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Heather Nicole McGee Well doctors said my pregnancy will not progress any further. One baby disappeared earlier on in the pregnancy and the other stopped growing all together and my hcg levels are still dropping which means no hope so I go in to see the doctor's tomorrow Read more ...
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Harford County Living
Harford County Emergency Management
Nationwide Drug Take Back Day, Saturday, April 26, 2014 from 10am to 2pm at HdG PD at 715 Pennington Ave, HdG, HCG 220 S. Main Street, Bel Air, and MSP Bel Air Barrack, 1401 Bel Air Road, Bel Air. Unused/unwanted prescription and over the counter dr Read more ...
ugs may be dropped off. No questions asked. Call Office of Drug Control Policy at 410-638-3333 for additional information.
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Trudie Norman
Harford County Emergency Management
Nationwide Drug Take Back Day, Saturday, April 26, 2014 from 10am to 2pm at HdG PD at 715 Pennington Ave, HdG, HCG 220 S. Main Street, Bel Air, and MSP Bel Air Barrack, 1401 Bel Air Road, Bel Air. Unused/unwanted prescription and over the counter dr Read more ...
ugs may be dropped off. No questions asked. Call Office of Drug Control Policy at 410-638-3333 for additional information.
9 hours ago
Harford County Emergency Management Nationwide Drug Take Back Day, Saturday, April 26, 2014 from 10am to 2pm at HdG PD at 715 Pennington Ave, HdG, HCG 220 S. Main Street, Bel Air, and MSP Bel Air Barrack, 1401 Bel Air Road, Bel Air. Unused/unwanted prescription and over the counter dr Read more ...
ugs may be dropped off. No questions asked. Call Office of Drug Control Policy at 410-638-3333 for additional information.
9 hours ago
Victor Alberto Gonzales Almeyda India hospitales de bajo costo India hospitales de bajo costo Document Transcript . 1. HBR.ORG NOVEMBER 2013 REPRINT R1311K THE GLOBE Delivering World- Class Health Care, AffordablyInnovative hospitals in India are pointing the way. by Vijay Govin Read more ...
darajan and Ravi Ramamurti This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement. . 2. Delivering World-Class Health Care, Affordably Innovative hospitals in India are pointing the way. by Vijay Govindarajan and Ravi Ramamurti The Globe India might be the last place on earth where you’d expect to find health care innovation. Government programs have finally brought some infectious diseases under control, but the nation’s ability to meet the basic medical needs of its citizens remains abysmal. Despite robust economic growth over the past two decades, the in- fant mortality rate is three times higher than China’s and seven times greater than that of the U.S. Of the 2million Indians in need of heart surgery, fewer than 5% get it. The majority of the country’s estimated 63million diabetics and 2.5million cancer sufferers haven’t been diagnosed, let alone treated. Seventy percent of India’s 12mil- lionblindpeoplecouldbecuredbyasimple surgery—if it were available to them. Although India boasts 750,000 doctors and 1.1million nurses, practitioner density is about one-fourth what it is in the U.S. and less than half that of China. Hospital beds are in short supply, and most medical facilities are dated, cramped, and often un- hygienic. In a country where the nominal per capita income is only $1,500 a year, pa- tients typically have to pay 60% of health care expenses from their own pockets. Still, Indians believe that good medical treat- ment is something everyone should have access to regardless of their ability to pay. Necessity spawns innovation. Despite the pressing demand and constrained sup- ply, a few relatively new Indian hospitals have devised ways of providing world- class health care affordably—and to scale. ABOVEA Narayana Health clinic in Mysore, India PHOTOGRAPHY:GETTYIMAGES FOR ARTICLE REPRINTS CALL 800-988-0886 OR 617-783-7500, OR VISIT HBR.ORG COPYRIGHT © 2013 HARVARD BUSINESS SCHOOL PUBLISHING CORPORATION. ALL RIGHTS RESERVED. November 2013Harvard Business Review2 This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement. . 3. These hospitals target well-off patients, which forces them to provide care that meets global quality standards. But their purpose is to serve everyone, including patients with very low incomes, which puts pressure on the organizations to lower costs dramatically. Such a business model scales because the low costs of these hos- pitals attract large volumes of patients and allow the overall enterprise to be profitable. As a result, the hospitals are able to sustain their operations not through the usual gov- ernment subsidies, charitable donations, or insurance reimbursements but through their revenues. Aravind Eye Care System, for instance, has paid for all its expansion projects from its profits, even though two- thirds of its patients receive free or subsi- dized care. These extraordinary private In- dian hospitals should serve, we believe, as an inspiration to those in other developing nations and as a wake-up call to hospitals in Europe and the United States. In fact, America’s health care system may soon find itself competing with one of India’s innovators. Building on the success of India’s medical tourism boom— a $1billion business that is growing by 30% a year—Narayana Health (NH) is open- ing a 2,000-bed multispecialty hospital in the Cayman Islands. A short hop from the American mainland, it will begin providing care in early 2014. Uninsured and underinsured patients will be able to receive high-quality treatment at an internationally accredited hospital for less than half of what they would pay in Amer- ica. The proximity of NH’s beachhead may well pressure U.S. hospitals to develop the innovative practices and systems that we describe in this article. India’s Hospital Exemplars Two years ago, we kicked off a project to understand how some Indian hospitals are able to provide world-class health care at ultralow cost. We