Archivi delle etichette: Health promotion

Without patient participation, there is no patient engagement @Medici_Manager

 | TECH | NOVEMBER 22, 2012

Healthcare innovation companies are just beginning to understand technology challenges that come with engaging patients with chronic diseases in care management and care transition. Many of healthcare IT vendors assumed that a simple access to portals with half-baked information and  fragmented medical records will do the trick. Boy… were they wrong!

For the past twenty years, the HIT industry has focused on developing software solutions exclusively for healthcare providers. These companies understand where the money comes from. HIT executives can tell you that patients will not spend a dime on their products. The great Google Health flop was testimonial to this hypothesis.  Google, and in some extent Microsoft, naively assumed that patients are indeed interested in managing their own health data. The executives in these brilliant companies sat around large tables in large conference rooms and brainstormed about a population they didn’t know much about. They made some very false assumptions.

For example, what patient wouldn’t like to access his/her data? Wouldn’t it be great if patients could have all their data in one place? Why wouldn’t we put patients in charge of managing their own data? How about making patients the custodians of their own information? These questions were logical but uninformed. Google, and again in some extent Microsoft, ignored some fundamental behavioral traits of the patient population.

Under pressure from CMS and private insurers, healthcare organizations are being gently ushered out of the fee-for-service model into the pay-for-performance system which rewards providers for keeping patients healthy and out of hospitals. Finally, after all these years, the concept of patient-centered care model is gaining ground. Patient engagement is big contributing factor to the success of the patient-centered care model. Patient engagement means different things to different people. But whatever your definition of patient engagement might be, one thing is for certain: without patient participation, there is no patient engagement.

Facing stage 2 Meaningful Use compliancy, ICD-10 and HIPAA 5010 requirements, healthcare organizations began to put pressure on their HIT vendors to come up with patient engagement solutions. Healthcare organizations needed solutions that would enable patients to access information online. This was a disaster waiting to happen. So, the executives in these HIT companies sat around large tables in large conference rooms and brainstormed about a population they didn’t know much about. And as a result, patient portals were adopted as the solution to the patient engagement problem. They made the same false assumptions that Google made. For example, why don’t we create patient portals and connect them to our own EMR and PM systems and allow patients to access their medical records, see their lab results, make appointments online, request refills and access patient education materials? Wouldn’t that be greater? We even throw in a mobile app.

Well, here is the problem: small number of patients has access to computers and Internet. Many of these patients will not login to portals. Patients who are computer savvy require the least amount of engagement and intervention. Computer literate patients take good care of themselves, take their medications on time, make their appointments and stay out of hospitals.

Patient portals leave behind those who need engagement the most. Elderly and low-income patients with chronic diseases have the highest rate of hospital readmissions. This patient population will not touch patient portals. They do not use gadgets, do not have access to smart phones, do not have internet and do not own computers. The same is true for many behavioral health patients.  If accessing information through patient portals is our only solution to patient engagement, then shame on us.

Elderly and low-income patients are the most venerable and often left behind when it comes to the use of technology in healthcare. As HIT innovators, it is our outmost responsibility to design products that especially accommodate this patient population. We need to walk away from the concept of accessing information and start thinking about ways to deliver information and education to patients. In addition to patient portals, we must develop products that are simple, cost effective, holistic and easily available to elderly and the low-income patients. We must develop multifaceted technology solutions that connect with patients based on the best method of communication available to the patient. Our patient engagement strategy must be built on patients’ requirements, not ours. The success of the patient-centered care model on the technology side depends heavily on availability of solutions that cover patients from all walks of life without any unintentional favoritism towards certain race, gender, income and age.

Mack Baniameri is CEO, Health Business Intelligence Corp.

How many times have you done this procedure, Doc? @Medici_Manager @kevinmd

Questions such as this from proactive, increasingly knowledgeable patients place a physician on the horns of an ethical dilemma.  Although fellows are closely supervised and trained under a gradually increasing responsibility principle (based upon subjective evaluation), a time will come when there is no one available to back you up in the catheterization lab.

Fact: Someone has to be a physician’s first case of any given type. However, no one really wants to be that person.

