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We have provided the original source link for you to also credit the image(s) owner as we have done here. Channel 9 Melbourne, Australia weather presenter Rebecca Judd is about to take some time off on maternity leave and her coworker leans in for a kiss and Rebecca is NOT having it! You don't have to imagine Jeff bouncing around in a leotard, you can check it out in the video below. Sofia Pedraza has quit her job as a school teacher to become a full-time Pokemon Go player. Sophia has a law degree and tells the Sun: a€?I downloaded it and immediately realised there is money to be made.
People at the New York music festival, Governor's Ball, who tried to use the porta-john, got pranked. I love how he keeps his character going without a flaw with the only exception being when Penn tells him that they both love the guy but how could you blame him? Science, Technology and Medicine open access publisher.Publish, read and share novel research. Electronic Documentation of Clinical Pharmacy Interventions in HospitalsAhmed Al-jedai1, 2 and Zubeir A.
Under the current Medicare program, beneficiaries may enroll in either the traditional Medicare fee-for-service program, or in a private plan, such as an HMO or preferred provider organization (PPO), in what is now known as the Medicare Advantage program. This Data Spotlight, like those prepared by us in previous years, reviews trends in Medicare Advantage plan choices available to beneficiaries, premiums and other plan characteristics in 2014. A total of 2014 Medicare Advantage plans will be available nationwide for general enrollment in 2014, down 60 plans from 2013, taking into account new entrants, consolidations, and departures.5 On average, Medicare beneficiaries will be able to choose from among 18 plans in 2014, two fewer than in 2013. Medicare Advantage choices available to beneficiaries in 2014 generally are similar to those in the past.  Average unweighted monthly plan premiums in 2014 are $49, down from $51 in 2013. In total, there will be 2014 Medicare Advantage plans nationwide available for individual enrollment in 2014 (Exhibit 1).  In aggregate, 60 fewer plans will be available in 2014 than in 2013, a relatively small change that reflects offsets of plan expansion and contraction (discussed below). New Entrants.  Among the 289 new plans offered in 2014, 80 percent are HMOs, the historically dominant plan type, 19 percent are local Preferred Provider Organizations (PPOs), and the remainders are Private Fee-for-Service (PFFS) plans and regional PPOs. As a result of firm consolidations, 208 of all Medicare Advantage plans in 2013 will be consolidated into 91 plans, resulting in the departure of 117 plans. Consistent with recent trends, the availability of PFFS plans nationwide continues to decrease, and 51 percent of beneficiaries (50% of beneficiaries in metro areas and 59% of beneficiaries in non-metro areas) will have access to a PFFS plan in 2014, down from 59 percent in 2013. When SNPs were authorized, there were few requirements beyond those otherwise required of other Medicare Advantage plans.  The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 required SNPs to conform to the specialized enrollment role originally set for them. While many organizations offer Medicare Advantage plans, a few – particularly Humana, United Healthcare, and the Blue Cross and Blue Shield (BCBS) affiliates – have particularly large geographic spread and these organizations historically account for a disproportionate share of enrollment.
Humana and UnitedHealthcare, and to a lesser extent the BCBS affiliates, define the regional PPO market; no other company operates in this market now. Premiums, benefits, cost sharing requirements and provider networks are important plan characteristics for beneficiaries to consider when choosing among Medicare Advantage plans, because of the potential effect on beneficiaries’ out-of-pocket costs and their access to preferred health care providers.
This brief does not include information on cost sharing requirements for individual services, such as hospitalizations or physician visits, which could be a major factor in an enrollee’s out-of-pocket expenses. In 2014, the average unweighted monthly premium for Medicare Advantage  Prescription Drug plans (MA-PDs) will be $49—a $2 decrease from 2013 and lower than the premium in 2011 or 2012 (Exhibit 6). Premiums for HMOs will average $35 per month in 2014, up $1 from 2013 but still lower than the average monthly premium for regional PPOs ($38), and substantially lower than the average monthly premiums for local PPOs ($70) and PFFS plans ($70).  In 2014, the only plan type with large changes in premiums  is PFFS plans, where average premiums of $70 are down $13 from $83 in 2013.
