We want to be clear WHEN many states created public policy to MOVE FORWARD global corporate GUARDIANSHIP able to hit ANY US 99% WE THE PEOPLE black, white, and brown citizens. This was 2013----OBAMA era----and it was tied to two events----the subpriming of US Treasury bonds leaving $20 trillion in US bond debt staging the sacking, looting, and colonization of America---ergo, let's hand global corporations the power to force citizens into GUARDIANSHIP. It was also tied to AFFORDABLE CARE ACT where this policy handed health systems the power to determine the 5Ws of patient care----where, why, when, what, and w-----how. We see below MANY US states have already pushed GUARDIANSHIP policies often tied to getting bad guys with guns off street---making sure of good medical results for patients---all sounding COMMON GOOD---SOCIAL BENEFIT---when the goals MOVING FORWARD are absolute global corporate FASCISM.
We noticed back in 2013 when all these policies were being pushed---not a sound against FASCISM---not a sound from FAKE CIVIL RIGHTS/CIVIL LIBERTY groups----NAACP/ACLU ------they are waiting until all these global corporate fascist policies are in place harming millions of US 99% and our new to US immigrant citizens until they will get REALLY MAD.
Below we see just a few US states MOVING FORWARD GUARDIANSHIP public policy......VA, NY, NM, FL, ID.
GUARDIANSHIP AND CONSERVATORSHIP ... - courts.state.va.us
The Office of the Executive Secretary, Supreme Court of Virginia ... GUARDIANSHIP AND ... an adult who has been found by the court to be incapable ...
Manual | NYCOURTS.GOV
... For Lay Guardians Appointed Under Article 81 of the New York State Mental ... by the Office of Guardianship and ... County Supreme Court in ...
New Mexico Adult Guardianship Study Commission - NM Courts
... Boards and Commissions > New Mexico Adult Guardianship Study ... Office of Supreme Court ... New Mexico Administrative Office of the Courts - The State of New ...
Guardianship / Conservatorship in Nebraska | Nebraska ...
... Office) What is Guardianship/Conservatorship? ... power of the state among the Supreme Court, ... courts. All state courts operate under the ...
Guardianship - FL Courts
Adult guardianship is the process by which the court finds an individual's ability to ... National Center for State Courts; ... Statewide Office of the Public Guardian;
Guardianship of An Incapacitated Adult | NY CourtHelp
The official home page of the New York State Unified Court ... Guardianship of An Incapacitated Adult. ... brought in Supreme Court or County Court under Article 81 ...
Guardianship / Conservatorship | Supreme Court
The online training module was developed by the Idaho Supreme Court Guardianship/Conservatorship ... court responses to elder abuse and adult ... State Bar’s ...
Below we see NEBRASKA------REVISING it's public policy surrounding GUARDIANSHIP -----and we see HEALTHCARE FACILITY--ANY HOME WHERE A CITIZEN IS RECEIVING CARE. If our US 99% WE THE PEOPLE are not READING REVISED policy having been on the books all last century-----seeing how they have been REVISED during OBAMA era----then we don't understand how MOVING FORWARD is taking away even our rights to SELF-DETERMINATION.
'The work of the Office of Public Guardian is guided by the Advisory Council on Public Guardianship. Work was begun on January 1, 2015, to develop the processes, guidelines, plans and personnel policies to implement the Public Guardianship Act'.
30-701. Terms, defined.
For purposes of sections 30-701 to 30-713:
(1) Adult child means an individual who is at least nineteen years of age and who is related to a resident biologically, through adoption, through the marriage or former marriage of the resident to the biological parent of the adult child, or by a judgment of parentage entered by a court of competent jurisdiction;
(2) Caregiver means a guardian, a designee under a power of attorney for health care, or another person or entity denying visitation access between a family member petitioner and a resident;
(3) Family member petitioner means the spouse, adult child, adult grandchild, parent, grandparent, sibling, aunt, uncle, niece, nephew, cousin, or domestic partner of a resident;
(4) Guardian ad litem has the definition found in section 30-2601;
(5) Isolation has the definition found in section 28-358.01;
(6) Resident means an adult resident of:
(a) A health care facility as defined in section 71-413; or
(b) Any home or other residential dwelling in which the resident is receiving care and services from any person;
(7) Visitation means an in-person meeting or any telephonic, written, or electronic communication; and
(8) Visitor means a person appointed pursuant to section 30-2619.01.