identified more than 40 hospitals with innovative strategies and selected nine of them for an in-depth study. Sevenofthehospitalsarefor-profitandtwo, not-for-profit. Four focus on a single spe- cialty, and the other five are multi­specialty institutions. Seven of the exemplars oper- ate as academic centers and integrate edu- cationandclinicalresearchwithhealthcare delivery. We visited all the hospitals, gath- ered data, and conducted more than 100 interviews with the founding doctors, their leadershipteams,physicians,staff,patients, and industry experts over several months. The Indian hospitals we studied treat medical conditions that range from prob- lems of the eye, heart, and kidney to ma- ternity care, orthopedics, and cancer. Their charges for most procedures are as much as 95%lowerthanthoseatU.S.hospitals.That isn’t because the Indian providers offer low-quality services; five of the exemplars are accredited by either Joint Commission International (JCI), the international arm of the Joint Commission—an independent nonprofit that certifies the quality of more than 20,000 health care organizations in the U.S.—or its Indian equivalent, the Na- tional Accreditation Board for Hospitals & Healthcare Providers, which uses stan- dards similar to those of JCI. A sixth is seek- ing accreditation and a seventh has chosen not to do so for fear that the process could stifle experimentation and curtail innova- tion. The other two are not big enough to seek accreditation yet. Some of these hospitals—for instance, the Apollo Hospitals Group’s flagship in Hyderabad—have recorded equivalent or better outcomes than the international standards for medical complications asso- ciated with knee, coronary, and prostate surgery as well as for infections related to the operating theater and catheters. NH’s 30-day postsurgery mortality rate for coro- nary artery bypass procedures at its Ban- galore hospital is below the average rate recorded by a sample of 143 hospitals in Texas. Similarly, the five-year survival rate for breast cancer patients at HCG Oncology is comparable to U.S. benchmarks. Dec- can’s five-year survival rate for peritoneal dialysis patients is the same as that for pa- tients in the U.S. undergoing hemodialysis, the more expensive treatment commonly used there. Rates of complications associ- ated with eye surgery at Aravind compare favorably with those of the best hospitals in the UK’s National Health Service. How are some Indian hospitals able to provide such high-quality health care at ultralow prices? The obvious answer—the differential in the cost of labor—does play a role: Cardiothoracic surgeons, nephrolo- gists, ophthalmologists, and oncologists in India earn anywhere from 20% to 74% of what their American counterparts do. For instance, Aravind’s ophthalmologists earn $50,000 annually compared with the $253,000averageforU.S.ophthalmologists. NH’s cardiothoracic surgeons gross be- tween$150,000and$300,000,whereasthe median income for their U.S. counterparts is $408,000. And the salaries of nurses, medical staff, and administrators in India are dramatically lower; some earn only 2% to 5% of what a U.S. hospital would pay. But the labor cost differential is just a small part of the story. We calculated the price of an open-heart surgery at NH after adjusting the salaries of NH’s doctors and other staff to match U.S. levels. Even with the higher wages factored in, the cost was still only 4% to 18% of a comparable pro- cedure in a U.S. hospital (see the exhibit “Salaries Are Only Part of the Equation”). Moreover,othercostsinIndiaarehigher than in the United States. Equipment, such as MRI machines, and supplies, such as stents, are more expensive, and so are the costs of capital and urban land. As a result, NH’s 21-point labor cost advantage rela- tive to the Cleveland Clinic, for example, is mostly offset by a 17-point disadvantage Innovation at Indian hospitals results not from a grand design but from constant experimentation, adaptation—and necessity. 3Harvard Business ReviewNovember 2013 THE GLOBE This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement. 4. in NH’s cost of supplies, pharmaceuticals, and other direct expenses. Todeliverontheirdualcommitmentsto high quality and ultralow cost, the Indian hospitals we looked at developed three powerful organizational advantages: a hub-and-spoke configuration of assets, an innovative way of determining who should do what, and a focus on cost-effectiveness rather than just cost cutting. Those process innovations allow the hospitals to lower their costs without compromising quality; in fact, the first two lower costs while si- multaneously improving quality. The inno- vations result not from a grand design but from constant experimentation, learning, adaptation—and necessity. Let’s look at the process innovations in turn. A Hub-and-Spoke Configuration of Assets Most of the hospitals in our study started by establishing urban hubs in which they concentrate high-quality talent and so- phisticated equipment. Spoke facilities are then arrayed around the hubs to reach un- derserved patients in far-flung towns and villages. Unlike suburban outposts of ur- ban hospitals in the West, the spokes aren’t miniature hubs but rather gateways. In the U.S., most hospitals invest in duplicate equipment and offer a full range of services in their suburban facilities, but they’re un- able to get much out of those investments in remote locations. Even when Western hospitals consolidate, their aim is to gain market power rather than to lower costs. In India, the spoke facilities focus mainly on diagnosis, routine treatment, and follow-up care; they channel patients to the hubs for sophisticated procedures andsurgery.HCG,forinstance,has17spoke hospitals arrayed around four urban hubs in Ahmedabad, Mumbai, Chennai, and Bangalore. Its specialists work in the hubs and have access to high-end equipment such as PET-CT scanners, cyclotrons, and linear accelerators, while at the spoke