Home>Homework Answsers>Nursing homework helphealth careAssignment:Exercises:Why should program evaluation be used for public health and not-for-profit institutions in the development of adaptive strategies?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 MICKAEL590By 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 becauseboth08.indd   590 both08.indd   590 11/11/08   11:46:25 AM 11/11/08   11:46:25 AM591a 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.LocationDr. 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 LayoutOne 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 BACKGROUNDboth08.indd   591 both08.indd   591 11/11/08   11:46:25 AM 11/11/08   11:46:25 AMCASE 8: DR. LOUIS MICKAEL592The 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 StructureDr. 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 1Treatment Room 2Private OfficeDr. Charles’ Office SpaceFront DoorCommon Waiting Room75’15’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 appropriateThe 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 greaterExhibitCASE 8: DR. LOUIS MICKAEL594and 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 AM595Exhibit 8/3: Trial Balance at December 311991 1992 1993Debits 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 $256,918Exhibit 8/4: Gross Revenue and Accounts ReceivableDecember 31 1979 1986Gross revenue $116,951 $137,126 Accounts receivable 15,684 32,137JANUARY 8, 1994 (MORNING)both08.indd   595 both08.indd   595 11/11/08   11:46:29 AM 11/11/08   11:46:29 AMCASE 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 ProfileWhen 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 aExhibit 8/5: Statements of Income for the Years Ended December 311991 1992 1993Operating 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) $350Exhibit 8/6: Balance Sheets at December 311991 1992 1993Assets 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 $40,467Liabilities 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 $40,467baby. 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 wouldExhibitCASE 8: DR. LOUIS MICKAEL598accept 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 PhysicianDr. 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 receivebothcalls 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 MICKAEL600The 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 forJANUARYCASE 8: DR. LOUIS MICKAEL602industrial 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 DayAs 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. TheExhibit 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 MedicineUniversity 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 $125.45initial 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.”5 years ago13.01.202020Report issueAnswer(1)wizard kim4.8(954)4.9(97)ChatPurchase the answer to view itProfessionalDevelopment.docxWork14.pdf5 years agoplagiarism checkPurchase $20Bids(69)GradesMaestroAllRoundBest TutorBethuel BestYoung NyanyaMath GuruuHomework ProRanju Lewiswizard kimBrainy BrianKelly JacobsRosie SeptemberRanchoddas Chanchad PhDMiss LynnElprofessoribrilliant answersPROF_TOMMYProf BerryCatherine OwensWendy Lewiskim woodsother Questions(10)1) the sample of fat value of n=10 randomly selected hot dogs made by a fast food was tested and found that the mean of fat value is 24.86 and the sample standard deviation is 4.134. the population mean fat value is known to be 21.90. assuming that the n=English Reflactionsee descriptionSmall System SDLC Design/Plan Project- FinalMath Discussion Question/MATH 300 StatisticsRent-A-Car ProjectPriceable of business RMTDetermine if each sequence could be arithmetic. If so, give he common difference

16, 14, 13, 11, 10, …a regular polygon has radii and apothem. find the measure of 1, 2, 3Okay, not homework, but I need some help estimating some fill dirt.  A client has a swimming pool that needs…

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Home>Homework Answsers>Nursing homework help- Analyze processes related to neurological and musculoskeletal disorders- Identify racial/ethnic variables that may impact physiological functioning-  Evaluate the impact of patient characteristics on disorders and altered physiologyScenario: 74-year-old male with a history of hypertension and smoking, is having dinner with his wife when he develops sudden onset of difficulty speaking, with drooling from the left side of his mouth, and weakness in his left hand. His wife asks him if he is all right and the patient denies any difficulty. His symptoms progress over the next 10 minutes until he cannot lift his arm and has trouble standing. The patient continues to deny any problems. The wife sits the man in a chair and calls 911. The EMS squad arrives within 5 minutes. Upon arrival in the ED, patient‘s blood pressure was 178/94, pulse 78 and regular, PaO2 97% on room air. Neuro exam – Cranial nerves- Mild left facial droop. Motor- Right arm and leg extremity with 5/5 strength. Left arm cannot resist gravity, left leg with mild drift. Sensation