Access to extensive medical information on the web has satiated some of our patient’s desire for information and expectations regarding medical procedures, which is a good thing. However, increased transparency and public awareness of medical errors has opened up a Pandora’s box regarding a physician’s skill level and experience.  The September 2012 issue of Men’s Health went as far as publishing peer reviewed data regarding the minimum numbers for particular procedures taken directly from medical journals. Specifically, coronary angioplasty and angiography minimums were reported as 50 and 82 procedures respectively.

Take home message: Hard numbers to meet your first month into fellowship.

Similar experience-responsibility disparities exist in commercial aviation.  However, in contradistinction to the patient-doctor encounter, passengers are neither cognizant of their captain’s flight hours nor face-to-face prior to boarding.  Further increasing the stakes, a new pilot’s first manifest could be 50 passengers or more. In response to public demand for greater safety, the airline industry was an early adopter of systems to increase reliable pilot performance including flight simulation technology and pre-flight checklists, which were quite effective in reducing fatal incidents for air travelers.  As a result, the latest National Safety Council in the U.S.A. calculated the lifetime odds of death for flying to be 1:7178 in 2008 compared to 1:98 for automobile deaths.

Interestingly, even experienced pilots are required scheduled simulation training to maintain their skills and prepare for rare-but-catastrophic events, which cannot be realistically produced in the air.  The auto industry, unique in their in inability to increase motorists’ skills, have been forced to develop safety technology to make the highways safer.

Reality check: Patients do not come with air bags or crash sensors.  Simulation and checklists are proven methods to increase safety.

Virtual reality simulation training programs allow students of all levels to gain familiarity with equipment selection, proficiency of the detailed steps for a given procedure as well as an awareness of the potential pitfalls and crucial moments in a safe environment. Furthermore, under experienced tutelage during practice, a modicum of fingertip finesse may be learned prior to laying hands upon their first patient.

While “ain’t nothing like the real thing” is unarguably the best way to learn any motor skill, having solid theoretical and practical experience makes the transition to live cases easier and might ameliorate the patient’s and the beginner’s shakes.

Max Berry is a vascular and interventional radiology fellow.

La Sanità di Iniziativa attraverso gli occhi dei pazienti @Medici_Manager

Anna Maria Murante, Laboratorio Management e Sanità della Scuola Superiore Sant’Anna di Pisa.

I risultati dell’applicazione del Chronic Care Model in Toscana.  Il 73 % dei pazienti dichiara che l’assistenza complessiva è migliorata e ora è in grado di gestire meglio la propria malattia. Il 67% dei pazienti dichiara che il suo stato di salute è migliorato.

Era il 1997 quando Edward Wagner portava la comunità scientifica a riflettere sui principali ostacoli che i sistemi sanitari incontrano nel dare risposta ai bisogni dei pazienti cronici, sui punti di forza e debolezza dei numerosi approcci assistenziali in uso in quegli anni e sugli effetti che le strategie adottate hanno sui pazienti cronici[1]. Dal dibattito che ne scaturì prese a delinearsi negli USA una nuova idea di assistenza per i pazienti cronici, poi tradotta nel modello organizzativo-assistenziale oggi noto a tutti come il Chronic Care Model. Un modello che ha nel self-managementdecision supportdelivery system design e clinical information system le sue principali componenti (Figura 1), e la cui implementazione dimostra sin da subito di poter assicurare migliori risultati in termini di processo e di outcome, oltreché una riduzione dei costi e degli accessi inappropriati ai servizi[2,3]. Questo modello viene presto esportato oltre oceano, arrivando ad essere applicato anche in alcune regioni italiane come la Toscana.

Figura 1. Il Chronic Care Model

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Con il Piano Sanitario Regionale 2008-2010 la Regione Toscana pone infatti le basi per un rinnovamento organizzativo e culturale che segna un cambio di rotta nell’assistenza dei pazienti cronici, definendo la strategia per il prossimo futuro: passare da una medicina d’attesa, re-attiva e pensata per i pazienti in fase acuta, ad una sanità che – basandosi sul modello del Chronic Care Model (vedi Assistere le persone con condizioni croniche) – va incontro al paziente, in maniera pro-attiva e programmata per «[…] assumere il bisogno di salute prima che la malattia cronica insorga, si manifesti o si aggravi […]». Nasce così la Sanità di Iniziativa, che muove i suoi primi passi nel 2010, quando 627 medici di famiglia, organizzati in 56 moduli multiprofessionali (composti oltre che dai medici di famiglia, anche da infermieri e operatori socio sanitari), aderiscono alla fase pilota del progetto (attualmente i medici che aderiscono al progetto sono oltre mille, circa il 38 % del totale dei mmg toscani). A livello regionale vengono definiti obiettivi chiari tanto per i moduli, il cui raggiungimento è monitorato con un set di indicatori (DGR 355 del 22/03/2010), che per i direttori generali delle aziende sanitarie, che a questi vedono legati una quota percentuale degli incentivi annuali.