facil- ities, less specialized doctors provide care using less sophisticated equipment. The Ahub-and-spokearchitecturealsohelps create large volumes. By reducing the barri- ers to treatment, NH now carries out more open-heart surgeries and Aravind does more eye surgeries than any other hospi- tals in the world. In turn, this has increased physician productivity: At NH, each sur- geon performs from 400 to 600 procedures a year, compared with 100 to 200 by U.S. surgeons. Similarly, Aravind doctors each perform from 1,000 to 1,400 eye surgeries a year, compared with an average of 400 by doctors in the United States. As volume rises, doctors, equipment, and facilities are used more efficiently and costs fall. A U.S. hospital might use a PET- CT scanner to evaluate three to five pa- tients a day; HCG conducts up to 20 scans a day. Several Indian exemplars run their MRI machines 24/7, sometimes charging lower prices at night when the machines would normally be idle, as an incentive to patients to get scans done at inconvenient times. Higher volumes also allow these hospitals to reap economies of scale in pur- chasing medicines, supplies, and medical equipment. The hub-and-spoke configuration al- lows hospitals not only to lower costs but also to improve quality. It does that by: Attracting and retaining doctors seeking to improve their skills rapidly. The high volume and sheer variety of cases attract talent to these hospitals; doctors can build their capabilities faster in them. All seven of the academic hospitals we studied recruit many of their doctors from among their students. The caliber of the re- cruits, in turn, contributes to the high qual- ity of outcomes at these hospitals. Developing and continually updat- ing treatment protocols that reduce errors. Unlike many U.S. hospitals, the Indian health care providers have devel- oped protocols for even relatively complex procedures, such as knee and hip replace- ments and cardiac and cancer surgery. For instance, at CARE Hospitals, angioplasty patients are assigned to one of three risk classes on the basis of objective criteria such as age, weight, medical history, and most highly trained oncologists, patholo- gists, and other physicians work in HCG’s center of excellence, a sort of super-hub, in Bangalore. The center houses equipment— such as an $8million high-precision, ro- botic radiosurgery system called the Cyber­ Knife—that HCG can’t afford to duplicate even in its other urban hubs. The hub-and-spoke approach is facili- tated by the use of technology—such as telemedicine, which enables the remote delivery of health care over the phone—al- lowing doctors in the hubs to effectively and efficiently serve patients seeking care at the spokes. Physicians can, for instance, read medical images remotely and discuss the findings with their patients. Unless expensive equipment, complex tests, or consultations with super-specialists are re- quired, patients receive care closer to their homes. That lowers the costs—such as lost wages during time away from work, trans- portation expenses, and room and board— that often deter poor people from seeking health care even when it is free. SOURCEHCG; COSTS ARE FOR A FULL SET OF INTENSITY- MODULATED RADIATION TREATMENTS $2,900HCGONCOLOGY $22,000 U.S.AVERAGE Cancer Treatment SOURCEDECCAN HOSPITAL AND U.S. RENAL DATA SYSTEM, 2012 ANNUAL REPORT; DECCAN AND U.S. COSTS ARE FOR PERITONEAL DIALYSIS PER PATIENT PER YEAR $12,000DECCANHOSPITAL $66,750 U.S.AVERAGE Kidney Dialysis Indian Hospitals’ Ultralow Costs FOR ARTICLE REPRINTS CALL 800-988-0886 OR 617-783-7500, OR VISIT HBR.ORG November 2013Harvard Business Review4 This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement. 5. lifestyle, and a different protocol is fol- lowed for each, taking extra precautions for high-risk patients. (U.S. hospitals don’t always develop or follow such protocols, which is one reason Atul Gawande, an American surgeon and journalist, wrote The Checklist Manifesto.) The results are impressive: Whereas data suggest that one in 200 angioplasty patients in the U.S. will require emergency surgery and half of those patients will die, only two out of 40,000 angioplasty patients at CARE Hospi- tals have required emergency surgery and just one has died on the operating table since the hospital’s inception in 1997. Creating specialists in relatively rare subspecialties of medicine. The large number of patients that come for treatment enables hub doctors to focus on specific types of medical problems. As volumes increase, relatively rare condi- tions are treated often enough that doctors become world-class experts in those areas. That’s how NH has become a global leader in pediatric open-heart surgery, attracting patients from across Asia and Africa. High volumes have allowed Apollo to become a leader in organ transplant surgeries and made L V Prasad Eye Institute (LVPEI) a top provider in corneal transplants. Promoting innovation that suits local conditions. Doctors in India pio- neered the beating-heart method of sur- gery, by which they can operate without shutting patients’ hearts down. This tech- nique enables surgeons to perform the procedure without expensive heart-lung machines, which are rare in a developing economy. The method also leads to fewer complications, requires shorter hospital stays (which results in a lower incidence of hospital-related infections), and allows patients to recover faster. High patient vol- umes have allowed Indian doctors to mas- ter the technique over time. Examples abound of innovations sparked by the need to overcome con- straints in emerging markets. Aravind has perfected the manual small-incision cata- ract surgery technique. It requires less so- phisticated equipment and less seasoned surgeons and uses cheaper lenses than the phacoemulsification technique favored by U.S. hospitals. CARE Hospitals and other Indian providers typically perform an- gioplasties by going in through the wrist (rather than the groin, which