Source:Laws 2017, LB122, § 1; R.S.Supp.,2017, § 42-1301; Laws 2018, LB845, § 1.
Effective Date: July 19, 2018
The US is seeing a SUBPRIMING of its strong developed-nation public health care and medical industries-----we will not go into BARBER SURGEON public policy ---but we will remind all US 99% WE THE PEOPLE AFFORDABLE CARE ACT created tiered levels of health care and super-sized the outsourcing to a massive network of ANYBODY opening a health clinic---a nursing residence----all with oversight and accountability STRIPPED. The REVISED policies surrounding FORCED GUARDIANSHIP now allow any of these networks of CARE----no matter what type of CARE-----to have power to assert FORCED GUARDIANSHIP.
If these policy REVISIONS are allowed to MOVE FORWARD------our 99% WE THE PEOPLE black, white, and brown citizens and our new immigrant citizens will have NO SELF-DETERMINATION. Anyone falling into the need for CARE-----will be in the hands of people able to determine FORCED GUARDIANSHIP. In the past our American policy on GUARDIANSHIP tied FAMILY to determining GUARDIANSHIP----not simply ANY TWO PEOPLE. That was never ideal as sometimes a family member----a husband commits a wife-----a child commits an aging adult ------but these REVISIONS are now opening the door to ANY INSTITUTION having the ability to claim FORCED GUARDIANSHIP with a board appointment controlled by GLOBAL BANKING 1%.
From Wikipedia, the free encyclopedia
This article is about self-determination in international law. For other uses, see Self-determination (disambiguation).
The right of a people to self-determination is a cardinal principle in modern international law (commonly regarded as a jus cogens rule), binding, as such, on the United Nations as authoritative interpretation of the Charter's norms. It states that a people, based on respect for the principle of equal rights and fair equality of opportunity, have the right to freely choose their sovereignty and international political status with no interference.
SO, MOVING FORWARD WILL SEE AN END TO SELF-DETERMINATION AND OUR 99% IN CONSTANT FEAR OF ANY GLOBAL CORPORATE CAMPUS DECIDING TO USE FORCED GUARDIANSHIP AGAINST ANY 99% WE THE PEOPLE CALLING IT -----SOCIAL BENEFIT.
Who knows better than our US 99% WE THE PEOPLE what is good for our families? Why, it's those global banking 1% SOCIOPATHS whose only talent is LYING, CHEATING, AND STEALING. OH, REALLY?????
Those global banking 5% freemason/Greek players running around selling social benefit to AFFORDABLE CARE ACT----pretending they are fighting for IMMIGRANT CHILDREN----all know these far-right authoritarian, militaristic, extreme wealth extreme poverty LIBERTARIAN MARXIST policies are MOVING FORWARD. Only the global 1% have RIGHTS back in 1000BC
What Is Self-Determination Theory?
By Kendra Cherry
Updated May 19, 2017
Self-determination theory suggests that people are motivated to grow and change by innate psychological needs. The theory identifies three key psychological needs that are believed to be both innate and universal:
- The need for competence
- The need for connectedness
- The need for autonomy
Self-Determination Theory: A Closer Look
Psychologists Edward Deci and Richard Ryan developed a theory of motivation which suggests that people tend to be driven by a need to grow and gain fulfillment. The first assumption of self-determination theory is that people are activity directed toward growth. Gaining mastery over challenges and taking in new experiences are essential for developing a cohesive sense of self.