I risultati che si ottengono dall’attività di monitoraggio sul processo e sugli outcome sulla base dei dati forniti direttamente dai moduli (che alimentano gli indicatori sopra citati) e sulla base della banca dati MaCro dell’Agenzia sanitaria regionale (ARS Toscana), da quest’anno sono completati dai risultati sull’esperienza dei pazienti presi in carico.

Tra febbraio e luglio 2012 è stata infatti condotta un’indagine telefonica (secondo la metodologiaComputer Assisted Telephone Interviewing) tra i pazienti presi in carico dai moduli della fase pilota della Sanità di Iniziativa. Un campione di circa 6500 pazienti, diabetici e scompensati, ha risposto al questionario costruito dai ricercatori del Laboratorio Management e Sanità della Scuola Superiore Sant’Anna di Pisa con il supporto di un panel di esperti a livello nazionale ed internazionale e approvato dalla Commissione Regionale CORMAS. Il questionario è strutturato in 7 sezioni: la fase di reclutamento, le visite di controllo, gli incontri di counselling, gli aspetti logistici, le visite specialistiche, il coordinamento tra le figure professionali e una valutazione complessiva in termini di informazione, empowerment, assistenza e benefici per lo stato di salute.

Il 72% dei pazienti intervistati ha più di 65 anni, soffre di diabete o di scompenso cardiaco in media da circa 11 anni.

I pazienti hanno accettato di essere assistiti secondo il nuovo paradigma assistenziale soprattutto perché hanno fiducia nel medico di famiglia che glielo ha proposto e perché desiderano avere un punto di riferimento nella gestione della malattia cronica. Hanno un minor peso in questa decisione l’auspicio di ottenere dei benefici in termini di salute o di migliorare la gestione della malattia. La presa in carico ha quindi un peso importante nelle scelte assistenziali dei pazienti cronici.

La pro-attività dei moduli nell’attività di follow up è buona, confermando che la sanità d’iniziativa «non aspetta sulla soglia dei servizi il cittadino» (PSR 2008-2010), ma va loro incontro,  ad esempio contattando i pazienti prima della visita di controllo per ricordare o fissare la data dell’appuntamento (è quello che accade al 73% dei pazienti intervistati).

Durante le visite di controllo l’infermiere del modulo lavora per aumentare l’empowerment del paziente, in primis attraverso un’educazione volta ad intervenire sugli stili di vita, e il paziente sembra apprezzare. Le informazioni fornite su una sana alimentazione,sull’attività fisica, sul consumo di alcolici e sul fumo (Figura 2) soddisfa infatti la quasi totalità dei pazienti (97%), e porta il 67% dei pazienti a dichiarare di sentirsi più informato sulla propria malattia cronica.

Figura 2. Le informazioni che il paziente riceve durante le visite di controllo

Cliccare sull’immagine per ingrandirla

Rispetto al monitoraggio dello stato di salute dei pazienti, emerge che la misurazione della pressione e della glicemia (o la verifica dei valori registrati a casa), e della circonferenza della vita (o del peso corporeo) avvengono regolarmente, mentre non è ancora una prassi il controllo del piede (Figura 3).

Figura 3. Le attività di follow up svolte durante le visite di controllo.

Cliccare sull’immagine per ingrandirla

Sono davvero pochi (9%) i pazienti che dopo aver incontrato l’infermiere si rivolgono al medico di famiglia per chiedere conferma o spiegazioni. Alla base di quest’ultimo risultato c’è sicuramente la completa fiducia che l’88% dei pazienti nutre nell’infermiere. Inoltre, il team composto dal medico di famiglia e dall’infermiere riceve valutazioni molto positive, soprattutto quando si parla di lavoro di squadra ( 91 volte su 100 è ottimo o buono). Il paziente dunque non ha alcun pregiudizio rispetto al ruolo assegnato all’infermiere nella gestione del proprio percorso assistenziale e risponde positivamente al cambiamento organizzativo, e al tempo stesso culturale, posto in atto dalla Regione Toscana con la Sanità di Iniziativa.