takes more time to heal), allowing them to discharge patients the same day. Deccan Hospital uses peritoneal dialysis, a home-based treatment for patients with chronic kidney disease that is substantially cheaper than hospital-based hemodialysis, the more common treatment in the United States. And LVPEI has developed technology that allows a single cornea to be sliced and used for more than one transplant patient. Rethinking Who Does What By shifting tasks, the best Indian hospitals match the skill levels of their people with the basic requirements of tasks. Assigning doctors to tasks that nurses can do, for in- stance, not only raises costs but may also reduce quality; doctors are often less profi- cient at routine tasks than are nurses. Indianhospitalshavetakentask-shifting toanewlevelbycreatingfreshcategoriesof low-cost health care workers at one end of thespectrumandhighlyfocusedspecialists at the other. Unable to lure trained person- nel to rural villages, for example, LVPEI has hired and trained high-school graduates as “vision technicians” in its spoke facili- ties, where they take over some of the func- tionsofoptometrists.Similarly,Aravindhas trained village girls to become ophthalmic paramedics; they constitute 64% of Ara- vind’s workforce and perform tasks such as admitting patients, maintaining medical records, and assisting doctors. At the high-skills end of the spectrum, NH encourages general physicians to be- come specialists, and specialists to become super-specialists. It trains nurses to ad- vancetothehigher-skilledpositionofnurse intensivist, akin to a nurse practitioner in the United States. Similarly, HCG has devel- oped a cadre of nurses to assist oncologists and intensivists, and LVPEI’s vision techni- cians have the option of enrolling at its op- tometry school to become optometrists. The exemplar hospitals maximize theirefficiencybyincreasingthenumberof staffsupportingtheirmostskilledsurgeons and specialists, radically extending their reach. Each Aravind surgeon, for example, has help from six paramedics in the clinical domain and four assistants for administra- tiveandsupportservices.Paramedicsgoto a village, screen patients, transport them to the spoke hospital, check their vitals, get tests performed, prepare patients for sur- gery, deliver postsurgical care in the ward, transport them back to the village, and pro- vide follow-up care. The surgeon performs only the actual procedure. To cut costs, U.S. hospitals often eliminate low-skill staff jobs, which forces doctors to spend more time on routine tasks—resulting in the wrong kind of task shifting. Another way of increasing surgeons’ productivity is to decrease the amount of time it takes to move one patient out of the operating theater and bring in the next one. That is the key factor limiting efficiency and a key driver of costs, according to a SOURCEDECCAN AND U.S. RENAL DATA SYSTEM, 2012 ANNUAL REPORT; 5-YEAR SURVIVAL RATE FOR END-STAGE RENAL DISEASE PATIENTS UNDERGOING PERITONEAL DIALYSIS 50%DECCANHOSPITAL 41% U.S.AVERAGE SURVIVAL RATES Renal Disease SOURCEHCG AND SEER DATABASE 5-YEAR SURVIVAL RATE FOR BREAST CANCER, STAGES 1–3 COMBINED 86.9%HCGONCOLOGY 89.2% U.S.AVERAGE SURVIVAL RATES Breast Cancer Indian Hospitals’ High Quality 5Harvard Business ReviewNovember 2013 THE GLOBE This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement. 6. global study of performance benchmarks in knee-replacement surgeries. Eric Wads­ worth, the coleader of Dartmouth’s health care delivery science program, concurs. “Instead of looking at when patients are wheeled into and out of surgery, hospitals should look at the interval between when one patient is wheeled out and the next is wheeled in.” Aravindtacklesthechallengeincataract surgery by setting up two surgical stations side by side, with the surgeon positioned between them, assisted by a swiveling microscope and two pairs of paramedics. For each patient, one nursing paramedic hands the doctor sterile instruments and the right implants, focuses the microscope, and bandages the patient. The other para- medic—called a running nurse—replaces used surgical instruments with sterilized ones and moves the patient into and out of the operating theater. Switching smoothly from one patient to another, Aravind’s doc- tors briskly perform operations in 10- to 12-minute intervals, completing five or six in an hour rather than the one or two that a surgeon can handle in a conventional oper- ating suite assisted by a single nurse. An extreme form of task shifting is self-service, where patients and family members take over tasks traditionally per- formed by hospital staff. At the NH hospital in Mysore, for instance, family members provide non-ICU postoperative care. As with other kinds of task shifting, success depends in large part on proper training. Working with Stanford University, NH has developed a four-hour audio and video curriculum that explains how to care for patients during the three days following heart surgery. Allowing family members to provide those services reduces costs, allows for personalized care, and ensures continuity of care at home, reducing post- surgical complications. Asserting Frugality Maximizing the volume of procedures performed is obviously not the goal of any hospital, but many aspects of the current U.S. system—especially approaches such clamps?” asks Devi Shetty, NH’s founder- chairman. In fact, JCI allows accredited hospitals to reuse devices as long as they adhere to its strict sterilization procedures. Indian hospitals economize on decorat- inglobbies,wards,patientrooms,hallways, and offices. Senior managers often share small offices, freeing space for mission- critical areas such as operating theaters. Several hospitals lease rather than buy land and buildings; both are quite expen- sive in India. Some choose not to purchase expensive diagnostic equipment but rather strike pay-per-use deals with equipment providers, as NH has done for more than one of its