of, a free at the point of delivery comprehensive health service? Once you have the answer to that one, the rest falls readily into place, and the nuclear option at the heart of the Bill lies plain for all to see.
I suppose in life, it is lucky to have school friends that might one day save your life.
No, it is not about money.
I suppose without sounding racist, it helps if you are Jewish, went to a Jewish school as you are likely to have school friends who are good doctors.
As they say, God works in mysteriously ways!
I was in the middle of some Scandinavian Fjord on a cruise when I came across a book called Open Heart. Yes, old habits die hard and I still find myself drawn to books about medicine or other people’s medical stories.
It is peculiar that the commonest diagnosis the average punter, sorry patient is going to hear from their doctor is:
Yes: It’s viral.
Well, remembering my biology, these creatures are smaller than bacteria and is not really easy to cultivate.
Or is it just a way of saying to the punter/patient, go home and do not ask for the antibiotic.
Now, it may well be OK if it were a simple cough. But what if you were told it is aviral cardiomyopathy?
Now, this is getting serious.
Yet this is what happened and it happened to Jay Neugeboren
after some investigations by two doctors, one a cardiologist.
About Jay Neugeboren:
Did he smoke? No!
Was he overweight? No! 5’7 150lb.
Did he exercise? Yes, swims a mile every day and plays tennis full court basketball regularly.
He must have a high cholesterol or BP or family history, it just is not right: No, he had no family history of heart disease, and had normal blood pressure, and better-than-normal levels of cholesterol (both 'good' and 'bad').
“I had, however, for two months prior to the surgery, been concerned about some shortness of breath I experienced, if intermittently, while swimming, and by an unfamiliar, sporadic pain -- more like a burning sensation -- in my back, between my shoulder blades. When my family doctor suggested I have a check-up with a cardiologist, the cardiologist performed an echo-cardiogram and diagnosed'a viral cardiomyopathy.'But he saw no urgency in my situation.”
Call his friend 3000 miles away:
At the same time, I had been talking regularly with a childhood friend, Richard Helfant, who was a cardiologist in Los Angeles, and had been Chief of Cardiology at Cedars-Sinai Hospital in Los Angeles. When I told him of the viral cardiomyopathy diagnosis, he shouted into the phone, "It's not viral, goddamnit-- I want you in the hospital as soon as possible."
So, to cut the long story short, a health New York Times author of some 20 books with no family history of heart disease, a better than normal cholesterol level non smoking 1 mile swimmer that would have been classed as healthy by NICE standards had at the age of 60 --had two of his three major coronary arteries turned out to be 100% shut down, and the third major artery, the LAD (Left Anterior Descending Artery, the so-called 'widow-maker') was more than 95% shut down.
His life was saved by emergency quintuple bypass surgery.
What went wrong or what went right?
His childhood friend had made an accurate diagnosis from 3000 miles away because he knew his friend and thus could place his specific symptoms in the context of his full story. What the cardiologist who had misdiagnosed him had done was to pay more attention to tests and numbers and, thus, to forget about the pain between his shoulder blades, which symptom -- referred pain from the heart -- was inconsistent with a diagnosis of viral cardiomyopathy.
His operation took six and half hours at Yale, New Haven Hospital: Medicine at its best and that was over 13 years ago.
It is also not comforting that a study in 1997 of 453 residents in internal medicine and family practice revealed that they failed to identify the distinctive sounds of common heart abnormalities with a stethoscope 80 percent of the time. True, using a stethoscope, listening to the patient and taking a careful history may not be the only ways to accurately diagnose heart disease. But in the words of Dr. Bernard Lown, inventor of the defibrillator, listening to the patient and taking a careful history remains ''the most effective, quickest and least costly way to get to the bottom of most medical problems.''
