tag:blogger.com,1999:blog-80446990786066620222024-03-13T22:00:05.267-07:00Health ManagementMotohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comBlogger25125tag:blogger.com,1999:blog-8044699078606662022.post-89510426464860090332013-01-10T08:23:00.001-08:002013-01-13T13:06:06.234-08:00Keeping your Horse Healthy During the Winter Season<br /><br /><div class="MsoNormal"><br /></div><br /><div class="MsoNormal"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /><a href="http://3.bp.blogspot.com/-GMrTJ5TpX2A/UNysYNCayfI/AAAAAAAAAGw/xPoyhw21IIE/s1600/stable_items_stock___4_by_childofatlas-d3kjux9.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="239" src="http://3.bp.blogspot.com/-GMrTJ5TpX2A/UNysYNCayfI/AAAAAAAAAGw/xPoyhw21IIE/s320/stable_items_stock___4_by_childofatlas-d3kjux9.jpg" width="320" /></a></div><br /><div class="MsoNormal"><br /></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">The grime that builds up on grooming brushes and<br />other tools is more than just unsightly; it may harbor bacteria and fungi that<br />can cause a number of diseases. Any tools that come in contact with your horse<br />or his wastes—including muck buckets, shovels, wheelbarrows and hoof<br />picks—ought to be sanitized with a disinfectant periodically. It’s especially<br />important to sanitize any tools you’ve used caring for a sick horse. Here are<br />the basic steps:<o:p></o:p></span></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Scrape or knock off any hair or caked-on dirt and<br />debris.<o:p></o:p></span></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Clean with a squirt or two of dish or laundry<br />detergent in a gallon or more of water. Scrub your grooming brushes against<br />each other to remove all dirt; use scrub brushes on larger tools and buckets.<o:p></o:p></span></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Rinse thoroughly with clean water.<o:p></o:p></span></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">For extra disinfection, soak the tools in a<br />commercial sanitizer, such as phenol, quaternary ammonium, accelerated hydrogen<br />peroxide or a peroxygen-based product, or a mild bleach solution for at least<br />10 minutes as recommended by your veterinarian. The type of disinfectant needed<br />will vary with the targeted micro-organism and the surface of the material<br />being cleaned. Read the labels for handling instructions and safety<br />precautions; use rubber gloves and safety goggles to protect your skin and<br />eyes.<o:p></o:p></span></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Rinse feed and water buckets thoroughly, making sure<br />no soap or chemical residue remains.<o:p></o:p></span></div><br /><div class="MsoNormal"><br /><span style="font-family: "Times New Roman","serif"; font-size: 12pt; line-height: 115%;">Set the items out in bright sunlight to dry—the<br />ultraviolet light will kill more pathogens.<o:p></o:p></span></div><br /><br />Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-69246471894375803212013-01-10T08:22:00.000-08:002013-01-13T13:06:06.197-08:00Seasonal Mare Behavior <div class="separator" style="clear: both; text-align: center;"><br /><a href="http://2.bp.blogspot.com/-ONCByvQ4qpA/UK0lcjNn0dI/AAAAAAAAAGc/Sse1CUphHvg/s1600/6207312867_8d5e728488_z.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-ONCByvQ4qpA/UK0lcjNn0dI/AAAAAAAAAGc/Sse1CUphHvg/s320/6207312867_8d5e728488_z.jpg" width="302" /></a></div><br /> If your other wise cranky mare mellows out this winter, shorter days may be the reason. A mare's reproductive cycle is controlled by her hormones, which in turn are influenced by exposure to sunlight. From early spring to late fall, she is in the estrus phase of her cycle, during which eggs mature and are released every 19-22 days.<br /><br /> So-called "marish" behavior aggressiveness, impatience and general grumpiness is more common during estrus because of increased hormone levels. As days become shorter, the mare's body produces the hormone melatonin, which shifts her into anestrus. During this period, no eggs are released. The transition to anestrus begins in late fall. By winter solstice, a mare will be in the deepest part of the phase and may seem more calm and easygoing.<br /><br /> Not all behavior changes in mares are hormone related, however, and it's wise to investigate them even if you think you know the cause. If your mare's personality seems different this winter, start recording your observations, including checks of her vital signs, in a daily journal. Call your veterinarian if she shows any other signs of illness. Continue the journal through the spring and summer, noting her reaction in various environments and situations, such as being in the pasture with other horses or being tacked up for riding. Comparing her attitudes during the winter and summer can help you identify possible hormone related behaviors. Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-2289551255528383862013-01-10T08:21:00.000-08:002013-01-13T13:06:06.176-08:005 Ways to Get Ready for Winter <br /><br /><div class="separator" style="clear: both; text-align: center;"><br /><a href="http://2.bp.blogspot.com/-YsJ6qfKSXow/UKKWfEUdfiI/AAAAAAAAAGM/LFC8kVGZ8h4/s1600/2749285156_33b33395c9.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="http://2.bp.blogspot.com/-YsJ6qfKSXow/UKKWfEUdfiI/AAAAAAAAAGM/LFC8kVGZ8h4/s400/2749285156_33b33395c9.jpg" width="400" /> </a></div><br /><br /><br /><br /><br /><div class="separator" style="clear: both; text-align: left;"><br /><b> 1. Protect Medication.</b> Check the labels of all injectable, topical and oral medications for information about proper storage. Many cannot withstand cold temperatures and will become useless, if not harmful, if they freeze. Either store cold-sensitive products in a climate-controlled tack room, or take them to your house for the winter. Check expiration dates and replace any products that have gotten too old. If you're unsure whether one of your drugs is still safe, ask your veterinarian. He can also advise you on how to properly dispose of old or damaged products.</div><br /><b>2. Mow and drag your pasture.</b> Cutting weeds before they go to seed will help keep them under control next year, and especially if you're taking your horse off the grass for the winter, dragging the manure will give it plenty of time to decompose. But don't mow to less than four inches-the grass still needs reserves to help the roots survive the cold months.<br /><br /><b>3. Walk your fence lines.</b> Shake the posts as you go, looking for loose boards or wires, protruding nails or fasteners, leaning or other signs of developing weakness. Carry a tool belt to make minor repairs as you go, as well as brightly colored tape to mark areas that will require more attention later. <br /><br /><b>4. Inspect your blankets.</b> Even if you cleaned and stored your blankets properly at the end of last season, it's a good idea to take them out and have a look at them well before you'll need them again. Mold, insects or rodents may have gotten to them while they were in storage. Check for loose straps, frayed fabric, holes or foul smells, and repair or replace any blankets that need attention. <br /><br />Also make sure each garment still fits properly. Youngsters, athletes, seniors or laid-up horses may have gained or lost a significant amount of weight over the summer and may not be able to wear the same blanket again. A properly fitting blanket allows a hand to fit snugly under and slide around along the shoulder, withers, and rump. <br /><br /><b>5. Adjust the airflow in each stall.</b> Too little ventilation in a horse's stall means the airborne dust can accumulate quickly to unhealthy levels; too much airflow can mean bone-chilling drafts. Check how the air is moving in each stall with one of these two methods:<br /><br /><i>Scuff your boots in the bedding, enough to kick up dust.</i> After five minutes use a flashlight or other light source to check the air. If you can still see floating particles, the air is too stagnant. <br /><br /><i>Hold a strip of toilet paper, about a foot or two long, at arm's length at different places in the stall.</i> You want to see it waving gently, to indicate a gentle breeze. If it's either hanging motionless or flapping vigorously, the airflow is too low or too high. Open and close the doors and windows until you reach the ideal amount of ventilation. Usually, a few open windows on the leeward side of the barn, sheltered from snow and rain, provide a healthy supply of fresh air. Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-22721292744003718982013-01-10T08:20:00.000-08:002013-01-13T13:06:06.175-08:005th Annual Client Appreciation BBQ <div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /><a href="http://2.bp.blogspot.com/_0JUBm3cwLNs/TOMCO10wc3I/AAAAAAAAAE0/wmOW57tgvWM/s1600/5175751810_1a5126a16e_b.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="291" src="http://2.bp.blogspot.com/_0JUBm3cwLNs/TOMCO10wc3I/AAAAAAAAAE0/wmOW57tgvWM/s320/5175751810_1a5126a16e_b.jpg" width="320" /></a><a href="http://1.bp.blogspot.com/_0JUBm3cwLNs/TOMCKEwPgFI/AAAAAAAAAEg/yu6gmIW_nio/s1600/5175129053_5ca55c9533_b.jpg" imageanchor="1" style="margin-left: 1em; 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margin-right: 1em;"><img border="0" height="255" src="http://3.bp.blogspot.com/_0JUBm3cwLNs/TOMCWsDp3vI/AAAAAAAAAFM/_53Pf4qoO7w/s320/5175834172_9106236a37_b.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div style="text-align: center;"><br /><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div style="text-align: center;"><br />DIDN'T SEE YOUR PICTURE WITH TYE THE ELEPHANT?</div><br /><div style="text-align: center;"><br />CLICK THE LINK TO FIND YOUR PICTURE AND DOWNLOAD TO YOUR HOME COMPUTER! <br /><br /><a href="http://www.flickr.com/photos/94597165@N00/">http://www.flickr.com/photos/94597165@N00/</a></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br /><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><br /><br />Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-5349959642691313042013-01-10T08:19:00.000-08:002013-01-13T13:06:06.191-08:00West Nile Innovator DNA VaccineRiverside county is still battling cases of West Nile. Our office alone has seen over 5 cases last year. <b>Now Available</b>, A revolutionary DNA <span class="blsp-spelling-corrected" id="SPELLING_ERROR_0">vaccine</span> that doesn't require a virus to carry it into the horse. Instead, the engineered DNA goes directly into the nucleus of the host's cells, causing the cell to create an immune response that mimics the body's response to natural infection. This process will enhance the ability to safely vaccinate the immune compromised patient young and old. <b>Call your doctor today for more information</b>.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-11219264106758064652013-01-10T08:18:00.001-08:002013-01-13T13:06:06.170-08:00<a href="http://www.thehorse.com/ViewArticle.aspx?ID=11359">http://www.thehorse.com/ViewArticle.aspx?ID=11359</a>Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-27566038604767221312013-01-10T08:18:00.000-08:002013-01-13T13:06:06.181-08:00VACCINE PROTOCOL UPDATEThe American Assoication of Equine Practitioners (AAEP) recently undated its Guidelines for Vaccination. <b>Rabies</b> has been added to the list of core vaccines that should be administered to all horses annually in addition to our current list of West Nile, Eastern Equine Encephalomyelitis, Western Equine Encephalomyelitis, and Tetanus.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-28437918084247425622012-06-27T13:34:00.000-07:002013-01-13T13:06:06.182-08:00Dutch Health System study tour - TuesdayTuesday morning was focused entirely on meetings with representatives from the Dutch Ministry of Health, Welfare and Sport. We were met by Annemarieke Taal and Paul Thewissen who took us through the organization, financing and delivery of health services in the Netherlands. Among the key facts shared with us were:<div><br /></div><div>The Netherlands has some 16 million persons living here and there are 83 general hospitals of which 28 are more specialized along with 8 academic health centers. The Netherlands has some 26,000 physicians and 82,000 support staff. Just under 1/3 of all physicians are general practitioners. There are just under 20 commercial health insurance companies that cover every Dutch citizen. The Netherlands spends about 60 billion Euros per year representing just over 10% of their GDP.</div><div><br /></div><div>Hospitals are run as non-profit entities most of which are 100 beds or more in size. In the Netherlands, primary care physicians play a central role as the gatekeepers to the system. 24/7 access is provided through a series of "posts" that are manned by general practitioners. Physicians are paid a fixed price quarterly based on the number of patients in their practice and will get additional negotiated monthly compensation based on providing consultations. </div><div><br /></div><div>The Dutch health insurance system provides care to everyone under the terms of an individual mandate. A basic group of services are provided to everyone including physician and hospital care including long term care. In 2006, The Health Insurance Act effectively expanded insurance coverage to everyone. Insurance companies must cover all citizens regardless of preexisting conditions. Health insurance is paid by a combination of taxes and a yearly deductible of 350 Euros.</div><div><br /></div><div>Cost control continues to be a major problem in the Netherlands as they try to get a handle on reducing a 4-5% annual increase in health costs and health expenses are rapidly crowding out spending on other public expenses.</div><div><br /></div><div>The bottom line for me is that despite the concerns expressed about the costs of the system, the Netherlands has an individual mandate that provides health insurance for each and every person at a GDP and per capita cost significantly less than the United States coupled with outstanding health status indicators.</div><div><br /></div><div>Our afternoon took us to The Hague, site of the seat of government for the Netherlands. We took the time to explore, Knights Hall (<a href="http://en.denhaag.nl/en/residents/culture-and-arts/to/Knights-Hall.htm">http://en.denhaag.nl/en/residents/culture-and-arts/to/Knights-Hall.htm</a>). This one time hunting lodge was converted to the site of the Queen's annual address the third Thursday in September. The Hague is a thoroughly charming city and I would recommend it to anyone considering a trip to the Netherlands.</div>Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-72688230029159476532012-06-25T13:45:00.000-07:002013-01-13T13:06:06.198-08:00Dutch Health System Study Tour - MondayOur travels today took us to two very different hospitals. Our first stop was to the VU (Free University) Medical Center ( <a href="http://www.vumc.com/patientcare/about/">http://www.vumc.com/patientcare/about/</a>). We met Dr. Fokke Rakers, Director of Real Estate for the hospital. They are one of a handful of academic health centers in the Netherlands. With 713 licensed beds and over 50,000 admissions in 2009, they are one of the smaller AHC's in the country. This is an AHC whose strategy is focused on the merger with a major psychiatric hospital, a strategic alliance with the Amsterdam Medical Center, adoption of lean, centralization of imaging functions, growth of human health and life science and network development. All of these new initiatives along with the tremendous number of new buildings on the campus are funded through internal resources and not government grants or reimbursement through insurance payments.<div><br /></div><div>We learned that the Netherlands spends about 10.5% of its GDP on health care with the second best clinical outcomes and health indicators in all of Europe (behind Sweden). We were informed that the lean journey began two years ago starting in the OR. Results to date have been very positive with little or no resistance by physicians and nurses.</div><div><br /></div><div>After the presentation by Dr. Rakers, we got to visit the new pediatrics unit. It presents a warm, welcoming and comforting environment for children undergoing treatment at the hospital and their parents.</div><div><br /></div><div>We then traveled to the Antoni van Leeuwenhoek Comprehensive Cancer Center (<a href="http://www.nki.nl/Research/">http://www.nki.nl/Research/</a>). Their total focus in on the prevention and treatment of cancer by doing both basic and clinical/scientific research. Their in-patient hospital has 180 licensed beds and in 2011, had 7,400 in-patient admissions and 30,700 outpatient visits. The hospital will be celebrating its centennial in October 2013. Theirs is a highly patient focused experience that seeks to provide to support patients and their families.