hospitals. Suppliers such as GE, Philips, and Siemens are happy to offer such arrangements because the volume of patients is huge. The hospitals we studied think care- fully about matching the sophistication of equipment to the task. LifeSpring orders smaller and simpler beds for its maternity wards but does not skimp on the delivery tables for operating rooms in its 12 hospi- tals in Hyderabad. Vaatsalya has opted for lower-resolution, black-and-white ultra- as fee-for-service payment models—cre- ate incentives for health care providers to move in that direction. In the hospitals we studied in India, the goal is to maximize the number of patients treated rather than the number of procedures conducted. To achieve that goal, those hospitals must embrace a mind-set of old-fashioned fru- gality, applied in ways both innovative and remarkably mundane. Cost cutting is an ongoing priority, even among doctors. Among the hospitals’ most straightfor- ward cost-cutting measures are efforts to prolong the working life of expensive tech- nology through careful maintenance and repair. To that end, NH has contracted with a U.S. maintenance company, TriMedx, to help double the life of diagnostic equip- ment. Some hospitals routinely reuse medical devices sold as single-use prod- ucts—such as $160 steel clamps employed during beating-heart surgeries, which CARE Hospitals and NH sterilize and reuse 50 to 80 times. “If no hospital in the world throws away their needle holders, forceps, and scissors, which are drenched in blood after every operation, why throw out the SALARIES ARE ONLY PART OF THE EQUATION Lower wages in India contribute to the lower health care costs there— but not as much as you might think. Narayana Health reports that the cost of open-heart surgery is $3,160 one-third of which goes to salaries. TOTAL SURGERY SALARIES $1,054 PLUS OTHER COSTS $2,106 Salary costs are split evenly between doctors and other staff. Assuming that U.S. doc- tors are paid twice as much as their Indian counterparts, on average, and other staff 20 times as much, here’s the sal- ary cost at U.S. levels: SALARIES AT U.S. LEVELS DOCTORS’ WAGES $527x2 +STAFF WAGES $527x20 TOTAL SALARIES AT U.S. LEVELS $11,594 So what is the total cost of the surgery when salaries are comparable to those in the United States? NARAYANA HEALTH’S TOTAL COST OF SURGERY AT U.S. LEVELS SALARIES AT U.S. LEVELS $11,594 +OTHER COSTS $2,106 TOTAL COST OF OPEN-HEART SURGERY $13,700 WHICH IS STILL LESS THAN THE TOTAL COST OF OPEN-HEART SURGERY IN THE U.S. $75,662– $342,087(RANGE IN TEXAS, 2010 DATA) FOR ARTICLE REPRINTS CALL 800-988-0886 OR 617-783-7500, OR VISIT HBR.ORG November 2013Harvard Business Review6 This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement. 7. sounds and three-parameter patient moni- tors, where appropriate, instead of five- parameter monitors in its 18 hospitals in Karnataka and Andhra Pradesh. Toreducewaste,Apollo Hospitals asked suppliers to shorten the length of sutures in each packet—and to lower the price ac- cordingly—after it found that its doctors were routinely discarding one-third of each suture after procedures. Some health care providers have gone further by coming up with less costly substitutes for supplies or equipment. CARE Hospitals, for instance, has developed stents priced from $240 to $360 apiece that perform as well as imports that cost 10 times as much. It has set up a subsidiarytomanufacturethestents,along with catheters and other devices. Aravind hassignedatechnology-transferagreement with the Florida-based IOL International and set up a company in southern India, Aurolab, to manufacture intraocular lenses. When the lenses debuted in the U.S., they sold for $200 each. By the mid-1990s, Auro- labwasturningoutlensesfor$5apiece,and the price had dropped to $2 a unit by 2013. The focus on costs applies to physicians’ wages as well. The exemplar hospitals pay doctors a fixed salary, offering no bonuses or other incentives for internal referrals for testsorprocedures—anapproachmuchdis- cussedbyhealthcarethinkersindeveloped countries but usually not implemented be- causeoffee-for-serviceincentives.Thebest Indianhospitalsofferfixedpricesforapack- age of common medical treatments rather than pricing for individual procedures or tests. The fixed-price model discourages doctors from ordering unnecessary proce- dures, while protocols ensure that essential procedures aren’t skipped. The hospitals we studied infuse cost awareness across the organization in many ways. At NH, all doctors receive a daily text message with the previous day’s P&L data. Thepracticeinducesdoctorstobeprudent; they can see how their decisions about which medicines, supplies, or tests to use affect the cost of treating patients. It also motivates them to suggest ideas for cost savings and process improvements. NH’s doctors get comparative performance data for their own hospital and 21 others in the group, which encourages them to share best practices. In contrast, most U.S. hos- pitals lack an understanding of their costs: Few CFOs, let alone doctors, seem to know the real cost of delivering services. Lessons for U.S. Hospitals Just how transferable is the Indian model to the developed world? Barriers certainly exist, among them regulations, fee-for- service incentives, pharmaceutical lobbies, trade unions, medical malpractice lawsuits, and investments in extensive hospital in- frastructure. However, the hurdles may be lower than many suppose. U.S. hospi- tals, for example, treat higher volumes of cardiac, kidney, and cancer patients than their Indian counterparts do, suggesting that opportunities exist to reap learning- curve benefits and economies of scale. Sal- ary differences, large as they are, aren’t in- surmountable since they constitute only a small part of the cost differential. Innovation has flourished in the U.S. in the development of new medications, pro- cedures, devices, and medical equipment— butinthefieldofhealthcaredelivery,there has been