La pro-attività del sistema è invece ancora poco strutturata quando il paziente ha bisogno di una visita specialistica. La prenotazione della visita il più delle volte viene fatta dal paziente o da un suo parente/amico attraverso il CUP, e solo poche volte è realizzata dal personale del modulo (15%). La figura dello specialista è ancora collocata fisicamente fuori dall’ambulatorio della sanità di iniziativa, se non in rari casi. Questi elementi identificano certamente degli ampi spazi di miglioramento su cui intervenire nella costruzione di un solida ed efficace continuità assistenziale.

Per finire, la rilevazione condotta tra i pazienti ha permesso di ottenere le prime valutazioni sull’efficacia della Sanità di Iniziativa in Toscana, direttamente dai pazienti. Il 73 % dei pazienti dichiara che l’assistenza complessiva è migliorata e ora è in grado di gestire meglio la propria malattia. Un altro risultato importantissimo in termini di outcome segnala che questa nuova modalità di presa in carico produce dei benefici sullo stato di salute dei pazienti nel 67% degli intervistati, vedi Figure 4 e 5.

Figura 4. Le valutazioni dei pazienti sul miglioramento dell’assistenza

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Figura 5. Un risultato di outcome: l’impatto della Sanità di iniziativa sulla salute dei pazienti.

Cliccare sull’immagine per ingrandirla

La rilevazione condotta in Regione Toscana conferma dunque i risultati presenti in letteratura sull’efficacia del Chronic Care Model, e fornisce alla governance regionale e agli operatori impegnati sul campo informazioni utili sugli ambiti in cui la presa in carico può essere ancora migliorata.


  1. Wagner, Managed Care and Chronic Illness: Health Services Research Needs, Health Services Research, 1997; 32(5): 702-714.
  2. Bodenheimer et al, Improving Primary care for Patients with Chronic illness: the chronic care model, Part 2, JAMA, 2002; 208: 1909-1914.
  3. Coleman et al, Evidence On The Chronic Care Model In The New Millennium, Health Affairs, 2009; 28(1):75-85.

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The positive side of physician burnout @Medici_Manager

by Kenneth H. Cohn

My 86-year-old mother, who values her privacy, would be upset to learn I am writing about her, but I suspect our situation is similar to that of many children trying to care for aging parents while living hundreds of miles away from home.

Last Friday, she developed painful leg swelling that turned out to be due to a blood clot. Our family arranged with her physician for visiting nurses to give her shots of Lovenox until she was anticoagulated on warfarin. Two days later, the visiting nurse contacted me that she seemed confused and out of breath; we arranged for an ambulance to take her to a nearby emergency room.

Within an hour, I received a phone call from the most pleasant emergency room physician with whom I have ever spoken. She explained my mother was experiencing a rapid heartbeat from atrial fibrillation. She outlined the tests she needed to run, estimated the time they would take and promised to call me back as soon as she knew the results. Her voice was professional and soothing. She spoke from experience and made my mother and me feel special.

She called me back hours before her estimate, reassured me that my mother had no evidence of a stroke, and arranged admission to a telemetry unit that would monitor her heart rate and rhythm continuously.

When I told her how easy it was to talk with her, she said she had been a heart surgeon until she began to experienceburnout after eight years in practice. Having spent a total of six months of my surgical residency on the cardio-thoracic surgical service, I could only imagine how difficult life had been for her. A thoracic surgeon I know wrote about surgery as an impairing experience in “Better Communication for Better Care.”

The happy ending for her and her patients is that this doctor has found her niche. She is the perfect cultural ambassador for patients and their families who come in through the ER.

When I mentor fellow physicians, I often hear them say it is easier to become a highly trained specialist than to figure out what to do with their lives after being in practice for several years (or decades). I could tell that my mother found the experience reassuring because, as she awaited transfer, she said to me, “Kenneth, I have just two words for you, ‘Don’t worry.'”