My old friend the cardiologist has similar concerns. ''The diagnostic acumen of the physician at the bedside, on the phone or in the office, has been severely compromised,'' he told me. ''Because the mind-set has become, 'Well, the tests will tell me anyway, so I don't have to spend a lot of time listening.' ''
…….I worry that our continued focus on medical testing and prescription drugs as the primary ways of preventing heart disease will distract us from a more important element in treating illness:the well-trained doctor who knows his patient.
But it is not Plan B! It is NHS circa 1957. Brilliant piece.
• The NHS Annual Budget should be decided by a single vote in Parliament, and then distributed pro-rata on a capitation weighted by deprivation basis by the treasury to hospitals and GPs, who would then spend the money as they see fit in the best interests of their patients. Political interference in allocations and how the money is spent should be expressly banned by primary legislation.
• Hospitals (all publicly owned) and general practices should be administered (not managed) by boards and partnerships who should include amongst their responsibilities a requirement to foster a sense of spirit and belonging in the institutions in which they serve. Matrons should be found on wards not in offices, and staff identifiable by uniform: white coats for doctors, and starch for nurses. Succour for patients should be provided by chintzy ladies pushing WRVS tea-trolleys, and porters become once again the oil that keeps the hospital wheels turning…
There is a good deal of time and effort wasted in discussing GP commissioning and some lip service paid to integrating Primary and Secondary Care.
Yet, those in power had little regard for Parliamentary democracy and all the signs are that Privateers are waiting in the wings like theBarracudafor its yummy meal.
Is it really that difficult to grasp! I wrote a little while back:
Most people in well paid jobs (including those at the GMC) have health insurance. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment (and Bare Foot doctors in the Mao era cannot do the latter either), from keyhole knee work for Cricketers to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.
When there are not enough specialists to go round in any country money is used to ration care.
There is unfortunately little realisation that soon, a large number of consultants would no longer be working in NHS Hospitals.
Stent, Hips and others
They will be working for Private Hospitals that initially will be offering services to NHS patients. But because of shortage of the said consultants, those that are concerned that at 78% obstruction, their heart and life may not last the wait and they will pay for the job.
My friend just did in some other country: a bargain at US$ 50,000. The cardiologist is easily earning $ 10 million per annum.
What about your painful hips, the Consortia decided to impose a wait time to limit cost. So you too paid for it. That is what my golfing friend did in Flroida for a bargain US$90,000 as he paid a co-pay of 25%.
So there are not enough Consultants and shortage creates demand and you can name your price. Consultants do not really want to waste time in consortia arguing about the price of Stents or Hips.
Private patients will now have priority and NHS patients will fill in the slack. Very clever indeed.
Reform will not save any money but it will make a few City people very rich, very rich indeed.
Ever since Barbara Castle took on Junior Doctors in 1974, there has been only losers in the battle between doctors and the government. Indemnity, OOH would be nothing compared with what is going on now.
Not doctors, not government.
Because if I am a good cardiologist, I am not going to waste time with all these matters as every stent is money and a life saved. I feel good either way.
Doctors stand to gain from all these reforms and so it is very noble that many of us object to it.
Prime Minister, you are on the verge of losing some of the cheapest doctors in the world.
It was 10 years ago when we went to this unusual Strauss.
That was certainly the take-away from Thursday’s performance. The Russian conductor Vladimir Jurowski drew a plush and surging account of Strauss’s miraculous score from the great Met orchestra. The cast was headed by the magisterial German soprano Anne Schwanewilms in her company debut as the Empress, the woman without a shadow. And this was a breakthrough night at the Met for the American soprano Christine Goerke, who received an ecstatic ovation for her powerfully sung and wrenching portrayal of the hard-bitten Dyer’s Wife. Ms. Goerke has evolved in recent years into a dramatic soprano of exciting potential.
Federal authorities announced charges Tuesday in the largest healthcare fraud scam in the nation's history, indicting a Dallas-area physician on charges that he bilked Medicare of nearly $375 million and accusing him of sending "recruiters" to scoop up patients and get them to sign for treatments he never provided.