intact. Neglect- Mild neglect to left side of body. Language- Expressive and receptive language intact. Mild to moderate dysarthria. Able to protect airway.5 years ago19.04.202025Report issueAnswer(1)Ultimate GEEK4.8(499)4.7(26)ChatPurchase the answer to view itNOT RATEDMUSCOSKELETONNEUROLOGICAL.docxmusculoskeletal.docx5 years agoplagiarism checkPurchase $999Bids(93)Quality AssignmentsTeacher TrumahnYourStudyGuruGuru OliviaBethuel BestGreat-Writerswriter respectAmanda SmithProf James KelvinDr. ElahiGabriella MalkAmerican TutorWriting WondersBrainy Brianhassan0906Quickly answerRosie SeptemberEmily ClareProf SapolskyElprofessoriother Questions(10)Benchmark-I need a article summarizeSloan Business – CODiscussion questions “magz64″Motivation and Performance Managementbusiness lawPublic Healthneed for 1 feb follow instructions give for the workMILESTONE 1 & 2Math 256

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Home>Homework Answsers>Nursing homework helpSundayurgentWatch the three-partCalifornia Nurses Association Historyvideos and determine the role of leadership in the success of this organization.Your paper should include in the review:Comprehension: Briefly summarize the efforts and outcome of the CNA.Application: Relate  core leadership concepts to the success of the CNA. Include the  relationship of empowerment, government, and cultural competency to the  struggles and success of the CNA.Analysis/Synthesis: Clarify understanding of the variables contributing to the success of the CNA group’s efforts.Evaluation: Summarize the efforts of the CNA as a model to enhance APRN practice.5 years ago14.06.202020Report issueAnswer(1)kim woods4.5(6k+)4.2(157)ChatPurchase the answer to view itNOT RATEDorder_140955_373240.doc5 years agoplagiarism checkPurchase $20Bids(102)BRIGHT MIND PROFYoung NyanyaDr. Ellen RMProf Double RPROFESSOR URGENTQuality AssignmentsnicohwilliamGuru OliviaAmanda SmithDr. Michelle_PhDPremiumDexterMastersQuickly answerTutor Cyrus KenArizona Writerwizard kimDr. AmeerahBrainy BrianBridget YoungProf. Eliud Petersonother Questions(10)Organizationalcomment power point presentationBusiness Management PaperPlease go to page 35 of your book. Pick one of the Problems presented on the middle of the page and write a short 2 page paper about this topic, citing at least one major IT magazine or academic review. Focus on addressing the assignment statement at thethis assignment is for nightingaleIntroduction to Histology HW #2A+ SolutionEssayECON201–GDP Research Paper–500 words minimumPhysics

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Home>Homework Answsers>Nursing homework helphealthmanagementIn this Assessment, you will use information from the case scenario below, along with the supporting documents provided, to demonstrate your ability to apply economic concepts to make recommendations for organizational decisions.Case Scenario: Launching a Cancer Drug: ComanapracilYou are a pharmaceutical executive. You believe that your firm, Ropache, may have developed a promising new drug, Comanapracil, which seems to arrest the progress of breast cancer for 2 years with no significant side effects. Clinical trials suggest that the drug is 100% effective for 2 years. After 2 years, tumor growth resumes at the same rate. Therefore, Comanapracil can only be used for a 2-year course, after which it loses its effectiveness.Professional Skills:Written Communication,Technology, andCritical Thinking and Problem Solvingare assessed in this CompetencyYour response to this Assessment should:Use the Assessment documents and video as required.Reflect the criteria provided in the Rubric.Adhere to the required assignment length.Use theAPA course template.Download theWriting Checklistto review prior to submitting your Assessment.This Assessment requires submission of two (2) files. Save your files as follows:Save Part I asFM005_PartI_firstinitial_lastname(for example, FM005_PartI_J_Smith).Save Part II asFM005_PartII_firstinitial_lastname(for example, FM005_PartII_J_Smith).When you are ready to upload your completed Assessment, use theAssessmenttab on the top navigation menu.InstructionsBefore submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.RubricAccess the following to complete this Assessment:U.S. Breast Cancer StatisticsAnnual Costs of Cancer Care—Cancer Prevalence and Cost of Care Projections:Chemo Costs in U.S. Driven Higher by Shift to Hospital Outpatient FacilitiesGDP Per CapitaHealth Expenditure Per CapitaLife Expectancy at Birth, Total (Years)Breast Cancer Drug – Comparison ChartThis assessment has two-parts.  