Pathophysiology and nursing role and scope (24 hours)

 

 1) Minimum 7 full pages (No word count per page)- Follow the 3 x 3 rule: minimum three paragraphs per page

           Part 1: minimum 1 page

           Part 2: minimum 1 page

           Part 3: minimum 1 page

           Part 4: minimum 1 page

           Part 5: minimum 3 pages (Due 48 hours)

   Submit 1 document per part

2)¨******APA norms

         All paragraphs must be narrative and cited in the text- each paragraph

         Bulleted responses are not accepted

         Don’t write in the first person 

         Don’t copy and paste the questions.

         Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references (APA format) per part not older than 5 years  (Journals, books) (No websites) 

Part 5: Include AACN, 2008

All references must be consistent with the topic-purpose-focus of the parts. Different references are not allowed.

5) Identify your answer with the numbers, according to the question. Start your answer on the same line, not the next

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

6) You must name the files according to the part you are answering: 

Example:

Part 1.doc 

Part 2.doc

__________________________________________________________________________________ 

Part 1: Pathophysiology

1. Describe some of the more common pathophysiological changes 

a. Abnormal findings associated with musculoskeletal, metabolic, 

b. Multisystem health dysfunctions. 

2. Explain what symptoms are associated with the findings 

a. How these affect patient function.

Part 2: Pathophysiology

1. Explain the risk factors for osteoporosis. 

2. What can a nurse do to help manage this health condition to restore the patient to optimal health?

Part 3: Nursing Role and Scope

1. Describe communication strategies for effective interprofessional teams.

Part 4: Nursing Role and Scope

1. Contrast the terms of terminal sedation, rational suicide, and physician-assisted suicide.

Part 5: Nursing Role and Scope ( Write in the first person)

Purpose:

  

The purpose of this XXX is to provide the student an opportunity to reflect on selected RN-BSN competencies acquired through the course.  

1.  Introduction (1/2 page)

 Introduces the purpose of the reflection and addresses  BSN Essentials (AACN, 2008) pertinent to healthcare policy and advocacy.

2. Course Reflection 

Reflect and reflect on your learning from the Nursing Role and Scope course on

a. “Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice.

b. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings.

c. Apply safeguards and decision-making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers.

d. Understand the use of CIS systems to document interventions related to achieving nurse sensitive outcomes.

3. Conclusion (1/2 page)

     

Communication disorders help | Education homework help

 

Hello,

Attached is the reading and 2 power points, information is listed below, 12 font, times new roman, APA, explain in 1.5 pages, may use 1 additional reference.

Our cultural background- including our ethnic, racial, and linguistic identities- influences the type of feedback we provide during communication. What are some ways communication may vary culturally?

We communicate for many different purposes. Consider the case of Mr. Shen in Case Study1-1. What communication purposes may be impacted by his hearing loss? 

Refence to use:

Justice, L. M., & Redle, E. (2013). Communication Sciences and Disorders [E-book]. Pearson Education.

Thanks

Rak, inc., has no debt outstanding and a total market value of

  

RAK, Inc., has no debt outstanding and a total market value of $250,000. Earnings before interest and taxes, EBIT, are projected to be $40,000 if economic conditions are normal. If there is strong expansion in the economy, then EBIT will be 20 percent higher. If there is a recession, then EBIT will be 20 percent lower. RAK is considering a $105,000 debt issue with an interest rate of 4 percent. The proceeds will be used to repurchase shares of stock. There are currently 10,000 shares outstanding. RAK has a tax rate of 35 percent.

2-1 Calculate earnings per share (EPS) under each of the three economic scenarios before any debt is issued. (Do not round intermediate calculations and round your answers to 2 decimal places, e.g., 32.16.)

EPS

Recession 12.80

Normal 16.00

Expansion 19.20

a-2Calculate the percentage changes in EPS when the economy expands or enters a recession. (Negative amounts should be indicated by a minus sign. Do not round intermediate calculations. Enter your answers as a percent rounded to 2 decimal places, e.g., 32.16.)

Percentage changes in EPS

Recession -20.00 0%

Expansion 20.00 0%

b-1 Calculate earnings per share (EPS) 111011 1301 of the three economic scenarios assuming the company goes through with recapitalization. (Do not round intermediate calculations and round your answers to 2 decimal places, e.g., 32.16.)

EPS

Recession 19.17

Normal 24.69

Expansion 30.21

b-2 Given the recapitalization, calculate the percentage changes in EPS when the economy expands or enters a recession. (Negative amounts should be indicated by a minus sign. Do not round intermediate calculations. Enter your answers as a percent rounded to 2 decimal places, e.g., 32.16.)

Pltblttoglbt2t.3th in EPS 

Recession -22.31 0 %

Expansion MEE %

…………………………………………………………………………………………………………………………………………………………….