Prosecutors said Roy and his office manager in DeSoto, Teri Sivils, who was also charged, sent healthcare "recruiters" door-to-door asking residents to sign forms that contained the doctor's electronic signature and stating that his practice had seen them professionally in their own homes.
They also dispatched "recruiters" to a homeless shelter in Dallas, paying the recruiters $50 every time they coaxed a street person to a nearby parking lot and signed him up on the bogus forms.
Even when officials suspended his Medicare license last June, they said, Roy found a way around that by shifting his business to another company. Claims that there is no socialised medicine in the US is unfounded an their expenditure is scary! Yet there are very talented people trying to scam the system and unfortunately that includes doctors that will even do stents and transplants. Why can we not learn!
Medicareis a nationalsocial insuranceprogram, administered by theU.S. federal governmentsince 1965, that guarantees access to health insurance for Americans ages 65 and older and younger people with disabilities as well as people with end stage renal disease. As a social insurance program, Medicare spreads the financial risk associated with illness across society to protect everyone, and thus has a somewhat different social role from for-profit private insurers, which manage their risk portfolio to maximize profitability by denying claims.
Medicare spending is projected to increase from $560 billion in 2010 to just over $1 trillion by 2022. In response, policymakers recently have offered a number of competing proposals to reduce Medicare costs.From Wikipedia.
Medicaidis theUnited Stateshealthprogram for certain people and families with low incomes and resources. It is ameans-testedprogram that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid areU.S. citizensor legal permanent residents, including low-income adults, their children, and people with certaindisabilities. Poverty alone does not necessarily qualify someone for Medicaid. Medicaid is the largest source of funding for medical and health-related services for people with limited income in the United States.
According to CMS, the Medicaid program provided health care services to more than 46.0 million people in 2001.In 2002, Medicaid enrollees numbered 39.9 million Americans, the largest group being children(18.4 million or 46 percent). Some 43 million Americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. InCalifornia, about 23% of the population was enrolled in Medi-Cal for at least 1 month in 2009-10.
Medicaid payments currently assist nearly 60 percent of all nursing home residents and about 37 percent of all childbirths in the United States. The federal government pays on average 57 percent of Medicaid expenses. From Wikipedia.
In the current push for applying market principles, the NHS is in serious danger of paying dearly for unnecessary treatment and worse, fraudulent claims by the new “suppliers” in the market place.
I have highlighted the problems in the US before. Fraud is seen as more profitable than drug dealing.
The US Medicare and Medicaid systems are in a way very similar to what the new market style NHS will be like. Tax-payers pay for them! The much hyped saving, if there is going to be any, will be swallowed up by paying for unnecessary treatment and fraud.
The U.S. healthcare system wastes between $600 billion and $850 billion annually, according to a white paper published by Thomson Reuters.
The report identifies the most significant drivers of wasteful spending - including administrative inefficiency, unnecessary treatment, medical errors, and fraud - and quantifies their cost. It is based on a review of published research and analyses of proprietary healthcare data.
"The bad news is that an estimated $700 billion is wasted annually. That's one-third of the nation's healthcare bill," said Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper. "The good news is that by attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care.
UNNECESSARY CARE(40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
FRAUD(19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.
“The Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public
and private healthcare programs are 3-10 percent of total health spending, or $75–$250
billion in fiscal year 2009.”
“Fraud and abuse” occupies the extreme end of the continuum of appropriateness of use and potential waste. While arguments can be made about the appropriateness of some of the care described in the previous section, and, therefore, its classification as waste, no reasonable argument can be made for the contribution of fraud and abuse to quality of care or outcomes. They are cases of intentional misrepresentation resulting in excess payment, including billing for services never rendered and the knowing provision of unnecessary care. Most fraudulent and abusive practices simply add cost with no value, but others actually expose patients to the risk associated with unnecessary procedures.