Availability of “Zero Premium” MA-PDs.  As in prior years, most Medicare beneficiaries nationwide (84%) will have access to at least one MA-PD that charges them no additional premium for coverage, other than the monthly Part B premium, also known as “zero premium plans” (Exhibit 8). Beneficiaries are most likely to have zero premium HMOs available and least likely to have zero premium PFFS plan available. The traditional fee-for-service Medicare program does not include a limit on out-of-pocket spending for services covered under Parts A and B, which is one reason most beneficiaries have supplemental coverage to limit their financial liability.  When HMOs were first offered under the risk contracting program in the mid-1980s, they covered most of Medicare’s cost sharing requirements, making out-of-pocket limits unnecessary. If MA-PD enrollees stay in the same plan in 2014, out of pocket limits will rise by about 15 percent, from an average of $4,294 in 2013 to $4,900 in 2014 (Table A7).  Average limits will be higher by about the same dollar amount for each type of plan, although they will continue to be lower for those in HMOs ($4,705) and local PPOs ($4,980) than regional PPOs ($6,348).
In other work, we also have documented variation across plans and found that it persists even when Medicare Advantage payment rates are taken into consideration.10 From a beneficiary perspective, this variation, together with the increase in out-of-pocket limits, means that it is important to review the details of plan benefits each time they are choosing a plan and to review such choices annually. Prior to 2006, traditional Medicare did not offer an outpatient prescription drug benefit, and Medicare Advantage plans were an important source of prescription drug coverage for people on Medicare. Half (50 percent) of MA-PD plans will offer some additional prescription drug coverage in the Part D coverage gap, also known as the Part D “donut hole”, other than that required by the ACA (Exhibit 10). Among MA-PDs providing coverage in the gap beyond that which is required by current law, half increase coverage only for generic drugs and half also include some expanded brand coverage as well. In 2014, as in 2013, a smaller share of regional PPOs (26%) than other plan types will provide any additional gap coverage, including HMOs (53%), local PPOs (46%), and PFFS plans (53%) (Exhibit 11). In 2014, Medicare beneficiaries will continue to be able to choose from among many Medicare Advantage plans, offered by many firms, in virtually all parts of the country. Over the years, Congress and various Administrations have made a number of changes to payments and participation rules for private risk-bearing plans that contract with the federal government to provide Medicare covered benefits, now called Medicare Advantage plans.  In the past, for example, Congress expanded the range of plans that could be offered to beneficiaries (BBA 1997 and MMA 2003) and imposed new requirements for plans, such as requiring PFFS plans to have networks of providers in most counties (MIPPA 2008). The Administration also made changes to the rules for Medicare Advantage plans, including policies seeking to encourage the consolidation of low enrollment and duplicative (“look alike”) plans and limit the use of cost sharing features that might adversely affect high cost beneficiaries, beginning in 2010.  In 2011, CMS began requiring plans to limit beneficiaries’ out-of-pocket expenditures to no more than $6,700 annually, with reduced scrutiny of beneficiary cost-sharing for plans that limited out-of-pocket expenses to $3,400 or less.
With respect to payments, after years of increasing federal payments in order to encourage more plans to participate, Congress enacted changes in payment policy in 2010 in response to evidence that Medicare was paying more for Medicare beneficiaries enrolled in Medicare Advantage plans than it would have paid for such beneficiaries in the traditional Medicare program.
Marsha Gold is with Mathematica Policy Research; Gretchen Jacobson, Anthony Damico, and Tricia Neuman are with the Kaiser Family Foundation. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California. Already added to cart sorry,for a reason unknown,temporarily chenwencai can't take your order(s). Return Policy details Buyers can receive a partial refund, and keep the item(s) if they are not as described, or possess any quality issues by negotiating directly with seller. Note: Due to possible delay of exchange rate update, price in various currencies is for reference only.