Click each of the items below to complete this assessment.Part I: Determine Pricing and Marketing Strategy for a New DrugYou have been tasked with developing a pricing and marketing strategy for Comanapracil. As you undertake this task, refer to the following resources mentioned above:U.S. Breast Cancer StatisticsAnnual Costs of Cancer Care—Cancer Prevalence and Cost of Care ProjectionsChemo Costs in U.S. Driven Higher by Shift to Hospital Outpatient FacilitiesBreast Cancer Drug—Comparison ChartCreate a 10- to 15-slide presentation, for the board of directors, to convince them that Comanapracil is a good investment. The presentation should address the following economic issues related to the marketing of Comanapracil:Develop and present estimates for the demand for Comanapracil and the price of the drug you think the market will bear. Be sure to include the number of customers for this drug.Describe where and to whom you will focus your marketing efforts. For each, detail why they are important.Explain how you will ensure that insurance companies pay for your drug.Explain the elasticity of demand for a drug like Comanapracil. What factors could potentially change the elasticity of demand?Assume you are able to obtain a patent, and are ready to go to market immediately. Explain the length of time for which your drug will receive patent protection, so that you are protected from competition prior to generics entering the market. Also, explain why patent protection exists in healthcare.Part II: Compare International Healthcare Systems to Develop an International Market Entry StrategyIt is your job to develop a market analysis for four different healthcare markets with unique insurance systems. These four analyses will be contained within one 10- to 11-slide presentation to the board of directors. Your analysis will serve as a basis for deciding which country to market Comanapracil:GermanyUnited StatesGhanaBrazilCreate your presentation as follows:The first slide will be an analysis of the relationship between spending on healthcare per capita and life expectancy in each country. Begin by referring to the World Bank charts “GDP Per Capita,” “Health Expenditures Per Capita,” and “Life Expectancy at Birth, Total (Years).” Using these, create a chart comparing the spending on healthcare per capita with the life expectancy in each country. Underneath the chart, on the same slide, address the question: Is there a relationship between life expectancy and healthcare spending?Next, based on what you have learned about the healthcare systems of Germany, the United States, Ghana, and Brazil, create four slides (one for each country) that summarize how each healthcare system is structured.Next, create another four slides (again one for each country). Each of these slides should summarize your findings from conducting a SWOT analysis for each country (that is, identify the economic strengths, weaknesses, opportunities and threats) associated with marketing Comanapracil in each country.Create one to two slides recommending which two countries are most attractive for marketing Comanapracil and why.Your board has shown a particular interest in the German market. In order to market your drug in Germany successfully, you must be approved by the German Institute for Quality and Efficiency in Health Care (IQWIG). Create two to three slides, addressed to the IQWIG, which argue for the importance of why your drug should be covered. Address the following issues:How much of a gain in health outcomes will this drug provide?Do other drugs provide similar effectiveness in treating this disease?How many people will benefit from this drug? Explain why some people will benefit from the drug more than others.CAMNEW.pdfKHarveyAcademicIntegrityReportWMB110420201.docx5 years ago30.10.202035Report issueAnswer(1)bennetsandova4.7(201)5.0(3)ChatPurchase the answer to view itNOT RATEDComanapracilInternationalMarketEntryStrategy.pptxLettertotheprofessor.docxLaunchingaCancerDrugComanapracilrevised.pptx5 years agoplagiarism checkPurchase $35Bids(103)Tutor Cyrus KenMUSYOKIONES A+WIZARD_KIMNightingaleDr. Michelle_KMProf Double RAmanda SmithDr. Elahiwizard kimKATHERINE BECKSDiscount AssignPapersGuruDr Michelle MayaANN HARRISbrilliant answersbennetsandovaMiss_AqsaTutor RisperDiscount AnsAgher Editorother Questions(10)GEN499 week 3 DQ 1I need help with my assigementLab to Determine the Outcome of HereditySociologyethicsDescribe the role of financial accounting in contemporary business.  Provide one specific, real-life example of how financial accounting helps external stakeholders make informed decisions.  Also, describe the role Generally Accepted Accounting PrinciplesHSM315: Emergency Planning Final Paper2 page essaySpecial educationTeamwork