Practices leading to waste include:
• The intentional provision of unnecessary or inappropriate services
• Billing for services never provided, often with patients’ participation in the fraud, often for
• Misrepresentation of the cost of care by insurers to group plan sponsors
• Kickbacks for referrals for unnecessary services
• Misbranding of a drug by a pharmaceutical company
• Abuse of the healthcare system by patients to receive harmful services, such as Medicaid recipients with drug addictions enrolling in multiple states.
ADMINISTRATIVE INEFFICIENCY(17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
HEALTHCARE PROVIDER ERRORS(12% of healthcare waste): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.
PREVENTABLE CONDITIONS(6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.
LACK OF CARE COORDINATION(6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.
Part Christian mythology, fairy tale, ritual and philosophical testament, "Parsifal" draws on sources as diverse as Buddhist thought, a 13th century German epic by Wolfram von Eschenbach and the 19th century German philosopher Arthur Schopenhauer to recount the drama of an "innocent fool," Parsifal, who gains compassion in the act of resisting temptation and is thereby able to restore the brotherhood of the knights of the Holy Grail.
Forgotten Ally: China’s World War II, 1937-45 The devastation that the Japanese invasion would wreak was indeed shocking. But as Rana Mitter shows in his illuminating and meticulously researched new book about the Sino-Japanese war, not only did Chinese history not end with the fall of Nanjing, but in many ways the war helped to create modern China. It was the anvil on which the new nation was forged.
Poncirus trifoliatais unquestionably an attractive plant, with refreshingly fragrant flowers and handsome autumn foliage, but that is by no means all. For one thing, it comes armed with some seriously offensive weapons in the form of long, sharp thorns, resulting in its regular appearance in the lists of rabbit-proof plants. This makes it eminently suitable for boundary planting or even as an informal hedge. As well as being an excellent intruder-repellent, it also provides the rootstock for many citrus cultivars, of which it is a close relative.
It has long been held that there is no alternative treatment to ADHD! Stimulant in its various forms is the answer. In life nothing is easy or indeed straightforward. Unfortunately pill popping is the preferred mode to deal with any problem by most and the sale of various OTC medication without prescription kept high street chemists busy and very happy. The alternative to medication treatment for ADHD is there, has always been. Just look at Michael Phelps. I have blogged sometime back about swimming, golf and music and I firmly believed that we may indeed have the answer all along. We just refused to work so hard. Golf: My friend just returned from a month at Spring City Golf & Lake Resort in Kunming, Yunnan. He showed me the score cards.
“You have to go.The weather is perfect, and so are the courses. You can play 18 holes and not sweat. The ball goes further at this altitude and the caddies are just wonderful.”
Kunming happens to be my birth place.It is north of Vietnam and is well known for its biodiversity and superb year round weather.
China, which just celebrated 60 years of Communist rule, is now embracing golf in a big way. Most golf courses are designed by big name western golf designers or golf champions turn designers.It must indeed seem ironical, as golf is seen by many as a game for the elite. Venezuela has just banned golf for that reason.
Bare Foot Doctors:
Changes in China since the early 80s have been phenomenal. First it abandoned the “Barefoot Doctors” that was started by Mao when doctors and intellectuals were seen as the elite and sent to remote villages to farm. “Barefoot Doctors” with minimal training cannot really deal with more complicated medical cases. It is a shame that we in England do not seem to have learned from the bad experience of China and the politicians have been pushing ahead with reforms in the NHS with the result that “Barefoot Doctors” known as Noctors (Dr. Crippen) are taking over.
At the height of the “Cultural Revolution”, the piano was seen as the definitive sign of bourgeois decadence.
Petroc Trelawny wrote in The Spectator that Fou Ts’ong (one of my favourite Chopin pianists) was forced to seek exile in London, where he later heard his parents had fatally poisoned themselves. Liu Shih Kun, who came second in the Tchaikovsky Competition when Van Cliburn won, was imprisoned by Madame Mao. He survived and has now established a number of piano kindergartens across China, in response to the craze created by Lang Lang’s performance at the 2008 Beijing Olympics.Many Chinese parents now want their children to learn the piano. The BBC reported that an estimated 30 million children in China are now learning the piano.