Just tried to grab the highest video quality scene posted to YouTube, and that one popped up. Not realizing that it's just a movie, the dog tries to warn a girl on the screen of her imminent demise.
Main Data entry screen of the web based documentation application.[7]Data entry screen for the patient demographic details of the web-based application with a mixture of drop down menus and free-text entry for comments. Data-entry screen for clinical significance of the web based documentation application.[7]The cursor highlights the definition of the intervention when it is placed on the icon, thereby ensuring consistency in the data that is collected. Nurgat3[1] Pharmacy Services Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia[2] Alfaisal University, College of Medicine, Riyadh, Saudi Arabia[3] King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia1.


The brief does not, however, analyze changes in benefits or cost sharing requirements for individual services, which could be major factors in an enrollee’s out of pocket expenses,2 nor does it examine changes in provider networks that could affect beneficiaries’ access to preferred physicians and other health care providers.3 This spotlight is part of a series of spotlights tracking key changes in the Medicare Advantage program.
As in prior years, choice will be more extensive in metro than non-metro areas (on average 20 versus 11 plans, respectively).  About 526,000 of current 2013 Medicare Advantage enrollees (5%) will have to make some change because their plan is not available in 2014. Most beneficiaries (84%) will have access to a Medicare Advantage plan offered in their area for no additional premium.  Enrollees who stay with their current plan (if available) will find that, on average, their premiums will increase by almost $5, from $35 to $39. The average Medicare beneficiary will have 18 plans available from which to choose in 2014, with beneficiaries in metro areas having an average of 20 choices and those in non-metro areas having an average of 11 choices, each down by two since 2013 (Table A1).  Conceptually, the number of choices in 2014 is a combination of the number offered in 2013 that remain in the market in 2014 and any new plans that enter. The role of PFFS plans in the Medicare Advantage marketplace has been declining substantially since the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 required most PFFS plans to adopt provider networks, and this historical trend will continue in 2014. Reasons for such consolidation include acquisitions or mergers of firms with similar plans, firms consolidating plans in response to market forces, and CMS’s push to have firms eliminate plans with few enrollees or that are very similar to others offered by the firm in the same service area.
The overall effect of plan departures on beneficiaries will be mitigated because new plans are entering the market and other plans are expanding their service areas. For example, authority for chronic or disabling conditions was limited to specific diagnoses or conditions and all SNPs were required to provide a care management plan to document how care would be provided for the unique subgroups covered by the plan. SNPs for dually eligible beneficiaries will continue to be the most common type of SNP, though the number will decline from 362 plans in 2013 to 347 plans in 2014.
In most other states, change was more limited.  There are no obvious geographical explanations for the overall decline in SNPs nationwide from 2013 to 2014.
This analysis focuses on national trends in premiums, out-of-pocket spending limits and Part D drug coverage, using data CMS released in September 2013. In 2014, 77 percent of beneficiaries will have at least one zero premium HMO available; in comparison, 28 percent of beneficiaries will have access to a zero premium regional PPO, 33 percent will have access to a zero premium local PPO, and 2 percent will have access to a zero premium PFFS plan.