  

(a-1)

EPS

  

Recession 

2.08 

  

Normal 

2.60 

  

Expansion 

3.12 

  

(a-2)

Percentage Change in EPS

  

Recession 

-20.00%

  

Expansion 

20.00%

  

(b-1)

EPS

  

Recession 

3.12 

  

Normal 

4.01 

  

Expansion 

4.91 

  

(b-2)

Percentage Change in EPS

  

Recession 

-22.35%

  

Expansion 

22.35%

Finance activities analysis | Finance 520 | Colorado State University–Global Campus

 

Option #1: Financing Activities Analysis: Hayes, Inc.

Answer the following questions in your submission.

Question #1: Some car companies currently face numerous lawsuits due to reported cases of failed brakes, which could negatively impact image of those companies. Such lawsuits are prime examples of contingent losses because the loss is contingent upon an adverse settlement or verdict in the case. The litigation loss contingency should be accrued if a loss is probable and can be estimated. Probable and estimable are difficult concepts that offer managers a fair degree of discretion.

  1. List two reasons why the managers in this case might resist quantification and accrual of a loss liability.
  2. In 1-2 paragraphs, describe a circumstance when managers might be willing to accrue a contingent loss that they had earlier resisted accruing.

Question #2: On January 1, 2014, Hayes, Inc. leases equipment from Smithsonian Company for an annual lease rental of $25,000. The lease term is five years, and the lessor’s interest rate implicit in the lease is 8%. The lessee’s incremental borrowing rate is 8.25%. The useful life of the equipment is five years, and its estimated residual value equals its removal cost. Annuity tables indicate that the present value of an annual lease rental of $1 (at 8% rate) is $3.993. The fair value of leased equipment equals the present value of rentals. (Assume the lease is capitalized.)

Required:

  1. Prepare accounting entries required by Hayes, Inc. for 2014.
  2. Compute and illustrate the effect on the income statement for the year ended December 31, 2014, and for the balance sheet as of December 31, 2014.
  3. Construct a table showing payments of interest and principal made every year for the five-year lease term.
  4. Construct a table showing expenses charged to the income statement for the five-year lease term if the equipment is purchased. Show a column for (1) amortization, (2) interest, and (3) total expenses.
  5. In one paragraph, discuss the income and cash flow implications from this capital lease.

Your submission should:

Essay questions | World history homework help

 

Essay Questions: Answer both questions. 3 pages for each.

1. The migrant experience in the Mumbai context reveals the precarious nature of the existence of workers in the informal sector. Using interview data from the Boo book, provide at least three examples from India’s performance on various social indicators (literacy, basic health care) on how the country’s development policies have actually inhibited social and economic mobility for the urban poor in Mumbai? 

2. China’s path to economic progress has been informed by the Lewis model and its management of urban migrants through the hukou system. Please highlight the major theoretical points of Lewis’s understanding of the migration process in respect to how these apply to Chinese urbanization? In what way does the hukou system complement Lewis’s model in explaining Chinese urbanization?

Short Answer questions: Answer both of the following questions (15 marks. 7.5 marks per question). 2 pages for each.

1) Urban informality has been a characteristic of development in both Indian and Chinese cities. Given that urban informality is a bigger problem in terms of how it affects people’s welfare in India than China, present five broad comparisons on how urban informality is tackled at the policy level in both countries?

2) Solomon Benjamin has used the term “occupancy urbanism” to describe the new politics and political economy of the large Indian metropolitan city. What are the three main arguments in his approach to highlight the distinctiveness of the Indian urban context in comparison to cities in other countries?

 

You are expected to use font 12 Arial and also reference your responses according to the APA format.

Magna carta reaction paper | History homework help

This paper will focus on your reactions to The Magna Carta.

This work was written in 1215 in Britain. It is a contract signed between John, King of England, and the nobles. The Magna Carta established constitutional monarchy in the British Isles, which would last until today.

Some questions you may wish to explore include:

1. Why would King John sign an agreement that limited his powers?

2. What does this document tell us about the relationship between the king and the aristocracy?

3. How important was the protection of property rights in this agreement?

4. Where do we see examples of justice and honor in the various agreements made between the king and the nobility?

5. How do you think this document has shaped future ideas of government in the Western world?

To complete this paper, you do not need to consult any sources outside of the book. It is discouraged that you look at such works, as your reaction should be based solely on The Magna Carta.

https://www.bl.uk/magna-carta/articles/magna-carta-english-translation

Reading summaries #8: butoh & mark morris

Part 1:

“Butoh: Twenty Years Ago We Were Crazy, Dirty, and Mad” by Bonnie Sue SteinPreview the document

From “Moving History/Dancing Cultures: a dance history reader,” Wesleyan University Press, 2001

Please copy this text into the box below, fill out the form, and bring a copy of your response to class.
Author:  
Title: 
Date published: 
Subject (Say what the text is about in a very few words): 

Thesis (What is the author’s point, argument or proposal – in one to three sentences?): 

What questions does the text raise for you?

Part 2:

Mark Morris: What the Body Means by Joan AcocellaPreview the document

From the Routledge Dance Studies Reader, 1998

Please copy this text into the box below, fill out the form, and bring a copy of your response to class.