While people are often motivated to act by external rewards such as money, prizes, and acclaim (known as extrinsic motivation), self-determination theory focuses primarily on internal sources of motivation such as a need to gain knowledge or independence (known as intrinsic motivation).
According to self-determination theory, people need to feel the following in order to achieve such psychological growth:
- Competence: People need to gain mastery of tasks and learn different skills.
- Connection or Relatedness: People need to experience a sense of belonging and attachment to other people.
- Autonomy: People need to feel in control of their own behaviors and goals.
How Self-Determination Theory Works
How exactly do people go about fulfilling these three needs?
It is important to realize that the psychological growth described by self-determination theory does not simply happen automatically. While people might be oriented toward such growth, it requires continual sustenance. According to Deci and Ryan, social support is the key. Through our relationships and interactions with others, we can either foster or thwart well-being and personal growth.
What other things that can help or hinder the three elements needed for growth?
According to Deci, giving people extrinsic rewards for already intrinsically motivated behavior can undermine autonomy. As the behavior becomes increasingly controlled by the external rewards, people begin to feel less in control of their own behavior and intrinsic motivation is diminished.
Deci also suggests that offering unexpected positive encouragement and feedback on a person's performance on a task can increase intrinsic motivation. Why? Because such feedback helps people to feel more competent, one of the key needs for personal growth.
Observations About Self-Determination Theory
- "SDT begins by embracing the assumption that all individuals have natural, innate, and constructive tendencies to develop an ever more elaborated and unified sense of self. That is, we assume people have a primary propensity to forge interconnections among aspects of their own psyches as well as with other individuals and groups in their social worlds."
- (Deci and Ryan, 2002)
- "Social environments can, according to this perspective, either facilitate and enable the growth and integration propensities with which the human psyche is endowed, or they can disrupt, forestall, and fragment these processes resulting in behaviors and inner experiences that represent the darker side of humanity."
So, why does a global banking 1% CNN carry this video about a family fighting against a foreign sovereignty of MALTA ---THE HOSPITALLERS freemasonry corporation-----THE MAYO CLINIC? Remember, US national media is LYING AND HIDING.
The reason is tied to the post a few days ago regarding ranking of US states regarding HEALTH COST AND HEALTH ACCESS-----with TEXAS ranked last and Vermont and Massachusetts ranked high. The goal of MOVING FORWARD is to have all states controlled by those few global health systems like MAYO and JOHNS HOPKINS. The CNN video told us the family trying to escape MAYO had to find a health facility NOT OWNED by MAYO.
MAYO CLINIC took control of all public health services in MINNESOTA to become this national and global health system----just as did JOHNS HOPKINS here in MARYLAND. Hopkins is taking almost all market share in MD with goals of all University of Maryland and non-profits enfolded into one giant HEALTH SYSTEM MONOPOLY ---as too with MAYO CLINIC. Remember, both MAYO and HOPKINS expanded globally these few decades of ROBBER BARON fleecing of our US MEDICARE AND MEDICAID TRUSTS.
What both MAYO and Johns Hopkins do not want is US 99% WE THE PEOPLE being made too poor to afford health care policies ---to try to come to their facilities---and nothing scares people away from global health systems more than images of families fighting FORCED GUARDIANSHIP.
So, a national media showing of this MAYO hospital incident plants FEAR.
- Mayo Clinic
Doctor & Clinic
9650 Santiago Rd ·(507) 266-5100 Columbia MD
- Mayo Clinic
Doctor & Clinic
717 Princess St ·(703) 683-1666 Alexandria, VA
- Mayo Clinic
6728 Old McLean Village Dr McClean, VA
MAYO CLINIC is NOT a non-profit---it is now a global health corporation. When these powerful global banking 1% corporations take our local communities they will get what they want---including FORCED GUARDIANSHIP.
4500 San Pablo Road
Jacksonville, FL 32224
Mayo Clinic is a nonprofit worldwide leader in medical care, research and education for people who need healing.