However cost sharing requirements have increased over time in Medicare Advantage plans, reflecting cost growth and other societal trends.9 In 2006, when they were first authorized, regional PPOs were required by law to have a limit on out-of-pocket spending for benefits under Parts A and B. In 2014, the average limit on out-of-pocket spending is lower for HMOs ($4,707) than local PPOs ($4,927) – both of which are substantially lower than for regional PPOs ($6,137).  Across all plan types, a fairly large share of plans have limits in excess of $5,000, including HMOs (38%), local PPOs (45%) and the vast majority (90%) of regional PPOs. Many plans offered some coverage for prescription drugs, which they often financed in part with the net difference between Medicare Advantage payments for Part A and B benefits and the plan’s cost for such benefits. Fifty percent of MA-PDs will provide some form of gap coverage in 2013, as compared to 17 percent of PDPs, down from 30 percent in 2013.13 One reason for this difference is that the structure of MA-PDs allows plans to offset prescription drug costs using any savings in Part A and B services. HMOs continue to be more numerous than other plan types, but the availability of local PPOs is growing. Additional research is needed to explore whether plans are making other changes in 2014 to constrain costs, for example, by increasing cost-sharing requirements for individual services or narrowing provider networks, which might have important implications for beneficiaries. The Affordable Care Act (ACA) of 2010 (the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care Education Reconciliation Act of 2010) imposed a freeze on maximum payments to plans (benchmarks) through 2010 and 2011, with payment reductions phasing in beginning in 2012, based on relative per capita traditional Medicare costs in the county.  Counties experiencing larger reductions will see them phased in over a longer period of time to minimize disruption. Then, open the DHgate APP, and click on "Shopping Cart" or "My favorites" to find the product(s) you added.
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Type of pharmacist Interventions Documented in US health-systems pharmacy directors survey (n=433). Free text entry must be kept to a minimum, in order to keep data entry simple and to improve the retrieval of information for reporting purposes. However, almost all of these enrollees (91%) will still be able to choose a plan of the same type, and often a plan that is offered by the same company.
Table A2 provides additional detail on the dynamics of change in available plans between 2013 and 2014 and the effects on current enrollees. As a result, the average beneficiary will see only a small change in the number of plans available.   However, some beneficiaries (526,127 beneficiaries or 5 percent of all those enrolled in Medicare Advantage plans) will be required to either switch to another Medicare Advantage plan or return to the traditional Medicare program. The analysis is based on Medicare Advantage plans that offer prescription drug coverage (and excludes the minority of Medicare Advantage plans that do not cover prescription drugs) because most Medicare Advantage plans (83%) offer drug coverage and holding drug coverage constant makes for clearer comparisons of premiums over time or by plan type.
Beginning with the 2011 plan year, CMS required all other Medicare Advantage plans to include a limit on enrollees’ out-of-pocket expenses, set to no more than $6,700. Beginning in 2006, all beneficiaries had access to a prescription drug plan, either through free-standing prescription drug plans (PDPs) or a Medicare Advantage plan that included drug coverage (MA-PD). These savings are declining because the ACA gradually reduces the Medicare Advantage benchmark payments, which currently are higher on average than the per capita costs of traditional Medicare in many counties. Also, beginning in 2012, plans’ quality ratings are being used to provide bonus payments and determine which plans can enroll beneficiaries throughout the calendar year. High-end mens sunglasses are expensive, here in our shop, you can enjoy the best police sunglasses and look like a super star with relatively lower price. The selection of a radio button is done by clicking themouse on the button, or the caption, or by using a keyboard shortcut. Virtually all (99%) beneficiaries in plans that are withdrawing from their area will continue to have access to one or more Medicare Advantage plans. CMS encouraged plans to limit enrollees’ out-of-pocket expenses to no more than $3,400 per year.
With some limited exceptions, beneficiaries choosing to enroll in a Medicare Advantage plan who wish to get the Part D drug benefit must receive the drug coverage from the Medicare Advantage plan selected. Itwas not possible to leave any of the radio buttons in a group unselected, as the user would not be allowed to move to the next screen.
The software allows for cumulative cost savings to be calculated at the end of each financial year for each individual pharmacist.