</div><div><br /></div><div>There were a number of interesting attributes about the Cancer Center. All of their physicians are on salary and are on the same six step salary scale. We learned afterwards that certain clinical specialists have the potential to earn additional revenue from various sources. The hospital is looking to grow by 70% in 2020 and partner with an academic health center in Utrecht. In the Netherlands, data about cancer patients and their treatment is collected on a national level and as a result, the hospital has adopted a robust operations management and quality improvement program. Another interesting piece of information was that the Dutch government and the commercial insurance companies have adopted standards related to the volume of services done and the willingness to pay for these services. Stated another way, insurance companies will pay only if a certain minimum number of procedures are done annually.</div><div><br /></div><div>After a brief tour of the hospital, it was time to depart for the day. Tomorrow, we travel to the Hague for a meeting with representatives from the Ministry of Health.</div>Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-84579848257671225952012-06-24T09:21:00.000-07:002013-01-13T13:06:06.202-08:00Dutch health system study tourHere we are back on the road - this time in the Netherlands as part of the AUPHA sponsored study tour of the Dutch health system. I will be blogging each night this coming week to share my thoughts and observations about the health system of this small country. Please send me a note if you have any thoughts or questions that I might address while we are here.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-47313179596025347942012-01-03T16:27:00.000-08:002013-01-13T13:06:06.189-08:00What the US healthcare system can learn from Israel<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> 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table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin-top:0in; mso-para-margin-right:0in; mso-para-margin-bottom:10.0pt; mso-para-margin-left:0in; line-height:115%; mso-pagination:widow-orphan; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-ascii-font-family:Calibri; mso-ascii-theme-font:minor-latin; mso-hansi-font-family:Calibri; mso-hansi-theme-font:minor-latin;} </style><![endif]--> <br /><div align="center" class="MsoNormal" style="text-align: center;"><span style="font-size: 12.0pt; line-height: 115%;">Rethinking Healthcare Reform: Lessons Learned from Israel</span></div><div align="center" class="MsoNormal" style="text-align: center;"><br /></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;">In what seems like a lifetime ago, the United States Congress in 2010 passed and President Obama signed into law the Affordable Care Act (ACA). While the Act is certainly complex and remains the fodder of heated political debate, the basic intent of the bill is to make healthcare more widely accessible to the tens of millions of Americans who do not currently have health insurance.<span style="mso-spacerun: yes;"> </span>The centerpiece of the ACA is the requirement that citizens purchase health insurance either through their employer or through one of several insurance exchanges.<span style="mso-spacerun: yes;"> </span>It is reasonable to ask how a system like that might work and how other nations who have adopted similar programs have done relative to health outcomes, consumer satisfaction and eliminating or reducing health disparities. <span style="mso-spacerun: yes;"> </span>While a number of industrialized nations provide health care through a single payer (government run) system, others have made a public-private system the model they use to guarantee health services to all their citizens. One of those nations is Israel which (as it turns out) has a lot to teach the United States on how to operate a universal health system that is based on both private and public inputs.</span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;">In close cooperation with the leadership and faculty from the Hebrew University of Jerusalem, Hadassah Hospital, and the Braun School of Public Health, seven students and two faculty members from the George Washington University School of Public Health and Health Services recently completed a two week study tour of Israel’s healthcare delivery system. The objective of the study tour was to allow these future healthcare leaders the opportunity to critically examine the organization, financing and delivery of health services throughout Israel. Through a combination of classroom and field based learning, the students discovered the following:</span></div><div class="MsoNormal"><br /></div><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">Israel adopted its national health system in 1995 requiring all permanent residents be provided a standard basket of services including physician care, hospitalization, prescription drugs and dental care for children </span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">Healthcare is paid for by a combination of earmarked health tax payments, funding from the Ministry of Health and co-payments paid when services are delivered.</span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">Four “sick funds” or HMO’s act as the insurance plan for all residents. Persons can freely choose any of the sick funds and can access any physician or hospital in the plan. The sick funds may offer supplemental coverage that is highly regulated.</span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">Health coverage for every resident of Israel is accomplished for 8.7% of GDP in contrast to the US cost of 17.6% where there are almost 51 million without health insurance</span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">By virtually all commonly used indicators including life expectancy and maternal and child health measures, Israel far outperforms the US.</span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">An electronic health record ties together all the patient information for each of the four health plans and is accessible to physicians, hospitals and patients </span></li></ul><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;">This is not to say that the healthcare system in Israel is flawless and could not be improved.<span style="mso-spacerun: yes;"> </span>The out of pocket costs to consumers continues to rise, there remain a number of critical health disparities particularly Israeli Arabs and peripheral populations and last year a 158 day physician strike over wages and working conditions revealed that provider working conditions must improve. </span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;">Despite the problems in Israel’s system, there are a number of important observations our students made that can have direct application to the United States and the implementation of the ACA including:</span></div><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">Cost control is essential particularly with respect to the payment to physicians and the reimbursement to hospitals. </span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">The patients and their health and well being are at the heart of the Israeli system. Here in the US, the physicians, hospitals and commercial health insurance all believe that the system exists for their benefit.</span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">An integrated electronic health record available to every one of the patients in the four HMO’s in Israel serves to reduce waste and duplication, gives physicians immediate access to clinical information and helps drive rational administrative decisions.<span style="mso-spacerun: yes;"> </span>We are moving in this direction but progress is slow and uneven</span></li></ul><ul><li><span style="font-family: Symbol; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%;">The national standard basket of services assures that all patients, regardless of the HMO they choose, are guaranteed a uniform basic set of health services, which supports social cohesion.<span style="mso-spacerun: yes;"> </span>Allowing each of the states to determine what services will be covered under the ACA forgoes this cohesion.</span></li></ul><div class="MsoNormal"><span style="font-size: 12.0pt; line-height: 115%;">Perhaps the most important lesson learned by our students is the level of support that exists in Israel particularly around healthcare delivery.