Is the piano China’s answer to the problem that is facing many parents in the west, i.e. ADHD? Could it be a novel substitute for Ritalin and other stimulants? With the advent of unproven modern approaches to education at all levels, very few subjects require memory work. Yet in the last decade or so, memory work has been shown to be beneficial to “brain power”, leading to a whole new approach to neuroplasticity. Learning a musical instrument is one way to give the brain the right amount of training. For now, just as the west is abandoning classical music training as part of the school curriculum, parents in China are paying for their children to have piano lessons. By some reckoning, North America probably consumes 90% of Ritalin and similar stimulants, whereas China is probably consuming 90% of the pianos produced. One factory in the south of China is currently producing 100,000 pianos a day. Swimming: Some will argue that such pressure on children is not good. Yet we have to look at Michael Phelps, whose parents abandoned drug treatment for his ADHD in favour of swimming.
.....For an athlete who took Ritalin for attention deficit hyperactivity disorder (ADHD) as a child, it is also his most surprising asset.
"Michael's ability to focus amazes me," says his mom, Debbie Phelps, a middle school principal who occasionally speaks on panels about ADHD. It's a condition that most frequently affects children, making it hard for them to pay attention to one thing or to sit for long periods.
Bowman, who began coaching Phelps at the North Baltimore Aquatic Club when the swimmer was 11, recalls how much time Phelps spent sitting near the lifeguard stand as a kid, benched because he was being too disruptive.
"He never sat still. He never shut up; he would never stop asking questions," his mom says. "He just wanted to go from one thing to another."
When he was in elementary school, a teacher told his mom that Phelps would never focus on anything. His mom disagreed. She had seen him at swim meets..... The modern Chinese parent may indeed have stumbled upon something similar to Michael Phelps’ swimming in dealing with problems of concentration. Many parents actually believe that the discipline of learning the piano is helpful in building a more rounded person, although some may have aspirations that their offspring might be the next Lang Lang. As China now moves into a new era, the piano practising child may have something else to practise: golf. The Independent reported that it is the new game that is the game of choice for China’s new elite. My friend told me that when he was at the Spring City Golf & Lake Resort, a nine year old just won a junior tournament. The boy was only 9 and he scored 71 on his final round playing from the red Tee He may well be the next Tiger, a piano playing Tiger. “There’s a sense that greater powers, profit-driven and amoral, are pulling the strings in our children’s lives. There’s a sense that those who should best protect us — our government and our doctors — are so corrupted that they can no longer do the job. There’s a sense that childhood has, in many ways, been denatured, that youth has been stolen, that the range of human acceptability has been narrowed for our kids to a point that it has become soul-crushingly inhuman.” Judith WarnerNew York Times
Ritalin has also become popular because it takes the blame away from those responsible for the child – the parents and often the teachers as well. Some parents who do not wish for their child to go on Ritalin are often put under tremendous pressure by the teachers. Very few have even bothered to find out if there is any non drug related method at all.”
“According to data obtained exclusively by Education Guardian under Freedom of Information legislation, there has been a 65% increase in spending on drugs to treat ADHD over the last four years. Such treatments now cost the taxpayer over £31m a year.” More>>>>
There is little doubt that overhydration is now the biggest threat to the runners. Most fatality is due to hyponatraemia and as far as my searches go, no one has died from dehydration during the various Marathons. Despite what you may have read: DEHYDRATION is not the problem. Low SODIUM is! Elite Marathon runners in the past rarely drank much during races. Mike Gratton, when he won the London Marathon in 1983, apparently drank nothing. It has been said that even doctors may overlook the role of low sodium in rescues especially as there are sports drinks in abundance. As runners from around the world prepared themselves for the New York marathon I will publish my take from an earlier post.