Our multidisciplinary team of experts works together to identify a patient’s disease and deliver exactly the care that’s needed for that particular patient. Physicians work with researchers to ensure patients benefit from the latest advances in diagnosis, treatment and quality of life care. Our three campuses – in Jacksonville, Fla.; Phoenix/Scottsdale, Ariz., and Rochester, Minn. – treat patients regionally, nationally and internationally. Mayo Clinic Health System includes clinics, hospitals and health care facilities that serve more than 70 communities in Iowa, Georgia, Wisconsin and Minnesota.
When the Jacksonville facility opened in 1986, it was Mayo’s first expansion beyond Rochester, Minn. The clinic’s 304-bed hospital opened in 2008, consolidating all services on the San Pablo Road campus in southeast Jacksonville. Virtually all medical services a patient might need – doctor visits, testing, surgery, hospital care – are available at a single location. Scheduling is done in a coordinated and efficient manner, and everyone involved with a patient’s care works with a single electronic medical record.
Mayo’s research programs are focused on cancer, neurological and neuro-degenerative diseases. The goal is to bring the advances from laboratory research to patient care as quickly as possible. Mayo provides residency and fellowship programs, medical student clerkships, continuing medical education for practicing physicians and allied-health training.
To help patients orient themselves around Mayo Clinic in Jacksonville, Florida, we are offering a Patient Video Guide series. Our host, Vivien Williams, explains more here.
This incident with MAYO telling us MAYO has the best doctors also shows how precarious are the surrounding hospitals futures. That hospital this family chose for SECOND OPINION will be forced out of business MOVING FORWARD. Here we see THE GUARDIAN in UK carrying this story----raging global banking 1% as too CNN.
What we are watching on national media is the beginning of a complete loss of civil rights across all 99% WE THE PEOPLE with media loving to show our US citizens in retreat trying to access ordinary services. Now, those MN police chasing down this patient were aware of GUARDIANSHIP laws knowing this young lady had the right to check out of a hospital. No mention of REVISED GUARDIANSHIP laws that will have the police chasing a citizen and forcing them back to the institution filing that FORCED GUARDIANSHIP. This escape ending will soon be REVERSED----REVISED.
MOVING FORWARD----that police officer will not question MAYO CLINIC ----or think about the rights of this young lady.
Family says woman, 18, was kept 'prisoner' until they helped her 'escape from the Mayo Clinic after the hospital refused to let her go' two months after brain surgery, and even tried to take guardianship of her
- Alyssa Gilderhus was admitted to The Mayo Clinic in Minnesota in December 2016
- She suffered a brain aneurysm on Christmas Day and required emergency surgery
- Afterwards, her parents say she was held 'prisoner' in the hospital's rehab unit
- They butted heads with doctors over her care and were eventually excluded from discussions about it
- Alyssa asked to be transferred but claims she was ignored repeatedly
- The hospital tried to have the county take guardianship of Alyssa even though she was 18
- On February 28, her stepfather pretended to take her to the parking lot to meet her grandmother and drove her away
- They drove for 12 hours to a hospital in South Dakota where doctors gave them a second opinion
- The hospital has not answered specific questions over its treatment of Alyssa but said it was acting in her best interest
Published: 12:31 EDT, 13 August 2018 | Updated: 23:57 EDT, 13 August 2018
A teenager has told how she was forced to escape from the Mayo Clinic after doctors 'refused' to discharge or transfer her and tried to take guardianship of her against her will following a brain surgery last year.
Alyssa Gilderhus, now 19, was a high school senior and 18-years-old when she was admitted to the world renowned hospital's Minnesota facility on Christmas Day, 2016.
She had suffered a brain aneurysm and required emergency surgery to save her life.
After neurosurgeons performed the procedure, Alyssa was transferred to the hospital's rehabilitation unit where she spent three weeks.
Over the course of those three weeks, her parents butted heads with doctors who she says were 'cruel' to her and did not listen to her needs.