Author:  
Title: 
Date published: 
Subject (Say what the text is about in a very few words): 

Thesis (What is the author’s point, argument or proposal – in one to three sentences?): 

What questions does the text raise for you?

PreviousNext

Health care strategic management | Nursing homework help

Assignment:

Exercises:

  1. Why should program evaluation be used for public health and not-for-profit institutions in the development of adaptive strategies?
  2. Explain the strategic position and action evaluation (SPACE) matrix. How may adaptive strategic alternatives be developed using SPACE?

Professional Development

Case Study #8: “Dr. Louis Mickael: The Physician as Strategic Manager”

Develop an environmental assessment and an internal capabilities analysis using decision support tools that have been introduced in this module (such as PLC analysis, BCG portfolio analysis, SPACE analysis and so on). Analyze alternative strategies to include pros and cons of each alternative, then conclude with a recommended strategy and brief implementation plan.

CASE 8: DR. LOUIS MICKAEL590

By the early 1980s, costs to provide these health care services reached epic proportions; and the financial ability of employers to cover these costs was being stretched to breaking point. In addition, new government health care regulations had been enacted that have had far-reaching effects on this US industry. The most dramatic change came with the inauguration of a prospective payment system. By 1984, reimbursement shifted to a prospective system under which health care providers were paid preset fees for services rendered to patients. The procedural terminology codes that were initiated at that time designated the maximum number of billed minutes allowable for the type of procedure (service) rendered for each diagnosis. A diagnosis was identified by the International Classification of Diseases, Ninth Revision, Clinical Modification, otherwise known as ICD-9-CM. The two types of codes, procedural and diagnosis, had to logically correlate or reimbursement was rejected. Put simply, regardless of which third-party payor insured a patient for health care, the bill for an office visit was determined by the number of minutes that the regulation allowed for the visit. This was dictated by the diagnosis of the primary problem that brought the patient into the office and the justifiable procedures used to treat it. These cost-cutting measures initiated through the government-mandated prospective payment regulation added to physicians’ overhead costs because more paperwork was needed to submit claims and collect fees. In addition, the length of time increased between billing and actual reimbursement, causing cash flow problems for medical practices unable to make the procedural changes needed to adjust. This new system had the effect of reducing income for most physicians, because the fees set by the regulation were usually lower than those physicians had previously charged. Almost all other operating costs of office practice increased. These included utilities, maintenance, and insurance premiums for office liability coverage, workers’ compensation, and malpractice coverage (for which costs tripled in the late 1980s and early 1990s). This changed the method by which government insurance reimbursement was provided for health care disbursed to individuals covered under the Medicare and Medicaid programs. Private insurors quickly adopted the system, and health care as an industry moved into a more competitive mode of doing business. The industry profile differed markedly from that of only a decade earlier. Hospitals became complex blends of for-profit and not-for-profit divisions, joint ventures, and partnerships. In addition, health care provided by individual physician practitioners had undergone change. These professionals were forced to take a new look at just who their patients were and what was the most feasible, competitively justifiable, and ethical mode of providing and dispensing care to them. For the first time in his life, Dr. Mickael read about physicians who were bankrupt. In actuality, Dr. Charles, who shared office space with him, was having a financial struggle and was close to declaring bankruptcy.

The last patient had just left, and Dr. Lou Mickael (“Dr. Lou”) sat in his office thinking about the day’s events. He had been delayed getting into work because 

both08.indd   590 both08.indd   590 11/11/08   11:46:25 AM 11/11/08   11:46:25 AM

591

a patient telephoned him at home to talk about a problem with his son. When he arrived at the office and before there was time to see any of the patients waiting for him, the hospital called to tell him that an elderly patient, Mr. Spence, admitted through the emergency room last night had taken a turn for the worse. “My days in the office usually start with some sort of crisis,” he thought. “In addition to that, the national regulations for physician and hospital care reimbursement are forcing me to spend more and more time dealing with regulatory issues. The result of all this is that I’m not spending enough time with my patients. Although I could retire tomorrow and not have to worry financially, that’s not an alternative for me right now. Is it possible to change the way this practice is organized, or should I change the type of practice I’m in?”

Practice Background When Dr. Lou began medical practice the northeastern city’s population was approximately 130,000 people, most of whom were blue-collar workers with diverse ethnic backgrounds. By 1994, suburban development surrounded the city, more than doubling the population base. A large representation of service industries were added, along with an extensive number of upper and middle managers and administrators typically employed by such industries.

Location

Dr. Lou kept the same office over the years. It was less than one-half mile from the main thoroughfare and located in a neighborhood of single-family dwellings. The building, constructed specifically for the purpose of providing space for physicians’ offices, was situated across the street from City General, the hospital where Dr. Lou continued to maintain staff privileges. Three physicians (including Dr. Lou) formed a corporation to purchase the building, and each doctor paid that corporation a monthly rental fee, which was based primarily on square footage occupied, with an adjustment for shared facilities such as a waiting room and rest rooms.