too little progress. Health care is still viewed as a craft, especially by doctors who guard their right to make autonomous decisions and view each patient as unique. Someofthepracticeswehavedescribed are being implemented by progressive U.S. hospitals. California-based CareMore, for instance, engages in task shifting, having created a category of health worker known as extensivists, who coordinate care for Medicare patients, producing better out- comes at a lower cost. Iora Health clinics in Las Vegas and Brooklyn employ former schoolteachers and athletic trainers to help patients make behavioral changes, freeing physicians to focus on diagnosis and treat- ment. Boston-based Steward Health Care uses a tele-ICU system to provide efficient intensive care across its 10 hospitals. The Vermont Department of Health is imple- menting a hub-and-spoke arrangement to treat people with opioid addiction. In the coming decade, U.S. hospitals will be under even more pressure to lower costs, improve quality, and expand ac- cess—the very things the Indian hospitals we studied have been tackling. Demand will surge as aging baby boomers are joined by the millions of patients who will be cov- ered by the Affordable Care Act in 2014. U.S. hospitals should use the swelling demand to get more out of the investments they’ve made—by reconfiguring assets, shifting tasks, promoting innovation, and culti- vating frugality. Such moves don’t require changes in legislation; only a commitment to reverse the inexorable rise in costs. INDIAN HOSPITALS, doctors, and admin- istrators have traditionally looked to the West for advances in medical knowledge, but it’s time the West looked to India for in- novations in health care delivery. Changes in the U.S. health care system will not come easily or quickly. However, the U.S. health care system could operate very dif- ferently if it were exposed to the kind of low-cost innovation that drives the best Indian hospitals.  HBR Reprint R1311K Vijay Govindarajan is the Earl C. Daum 1924 Professor of International Business at Dartmouth’s Tuck School of Business and a Distinguished Fellow of the Dartmouth Center for Health Care Delivery Science. Ravi Ramamurti is the DMSB Distinguished Professor of Interna- tional Business and Strategy and the director of the Center for Emerging Markets at Northeastern University’s D’Amore-McKim School of Business. Apollo Hospitals asked suppliers to shorten the length of sutures—and to lower the price—after it found that its doctors routinely discarded one-third of each suture. 7Harvard Business ReviewNovember 2013 THE GLOBE This article is made available to you with compliments of Prof. Ravi Ramamurti. Further posting, copying, or distribution is copyright infringement.
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Keke Iaso Tea Iaso HCG Drops Lose 1 or 2 pound daily www.totallifechanges.com/2151711
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Keke Iaso Tea Iaso HCG Drops Lose 1 or 2 pound daily www.totallifechanges.com/2151711
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Hcg Diet Ireland
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Hcg Diet Ireland
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11 hours ago
Hcg Diet Ireland
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HCG is a natural hormone, quickly absorbed, that activates the Hypothalamus to release and mobilize the abnormal (extra) fat that is find in your body and uses this as source of energy and food. When you are on a very low calorie diet, HCG Life Drops Read more ...
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HCG is a natural hormone, quickly absorbed, that activates the Hypothalamus to release and mobilize the abnormal (extra) fat that is find in your body and uses this as source of energy and food. When you are on a very low calorie diet, HCG Life Drops Read more ...
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17 hours ago
trolleytrends HGC for Weight Loss I did not trust the diet pills, so I choose the HGC for weight loss. I heard the HGC from my friend, Jane. Actually I was still worrying about my body shape ten months ago, since I was laughed at by the people around me very oft Read more ...
en for overweight before. And I tried to lose weight many times but always failed. I try diet pills for weight loss, the pill could be effectual, but it also makes my appetite decreased and inhibits my diet. When I stopped taking the pills, my appetite will be back again and I was unable to stop myself from pigging out, so I could not lose weight any more. I thought that there is nothing on earth that can help me lose my unwanted weight until I decided to try the HGC for weight loss. I was so lucky to have such a diet which can make me lose at least a pound on the first day when I firstly use it-the answer is the HCG Diet. HGC diet makes use of a natural hormone that is tremendously beneficial in weight loss. This hormone was discovered to be produced only by pregnant women. Meanwhile, we can now easily manufacture this hormone in a lab and the hormone has the ability to speed up the way of body processes food. This is what the HCG diet can do for you. We are known traditional weight loss product usually lose muscle mass in the process. But HCG for weight loss can prevents this from happening. It prevents the risk of muscle mass when we speed up our metabolic rate. This means that you will never have any problems when it comes to sculpting your body and retaining strength. My dear friends, above is what I have ever been experienced and suffering, If you are facing the same problem with me, I strong recommend you to have a test of HCG for weight loss. Wish god will bless you. Article Source: http://www.hcgdietinsight.com HCG Diet Insight - What's HCG Diet?Any HCG Diet Dangers?Everying about HCG Diet Reviews,HCG Drops & HCG Injections,HCG Side Effects,HCG Diet Menu,HCG Diet Recipes,HCG Weight Loss,HCG Diet Protocol & more Dr Simeons HCG Diet info.