'The fight is over $11.5 million Mayo wants back as refunds for several tax years going back 15 years. That much money is not chicken feed, but neither is it going to be missed, given Mayo’s $16.3 billion balance sheet as of the end of March'.
Here is MAYO which started several decades as simply PRETENDING it was a religious non-profit taking a public hospital here and there-----being made just as Baltimore's Johns Hopkins a behemoth controlling all social services. So, MAYO having billions of dollars is fighting for a few hundred in taxes paid because it was LEGALLY REQUIRED TO.
So, MAYO is simply acting like any global corporate campus in US FOREIGN ECONOMIC ZONES---which do not pay ANY TAXES. As MAYO and JOHNS HOPKINS capture more and more and more of market share across every industry -----especially all that was our US PUBLIC SECTOR-----they are allowed to be that global banking 1% OLD WORLD KINGS AND QUEENS colonial entity----just as the EAST INDIA CORPORATION back when America was a colony.
THIS IS FAR-RIGHT WING, AUTHORITARIAN, EXTREME WEALTH EXTREME POVERTY LIBERTARIAN MARXISM. THE GLOBAL RICH HAVE THE RIGHT TO DO ANYTHING TO ACCUMULATE WEALTH AND POWER---AND THE 99% HAVE ABSOLUTELY NO RIGHTS.
What do you mean PAY TAXES says MAYO----we are educational---we are health care----we are social services---we are research-----you know---we are EVERYTHING.
'It would be interesting to know how the IRS treats income from a debt-financed property for Johns Hopkins'.
Is Mayo primarily a clinic? Millions in tax refunds at stake
June 20, 2018 — 7:30pm
Mayo Clinic signage at an event
LEE SCHAFER @LeeASchafer
The Mayo Clinic and federal tax authorities are fighting in federal court about whether the Mayo Clinic is primarily a clinic.
While it’s obvious the Mayo Clinic is a health care provider, it’s not at all obvious that this is the best way to describe it. So never mind what happens to Mayo’s relatively small tax refund, this technical little tax lawsuit has Mayo arguing about its core identity. That’s what makes this worth paying some attention to.
This litigation has been grinding along since 2016 and started with an Internal Revenue Service audit of tax years 2005 and 2006. A trial won’t take place at least until March of next year. The sparring between sides in the news recently has been over what material should be ruled in bounds as both sides seek to prepare.
Among other things, the clinic is trying to keep Mayo CEO John Noseworthy — a neurologist by background, not a tax lawyer — from being forced to answer questions from the government’s lawyers in the pretrial phase.
The fight is over $11.5 million Mayo wants back as refunds for several tax years going back 15 years. That much money is not chicken feed, but neither is it going to be missed, given Mayo’s $16.3 billion balance sheet as of the end of March.
It may seem odd that the nonprofit Mayo Clinic, based in Rochester, even has an income tax hassle at all. Yet nonprofits can have taxable subsidiaries and also get taxed for what’s called unrelated business income, a principle in tax law that makes sense. If a nonprofit makes money at a regular activity not really related to its core nonprofit purpose, it could be fair to see it treated the same as taxable companies.
The dispute with the IRS arose over how to treat unrelated business income from debt-financed real estate investments, so this one’s pretty deep in the weeds of tax law.
Based on my layman’s understanding of the law, how this income was earned wouldn’t matter if Mayo were the right kind of “qualified organization.” One of the ways to get that status is to be an “educational organization.”
That’s what the IRS got wrong, according to the clinic. Mayo really is an educational organization.
So, who didn’t know that in addition to running world-renowned medical centers, Mayo teaches medical students, too?
Mayo happens to have the sixth-ranked medical school for research, according to U.S. News & World Report, tied in the latest ranking with the University of Pennsylvania and well ahead of the University of Minnesota.
Mayo has pointed out to the court that it really has five distinct educational institutions, including Mayo’s school of continuing medical education. Mayo has more than 3,800 enrolled students, and by counting all the practitioners coming through its continuing education programs Mayo gets the total student count up to more than 100,000.