Of 766 runners enrolled, 488 runners (64 percent) provided a usable blood sample at the finish line. Thirteen percent had hyponatremia (a serum sodium concentration of 135 mmol per liter or less); 0.6 percent had critical hyponatremia (120 mmol per liter or less). On univariate analyses,hyponatremia was associated with substantial weight gain, consumption of more than 3 liters of fluids during the race, consumption of fluids every mile, a racing time of >4:00 hours, female sex, and low body-mass index.
Modern marathon advice is to up the intake of salty food in the pre-race preparation. When dehydrated taking salt and water alone will not work: see below.
When I was growing up in the tropics, one of the fruits we were given after a long walk was watermelon with salt sprinkled on it. This was long before the current understanding of Oral Rehydration. My parents were careful to warn us then that just drinking water is no good. Why? They did not know!
Now I do but watermelon is still my favourite and in the tropics you can buy fresh water melon juice in the summer.
Chinese farm workers:
It has to be said that the diet of many Chinese farm workers was generally higher in sodium, from dried salted fish and vegetables. It is likely that the serum sodium of many such workers would have been at the high end of the normal range. Modern advice on cutting down sodium often does not take account of sweating in hot countries. A friend of mine with hypertension had an epileptic seizure when he went to work in Singapore. Luckily the medical services there were alert to the problem and he survived. He was on a low sodium diet and on diuretics amongst other medications.
I also remember one very hot August day when we hiked down Grand Canyon to Angel Point. There were warnings everywhere of the risks and even fatalities on such walks. The National Park did have clean drinking water taps along the way and one particular girl overdid the drinking. She had a narrow escape, as the Ranger fortunately knew a thing or two about rehydration. He put some salt in a can of Sprite and reverted a potentially serious situation.
The first time we went to Thailand the most amazing dip was simply a bowl of sugar that has been mixed with salt and some chopped chilies for good measure. This dip was used for serving unripe mangoes, papayas, guavas and other local fruits, and gave me a taste sensation that was unforgettable. Same principle as ORT.
In Thailand, workers in rice fields, fruit orchards and vegetable patches manage to survive temperatures of over 100°F.
The Cockroach Catcher plays golf in his holiday home in the tropics and he uses his own mix of diluted Pomegranate juice and a pinch of salt for Oral rehydration. I would never drink plain water alone. This is one time where a bit of sugar helped the body to absorb salt and fruit juice is higher in potassium.
When the first public golf course was opened on the beautiful island ofKau Sai Chauin Hong Kong,drinking water was provided along the course. One player drank so much that he nearly died of water intoxication (result of drinking excessive amounts of plain water which causes a low concentration of sodium in the blood leading to amongst other problems: ‘brain’ swelling---cerebral oedema).
It seems wrong to recommend alcohol but has anyone worked out why cocktails from hot countries would be served with the rim of the glass covered in salt!!!
I remember one of my professors telling us: the body survives dehydration much better than drowning. How right he was, as water intoxication is in a sense a kind of drowning.
I well rememberHong Kong’s cholera epidemic in 1961 and the major cause of death was the rapid loss of fluid due to a specific secretive action of the cholera germ. Patients could die in a matter of hours. The medical profession has long been of the strong belief that Intravenous Fluid (IV Fluid) is the only answer.In that situation, the patient is in shock and to find a vein means a cut-down: literally cutting through the skin to find one. It is a messy business as the patient is violently pumping out fluid in the most horrendous fashion.
Johns Hopkins established a centre inCalcuttain the 1960s to study precisely a better way to replenish the fluid. IV fluids were expensive to manufacture and required medical personnel to administer.Their Clinicians sought help from basic physiology and carried out the first carefully controlled study which showed that intestinal perfusion of cholera patients with saline solutions containing glucose strikingly reduced fluid loss.Put simply, the patients could just drink a glucose and salt solution and the glucose would allow the salt to be piggy backed and absorbed, thus sparing the need to use IV fluids.
“……These compelling findings, however, did not convince the medical establishment, who remained sceptical that such a simple therapy could substitute for traditional intravenous fluid replacement in severely stricken patients under epidemic conditions in the field.”