Some days I play it for 18 hours a day because you can play all the time even when youa€™re out with your friends in bars and clubs. Many of the plans that do not offer drug coverage are designed for beneficiaries who may have access to other sources of prescription drug coverage, including former employers such as the Department of Veterans Affairs. The RPS recommends that interventions should be made as soon as possible after the event has occurred as this would enable the recording of details to be more accurate. Further recommendations include the recording of interventions into the patient’s medication records either manually or electronically and they should be used to ensure consistency and continuity of standards and for reflective learning within the pharmacy team. Clinical Interventions Report.[7]Percentages are based upon the total number of interventions. The controversy of whether near miss or other interventions that prevent significant harm to patients by hospital pharmacist should be documented in patients' hospital health records when making recommendations will not be discussed in this chapter.
Since the majority of hospitals have separate reporting systems under risk managements for near misses and adverse drug reactions this will be not bereviewed in this chapter rather pharmacy stand-alone systems for documentation purpose will be reviewed as this is the most popular way for documenting pharmacist interventions.3. Methods of pharmacy interventions documentation- A global lookVarious methods of documenting pharmacist interventions have been explored.[24]-[27]Earlier systems ofdocumentation interventions used manual recording on a paper-based form and later on moved to electronic versions when they became available. Interestingly, the paper based intervention documentation system is still the preferred system of documenting of pharmacist interventions in some countries as shown by the survey of New Zealand Hospitals in 2008 where 88% collected data on paper, the majority using pre-printed forms and some using notebooks. Adverse drug reactions, formulary selection, medication selection and pharmacokinetic consultation were also frequently reported. Less frequently reported interventions were pharmaceutical care plans, Admission medication history and patient medication history.


Whereas the survey from New Zealand,[3] free text of the intervention description was frequently reported in addition to the pharmacist identification. Challenges and drawbacks of current systemsThe prevalence of in-housedocumentation systems has been the most significant drawback in terms of standardising and achieving consistency of recording of pharmacist interventions and eventually using the data as a bench mark for comparison of clinical pharmacist’s contributions. Another challenge is to capture all information that was previously entered on paper, increase the data-entry speed, and modify the database to address specific needs that was identified by the end users.One major advantage of an electronic system is the ease with which it facilitates monthly and annual reporting for departmental quality assurance programs. Numerous articles have been published on electronic pharmacist intervention programs in the literature and most have focused on a main frame computer terminal based in the pharmacy department. The King Faisal Specialist Hospital’s experience, a personal-perspectiveWe had faced similar problems with our paper based documentation systems as described above, and in an attempt to improve the documentation of pharmacist’s intervention we successfully developed and implemented a computerised application program to facilitate the collection and analysis of the data.
Prior to this, pharmaceutical care activities and clinical interventions were either not documented or inconsistently documented(see figure 2).Later, the multi-user PC version and the subsequent enhanced version, the web based application revealed an increase in the number of interventions done by individual pharmacist with more pharmacists participating in the interventions recording regularly. We were able to show that by keeping the intervention program simple and easy to use; the contributions of individuals not only increased but were consistent. Here we describe in detail how we managed to develop our in-house documentation systems which may assist others in making similar documentation systems.
The softwareTraditionally two main types of electronic system of documenting of pharmacists interventions have been available to pharmacists for documentations of their interventions. It allows the mangers to monitor performance of individual pharmacists by evaluating the number of interventions made and the acceptance for daily interventions. In addition, it provides reports for the hospital administration on clinical pharmacists' activities and the data generated can be used to justify additional clinical pharmacists' positions. However, the system requires installation of the software in individual stand-alone personal computers (PCs). With the limited numbers of PCs that could be accessed by the pharmacists at the point of need e.g. This may be achieved using any PC, laptop or even wireless personal digital assistant (PDA) connected to the hospital intranet. The ability to access the intervention program from any point is one major advantage of the web based intervention program. The web based application had one big advantage over the multi-user PC version since installation was not required in every PC and the program could be accessed from any location with intranet access. Since all in- patient areas and clinics were connected to the intranet, the easy access enabled the pharmacist to enter interventions from any workstation, in the clinics and on the ward during the physician rounds. This has been reflected in our recent study,[7] where the use of the web-based application revealed a 40% increase in the total number of documented interventions compared to multi-user PC software. Intervention entryFigure 4 depicts the “main intervention form” with the major categories e.g. It allows for the identification of the patient through the patient Medical Record Number (MRN), as well as the date and the location of the intervention. The pharmacist documenting the intervention is identifiable through the Drop-down pharmacists list which is password protected. The form further allows the pharmacist to document the main types of intervention inclusive of an intervention summary and the pharmacist recommendation.