<span style="mso-spacerun: yes;"> </span>There is an overt and covert sense that everyone is in this particular boat together and that it makes sense for everyone to have access to healthcare. In the end, this is what the ACA is trying to accomplish. All we need do is look to a small nation on the Eastern Mediterranean for an example of how to do this right. </span></div>Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-40614896965200543962011-12-23T19:56:00.000-08:002013-01-13T13:06:06.185-08:00Israel trip day 13 - 23 DecemberWell, this is it - our final day in Israel. We met as a group first thing in the morning to debrief the trip on a number of levels: content, culture and logistics. The comments from everyone in the group were so helpful as we begin the work of planning the next study tour to Israel. The one thing that we must do is thoroughly brief the participants about the US healthcare system if we expect everyone to be on the same page when comparing the US system with any other. We also need to make sure that the students arrive in country first thing in the morning and then give them that day to rest and prepare for subsequent activities.<br /><br />I want to be sure to thank Orly Manor, Director of the Braun School of Public Health at Hebrew University for making herself and her faculty available to us at every turn. All of the Braun School faculty are truly wonderful and dedicated teachers and scholars. Dr. David Chinitz is truly a mensch. His vision and energy gave us access to the breadth and depth of the Israeli health care system in a way I could have never imagined. He is also a passionate and inspiring teacher and is someone who I look forward to working with long into the future. Thanks to Vardit Luzon who worked so hard to put together a travel package that came in under budget while at the same time meeting and exceeding all of my expectations. Thanks to Nathan our guide whose encyclopedic knowledge of Israel was something to behold. Thanks as well to Sami whose skill at maneuvering our bus through impossibly crowded and busy streets was nothing short of magical. Thanks to Laura Ochs at the George Washington University International Studies Office for all of her efforts to keep me calm and focused during the planning of the trip. Thank you to Bob Burke, Chairman of the Department of Health Services Management and Leadership and Lynn Goldman, Dean of the School of Public Health and Health Services for your trust, confidence and commitment.<br /><br />Special thanks and appreciation must go to Arthur Shorr. Three years ago, Arthur had a vision to bring a group of students to Israel and provide them with an opportunity to learn about the way health care is delivered in this very special nation. He remained persistent and focused throughout. I am glad that we gave him a chance to upgrade his Hebrew since he was speaking it like a native at the end. Arthur is an inspiration to me and I am so grateful he was here with us.<br /><br />Finally, thanks to Teke, Vincent, Karen, Bijay, Morgane, Jeremy and LeMia - our students for whom this trip was intended and who were always fully engaged and energized even when it seemed like the days would never end. The seven of you are truly wonderful and special people and without you, none of this would have happened. Thanks to the seven of you for helping me to learn more.<br /><br />So, on this early Saturday morning 24 December, let me wish all of you Shabat shalom and best wishes for a happy and healthy 2012.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-22913439930840964782011-12-23T07:00:00.000-08:002013-01-13T13:06:06.178-08:00Israel trip day 12 - 22 DecemberI have difficulty believing that we are just about done with our trip to Israel. The last 12 days have flown by in a blur. Today we began with a visit to the <a href="http://web.nli.org.il/sites/NLI/English/Pages/default.aspx">National Library of Israel</a> which is on the campus of <a href="http://www.huji.ac.il/huji/eng/">Hebrew University of Jerusalem</a>. The National Library is equivalent to our Library of Congress. It is housed in a building that is clearly too small for the collection and the many scholars, librarians and visitors that come in each year. We spent the large part of our time in the archives and rare books section where we were treated to an up close view of a number of books that focused on the history of medicine including a first edition of the book written in 1543 by the Flemish anatomist <a href="http://evolution.berkeley.edu/evolibrary/article/history_02">Andreas Vesalius</a>. <br /><br />Our visit to the National Library was done too soon and we took the short walk to the <a href="http://www.english.imjnet.org.il/htmls/home.aspx">Israel Museum</a>. This is truly one of the most magnificent museums in the world that combine multiple worlds including art, culture and history. Spending 3.5 hours at the was far too short a time to take in everything from the Dead Sea Scrolls, the extensive archaeology section, sculpture throughout the exterior, Impressionist galleries, Jewish art and life and the Second Temple Model.<br /><br />In mid afternoon, we met up with David Chinitz and walked to the <a href="http://brookdale.jdc.org.il/">Brookdale Institute for Applied Social Research</a>. There, we were met by Dr. Bruce Rosen, Director of the Smokler Center for Health Policy Research. According to their website and verified by David Chinitz and others, <span style="font-family: Times, 'Times New Roman', serif;">"<span style="background-color: white; text-align: justify;">The main objective of the Smokler Center for Health Policy Research is to contribute to reforms and the development of Israel's national health services by offering objective data and independent analysis to improve the organization, delivery and financing of health services. In addition to hearing about the important work done by the Smokler Center, Dr. Rosen was particularly interested in hearing from our students about their impressions of Israel's health care delivery system. Wanting to hear from our students was so gratifying to me as I listened to what they shared with some of the leading figures in health services research in Israel.</span></span><br /><span style="font-family: Times, 'Times New Roman', serif;"><span style="background-color: white; text-align: justify;"><br /></span></span><br /><span style="font-family: Times, 'Times New Roman', serif;"><span style="background-color: white; text-align: justify;">Leaving the Brookdale Institute, we had come to the end of our formal academic segment of the trip. One more day on Friday and then it is time to depart.</span></span><br /><span style="font-family: Times, 'Times New Roman', serif;"><span style="background-color: white; text-align: justify;"><br /></span></span>Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-21865735077532934052011-12-23T06:06:00.000-08:002013-01-13T13:06:06.173-08:00Israel trip day 11 - 21 DecemberWe were packed and on the bus early today for our 8:00 AM appointment with the chief medical officer at the <a href="http://en.wikipedia.org/wiki/Unit_669">669th Airborne Division</a> of the Israeli Air Force housed at <a href="http://en.wikipedia.org/wiki/Tel_Nof_Airbase">Tel Nof Air Base</a> located about a half hour south of Tel Aviv. We were not permitted to take photographs while on the base and while the CMO was giving his presentation, there were two intelligence officers present to make sure he did not say anything against the rules. We were given a very thorough briefing of the activities of the 669th including a lengthy discussion of the role they played in the immediate aftermath of the Haiti earthquake in 2010 when the physicians and medics were sent to Port au Prince to establish a field hospital that treated hundreds of victims during the time they were in country. We were shown their search and rescue gear and got to see their training hanger where they can simulate virtually any environmental condition to allow their paramedics to practice their skills at rescue and patient evaluation.<br /><br />Once we were escorted out of Tel Nof, we drove back to Tel Aviv where we bid farewell to our guide, Nathan. He was wonderful and was an absolute treasure trove of insights and information. We headed for lunch at a wonderful seafood restaurant in Old Jaffa named, Old Man and the Sea (note the Ernest Hemingway allusion). Small plate after small plate of Mediterranean inspired salads and wonderful pita bread followed by your choice of whole fish that was likely swimming nearby not long before. Simply seasoned and grilled, the only hassle was that you had to work around the bones.