The World had to wait for a war, this time in Pakistan, when Bangladesh fought for its independence in 1971 and 9 million refugees poured into India and with them cholera. When IV saline treatment was exhausted,Dr Mahalanabis,who had worked at the Johns Hopkins Centre inCalcutta, took the gamble and decided to prescribe a simple solution of glucose and salt in the right proportion for the friends and relatives of thecholerapatients, thus saving at least 3.5 million people.Since that time it was estimated that such a simple and cheap remedy saved at least 40 million more lives.
Simon Stevens: now with UnitedHealth Now Stevens is to play a crucial role in presenting the more responsible face of American healthcare and in persuading the key players in Britain that they need to allow companies such as his into the NHS. Recently UnitedHealth's European division won the right to take over two GP practices, in Normanton and Cresswell in Derbyshire. Stevens, who was running the European division at the time, was key to winning the contracts.
The company is a huge force within US healthcare, with 70 million Americans on its books, employing 400,000 doctors in 4,000 hospitals. UnitedHealth is America's biggest health insurer. And it's growing in influence in Britain.
It already runs two GP practices in Derbyshire and now the government has given the green light to 14 companies, including United, to bid for potentially much bigger contracts from the primary care trusts that run hospitals. They would be paid for providing data analysis and research, giving trusts a clearer idea of how to manage patients with chronic conditions such as diabetes.
But their role may be bigger than that. Companies may also be invited in to act as middlemen, negotiating with hospitals on the trusts' behalf to reduce costs, ushering in the prospect that some patients may find their care plan managed not by a doctor but by an American insurance company.
Allowing UnitedHealth and others into the NHS fills the unions and many health workers with horror. That dismay will be amplified when they watch Michael Moore's latest film, Sicko, which alleges that United and other big US insurers routinely deny care for patients who may be critically ill.
“……UnitedHealth Group Inc. (UNH) agreed to pay $912 million to settle two class-action lawsuits regarding its stock-options practices……” Rewind to last year in theNew York Times:
“In one of the largest corporate pay give-backs ever,William W. McGuire, the former chief executive ofUnitedHealth Group, has agreed to forfeit at least $418 million to settle claims related to back-dated stock options.”
How very sad! $418 million is a lot of money!
“The payback is on top of roughly $198 million that Mr. McGuire,an entrepreneurwho built UnitedHealth, had previously agreed to return to his former employer.”
An entrepreneur!This reminded me ofDr Crippen’s blogabout NHS entrepreneurs, and I duly alerted him. UnitedHealth is said to cover the Health Insurance of 70 million US Citizens.
“As part of the settlement with the S.E.C., Mr. McGuire will pay a $7 million fine and will be barred from serving as a director of a public company for 10 years.”
Oh, no, another $7 million and 10 years!You must feel sorry for him.
“He will, however, be allowed to keep stock options valued at more than $800 million, including many that have been sharply criticized.”
UnitedHealth Profit Jumps as Medicare, Medicaid Grow
UnitedHealth Group Inc., the biggest U.S. health insurer by sales, raised its full-year profit forecast after increased enrollments and lower-than-projected medical costs lifted second-quarter earnings 30 percent.
The insurer forecast 2010 profit of $3.40 to $3.60 a share compared with a previous projection of $3.15 to $3.35, citing growth in sales or membership for all business units. Net income rose to $1.12 billion, or 99 cents a share, for the quarter, from $859 million, or 73 cents, a year earlier, the company said today. The earnings and forecast topped estimates.
Chief Executive Officer Stephen Hemsley boosted enrollment in Medicare Advantage, the U.S.-backed program for the elderly. Weakness in the economic recovery in the U.S. also helped, by keeping people away from doctors and hospitals, said Jason Gurda, a Leerink Swann & Co. analyst in New York. UnitedHealth did better than expected for commercial enrollment, taking business from rival insurers, he said.