The web based program further enables the pharmacist to document cost saving only interventions on the main intervention form.
The cost saving interventions includes changes in dosage regimens, substitution with a less expensive drug, discontinuation of unnecessary drug and other indirect savings such as change form intravenous to oral formulation. Database construction and useIdeally the use of free text entry should be kept to a minimum, in order to keep data entry simple and improve retrieval of information for reporting purposes.
The location and the intervention date can be entered using the drop down menus and radio buttons. The radio buttons are arranged in pre-determined groups of related options on the main data entry point based on our pharmaceutical care manual intervention form i.e. Different types of clinical interventions were available under the tab of the type of intervention i.e. Description of softwareThe construction of the database of the web based intervention program must take into consideration the feedback of the participating and non participating pharmacists, the departmental quality assurance pharmacist and the limitations of the multi-user PC version.
The database must be designed to be user friendly with a multi-option of radio buttons, check boxes, and drop down menus.
The free-text entry is to be kept at minimum for the descriptive nature of the interventions. The data entry must be user ID and password protected and the individual user documenting the intervention should be identifiable through their password which requires user authentication. Only one tab must be activated at a time and the user cannot continue to the next step if there was missing details in the intervention form. Minimal manual data entry was required for documentations of interventions, with only the detail of the interventions done by free text. Figure 5.Data-entry screen for drug related problems of the web based documentation application.
Validation of pharmacy intervention documentationThe reliability and validity of pharmacist intervention data documented has been questioned by some and have highlighted the lack of consistency in categorising interventions.[18] The lack of reliability in the individual pharmacist coding of interventions should be of concern especially if there is a lack of the reliability of the data generated.
Documentation of cost savingsInaccurate cost savings projections and the difficulty in making accurate cost savings projections have been cited as one of the major shortcomings in pharmacist intervention documentation systems in the surveys of US health systems pharmacy directors and New Zealand hospital pharmacies.
In these surveys only 27% of US health-systems pharmacists and 33% of New Zealand pharmacists documented cost savings interventions. Although cost saving interventions was not specifically mentioned in the recommendations posted by the professional or regulatory bodies on documenting pharmacist interventions, they easily justify their inclusion in the clinical pharmacist’s documentation system.
In addition to justifying the hiring of additional clinical pharmacists, cost savings information helps emphasize the critical role of pharmacy in managing hospital drug budgets. These costs have risen dramatically in the recent years and continue to climb, which has resulted in pressure from hospital administrators to contain these costs. Taken together, consideration of the cost savings that result from clinical pharmacist interventions is an important factor in modern clinical practice. Nevertheless, the significant sums of money involved are a justification for its inclusion in the pharmacist intervention program which was not included in the RPSGB guidance on recording of interventions. Cost savings interventions made by the pharmacists can be used to justify additional clinical pharmacist positions while emphasising the role played by the pharmacy department in managing the hospital drugs budget with the hospital administration.9.
How to use these recordsThe ease with which monthly or periodical reports are generated is one advantage of the web-based system.
The system enables one to run monthly or periodical statistics on all interventions entered in the system. The generation of the clinical intervention reports may be utilised by the departmental managers during the annual staff appraisal and more importantly in the departmental quality assurance programs.
The monthly or the periodical reports generated further ensure consistency and continuity in interventions standards. Moreover, junior pharmacists and pharmacy residents working in the department can utilise the data as a technical aid for documenting interventions.



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