<br /><br />Once lunch was done, we went to headquarters of <a href="http://www.maccabi4u.co.il/1781-he/Maccabi.aspx">Maccabi Healthcare System</a> in Tel Aviv where we were met by Dr. Rachelle Kay, Deputy Director of the Division of Finance and Planning and Director of the Maccabi Institute for Health Services Research. Maccabi is the second largest HMO in Israel with 1.9 million members and 5,000 employed physicians. They have contracts with every public hospital in Israel and owns Assuta Medical Centers. Last year, Maccabi rolled out a comprehensive electronic health record connecting every one of their physicians to their hospitals. This EHR allows every physician access to a dashboard looking at multiple quality indicators. Data is pulled from a data warehouse that contains comprehensive clinical information for each and every Maccabi patient. We were joined by a number of other key Maccabi staff members who shared with us the work they were doing in medical informatics, telemedicine and quality management. The only comparable non-federal US health care organization doing similar work is Kaiser-Permenante. I was very impressed with their dedication to using data to make good clinical and administrative decisions. Dr. Kaye did acknowledge that for the first time Maccabi was running a deficit and this was an important focus for the organization.<br /><br />Just as the lights for the second night of Hanukkah were being lit, we got back on the bus for the long drive back to Jerusalem. It was comforting to get back to Jerusalem where we knew our way around. It was a bit like coming home.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-74457303154177042602011-12-22T11:32:00.000-08:002013-01-13T13:06:06.201-08:00Israel trip day 10 - 20 DecemberThis was a bit of an out of the ordinary day. Up until now, we had focused on the delivery and payment of health services in Israel. This morning, we were dropped off near a local shopping area and walked to the offices of the <a href="http://www.kavlaoved.org.il/media-view_eng.asp?id=3348">Migrant Workers Hotline</a>. We received an in-depth briefing from one of their senior staff on the plight of foreign workers who enter Israel to typically work in a variety of service or agricultural activities. There are over 100,000 legal migrant workers in Israel who are typically here from either the Philippines or China. These workers are allowed to be in the country for up to five years if they have a contract from their employer who is responsible for purchasing health insurance for these workers. We learned that these workers can not become Israeli citizens even if their children are born in Israel. <div><br /></div><div>Another group we learned about were refugees, typically from Eritrea. Israel has a relatively open border to the non-Arab parts of Africa and many refugees enter the country by crossing into the Negev Desert. While the living conditions of the refugees is pretty sad, it is far better than what they left behind in Eritrea. Many of these people earn a living as a day laborer or in some cases, run their own businesses in an area close to the Central Bus Station. Walking through this area was certainly not something typically found in the tour books.</div><div><br /></div><div>After our morning walk and post graduate education about a part of Israel most people don't think about, we stopped for lunch and then gave everyone the rest of the afternoon off. While the students went off in various directions to explore Tel Aviv, Arthur Shorr and I went to the old city of <a href="http://www.inisrael.com/tour/telaviv/jaffa.html">Jaffa</a>. This is a beautiful destination that hugs the coast just south of Tel Aviv. Lots of art galleries, shops, museums and places to stop and enjoy a cappuccino at a sidewalk cafe. </div><div><br /></div><div>The evening was spent grading final exams and posting grades. Later in the evening, was met by the brother and sister in law of the travel agent who set up the trip. Both Ruthie and Miky are pediatricians who work for one of the large health plans in Tel Aviv. They were absolutely lovely people and I thoroughly enjoyed my time with them.</div>Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-37010750325521383942011-12-21T12:13:00.000-08:002013-01-13T13:06:06.184-08:00Israel trip day 9 - 19 DecemberThe Madison Nahariya hotel won the prize with the students for the best dinner and breakfast so far on trip. We packed up and boarded the bus for a short drive to the <a href="http://www.wgh.org.il/?CategoryID=655">Western Galilee Hospital</a>. We were met by their director Masad Barhoun who shared with us the history and interesting attributes of the hospital. In contrast to Hasassah Hospital, Western Galilee is a public hospital dependent almost totally on funding from the government. The hospital has 660 beds and is considered a rural hospital despite its size. One other thing of note, is that the hospital is just six miles from the border with Lebanon and came under fire during the 2006 war with Lebanon. Over 800 rockets fell in the vicinity of the hospital and one struck the ophthalmology wing. Fortunately no one was killed since the hospital had moved all the patients and staff into a subterranean hospital that had been designed just for this type of event. We took a tour of the hospital including the new ER which is designed to withstand virtually any type of attack scenario as is the new women's health center and cardiac wing. One of the things that was emphasized over and over was the drill and training all the staff go through to confront any type of emergency. This continuous drilling gives the hospital and the staff the resilience to respond to essentially any type of disaster scenario. How amazing would it be if US hospitals were equally prepared to deal with a disruptive event?<br /><br />After departing the hospital we, made the short drive to a community clinic run by <a href="http://www.clalit.co.il/he-il/english">Clalit</a>, the largest of the four national HMO's in Israel. We got to meet the director, Dr. Saab Anwar who took us through the organization and operation of Clalit and his clinic in Nahariya. One of the notable attributes to Clalit is their dedication to health and wellness with the focus on the patient first and foremost. We visited with the staff from the pediatric clinic, women's health clinic and pharmacy. Their electronic health record ties together all patient encounters whether with a physician or a hospital. I think that all of us came away impressed by the passion and dedication shown by all the persons we met at the Nahariya Clalit clinic.<br /><br />When finished at Nahariya, we drove south into Tel Aviv. With afternoon traffic it took two hours but we would our hotel adjacent to the beach and close to Ben Yehuda Street. Thankfully, there was a coffee shop nearby that had blazing fast internet access since the hotel's router was down and out. 13 shekels for a cappuccino and internet access until they closed at 10:00 is a great deal.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-41609437544334735432011-12-21T11:15:00.000-08:002013-01-13T13:06:06.186-08:00Israel trip - weekend activitiesAs previously noted, I took a break from the blog when we took a break from the academic part of our visit. Unfortunately, between very spotty internet in Nahariya and our hotel in Tel Aviv coupled with the need to get grades done for my class, I am only returning to my writing tonight. Rather than provide an overly long and overly boring essay, I will start with the weekend activities and begin anew with our activities and impressions on Monday, Tuesday and Wednesday.<br /><br />Friday morning was dedicated to touring the Old City of Jerusalem. We started in the Jewish Quarter and made our way through the Muslim and Christian Quarters. For those of you who have never been here, the Old City is truly the crossroads of the three monotheistic religions yet all seem to be able to successfully coexist. We started in the Garden Tomb in East Jerusalem then made our way through Herod's Gate and into Muslim Quarter. After walking past store after store and vendor after vendor, we entered the Church of the Holy Sepulcher where we spent a significant time exploring this amazing structure. Once the Old City was done, we gave everyone the afternoon off to spend the rest of the day on their own. In Israel, Shabat effectively begins at 3:00 when almost every retail outlet, bank and restaurant shuts through Saturday at sundown. This was also the day we said farewell to my lovely wife Lydia who had to fly back to Washington that evening.