Mayo has insisted that all the IRS needed to do was look at the plain language of the relevant statute for the definition of an educational organization. What’s needed is a regular faculty and curriculum for a regularly enrolled group of students attending at a place where teaching is normally carried out. Mayo easily qualified.
Total students north of 100,000 sure sounds like a huge operation, too. Yet it’s not, if you put it in the context of everything else going on at Mayo.
In the first quarter of this year, Mayo had revenue from medical services of $2.6 billion. Fees and tuition revenue were not broken out on a separate line, probably because it didn’t matter enough in the financial statements of such a large patient-care organization.
Mayo declined to make an executive available to discuss the situation, given that it’s an ongoing lawsuit. But a good guess is that any revenue from its educational programs had to be lumped in with “other” revenue in the quarterly financials.
The IRS apparently looked at these numbers and decided that the “primary” activity of Mayo must be patient care.
Mayo lawyers have argued that even if looking at the primary activity was the right way to decide — and it’s not — the IRS still got it wrong. And here’s where its case gets more interesting.
If primary means first priority, then the IRS has failed to understand something pretty fundamental about how the Mayo Clinic operates. Its first priority is education.
That’s the message Mayo delivered in a number of ways, including how it filled out its own tax return. Part of the IRS Form 990 gives a nonprofit the chance to say what it does for a tax-exempt purpose and list its accomplishments. Mayo chose to lead with education on its form.
Among the facts buried in a very dense page of itty-bitty type on this section of Mayo’s 2016 tax form is Mayo’s boasting of more than 23,000 alumni who have come through its medical-specialty programs since 1915.
The real point here is that it’s impossible to tease out education from the other activities of any organization set up and run like the Mayo Clinic. Physicians who staff the Mayo are also the faculty and often the researchers. The people enrolled in its schools see patients and assist on research.
Mayo doesn’t exactly have a unique approach, either. Johns Hopkins in Maryland certainly looks much like Mayo, although it’s affiliated with a major university. Johns Hopkins teaches medical students, of course, yet it also operated six hospitals and more than 40 other patient care facilities as of last count.
It would be interesting to know how the IRS treats income from a debt-financed property for Johns Hopkins.
Mayo Clinic could give up its educational mission, I suppose, maybe turning over its medical school to the University of Minnesota and winding down its other educational programs. It would still be a draw for patients from around the world.
Well, at least it would remain a destination medical center for a while. Without education it’s hard to imagine how Mayo Clinic can still remain Mayo.
'Who We Are
The Sovereign Order of St. John of Jerusalem, Knights Hospitaller (Sovereign Order)'
We will have to give THE HOSPITALLERS a break as they are working from 1000BC DNA------they have no idea of how to operate in an AMERICA having freedom, liberty, justice, with CITIZENS having a BILL OF RIGHTS----with no OLD WORLD KINGS AND QUEENS in sight!
All of this is MOVING FORWARD back to DARK AGES what was a society completely controlled by FAKE 5% religious institutions simply working for OLD WORLD KINGS AND QUEENS---not going back 900 years----but going back to pre-Christian NERO, CATO, SENECA----that is why these institutions expanded while stealing our US 99% of WE THE PEOPLE'S wealth, assets, health savings accounts not caring that they are literally sending people to their graves UNNECESSARILY.
MAYO AND JOHNS HOPKINS----ET ALL US HEALTH SYSTEMS ENFOLDING ALL US SOVEREIGN PUBLIC HEALTH INTO FOREIGN SOVEREIGNTY OF MALTA---KNIGHTS OF MALTA.
Not much self-determination back in DARK AGES.
Who is behind all that few decades of ROBBER BARON sacking and looting of America----with Maryland Governor O'Malley and Hogan having all those global banking 5% freemason/Greek players in PAY-TO-PLAY PATRONAGE for helping to rob 99% WE THE PEOPLE?