I welcome your input.

Ken is a practicing general surgeon/MBA and CEO, who divides his time between providing general surgical coverage and working with organizations that want to engage physicians to improve clinical and financial performance.


WHO: Climate change and human health @BertolliniR @Medici_Manager

Atlas of health and climate

The Atlas of health and climate is a product of this unique collaboration between the meteorological and public health communities. It provides sound scientific information on the connections between weather and climate and major health challenges. These range from diseases of poverty to emergencies arising from extreme weather events and disease outbreaks. They also include environmental degradation, the increasing prevalence of noncommunicable diseases and the universal trend of demographic ageing.

Related links

Nine Lessons on How to Teach 21st Century Skills and Knowledge @Medici_Manager @RANDCorporation

As Thomas Friedman put it in a recent New York Times column, globalization compounds the urgency for students to develop the skills and knowledge they need for economic and civic success in the 21st century. Yet despite widespread agreement among parents, educators, employers and policymakers worldwide that students need skills like critical thinking, problem solving, teamwork and creativity, these skills are stubbornly difficult to teach and learn.

The “transmission” model, through which teachers transmit factual knowledge via lectures and textbooks, remains the dominant approach to compulsory education in much of the world. Students taught through this method typically do not practice applying knowledge to new contexts, communicating it in complex ways, solving problems or developing creativity. In short, as our new paper lays out, it is not the most effective way to teach 21st century skills.

Decades of empirical research about how individuals learn, however, provide valuable insight into how pedagogy can address the need for 21st century skills. Indeed, the research suggests nine lessons that inform how to teach these skills:

  1. Make it relevant. The relevance of learning specific knowledge and skills is much clearer to students—and much more motivating—if they understand how a given topic fits into “the big picture,” or a meaningful context.
  2. Teach through the disciplines. Students develop their 21st century skills and knowledge as they learn why each academic discipline is important, how experts create new knowledge, and how they communicate about it.
  3. Develop lower and higher order thinking skills—at the same time. Students need to comprehend relationships between given variables and how to apply this understanding to different contexts.
  4. Encourage transfer of learning. Students need to develop the ability to apply skills, concepts, knowledge, attitudes and/or strategies they develop in one context, situation or application to another, reflexively (low-road transfer) or after deliberate thought and analysis (high-road transfer).
  5. Teach students to learn to learn (metacognition). Since there is a limit to how much students learn through formal schooling, they also must learn to learn on their own.
  6. Address misunderstandings directly. People have many misunderstandings about how the world works that persist until they have the opportunity to develop alternative explanations.
  7. Promote teamwork as a process and outcome. The ability to work collaboratively is an important 21st century skill, not to mention an important condition for optimal learning of other key skills.
  8. Exploit technology to support learning. Use of technology is another critical 21st century skill, essential to help develop many of the other skills mentioned here.
  9. Foster students’ creativity. Creative development requires structure and intentionality—the ability of the mind to form representations—from teachers and students, and can be learned through each of the disciplines, not just through the arts.

Progressing from the outdated “transmission” model to the “21st century” model will involve entire educational systems. As educational purposes change, curriculum frameworks, instructional methods and assessments must also. The changes demand increased teacher and administrator capacity and affect many facets of human capital, including teacher training, professional development, career mobility and the teaching profession’s cultural standing.

While there has been progress in preparing students for the 21st century, the remaining work will require of teachers, administrators and policymakers precisely the skills that we deem critical for students—as well as the political will to ensure that educators directly involved in transitioning to the 21st century model have the time, support and resources they need.

This study was presented as part of Asia Society’s Global Cities Education Network Symposium in May at our new Centre in Hong Kong. Anna R. Saavedra is an associate policy researcher at the nonprofit, nonpartisan RAND Corporation, and V. Darleen Opfer is director of RAND Education.

This commentary appeared on Education Week on October 24, 2012.

How to strengthen the partnership with your medical team @Medici_Manager @kevinmd

by  on October 20th, 2012in PATIENT
Most of us have find it challenging to make sense of the wave of information when we enter our cancer journey. This is foreign territory, with its own language, culture and routines. It takes time to absorb and understand.
We are not oncologists or hematologists. However, we can learn to improve our discussion with our medical team.Build your knowledge. By the time you start your treatment, you will likely have searched the web and read brochures on your cancer. Ask your medical team which sites have reliable and up-to-date information to avoid old and possibly discouraging information on treatment outcomes.