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Home>Homework Answsers>Nursing homework helphumanLeadership3.1 Case Study—Several Different Styles Vanessa Mills was recently hired to work at a branch of Lakeshore Bank as a personal banker. The branch is very busy and has a large staff, including three on-site managers. As a new employee, Vanessa is trying to figure out how to succeed as a personal banker while meeting the expectations of her three very different managers. Vanessa is paid a salary, but also receives a commission for activities including opening new accounts and selling new services to customers such as credit cards, lines of credit, loans, and stock accounts. Personal bankers are expected to open a certain number of accounts each month and build relationships with customers by exploring their various banking needs and offering services to meet those needs. Marion Woods is one of the managers at Vanessa’s branch. She has worked for Lakeshore Bank for 10 years and prides herself on the success of the branch. Marion openly talks about employees’ progress in terms of the number of accounts opened or relationships established, and then commends or scolds people depending on their productivity. Marion stresses to Vanessa the importance of following procedures and using the scripts that Marion provides to successfully convince customers to open new accounts or accept new services with the bank. As a new banker, Vanessa has not opened many accounts and feels very uncertain about her competence. She is intimidated by Marion, believing that this manager is continually watching and evaluating her. Several times Marion has publically criticized Vanessa, commenting on her shortcomings as a personal banker. Vanessa tries hard to get her sales numbers up so she can keep Marion off her back. Bruce Dexter, another manager at Vanessa’s branch, has been with Lakeshore Bank for 14 years. Bruce started out as a teller and worked his way up to branch manager. As a manager, Bruce is responsible for holding the bank staff’s Monday morning meetings. At these staff meetings, Bruce relays the current numbers for new accounts as well as the target number for new accounts. He also lists the number of new relationships the personal bankers have established. After the meetings, Bruce retreats back into his office where he sits hidden behind his computer monitor. He rarely interacts with others. Vanessa likes when Bruce retreats into his office because she does not have to worry about having her performance scrutinized. However, sometimes when Vanessa is trying to help customers with a problem that falls outside of her banking knowledge, she is stressed because Bruce does not provide her with any managerial support. The third manager at the branch is Heather Atwood. Heather just started at Lakeshore Bank within the last year, but worked for nine years at another bank. Vanessa finds Heather to be very helpful. She often pops in when Vanessa is with a customer to introduce herself and make sure everything is going well. Heather also allows Vanessa to listen in when she calls disgruntled customers or customers with complicated requests, so Vanessa can learn how to manage these types of interactions. Heather trusts her staff and enjoys seeing them grow, encouraging them by organizing games to see who can open the most accounts and offering helpful feedback when customer interactions do not go as planned. Vanessa is grateful for the advice and support she receives from Heather, and looks up to her because she is competent and kind. Vanessa is coming up on her three-month review and is very nervous that she might get fired based on her low sales record and the negative feedback she has received from Bruce and Marion regarding her performance. Vanessa decides to talk to Heather about her upcoming review and what to expect. Heather assures Vanessa that she is doing fine and shows promise even if her numbers have not reached that of a seasoned banker. Still, Vanessa is concerned about Bruce and Marion. She has hardly had more than two conversations with Bruce and feels intimidated by Marion who, she perceives, manages by running around barking numbers at people.QuestionsBased on the assumptions of Theory X and Theory Y, how would you describe each manager’s philosophy and style of leadership? In what way do the managers’ attitudes about Vanessa affect their leadership?In this type of customer service setting, which leadership style would be most effective for the bank to meet its goals?From the bank’s perspective, which (if any) manager exhibits the most appropriate leadership?Discuss. What advice would you give to each of the managers to enhance his or her leadership skills within the bank?What do you think Vanessa can do to prepare herself for her three-month review?3.2 Case Study—Leading the Robotics Team Anders Dahlgren is the mentor for a high school robotics team that has spent the past three months designing, building, and programming a robot for competition. The team is composed of 14 boys and one girl, and the students range from freshmen to seniors. With the first competition in three weeks, Anders needs to designate a team captain so the team can get used to working under a new leader. During the competition, the team captain is often called on to make crucial team decisions. The robotics team is divided into groups: Mechanical, whose members design and build the robot, and Programming, whose members develop the computer code that tells the robot how to complete its tasks. During competition, the team captain will have to work with both groups to tweak the robot’s design and programming on the fly to improve the robot’s performance. It can be a high-pressure job for any teenager, and with emotions and