Office Layout

One of the physicians, Dr. Salis, was an orthopedic surgeon who occupied the entire top floor of the building. Dr. Lou and the other physician, Dr. Charles, were housed on the first floor. Total office space for each (a small reception area, two examining rooms, and private office) encompassed a 15′ × 75′ area (see Exhibit 8/1). The basement was reserved for storage and maintenance equipment. The reception area and each of the other rooms that made up the office space opened on to a hallway that Dr. Lou shared with Dr. Charles. The two physicians and their respective staff members had a good rapport; and because the reception desks opened across from each other, each staff was able to provide support for the other by answering the phone or giving general information to patients when the need arose.

PRACTICE BACKGROUND

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CASE 8: DR. LOUIS MICKAEL592

The large, common waiting room was used by both physicians. After reporting to their own doctor’s reception area, patients were seated in this room, then paged for their appointment via loudspeaker. Dr. Charles was in his mid-forties and in general practice as well. His patients ranged in age from 18 to their mid-eighties, and his office was open from 10:00 A.M. until 7:30 P.M. on Mondays and Thursdays, and from 9:30 A.M. until 4:30 P.M. on Tuesdays and Fridays; no office hours were scheduled on Wednesday. He and Dr. Lou were familiar with each other’s patient base, and each covered the other’s practice when necessary.

Staff and Organizational Structure

Dr. Lou’s staff included one part-time bookkeeper (who doubled as office manager) and two part-time assistants. The assistants’ and bookkeeper’s time during office hours was organized in such a way that one individual was always at the reception desk and another was “floating,” taking care of records, helping as needed in the examining rooms, and providing office support functions. There were never more than two staff people on duty at one time, and the assistants’ job descriptions overlapped considerably (see Exhibit 8/2 for job descriptions). Each staff member could handle phone calls, schedule appointments, and usher patients to the examining rooms for their appointments. Although Dr. Lou was “only a phone call away” from patients on a 24-hour basis, patient visits were scheduled only four days a week. On two of these days (Monday and Thursday) hours were from 9:00 A.M. to 5:00 P.M. The other two were “long days” (Tuesday and Friday), when office hours officially were extended to 7:00 P.M. in the evening, but often ran much later.

Front Desk Treatment Room 1

Treatment Room 2

Private Office

Dr. Charles’ Office Space

Front Door

Common Waiting Room

75′

15′

Job Description: Bookkeeper/Office Manager In addition to responsibility for bookkeeping functions, ordering supplies, and reconciling the orders with supplies received, this person knows how to run the reception area, pull the file charts, and usher patients to treatment rooms. In addition, she can handle phone calls, schedule appointments, and enter office charges into patient accounts using the computer.

Job Description: Assistant 1 The main responsibility of this position is insurance billing. Additional duties include running the reception area, pulling and filing charts, ushering patients to treatment rooms, answering the phone, scheduling appointments, entering office charges into patient accounts, and placing supplies received into appropriate storage areas.

Job Description: Assistant 2 This is primarily a receptionist position. The duties include running the reception area, pulling and filing charts, ushering patients to treatment rooms, answering the phone, scheduling appointments, entering office charges into patient accounts, and placing supplies received into appropriate 

The fifth weekday (Wednesday) was reserved for meetings, which were an important part of Dr. Lou’s professional responsibilities because he was a member of several hospital committees. He was one of two physicians residing on the ten-member board of the hospital, and this, along with other committee responsibilities, often demanded attendance at a variety of scheduled sessions from 7:00 A.M. until late afternoon on “meetings” day. Wednesday was used by the staff to process patient insurance forms, enter patient data into their charts and accounts receivables, and prepare bills for processing. When paperwork began to build after the PPS regulations came into effect in the 1980s, patients had many problems dealing with the forms that were required for reimbursement of services received in a physician’s office. It was the option of physicians whether to “accept assignment” (the standard fee designated by an insurance payor for a particular health care service provided in a medical office). A physician who chose to not accept assignment must bill patients for health care services according to a fee schedule (“a usual charge” industry profile) that was preset by Medicare for Medicare patients. Most other insurances followed the same profile. Dr. Lou agreed to accept the standard fee, but the patient had to pay 20 percent of that fee, so the billing process became quite complicated. In 1988, Dr. Lou decided that he needed to computerize his patient information base to provide support for the billing function. He investigated the possibility of using an off-site billing service, but it lacked the flexibility needed to deal with regulatory changes in patient insurance reporting that occurred with greater 