HERE THEY ARE--------------BUT WE ARE CHRISTIAN ----Oh, really?????
Who We Are
The Sovereign Order of St. John of Jerusalem, Knights Hospitaller (Sovereign Order) is a Christian, chivalric, ecumenical and international community of members, who continue more than 900 years’ tradition of helping the sick and the poor of all nationalities, races and creeds.
Our Motto is Pro Fide, Pro Utilitate Hominum. For Faith, For Service to Humanity.
Our modern day Order is divided into 27 Commanderies (chapters) in 14 countries in Europe and North and Central America, consisting of approximately 850 members worldwide. The International office is located at Vancouver, Canada.
The Sovereign Order is Christian. It was founded on chivalric principles of putting others before self. Members of the Sovereign Order serve their community, just as the original monks and Knights of the Order vowed to do 900 years ago. Through goodwill and devotion to a just cause, the Sovereign Order has been in the forefront of some of history’s greatest moments.
The following video is a 17 minute summary of the Sovereign Order as it is today. It was developed by the Vancouver Commandery to celebrate the 900th anniversary. Despite some localisms, it gives a good overview of our structure and purpose.
The MAYO doctor was a global health corporation cog having to live inside AFFORDABLE CARE ACT deregulation, profiteering, predatory corporate data as EVIDENCE-BASED medicine. We will look more closely at the driver behind the GREAT PATIENT ESCAPE----that being US hospitals not getting paid unless they control each aspect of patient care with no margin for readmission. So, the MAYO doctor was driven to keep the run-away patient in the MAYO health system ---in this case the rehabilitation division. The doctor was not concerned about the welfare of patient---he was concerned about profiteering keeping the patient in the MAYO HEALTH SYSTEM.
So, the escaping patient at MAYO was placed on OBSERVATION STATUS----the patient knowing that level of care was not QUALITY---wanting to leave for another hospital---but not allowed to discharge......all tied to reimbursement from private or Medicare/Medicaid insurance.
When we see the RANKINGS BY STATE-----on COSTS AND ACCESS-----these are the TRICKS inflating DATA having no basis in REAL INFORMATION.
– “Become good at cheating and you never need to become good at anything else.”
Aren't Christian tenets---do not LIE, CHEAT, OR STEAL? Seems the KNIGHTS OF MALTA have lost touch with what being Christian means---perhaps that is because they are 1000BC---pre-Christian.
Readmission penalties dodged by placing patients on observation status
Posted by Don McCanne MD on Thursday, Aug 27, 2015
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Quality Improvement: ‘Become Good At Cheating And You Never Need To Become Good At Anything Else’
By David Himmelstein and Steffie Woolhandler
Health Affairs Blog, August 27, 2015
The Centers for Medicare and Medicaid Services (CMS) has trumpeted the recent drop in hospital readmissions among Medicare patients as a major advance for patient safety. But lost amidst the celebration is the fact that hospitals are increasingly “observing” patients (or treating returning patients in the emergency department) rather than “readmitting” them. But while re-labeling helps hospitals meet CMS’ quality standards (and avoid costly fines), it probably signals little real quality gain and often leaves patients worse off financially.
In most cases, observation patients receive care in a regular inpatient unit, and get treated just like other inpatients. And in many cases, observation stays stretch out to several days: in 2012, 26 percent lasted two nights and 11 percent at least three. But from Medicare’s point of view, this is outpatient care, which leaves patients responsible for more of the bill, and ineligible for Medicare-paid rehab or skilled nursing care.
Hospitals started designating more stays as “observation” after Medicare’s auditors began disallowing the entire payment for hospital “admissions.” Even though “observation stays” pay less than inpatient admissions, hospitals took a better safe than sorry approach, classifying many brief stays as “observation.” Between 2006 and 2013, observation stays increased by 96 percent, accounting for more than half of the apparent decline in total Medicare admissions during that seven-year period.