stress levels of other team members running on high, the captain will not only need an understanding of both the mechanical and programming aspects, but must also be able to keep 14 other personalities and egos working toward a common goal. There are three members of the robotics team that Anders is considering for captain: • Pria is a junior and the only girl on the team. This is her second year on the team, and she is in the Programming group. Anders describes her as being very serious and a whiz at coding, and she has offered some great design ideas. Pria is very organized—after the team’s first meeting of the year, she developed a schedule with tasks and deadlines and wrote it on the large whiteboard in the workshop so team members could follow it. Pria doesn’t have a lot of patience with teenage boy shenanigans and will admonish her group members to “focus, please” whenever she thinks they’ve gotten off task, such as when they start talking about YouTube videos or music. Pria is very rule-bound and will point out when team members try to cut corners or haven’t adequately followed instructions or the schedule. Anders has noticed that when the other programming group members have a problem or obstacle, they defer to Pria for a solution. He suspects it’s partly because they respect her opinion and partly because they know she’ll tell them how to fix it regardless. Once, though, when Pria was home sick, Anders overheard several of the boys from both groups call Pria “bossy” and say she “stressed them out” with her deadlines and rigidity. • Justin, a senior, is also in his second year on the team. An upbeat, congenial kid, Justin is a member of the Mechanical group. He isn’t much for planning, however; he has a tendency to pick up a power tool and use it before he has actually thought out what he is going to do with it. The other Mechanical group members call him “MacGyver” because he is great working with his hands and often comes up with fixes to mechanical problems by just fiddling around with different pieces and parts for an hour or so. The group members are also pretty forgiving when Justin makes a mistake because his sense of humor keeps them all laughing and he always finds a way to fix it. Anders notices that the Mechanical group is the most creative when Justin is at the helm, but that work sessions can devolve into chaos pretty quickly if Anders doesn’t step in and set parameters and establish goals. • Jerome, also a member of the Mechanical group, is quiet, respectful, and polite. He is a senior and has been on the robotics team since his freshman year. He is a veteran of robotics competitions, and what he has learned over the years has informed a lot of the team’s efforts this year. He is most happy working on the computer-aided designs for the robot and helping those building it to understand and follow the plans and schematics. When group members question elements of his design, however, he will ask, “How do you think we should do it?” He listens to their ideas, and if the other group members agree, they will implement an idea even when Jerome personally doesn’t think it’ll work. Jerome’s method of allowing for trial and error often slows down progress; when the group realizes an idea won’t work, the team members will have to take apart what was built and start over. Anders asked Jerome why he isn’t more assertive in defending his plans, and Jerome answered, “That’s just not my style. How do I know I have all the right answers? We are all supposed to be learning, right? And if I insist they do it my way all the time, how will we learn anything?”QuestionsHow would you describe the individual leadership styles of Pria, Justin, and Jerome?Based on the assumptions of Theory X and Theory Y, how would you describe Pria, Justin, and Jerome’s individual philosophies of leadership?The robotics team will be asked to compete in a situation that sounds like it will be intense and stressful. Do you think a democratic leader would be as effective as an authoritarian leader in this situation?TheoryXandY.pptxLeadershipInAction.docx5 years ago17.11.202035Report issueAnswer(1)Miss Lynn4.8(407)4.9(19)ChatPurchase the answer to view itLeadershipInAction.docx5 years agoplagiarism checkPurchase $35Bids(87)Tutor Cyrus KenWIZARD_KIMQuickly answerNightingaleabdul_rehman_Dr. Ellen RMQuality AssignmentsDr. Michelle_KMMiss LynnAmanda SmithDr. Elahiwizard kimDr shamille Clarabrilliant answersTutor RisperDr Michelle MayaCreative Geekmichael smithPROF_TOMMYCamile Faithother Questions(10)Five-Year Global Workforce Forecast (8–10-page executive report in Word format.Apply APA standards to citation of sourcesmadam-professor onlyPhase 2 DB System ResourcesSTATISTICS MA3110 Final Exam Quizneed help answering these questions questionWeek 1: Group DiscussionCriminal Justice Homeworkfor creative instructorAmazon Buisness Strategymy homework about marketing..

Read the JetBlue case on pages 3 and 4 of the text. Based on the information found…

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