Exhibit 

CASE 8: DR. LOUIS MICKAEL594

and greater frequency. Dr. Charles was asked if he wished to share expenses and develop a networked computer system. But the offer was declined; he preferred to take care of his own billing manually. An information systems consultant was hired to investigate the computer hardware and software systems available at that time, make recommendations for programs specifically developed for a practice of this type, and oversee installation of the final choice. After initial setup and staff training, the consultant came to the office only on an “as needed” basis, mostly to update the diagnostic and procedure codes for insurance billing. Computerization was an important addition to the record-keeping process, and the system helped increase the account collection rate. However, at times problems would arise when the regulations changed and third-party payors (insurance companies) consequently adjusted procedure or diagnosis codes. For example, there was often some lag time between such decisions and receipt of the information needed to update the computer program. Fortunately, the software chosen remained technologically sound, codes were easily adjusted, and vendor support was very good. Although the new system helped to adjust the account collection rate, fitting this equipment into the cramped quarters of current office space was a problem. To keep the computer paper and other supplies out of the way, Dr. Lou and his staff had to constantly move the heavy boxes containing this stock to and from the basement storage area.

January 8, 1994 (Morning)

On Dr. Lou’s way in that day, the bookkeeper told him that something needed to be done about accounts receivable. Lag time between billing and reimbursement was again getting out of hand, and cash flow was becoming a problem (see Exhibits 8/3 through 8/6 for financial information concerning the practice). Cash flow had not been a problem prior to PPS, when billing for the health care provided by Dr. Lou was simpler, and payment was usually retrospectively reimbursed through third-party payors. However, as the regulatory agencies continued to refine the codes for reporting procedures, more and more pressure was being placed on physicians to use additional or extended codes in reporting the condition of a patient. Speed of reimbursement was a function of the accuracy with which codes were recorded and subsequently reported to Medicare and other insurance companies. In part, that was determined by a physician’s ability to keep current with code changes required to report illness diagnoses and office procedures. Cathy, the receptionist, had a list of patients who wanted Dr. Lou to call as soon as he came in. She also wanted to know if he could squeeze in time around lunch hour to look at her husband’s arm; she believed he had a serious infection resulting from a work-related accident. The wound looked pretty nasty this morning, and Cathy thought maybe it should not wait until the first available appointment at 7:00 P.M.

both08.indd   594 both08.indd   594 11/11/08   11:46:29 AM 11/11/08   11:46:29 AM

595

Exhibit 8/3: Trial Balance at December 31

 1991 1992 1993

Debits Cash $15,994 $9,564 $8,666 Petty cash 50 100 100 Accounts receivable 19,081 25,054 28,509 Medical equipment 11,722 11,722 11,722 Furniture and fixtures 3,925 3,925 3,361 Salaries 117,455 124,608 132,325 Professional dues and licenses 1,925 1,873 1,816 Miscellaneous professional expenses 1,228 2,246 3,232 Drugs and medical supplies 2,550 1,631 2,176 Laboratory fees 2,629 524 1,801 Meetings and seminars 2,543 838 3,880 Legal and professional fees 5,525 2,057 5,400 Rent 16,026 16,151 18,932 Office supplies 4,475 3,262 4,989 Publications 1,390 406 401 Telephone 1,531 1,451 2,400 Insurance 8,876 9,629 11,760 Repairs and maintenance 3,547 4,240 5,352 Auto expense 1,009 1,487 3,932 Payroll taxes 3,107 2,998 3,780 Computer expenses 846 938 1,905 Bank charges  438 455 479 $225,872 $225,159 $256,918 Credits Professional fees $172,281 $172,472 $204,700 Interest income 992 456 210 Capital 46,122 43,137 40,117 Accumulated depreciation (furniture and fixtures) 1,692 2,151 2,796 Accumulated depreciation (medical equipment) 4,785 6,943 9,095 $225,872 $225,159 $256,918

Exhibit 8/4: Gross Revenue and Accounts Receivable

 December 31 1979 1986

Gross revenue $116,951 $137,126 Accounts receivable 15,684 32,137

JANUARY 8, 1994 (MORNING)

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CASE 8: DR. LOUIS MICKAEL596

“I’m just starting to see my patients, and I’ve already done a half-day’s work,” Dr. Lou thought when he buzzed his assistant to bring in the first patient. He was 45 minutes late.

Patient Profile

When Dr. Lou walked into Treatment Room 1 to see the first patient of the day, Doris Cantell, he was thinking about how his practice had grown over the years. His practice maintained between 800 and 900 patients in active files. In comparison to other solo practitioners in the area, this would be considered a fairly large patient base. “Well, how are you feeling today?” he asked the matronly woman. Doris and her husband, like many of his patients, were personal friends. In the beginning years of practice, Dr. Lou’s patients had been primarily younger people with an average age in the mid-thirties; their average income was approximately $15,000. Their families and careers were just beginning, and it was not unusual to spend all night with a new mother waiting to deliver a 