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23 hours ago
Annemarie Cronje How Does the HCG Diet Work? The idea behind hCG diets in general is that the hormone allows your body to access fat stores more quickly than normal. Instead of losing bone and muscle mass you start losing body fat right away. When following the hCG Read more ...
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Low carb diet (Lose 30-40 lbs in 2 months)
Low carb diet (Lose 30-40 lbs in 2 months) http://mackinreviews.hubpages.com/hub/Low-carb-diet-Lose-30-40-lbs-in-2-months   What is a "Low-Carb" Diet? A Low-carb (Carbohydrate) diet is one of the fastest ways to lose weight, due to your body not Read more ...
taking in enough nutrients to survive, plain and simple. Your body attacks and metabolizes your fat cells and uses the nutrients for energy. Unfortunately, however your body also attacks your muscles before it attacks your fat cells, but there is a way to divert this, and have your body directly attack your fat cells for the energy, and cause you to shed pounds daily, and literally watch the weight fall off.   So how does it work? This is an extreme diet, and is not recommended for the feint of heart. This diet requires a lot of dedication and will power, however, the dedication and willpower come easier and easier the more you see results, its just how human nature is. This is definitely a results driven diet, and drives results in such a fast manner, that you'll only need to really force yourself for the first 3-7 days to stay on such a strict regime, after that it just comes natural and you can keep it up for as long as you want. Though, I don't recommend keeping this diet for longer than a 2-3 month cycle, due to losing weight at such a fast pace, it can cause health problems, and lots of extra lose skin that you'll hate and have to fill into with muscle, or wait for it to naturally repair itself and shrink and reform to your body (which takes quite a while, so why not just fill the voids with muscle!) I recommend this diet for those special occasions where you're seeing people you haven't seen in a long time, like a reunion, or a family gathering, or a party where you're going to see your ex and you just want to metaphorically slap them in the face with your new hot bod. The FIRST STEP in this diet, is preparedness. The first thing you're going to want to do is prepare yourself by picking a date, telling yourself that you are going to start this diet, on that date and DO NOT under any circumstances move the date further back, you will subconsciously tell your body that you are not ready for such an extreme diet, and you will fail. Trust me. The next step, is to go through your pantry, your kitchen, your fridge, the fridge in your garage, the secret stash hidden under your bed or in your closet, and THROW EVERYTHING AWAY. Don't take that "one last bite", toss it. This trains your mind, you will subconsciously tell your body and your mind, flat out NO because eating junk food won't even be an option. This step is just as crucial as the first one because it allows you control over what you're going to eat, by making sure there are no unhealthy or carbohydrate loaded decisions laying around the house in any shape or form, and you have no choice but to eat the healthier choices, or not at all. If you can keep this step up for two weeks, and not cave into any junk food, this will now become programmed into your body, and into your brain which will now allow you to not go back to the old way of eating carbohydrate loaded goodies or fattening foods. This will also set you up for when you are done with the this strict diet, to allow your body to make natural and healthy decisions from this point on, trust me, you really won't miss those Funions or Lays potato chips which you used to love so much.   I wont sugar coat it. Its is hard. After the first two steps have been taken, your goal is to eat as little as possible throughout the day. How you do this, is on you, but the best way I find, is figure out why you eat when you eat? Is it REALLY because you are hungry? or is it more out of boredom, or do you eat emotionally? Once you figure this out, you find the root of why you eat what you eat. So, if its boredom, find something to keep your mind busy. I for one, get sucked into my job so easily, that 1 hour turns into 10-12 and I haven't eaten at all, then I go home, its time for dinner and then bed. Daily calorie intake should be about 2300 for most men, just to maintain their weight. If you go all day without eating, while working and keeping a moderate pace of burning calories, even if your just sitting at a desk, constantly getting up to grab things off a printer, or moving around, burns calories. So, your shooting for a caloric goal of 500 per day, with a carbohydrate ratio of no more than 20 carbohydrates per day. This diet keeps you at a 1500 deficit daily. There are 3000 calories found in 1 lb of fat. 2 days of 1,500 caloric deficits will burn 1lb per 2 days, due to their being 3,000 calories in one pound of fat. Keeping this math in mind, if you work out. Say, you run a mile at a decent rate, or even lift a couple weights throughout the day, or do some physical movements like moving heavy objects, anything that may require you to test your bodies abilities at all, you burn calories. (Remember, this isn't the safest diet, but it is very effective.) Calorie deficiency is what makes the HCG diet so successful (I'm sure you've heard of the HCG diet) The HCG requires you to take useless drops, all while maintaining a calorie deficient diet. The only difference here, is that you aren't buying over-priced weight loss drops that don't do anything for you at close to $50.00 a bottle. HOWEVER, I do recommend buying an appetite suppressant, or some form of fat burner, this will boost your weight loss and calorie burn exponentially!   