<br /><br />Saturday we got an early start when we headed south into the Judean desert to visit Masada and the Dead Sea. For those unfamiliar with the story of Masada, you might want to check out <a href="http://www.jewishvirtuallibrary.org/jsource/Judaism/masada.html">http://www.jewishvirtuallibrary.org/jsource/Judaism/masada.html</a> where you can read the complete story. Rather than climb the snake trail up the side of the mountain, we took the tram and had an amazing visit to this truly wondrous sight. Returning from Masada, we stopped at a beach next to the Dead Sea. Located almost 1,400 feet below sea level, it is the lowest spot on earth. A number of our students took a dip in the ultra salty water and then came out to cover themselves in Dead Sea mud. The day was perfectly clear and we could see the coast of Jordan directly across the Dead Sea.<br /><br />Sunday was a day of transition. We checked out of our hotel to head north but first, we were able to get into the tunnels beneath the Western Wall. Our guide gave us a wonderful introduction to the tunnels and pulled together for us how the Old City has evolved since the time of Herod. We said farewell to Jerusalem and drove north to the north coastal site of <a href="http://www.jewishvirtuallibrary.org/jsource/vie/Caesarea.html">Casearea</a>. These old Roman ruins date back to the time of (you guessed it) Herod who found it a convenient port to resupply his efforts to build his little empire. There are a number of lovely little seaside restaurants, art galleries and other vendors. After our visit to Casearea, we drove through Haifa and stopped in <a href="http://www.jewishvirtuallibrary.org/jsource/vie/Acco.html">Akko</a> for an all too brief visit to this amazing underground city. By all indications, Akko is one of the oldest continuously occupied cities in the world dating back to the time of ancient Egypt and the Pharaohs. Departing Akko after dark, we drove another 45 minutes or so until we arrived at our final destination for the day, Nahariya, a beautiful coastal resort just 10 kilometers (6 miles) from the border with Lebanon. Just a side note, the hotel was hosting a convention of police officers from across Israel and everyone of them was packing heat.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-10335373055338392432011-12-15T10:54:00.000-08:002013-01-13T13:06:06.169-08:00Israel Trip Day 5 - 15 December 2011Today was less hectic than we had experienced previously. We heard two lectures at Hebrew University and the Braun School of Public Health. The first was jointly conducted by Professor Orly Manor, Dr Amnon Lahad and Dr. Dina Jaffe on the theme of the Community Medicine Quality Standards. In 2004, the Ministry of Health adopted a program for quality indicators in community health care. It was designed to provide consumers and policy makers with information on the quality of community based care delivered by the four HMO's in Israel. Virtually the entire population is part of the database. The data is developed on the basis of: importance/relevance; evidence based; ability to quantify; available electronically; and possible to be implemented. There are six broad measures including: asthma; cancer screening; rate of immunizations for older adults; child and adolescent health; cardiovascular health; and diabetes. A number of quantifiable measures are associated with each measure. The main findings from 2007-09 were that in most areas, healthcare quality had increased over the prior five years and that disparities continue to exist.<br /><br />The second and final presentation was on economic behavior in Israel's health care system. Dr. Amir Shmeli, a very well known and respected health economist here pointed out that the HMO system was based on managed competition and that risk selection is a crucial part of the larger system. Budgets to the HMO's is based on age based risk insurance adjustment. I am certain that what Dr. Shmeli was presenting was very important but I felt like I needed to be a health economist to understand and appreciate what he was sharing with everyone. <br /><br />The afternoon took us to a flaffel stand downtown for a particularly yummy lunch then it was off to the Knesset. We were given a guided tour of the Knesset by Daniel who explained very clearly the way in which the Israel Parliament was structured and the way in which Knesset members were elected (by party and not as individuals). He took us to the Plenum and pointed out that the seats for the 120 members were arranged like a menorah. We then went into the Great Hall and stood in awe of three Chagall tapestries along with his mosaics on the floor and the wall. There is a replica of the Proclamation of Independence in the hallway that spells out the key provisions of the State of Israel.<br /><br />Once done at the Knesset, we headed off for the Old City of Jerusalem and the Western Wall. This was a very emotional time for me when I had the opportunity to leave a note in the Wall for my old friend Steve Elefant and said a prayer for my mother who passed away in April. We were suppose to go through the tunnels beneath the Old City but the reservation was mixed up. Our tour guide Nathan did a very nice job explaining the history of the first and second temples along with the significance of the Christian and Muslim roles in the Old City.<br /><br />Tomorrow through Sunday are focused on travel and tourism. Monday, we start up the academic part of the program again with a visit to a hospital and community clinic in Nahariya. I will post my next blog on Sunday and share with you our experiences over the weekend.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-55316078112489173822011-12-14T08:21:00.000-08:002013-01-13T13:06:06.193-08:00Israel trip day 4 - 14 DecemberWe got to experience a number of interesting and important presentations from Yehuda Neumark on Community Oriented Primary Care, Ted Tulchinsky on Changing Concepts and the New Public Health and finally Milka Donchin on Health Promotion in Israel. The most meaningful part for me was the lecture by Dr. Tulchinsky where as part of the new public health, he notes that health system management is a core competency for effective public health particularly in an era of chronic disease, enhanced community health and resource constraints. His book by the same name was released in its second edition last year. The afternoon took all us to Bethlehem where we visited the Church of the Nativity. Traveling in the Palestinian Territorities was an eye-opener for me.<br /><br /><br />During lunch, we had a lively discussion around a question in which we again sought to compare and contrast the health care delivery systems of both countries. Granted that Israel has but 7.1 million people in a geographic area the size of New Jersey and the United States has over 300 million in a much larger geographic area with a much more heterogeneous population. That said, in 1995, Israel made the political, social and economic decision to craft a national health plan that provided a basket of services to each and every citizen regardless of religious affiliation. While there are additional details mentioned on Day 2, the question is why Israel and not the United States. The one thing that keeps coming up over and over again is social solidarity which I think about as a pre-condition for social capital. There is a sense that people care about one another and will sacrifice a little so that everyone has the essentials. I have a hard time imagining people in the United States agreeing to a basic basket of health services that would be paid by individual taxes. The more I listen to people at the Braun School of Public Health as well as regular Israeli's, the more I am convinced I am that legislation alone will not be enough to create and sustain a universal health plan in the US. What is needed is a change of mind set and perspective that says it is important that we take care of each other and not just maximize our own personal economic and social benefit. How we will get there, I don't know but the journey must begin now.