Exhibit 8/5: Statements of Income for the Years Ended December 31

 1991 1992 1993

Operating Revenues Professional fees $172,281 $172,472 $204,700 Interest income 992 456 210 Total revenues 173,273 172,928 204,910 Operating Expenses Salaries (Dr. Mickael, Staff) 117,455 124,608 132,325 Professional dues and licenses 1,925 1,873 1,816 Miscellaneous professional expenses 1,228 2,246 3,232 Drugs and medical supplies 2,550 1,631 2,176 Laboratory fees 2,629 524 1,801 Meetings and seminars 2,543 838 3,880 Legal and professional fees 5,525 2,057 5,400 Rent 16,026 16,151 18,932 Office supplies 4,475 3,262 4,989 Publications 1,390 406 401 Telephone 1,531 1,451 2,400 Insurance 8,876 9,629 11,760 Repairs and maintenance 3,547 4,240 5,352 Auto expense 1,009 1,487 3,932 Payroll taxes 3,107 2,998 3,780 Computer expenses 846 938 1,905 Bank charges 438 455 479 Total operating expenses 175,100 174,794 204,560 Net Income (Loss) ($1,827) ($1,866) $350

 Exhibit 8/6: Balance Sheets at December 31

 1991 1992 1993

Assets Capital equipment Medical equipment $11,722 $11,722 $11,722 Furniture and fixtures 3,925 3,925 3,361 Less-accumulated depreciation (6,477) (9,094) (11,891) Total capital equipment 9,170 6,553 3,192 Current assets Cash 15,994 9,564 8,666 Petty cash 50 100 100 Accounts receivable 19,081 25,054 28,509 Total current assets 35,125 34,718 37,277 Total assets $44,295 $41,271 $40,467

Liabilities Current liabilities Income taxes payable ($639) ($653) $122 Dividends payable 1,158 1,154 1,154 Total current liabilities 519 501 1,276 New income (1,188) (1,213) 228 Less dividends 1,158 1,154 1,154 Retained earnings (2,346) (2,367) (926) Capital 46,122 43,137 40,117 Total owner’s equity 43,776 40,770 39,191 Total liabilities and owner’s equity $44,295 $41,271 $40,467

 baby. Although often dead tired, he enjoyed the closeness of the professional relationships he had with his patients. He believed that much of his success as a physician came from “going that extra mile” with them. Many things had changed. Today all pregnancies were referred to specialists in the obstetrics field. His patients ranged in age from 3 to 97, with an average of 58 years; their median income was $25,000. Most were blue-collar workers or recently retired, and their health care needs were quite diverse. Approximately 60 percent of Dr. Lou’s patients were subsidized by Medicare insurance, and most of the retired patients carried supplemental insurance with other third-party payors. Three types of third-party payors were involved in Dr. Lou’s practice: (1) private insurance companies, such as Blue Cross and Blue Shield; (2) government insurance (Medicare and Medicaid); and (3) preferred provider organizations. Preferred provider organizations and health maintenance organizations were forms of group insurance that emerged in response to the need to cut the costs of providing health care to patients, which resulted in the prospective payment system. Both types of organizations developed a list of physicians who would 

Exhibit 

CASE 8: DR. LOUIS MICKAEL598

accept their policies and fee schedules; using the list, subscribers chose the doctor from whom they preferred to obtain health care services. Contrary to reimbursement policies of most other major medical third-party payors, PPOs and HMOs covered the cost of office visits, and the patient might not be responsible for any percentage of that cost. Although the physician had to accept a fee schedule determined by the outside organization, there was an advantage to working with these agencies. A physician might be on the list of more than one organization, and a practice could maintain or expand its patient base through the exposure gained from being listed as a health service provider for such organizations. Those patients who were working usually had coverage through work benefits. Some were now members of a PPO. Dr. Lou was on the provider list of the Northeast Health Care PPO; only a few of his patients were enrolled in the government welfare program. “How’s your daughter doing in college?” Dr. Lou asked. He had a strong rapport with the majority of his patients, many of whom continued to travel to his office for medical needs even after they moved out of the immediate area. “Are you heading south again this winter, and are you maintaining your ‘snowbird’ relationship with Dr. Jackson?” It was not unusual for patients to call from as far away as Florida and Arizona during the winter months to request his opinion about a medical problem, and Doris had called last year to ask him to recommend a physician near their winter home in the South. Because of this personal attention, once patients initiated health care with him, they tended to continue. Dr. Lou had lost very few patients to other physicians in the area since he began to practice medicine. The satisfaction experienced by his patients provided the only marketing function carried out for the practice. Any new patients (other than professional referrals) were drawn to the office through word-of-mouth advertising.