What to drink? Again, I cannot stress enough how important it is to realize that this diet is NOT the safest diet to go through. If you are still adventurous enough to partake in such a diet, then you must know that you need to drink water, CONSTANTLY. Drinking COLD water will not only cool your body down (Which burns even more calories due to your body warming the cold water up to keep your body temperature at a normal rate) but it will also keep you feeling full. Water is extremely beneficial for you, and it will help clear the toxins out of your body. If you get sick of the taste of water, add lime juice to it! Not only does it change the taste of water, it also boosts weight loss and even makes you feel more energized .Here is a link to another article I've written on the health benefits of Lime Water.   Remember.. WATER, WATER, WATER, WATER!! Drink nothing but WATER!   What to eat? Say NO to carbs! Now onto the food. The idea behind this diet in particular is to limit yourself, and limit your calorie intake and your carbohydrate intake. By doing so, you will shrink the size of your stomach because your meal portions will be smaller due to the smaller calories and carb allowances. Eat NOTHING BUT LOW CARBOHYDRATE FOOD(S). Don't look at anything but the carbs. Things that state they are low calorie, can be high in carbs and can be misleading, however, if you lower carbohydrate intake, then you are lowering your true calorie intake, as well as sugar intakes. Which ultimately has a bigger impact on your body, because you are basically fighting 3 sources of fat, and not just 1. Low carb foods you can allow yourself to eat; (Just remember to keep it between 10-20 carbs per day, and it will be hard for the first few days) - Lean steak or chicken (No dark meat, or deli lunch meats, these have added sugars, which in turn lead to "Invisible" carbs.) - All forms of fish (No batter, obviously. Cooked in lemon juice this is a great low carbohydrate way to fill you up, and keep you healthy while losing weight.) - All forms of chicken or turkey (No glaze or sauces, as they contain large amounts of carbs and calories. Chicken is high in protein which is a great way to keep you full too!) - All forms of shell fish (Again, no sauces as they contain carbs. Fish is low in carbs and high in protein as well, plus the oils from the fish are very beneficial to your health!) - Turkey bacon. (If you use regular bacon, limit yourself due to the nitrates. Turkey bacon is a healthier form and also contains even less carbs than its counterpart, due to having less fat.) - Eggs Whites (Be careful of the yolks, limit these, it is best to eat nothing but the egg whites.) - Salsa (Regular salsa, nothing fancy. Great tasting low carb solution to dressings, and toppings for salads or chicken!) - Cheese (Cheese is extremely low in carbohydrate counts. Cheese sticks are a good way to keep your metabolism going throughout the day, you can keep a few of these at work or at home, and just quickly grab and snack.) - Salads (Salads are a great way to keep yourself full and low on carbs. However, most people who go on diets and eat nothing but salads choose the wrong dressings. This is a problem, which deems the salad diet redundant because of the carbohydrates and calories found in the dressing, and the amount placed on the salad. Sometimes in this scenario you're just better off going with the slice of pizza you passed up for the "healthy" salad..) - Milk (Milk is okay to drink, just be sure that it is skim, low fat, coconut, soy or almond milk. Keep track of the calories and the carbs in the different milks though and don't over do it!) - Protein Powder (Protein powder delivers a large amount of nutrients to your body when consumed, either mix with the above mentioned milk beverages, or water! Make sure you choose a protein powder that is designed to help lose weight and build muscle, and not to gain muscle. 1-5 carbs per serving, this can also be used a meal replacement, 3 times per day with water, and you are golden to lose weight. Not only is it beneficial but it allows you to feel full longer and not think about food as much. Ensure to get at least 2 different flavors if you are taking protein powder 2+ times per day to stop you from getting bored and help you stay on track!)         What to stay away from? Foods are tempting, but keep away from the bad ones and you will drop weight like there is no tomorrow. Stay away from carbs, literally, when you see something with more than 5 or 10 carbohydrates on that nifty little nutrients label found on products, say NO! Don't do your best to avoid these foods, doing your best implies that there is a small chance you still might cave in and consume them because nobody is perfect, just say NO to them, and quite LITERALLY avoid them. Any form of bread or pastry Sauces made from milks or cream Fried foods Foods with a high fat content Fast food Sugar in general (Including sugar loaded beverages, candies, snacks, chocolate, anything processed or sealed in a container such as a lunch meat.) Again, I can't stress enough how hard this diet is. Always be sure to drink plenty of water, and keep up with the dedication and willpower needed to perform such a feat. This diet works, it is harsh, but it works, and will shock your body into burning fat cells stored all over your body. If you feel like you are going to be sick, or are going to feint, or may have trouble with the diet once you have started. Make sure you eat, know your body and know your limits before constricting your calorie and carbohydrate intake to such drastic and low levels. Your body needs them to perform, which is why it works so well because it will burn what is in your fuel reserves and your fat cells will disappear. Just remember to be safe!
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