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-88844015458763314432011-12-13T11:04:00.000-08:002013-01-13T13:06:06.233-08:00Israel trip day 3 - 13 DecemberAnother terrific day here in Jerusalem. We started at Hadassah Ein Kerem University Hospital where we arrived a bit early and got to spend some time with the Chagall windows. There was a wonderful narration explaining each of the 12 windows located in the on-hospital synagogue. They absolutely took my breath away. We then moved to the board room where we met Dr. Yuval Weiss, Director of the hospital. Hadassah Hospital was founded in1912 by three American women who were focused on Public Health and women's and children's health issues. Their current building was constructed in 1971 and many of the current med/surg beds will move into their new wing in March 2012. Hadassah serves five roles as a community hospital, tertiary hospital, university teaching hospital, military hospital and research center. Their Ein Karen campus has 775 beds while the Mt. Scopus campus has 320 beds. Their funding was particularly interesting. Revenue from patient care pays for general operations while building, equipment and all research is funded by fundraising and development. <br /><br />We were taken on a tour of the hospital where we got to see their new pediatric children's wing. A particularly interesting attribute is that the waiting area and play area can quickly be transformed into an emergency room complete with oxygen, air and suction. Our visit to the Emergency Room showed us a facility that was fully equipped to withstand a direct attach from a chemical, nuclear or biological weapon. This was truly an amazing organization whose existence is due in large part to the generosity of persons around the world.<br /><br />The morning class took place in the Braun School of Public Health and was conducted by David Chinitz, Professor of Health Policy. His lecture compared and contrasted the characteristics of the US health care system with those in Europe and Israel from 1990-2010. Among the many distinctions between these systems of financing and delivery of care, one stood out for me. Dr. Chinitz talked about the theme of social solidarity being a critical attribute in the European and Israeli systems. Social solidarity is about the willingness of a society to consciously do for one another and that the role of government is to assure a basic level of services for everyone even if it means that those more well off have to provide a little bit more. A more complete reference can be found in the Summer 2010 issue of the Journal of Health Politics, Policy and Law.<br /><br />Our day ended at Yad Vashem, the Holocaust Memorial. While similar to the US Holocaust Memorial in Washington, DC Yad Vashem is a required stop for all dignitaries visiting Israel. I was moved beyond words and continue to wonder there are so many people who want to continue the work the Hitler and the Third Reich started. I could have spent the entire day going from one exhibit to the next.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-73501687555142484352011-12-12T11:57:00.000-08:002013-01-13T13:06:06.199-08:00Israel trip day 2 - 12 DecemberEveryone met for a very good breakfast at 7:00 at the hotel then we boarded the van to drive over to Hebrew University's campus at Hadassah Hospital in West Jerusalem. We were met by Professor David Chinitz who provided an introduction to the day's speakers. We led off with a summary of payment and delivery of health services in Israel by Dr. Leon Epstein. Among the things we took away was the passage in 1994 of the National Health Insurance Law that was based on the principles of "justice, equity and solidarity." The law provides for a number of important attributes:<br /><ul><li>Universal coverage for all citizens of Israel</li><li>Payment by a progressive health tax paid by individual taxpayers and not employers</li><li>Standardized basket of health services</li><li>Capitation to four HMO's or Kaupt Holim (sick fund)</li></ul>Of the four Kaput Holim, there is one dominant player with over 50% of the market, one with about 24% and the remaining two splitting the difference. As currently structured, Israel consumes about 8.1% of GDP to cover their 7.1 million citizens. Some of the issues confronting the system are:<br /><br /><ul><li>Significant problem with shortages of physicians and nurses</li><li>Areas of major health inequality</li><li>The percentage of out of pocket funding for health care continues to rapidly increase</li></ul>Dr. Ari Israeli, former Director General of the Ministry of Health and current faculty member at Hebrew University was next and he continued with the discussion about the problems associated with adding new medical students in Israel. He pointed out that the basket of services specified in the National Health Law is overly long and complex including specific indicators, conditions and treatments for literally thousands of health care conditions. He also pointed out that almost 100% of every community physician had adopted electronic health records and that hospitals were approaching the 100% level. The two largest sick funds use the same EHR as do 9/26 hospitals in Israel.<br /><br />Alex Leventhal, former head of Israel's Public Health Ministry and now in charge of international realtions for the Ministry of Health shared his perspective on the fact that Israel is now part of the OECD and is considered to possess one of the best health systems in the world. <br /><br />Hagai Levine, a new faculty member in the Braun School shared his perspective on the role that environmental health played particularly around a process called a health impact assessment or HIA. The purpose of the HIA is to examine how policy affects the health of a population and the distribution of those effects in the population. Just imagine how different US health care would be were an HIA done prior to the passage of a particular piece of health legislation.<br /><br />Finally, we were joined by a large group of International MPH students for the final lecture by Schlomo Mor-Yosef, President of the National Institute for Health Policy Research. He led off with an in depth conversation about the after affects of the recently settled Israeli physicians strike (more on that later). As a result of the National Health Insurance law, 0.1% of the tax is dedicated to conduct research, evaluation and policy oriented studies and seminars on the impact of the law and development of the health care system in Israel. The Institute exists as a independent, non-profit research center beholden to no one.<br /><br />After a long day in the classroom we were escorted up to Mt. Olives, overlooking the Old City from the East. We heard about the creation of the modern state of Israel along with the history of the Old City from biblical times forward. <br /><br />At the end of the day, Director Manor hosted a reception for her faculty, our students and the 36 or so students in the International MPH. It was a wonderful evening (thanks to Arthur Shorr for being our expert photographer) capped by a short presentation by Director Manor's husband who serves as a senior official in Israel's foreign ministry and is the former ambassador to Sweeden.<br /><br />Overall a busy but truly memorable day!<br />Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-46987329311191880032011-12-09T06:54:00.000-08:002013-01-13T13:06:06.188-08:00Blogging from IsraelFrom December 11-24, a group of students and other HSML faculty will be in Israel studying their healthcare delivery system. Look for regular updates as we spend time with the faculty and students of the Braun School of Public Health at Hebrew University in Jerusalem.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-57366790275305232232009-09-01T05:07:00.000-07:002013-01-13T13:06:06.194-08:00Linking health management with health reformPresident Obama has made health care reform the cornerstone priority for his administration. An indicator of the seriousness that he is placing on health care is the quality of the persons that he has selected to fill important decision making roles who will be tasked with reshaping the healthcare payment and delivery systems. By and large, these appointees are individuals with great skill and experience in the areas of health policy or health economics. <br /><br />I do not question for even a moment that meaningful health care reform needs to be established on sound economic principles and based on policies that can be agreed to by the largest number of key stakeholders. However, from our perspective, there is an important element that is missing from the public conversations about health care reform. Where is the discussion about the impact of health reform on the organization and, more importantly, the patient.