Dr. Lou: Profile of the Physician

Dr. Lou had grown older with many of his patients. His practice spanned more than three generations; a lot of families had been with him since he opened his doors in 1961. Caring for these people, many of whom had become personal friends, was very important to him. However, as the character of the health care industry was changing, Dr. Lou was beginning to feel that he now spent entirely too much time dealing with the “system” rather than taking care of patients. Eighty-year-old Mr. Spence was a good example. Three weeks before, he was discharged from the hospital after having a pacemaker implanted. He had been living at home with his wife, and although she was wheelchair bound, they managed to maintain some semblance of independence with the assistance of part-time care. Lately, however, the man had become more and more confused. The other night he wandered into the yard, fell, and broke his hip. His reentry to the hospital so soon meant that a great deal of paperwork would be needed to justify this second hospital admission. In addition, Dr. Lou expected to receive 

both

calls from their children asking for information to help them determine the best alternatives for the care of both parents from now on. He had never charged a fee for such consultation, considering this to be an extension of the care he normally provided. “Things are really different now,” he thought. “Under this new system I don’t have the flexibility I need to determine how much time I should spend with a patient. The regulations are forcing me to deal with business issues for which I have no background, and these concerns for costs and time efficiency are very frustrating. Medical school trained me in the art and science of treating patients, and in that respect I really feel I do a good job, but no training was provided to prepare me to deal with the business part of a health care practice. I wonder if it’s possible to maintain my standards for quality care and still keep on practicing medicine.”

Local Environment The actual number of city residents had not changed appreciably since the early 1960s, although suburban areas had grown considerably. In the mid-1970s, a four-lane expressway, originally targeted for construction only one mile from the center of the downtown area, was put in place about eight miles farther away. Within five years, most of the stores followed the direction of that main highway artery and moved to a large mall situated about five miles from the original center of the city. Many of the former downtown shops then became empty. Government offices, banking and investment firms, insurance and real estate offices, and a university occupied some of this vacated space; it was used for quite different (primarily service-oriented) business activities. Numerous residential apartments devoted to housing for the elderly and lowincome families were built near the original, downtown shopping area. Several large office buildings (where much space was available for rent) and offices for a number of human services agencies relocated nearby. As he headed across the street to lunch in the hospital dining room, Dr. Lou was again thinking about how things had changed. At first, he had been one of a few physicians in this area. Within the past ten years, however, many new physicians had moved in.

Competition Two large (500-bed) hospitals within easy access of the downtown area had been in operation for over 40 years. One was located immediately within the city limits on the north side of the city; the other was also just inside city limits on the opposite (south) side. They were approximately three miles apart and competed for a market share with City General, a 100-bed facility. This smaller hospital was only two blocks from the old business district; it was the only area hospital where Dr. Lou maintained staff privileges. Exhibit 8/7 contains a map showing the location of the hospitals and Dr. Lou’s office.

CASE 8: DR. LOUIS MICKAEL600

The two large hospitals had begun to actively compete for staff physicians (physicians in private practice who paid fees to a hospital for the privilege of bringing their patients there for treatment). In addition, these two health care institutions offered start-up help for newly certified physicians by providing low-cost office space and ensuring financial support for a certain period of time while they worked through the first months of practice. City General recently began subsidizing physicians coming into the area by providing them with offices inside the hospital. Most of these physicians worked in specialty fields that had a strong market demand, and the hospital gave them a salary and special considerations, such as low rent for the first months of practice, to entice them to stay in the area. These doctors served as consultants to hospital patients admitted by other staff physicians and could influence the length of time a patient remained in the hospital. This was an extremely important issue for the hospital, because under the new regulations a long length of stay could be costly to the facility. All third-party insurors reimbursed only a fixed amount to the hospital for patient care; the payment received was based on the diagnosis under which a patient was admitted. Should a patient develop complications, a specialist could validate the extension of reimbursable time to be added to the length of stay for that patient. In the past few years, many services to patients provided by all these hospitals changed to care provided on an outpatient basis. Advancements in technology made it possible to complete in one day a number of services, including tests and some surgical procedures, which formerly required admission into the hospital and an overnight stay. Many such procedures could also be done by physicians in their offices, but insurance reimbursement was faster and easier if a patient had them done in a hospital. As an example of the degree of change involved, in the mid-1980s, outpatient gross revenue was only 18 percent of total gross revenue for City General. In 1992 this figure was projected to be approximately 30 percent.

January 8, 1994 (Lunchtime)

“May I join you?” Dr. Lou looked up from his lunch to see Jane Duncan, City General’s hospital administrator, standing across the table. “I’d like to talk with you about something.” Dr. Lou thought he knew what this was about. The hospital had been recruiting additional staff physicians (doctors who owned private practices in and around the city). A number of these individuals held family practice certification, a prerequisite for staff privileges in many hospitals. The recruitment program offered financial assistance to physicians who were family practice specialists wishing to move into the area, and also subsidized placement of younger physicians who had recently completed their residencies. In contrast to physicians designated as general practitioners, who had not received training beyond that received through medical school and a residency, “family practitioners” received additional training and passed state board exams written to specifically certify a physician in that field. Last week after a hospital staff meeting, Duncan had caught him in the hall and wanted to know if Dr. Lou had thought about his retirement plans. “It’s really not too soon,” she had said. Dr. Lou knew that one of the methods used to bring in “new blood” was to provide financial backing to a physician wishing to ease out of practice, helping pay the salary of a partner (usually one with family practice certification) until the older physician retired. “She wants to talk to me again about retirement and taking on a partner,” he thought. “But I’m only in my late fifties. And I’m not ready to go to pasture yet! Besides, there’s really no room to install a partner in my office.”