Medicare’s recent adoption of penalties for readmissions offered hospitals a new incentive to shift some patients returning within 30 days of their discharge to observation status. A patient stay labeled “observation” doesn’t count as a readmission, allowing hospitals that might otherwise be fined for having too many readmissions to skirt the penalty.
About 10 percent of all hospital stays occurring within 30 days of discharge are now classified as “observation;” a quarter of hospitals classified 14.3 percent or more of all repeat stays as “observation.” Moreover, analysis of time trends in observation stays makes it clear that they account for a significant chunk of the reduction in readmissions. Between 2010 and 2013, 36 percent of the claimed decrease in readmissions was actually just a shift to observation stays.
Emergency Department Use
And it’s not just observation stays that have been on the increase. More of the recently discharged patients are being treated in emergency departments (EDs) — without being admitted — as well.
Factoring in the 0.4 percent increase in ED visits within 30 days of discharge, the fall in the percent of discharged patients returning to hospitals for urgent problems is only 0.3 percent over the past three years — less than one-third of the improvement that CMS claims. And even this 0.3 percent overall fall may be partly an artifact of hospitals’ “upcoding” (exaggerating the severity of patients’ illnesses), which boosts diagnosis-related group (DRG) payments, and could also corrupt the formula used to risk-adjust expected readmission rates.
Medicare’s readmission penalties are among the growing number of pay-for-performance (P4P) and value-based purchasing initiatives that offer bonuses to high performers and/or penalize the laggards. We previously pointed out that the evidence for this carrot and stick approach is unconvincing. More recently, a long-term follow-up of the English hospital P4P program found that P4P generated no improvement in patient outcomes, damping the enthusiasm generated by the rosy short-term findings, and reinforcing the need for skepticism.
Adopting unproven everywhere P4P strategies that have been proven nowhere risks quality failure on a monumental scale. It pressures hospitals to cheat, saps doctors’ and nurses’ intrinsic motivation to do good work when no one is looking, and corrupts the data vital for quality improvement.
As the graffiti artist Banksy once said: “Become good at cheating and you never need to become good at anything else.”
In lieu of adopting comprehensive health care financing that actually would improve value – a single payer system – our national leaders have elected to continue with our current dysfunctional system and try to make it work. One measure that has been introduced is the assessment of penalties for patients who are readmitted within 30 days of being discharged from a hospital – on the theory that the patients should be fully stabilized at discharge with followup arranged that would prevent the need for readmission.
Physician and hospital administrators do not want patients readmitted soon after discharge. Their efforts are directed at providing the best care appropriate to improve patient outcomes. But there are some clinical conditions that are inherently unstable, or that can have unavoidable complications, that can result in the need for readmission. Also, in spite of outreach efforts, socioeconomic variables can result in destabilization of the patient’s condition. Some readmissions are absolutely inevitable.
This report is important because it shows that the improvement in lowering readmission rates that occurred after the introduction of penalties is not so much due to improved inpatient and post-discharge management, but rather is due to gaming rules that are characteristic of pay-for-performance (P4P) schemes.
Specifically, there has been a dramatic increase in placing patients on observation status instead of formally admitting them to the hospital. The care may be identical – provided in the inpatient service departments – but by not certifying the patient as being a formal readmission within 30 days of the last admission, the penalty is avoided. Medicare comes out ahead since outpatient services are priced lower than inpatient services, even if they are identical services – thus the trumpeting by CMS of another success in their reform efforts. But the patient loses since the cost sharing requirements for outpatient services are much higher than they are for inpatient. But then who ever said that health care reform was to benefit patients?
A variation of this gaming is to manage the followup hospitalization completely within the emergency department, perhaps even holding the patient overnight. The result is essentially the same as holding them on observation status.
This P4P-type gamesmanship is really a form of cheating. But it works. Instead of shifting to a much more efficient financing infrastructure – a single payer system – we can continue to follow the Banksy dictum – “Become good at cheating and you never need to become good at anything else.”
Maybe we should start to think about becoming good at financing health care instead.