<br /><br />We must recognize that policies and economic decisions made without consideration to implementation at the organizational level and ultimately at the bedside are a serious oversight. The law of unintended consequences reminds us that policies or actions taken without thinking through how those actions might affect real people can play out in ways that have unplanned and often serious outcomes. As President Obama and members of the executive and legislative branches think through the myriad of ways that health care might be reformed, we recommend that the following points be kept in mind with the respect to the implementation of any chosen policy:<br /><br /><em>Strive for Excellence</em><br />No one wants average or even good health care for themselves or their families. There is a general expectation that health care received in the United States will be uniformly excellent. The question then is--how do we define and operationalize excellence? In our experience, clinical excellence (usually thought of as the outcome) is a necessary but not sufficient condition. In addition, patients want and expect to be treated with dignity and respect, in a culturally appropriate manner, in settings that are clean and accessible. And outstanding patient experiences do not take place without staff who feel valued, are given the tools they need to do their job, and are surrounded by other high performing colleagues.<br /><br /><em>Chaos and Complexity<br /></em>A hallmark of US health care is that it is a series of interconnected systems as opposed to "the US Healthcare System". The implication for health policy reform is that optimization of a single component of the system (whether at the macro level involving access, costs, and outcomes, or at a micro level of direct services provision) has the potential to simultaneously create both improvements and disruptions in intended changes. The inherent chaos embedded in a structure of variability requires that policy change provide for substantial flexibility at the operational level to both create positive enhancements to the provision of health care and to minimize the negative effects deriving from sweeping change. An example of this is seen in the efforts of hospitals to reduce unintended deaths and injuries during the time a person is in the hospital. Rather than think about health care delivery as a whole set of interrelated subsystems, most efforts in this area still attempt to find the person who made the error and fix what went wrong in that specific instance. We retain the old maxim of "blame and shame" or "blame and train" rather than look more critically at the larger system.<br /><br /><em>All Health Care (or at least most) is Local<br /></em>Meaningful change in an environment as fragmented and diverse as the American health care industry will require implementation of and experimentation with multiple potential solutions. The state-level reforms that have promise in Oregon and Massachusetts may not be feasible in West Virginia or New York. Broad national mandates across large population segments will likely guarantee less than optimal care delivery n regional or local settings. Extensive input from health care providers at the state and local level will be required to insure that health care networks are not made less responsive as a result of national policy. The development Regional Health Information Organizations (RHIOs) show promise as a mechanism to coordinate national policy imperatives while incorporating variation in health services delivery mechanisms at a local level.<br /><br /><em>Healthcare is an Industry</em><br />Health policy is obviously directed at improving the health status of our citizens, but the implementation of policy must recognize the economic realities the health care sector. The mantra "no margin, no mission" acknowledges the importance of profit motives as drivers of organizational performance, regardless of the legal and tax status of the health care entity providing services. And business competency is no more a given in this industry than in others such as finance, banking, housing, and retail, where seismic changes have resulted in long-standing, ostensibly well-managed corporations disappearing virtually overnight. The health care industry is not immune to these potential disruptions, regardless of the intent of policy implementers to create a rational "system".<br /><br /><em>Think Outside the Box<br /></em>Is there a way to deliver care that is timely, efficient, safe, and effective and yet works to address the terrible stress on hospitals and physicians caused by the growing number of elderly coupled with 45 million uninsured Americans? Using the current models of care (private physician office practices and private hospitals) is one answer but this is not sufficient. Instead, we need to think about non-traditional ways to deliver care. These can be in pharmacy based clinics, urgent-care centers, public health clinics, or any number of alternative delivery settings. Again, solutions should consider the needs and resources of local populations. The current excitement over the concept of a patient-centered medical home is no more the ultimate solution to the efficient delivery of health care services than was the gatekeeper model of capitated care in the 1990's. However, the goals of this approach, such as avoiding duplication of services, helping to eliminate medication errors, coordinating the timely dissemination of crucial medical information, and reducing administrative costs utilizing a comprehensive electronic health record are clearly what we want to achieve.<br /><br />There is no question that comprehensive health care reform has to begin with careful consideration of policy and economic questions. However, health care reform without equally careful attention paid to where and how care is delivered will result in the sub-optimization and ultimate failure of even the best-intended policies. We urge President Obama, Nancy-Ann DeParle, newly appointed director of the White House Office for Health Reform, HHS SecretarySebelius and other key decision leaders to include examination of the structures of health care delivery as part of their deliberations.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-25091826059084040002008-08-13T18:40:00.000-07:002013-01-13T13:06:06.179-08:00I am en-route home from the Academy of Management meeting. My experience is that this is the best scholarly meeting around whose focus is on management research in general and health management research in particular. All of the sessions were worthwhile on one level or another but one late today captured my attention. The three papers were around the idea of competencies that health managers would need in order to become effective leaders. However, one in particular got my attention. That paper asked what competencies health care leaders would need in order to be effective in a complex adaptive system. I find this interesting since we prepare students within the context of learning specific skills like finance, HR, IS/IT, and the many other content areas. However, nowhere do we prepare students to think about managing complexity much less systems approaches to organizational change. My question really is what competencies are we going to propose and ultimately assess if we think that health care leaders need to think about their organizations as complex systems.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.comtag:blogger.com,1999:blog-8044699078606662022.post-1718746272610237042008-04-13T20:38:00.000-07:002013-01-13T13:06:06.172-08:00Welcome to this initial blog entry on my thoughts about health management education and how this activity can shape a better health care system. I do not presume to be the final word about this topic but as one of several hundred program directors and faculty in health management, I do have a number of thoughts and concerns about the state of health management education. In general, I am very optimistic about the role of health management education in preparing leaders for this critically important field of practice. About once a week or so, I will put some of my thoughts and ideas into writing and post them in this space. I invite you to read, comment, think and react to what I and others are saying.<br /><br />Thanks for joining me in this new adventure and I look forward to hearing from you.Motohttp://www.blogger.com/profile/13229222159949529021noreply@blogger.com