Stephen Hemsley, who upon being hired in June 1997 was presented with 400,000 stock options with an issue date of five months earlier. Hemsley told the Wilmer Hale lawyers that he "didn't recall focusing at the time" on the $2.9 million gimme he'd just been handed as a result of the backdating.
You might say that Hemsley comes honestly to his lack of focus and ethical sensitivity. Before coming to UnitedHealth -- I'm not making this up -- he'd spent the previous 23 years at Arthur Andersen, rising to chief financial officer. That's the same accounting firm that helped bring you Enron, WorldCom and Freddie Mac. And, you'll be shocked to learn, it's the same Arthur Andersen that served as a consultant to Spears and other members of UnitedHealth's compensation committee.
Hemsley was rewarded for his lack of focus by being named to succeed McGuire as chief executive. He was also directed to root out the senior executives in the legal, accounting and personnel departments who provided the bad advice on which the board and chief executive now say they have relied. Hemsley, too, has volunteered to reprice his options.
Chief executive Stephen Hemsley pulled in $102 million in 2009, with $98.6 million coming from exercised stock options, according to a filing with the Securities and Exchange Commission Wednesday. Star Tribune
The Minnesota-based firm beat Bupa and Humana to win the contract from the health department to advise PCTs
The Minnesota-based UnitedHealth has already become a key adviser to primary care trusts (PCTs) on commissioning health services and operating bids to run GP practices. Earlier this month it beat Bupa and Humana, another US health insurer, to win the contract from the health department to advise PCTs.
The decision follows successful bids to run two GP practices in Derbyshire in 2006 and three practices in central London in 2008, taking over from the Brunswick Group. In April the company announced a 21% increase in profits for the first three months of the year to $1.2bn (£784m).
United said it brought high level management expertise and efficient provision of services to the UKhealth service but it has faced accusations of overcharging and malpractice in a series of legal suits.
UnitedHealth Group Inc., the biggest U.S. health insurer, said it will spend $400 million to settle allegations it has manipulated payments to doctors and patients for the last 15 years. The company agreed to put $350 million into a class-action restitution fund to pay physicians and policyholders for services provided by out-of-network providers, the company said in a statement today. On Jan. 13, the Minnetonka, Minnesota-based insurer settled allegations from New York Attorney General Andrew Cuomo by paying $50 million and transferring to a nonprofit group its database that set the amount to be reimbursed when patients used doctors outside their network. UnitedHealth has been battling the largest physician group, the American Medical Association, over out-of-network costs since 2000. The settlement affects less than 10 percent of health benefits because most policyholders use their health plan’s network providers to minimize out-of-pocket expenses. Still, the AMA said it stopped rampant cheating Its California subsidiary was fined a record $3.5m in the same year for mishandled claims against patients and doctors. In 2006 The UnitedHealth chief executive William McGuire resigned after an investigation "concluded he had received stock option grants 'likely backdated' to allow insiders to maximise financial gains." During his tenure as chief executive, McGuire was granted more than $1.6bn in stock options. In 2007, McGuire avoided trial after he agreed to repay $468m. In one example, Cuomo’s office said that when $200 was a fair-market rate for a 15-minute doctor’s visit for a common illness, Ingenix said it was $77. UnitedHealth would pay $62 when it should have paid $160, leaving the consumer with a $138 bill.
I recently learned that this month a class-action lawsuit has been filed against California United Behavioral Health (UBH), along with United Healthcare Insurance Company and US Behavioral Plan, alleging these companies improperly denied coverage for mental health care.
According to the class action lawsuit, United Behavioral Health violatedCalifornia’s Mental Health Parity Act, which requires insurers to provide treatment for mental-health diagnosis according to “the same terms and conditions” applied to medical conditions. Specifically, the insurer is accused of denying and improperly limiting mental health coverage by conducting concurrent and prospective reviews of routine outpatient mental health treatments when no such reviews are conducted for routine outpatient treatments for other medical conditions.