January 8, 1994 (Afternoon)

After lunch Dr. Lou ran back to the office to take a look at Cathy’s husband’s arm before regular office hours started. This was a work-related case. As he treated the patient, he began thinking about industrial medicine as an alternative to full-time office practice. Right then the prospect seemed quite appealing. He had investigated the idea enough to know that there were only a few schools that provided this kind of training but one was within driving distance (Exhibit 8/8 contains information on industrial medicine). As health costs rose over the past decade, manufacturing organizations began to feel the cost pinch of providing health care insurance to employees. Some larger companies in the area began to recognize the cost benefit of maintaining a private physician on staff who was trained in the treatment of health care needs for 

JANUARY 

CASE 8: DR. LOUIS MICKAEL602

industrial workers. Dr. Lou had been considering going back for postgraduate training in industrial medicine, and while wrapping the man’s arm, he began to think about working for a large corporation. “Work like that could have a lot of benefits; it would give me a chance to do something a little different, at least part time for now,” he thought. “The income was almost comparable to what I net for the same time in the office, and some days I might even get home before 9:00 P.M.!”

End of the Day

As he was putting on his coat and getting ready to leave, Dr. Charles, the physician from across the hall, phoned to ask if Dr. Lou might be interested in buying him out. “I think you could use the space,” he said, “and my practice is going down the tubes. I can’t seem to get an upper hand with the finances. I’ve had to borrow every month to maintain the cash flow needed to pay my bills because patients can’t keep up with theirs. City General has offered me a staff position, and I’m seriously considering it. I thought I’d give you first chance.” After some minutes of other “office talk,” Dr. Charles said good night. “If I wanted to take on a new partner, that could work out well,” thought Dr. Lou. “It might be interesting to check into this. I wonder what his asking price would be? It could not be too much more than the value of my practice; although his patients are a bit younger and some of his equipment is a little newer. The 

Exhibit 8/8: Industrial Medicine as a New Career for Dr. Mickael “Industrial Medicine” is an emerging physician specialty. Training in this new field entails postgraduate work and board certification.

As yet, only a few schools provide such training. One is located in Cincinnati, Ohio, which is geographically close enough to be feasible for Dr. Mickael. The time spent in actual attendance amounts to one two-week training period beginning in June of the year in which a physician is accepted for the training. Two additional training periods are each one week in duration: these take place in the months of October and March. After this, the physician was expected to individually study for and take the board certification exams, which were given only once per year; the exams were comprehensive and extended over a two-day period.

Training Program Costs: Industrial Medicine

University Residency: Three, on-site class sessions $4,000.00 Per night cost for room 47.87 Books and supplies (total) 580.53 Transportation, Air: Three, round-trip fares $1,650.00 Transportation, Ground: Car rental, per week with unlimited mileage $125.45

 initial hospital proposal to buy me out indicated that my practice was worth about $175,000. So that means I should be able to negotiate with Dr. Charles for a little less than $200,000.” It was 9:30 P.M. when Dr. Lou finally left the office, and he still had hospital rounds to make. “This is another situation caused by these insurance regulations,” he thought. “I feel as though I’m continuously updating patients’ hospital records throughout the day, and more of my patients require hospitalization more often than they did when they were younger. All things being equal, I’m earning considerably less for doing the same things I did a decade ago, and in addition the paperwork has increased exponentially. There has to be a better way for me to deal with this business of practicing medicine.”

Write at least 300-400 words fractional ownership and it’s relation

 

Write at least 500 words fractional ownership and it’s relation to cloud computing. Use at lesat one example from another industry.    

Use at least three sources. Include at least 3 quotes from your sources enclosed in quotation marks and cited in-line by reference to your reference list.  Example: “words you copied” (citation) These quotes should be one full sentence not altered or paraphrased. Cite your sources using APA format. Use the quotes in your paragaphs.

Practical connection assignment for the course access control

 Notq 

linking research with practice and knowledge with ethical decision-making. This assignment is a written assignment where students will demonstrate how this course research has connected and put into practice within their own careers.

Assignment:

Provide a reflection of at least 500 words (or 2 pages double spaced) of how the knowledge, skills, or theories of this course (Access Control) have been applied or could be applied, in a practical manner to your current work environment. If you are not currently working, share times when you have or could observe these theories and knowledge could be applied to an employment opportunity in your field of study. 

Requirements:

Provide a 500 word (or 2 pages double spaced) minimum reflection.

Use of proper APA formatting and citations. If supporting evidence from outside resources is used those must be properly cited.

Share a personal connection that identifies specific knowledge and theories from this course.

Demonstrate a connection to your current work environment. If you are not employed, demonstrate a connection to your desired work environment.

You should not provide an overview of the assignments assigned in the course. The assignment asks that you reflect on how the knowledge and skills obtained through meeting course objectives were applied or could be applied in the workplace.