While blogs and support fora help give a real world view of the range of experiences, you are an individual, and too much thinking about what happens to others, good or bad, increases worry further. Moderation!

To save time, set up Google Reader for news sites, blogs and fora, and use the search function (general terms like cancer or lymphoma) to narrow down articles of interest.

Keep a notepad. At each appointment, take notes. Chemo brain or not, this is new territory, and hard to master. Come with someone, either as a listener or a scribe. My wife played the first role and it helped ensure that we both heard and understood the consequences the same way.

Start a binder. As you go through treatment, you will get more and more paper. I started a binder, organized with these categories: contact info (first page!), treatment plan, test results, background information, and drug information.

The purpose is to have all reference material in one place, to consult and take to hospital and clinic visits.

Be prepared. Prepare a list of questions for the medical team for your clinic check-ups (I found it harder during the daily hospital routine). My doctors are busy people. However, they always give me time to answer my questions. If I was not prepared, the appointment would be limited to a brief summary of my condition.

As treatment varies depending on the doctor, having detailed notes and questions helps track any changes. Given my group practice, I questioned my team about changes (scan or not to scan, when to stop immunosuppressants) – not to challenge their judgement but to ensure I understood their rationale for the change.

While every patient gets good care, an empowered patient becomes a partner in treatment, one that my medical team appreciated, and may have resulted in better care.

Go electronic. I started with a paper system. My second time round, I switched to an iPad (initially to have a new toy). This included the following apps (equivalents available for Android):

  • Evernote for clinic notes and questions, as it kept everything easy to find
  • Numbers to track my blood counts
  • Withings to track my blood pressure and weight
  • Documents to Go for Word files such as my journal

This was very effective in keeping me on top of my medical file with my medical team – they become used to me being very prepared.

While all of us have different ways, being organized is one of the few areas in which one can have some control in something beyond one’s control, and strengthen the partnership with one’s medical team. It may not change the outcome, but it will increase one’s confidence in treatment pursued.

Andrew Griffith is a cancer survivor who blogs at My Lymphoma Journey.  He can be reached on Twitter @lymphomajourney.

10 Guiding Principles for Patient-Centered Care @Medici_Manager @HarvardSPH_ECPE

Written by Sabrina Rodak | October 18, 2012

In August, Mountain States Healthcare Alliance, a 13-hospital integrated healthcare delivery system based in Johnson City, Tenn., received the 2012 National Quality Healthcare Award from the National Quality Forum, recognizing the system’s achievement of multiple quality-focused goals. Rather than just representing a culmination of efforts, the award is spurring the system to continue providing quality care, according to Dennis Vonderfecht, president and CEO of MSHA.

“No matter how many quality awards we receive, we can never sit back and say we are satisfied with the level of quality we have achieved,” he says. “So while we are extremely gratified to be recognized at this level, we will continue to work just as diligently to ensure that we are providing the best care possible to the people of our region.”

One of the areas NQF praised MSHA for was its commitment to patient-centered care. MSHA follows 10 patient-centered care guiding principles to ensure the health system puts the patient first in every decision. Tamera Parsons, vice president of quality and patient safety at MSHA, describes the 10 patient-centered care guiding principles.

1. All team members are considered caregivers. Under this principle, everyone in the workforce, from housekeeping staff to the CEO, is part of patients’ care experience. Regardless of one’s role, each person is expected to put the patient first. To create a patient-centered culture, MSHA has patient-centered care training for new employees. “They learn from day one that all team members are caregivers,” Ms. Parsons says. In addition, MSHA recognizes employees through thank you notes and awards for demonstrating patient-centered care principles.

2. Care is based on continuous healing relationships. This principle reinforces a focus on the continuum of care for patients rather than episodes of care. “We’re here to not only provide care, but also to provide healing — a more personal level of healthcare,” Ms. Parsons says.

3. Care is customized and reflects patient needs, values and choices. The principle of customizing care recognizes that each patient is different and may have different needs and preferences. In addition to customizing the care plan for each patient, MSHA works to make the environment comfortable to individual patients. For example, one patient may want music in the room, where another patient may not. “It allows the patient’s individuality to be a component of care,” Ms. Parsons says.”

4. Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers. In a patient-centered environment, all members of the care team — including the patient — need to be aware of the patient’s status and care plan. “If the patient is going to be the center of care, [he or she] absolutely needs to be informed and part of the decision-making,” Ms. Parsons says.

5. Care is provided in a healing environment of comfort, peace and support. Part of a patient-centered culture is the environment. MSHA has several features that create a healing environment for patients, including music, healing gardens, soothing color schemes and pet therapy programs. The hospitals also ensure rooms have pleasing scents, such as lavender or the smell of baked cookies, according to Ms. Parsons.

6. Families and friends of the patient are considered an essential part of the care team. MSHA recognizes that family and friends are essential supports for the patient’s healing process. Family and friends support patients not only emotionally, but also physically, as they can help patients understand physicians’ instructions. In the health system’s Very Important Partner program, patients identify an individual to listen to care information with them. “Patients [may be] in a state of discomfort and pain or fear, and don’t always hear information, so it [allows] a trusted family member or friend identified by the patient to participate in the sharing of information and guidance we give before sending patients home or to the next level of care,” Ms. Parsons says.

7. Patient safety is a visible priority.
 Making patient safety a visible priority demonstrates the organization’s commitment to patient care. MSHA implements policies and procedures to enforce patient safety best practices. For example, the system had a campaign around employee immunization and hand hygiene. MSHA also has a balanced scorecard called the blue print. The scorecard tracks the system’s performance in key areas, such as heart failure, pneumonia and surgical care.

8. Transparency is the rule in the care of the patient.
 This principle recognizes that true patient-centered care requires transparency between providers and patients and among providers. Providers should be “upfront and honest with information so [patients] can make informed decisions with us,” Ms. Parsons says. One way MSHA supports transparency is by posting its quality and safety performance on its website.

9. All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient. All processes at MSHA, even those that don’t involve patients, should be performed from a “patient-value” perspective,” Ms. Parsons says. For example, she says the coding and billing process is done from the perspective of the patient; staff has worked to make bills clear and easy to understand for patients.

10. The patient is the source of control for their care. A core tenet of patient-centered care is that the patient controls his or her care. “Making patients the source of control of their care is the result of effective deployment of all other guiding principles,” Ms. Parsons says. “To be the source of control, you have to have transparency and share information, create an environment that allows the patient to heal and focus work on the patient.
After discharge, patients can still have a degree of control by participating in a patient advisory group that meets regularly at each MSHA facility to provide input on how the system can improve care and become more patient-centered. The groups are composed of six to 12 patients who provide input on specific care models, such as diabetes programs. Soliciting suggestions from those on the receiving end of healthcare gives patients some control over future healthcare services and helps MSHA continue to put patients first in their decisions.

Embedding principles in everyday work
To emphasize the importance of these principles to all MSHA operations, system leaders explicitly connect policies to one or more of these patient-centered care principles. For example, MSHA’s social media policy states, “MSHA seeks to optimize communication and social presence through the official use of social media and also recognizes the importance of supporting team members in shaping industry conversation through their responsible use of social media.” The policy then lists “All team members are considered caregivers” and “Patient safety is a visible priority” as applicable patient-centered care principles. By clearly linking policies to these principles, MSHA brings patient-centered care from an abstract philosophy to a concrete practice.

More Articles on Hospital Quality:

National Association for Healthcare Quality Offers 5 Recommended Practices for Quality
How Health Systems Can Create a Robust, Enterprise-Wide Patient Safety Program 

Pay-for-Performance May Backfire on Quality, Report Suggests

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Livelli Essenziali di Assistenza: la grande incompiuta? @Medici_Manager @SIHTA_Italia @GIMBE

Le recenti valutazioni del Presidente Monti sulla limitata sostenibilità della sanità pubblica hanno seminato il panico tra tutti gli stakeholders della sanità italiana.

In questo scenario particolarmente critico per il SSN, spettatore di un perenne conflitto tra Governo e Regioni che ha portato perfino alla mancata sottoscrizione del Patto della Salute, è quanto mai istruttivo rileggere tre principi dievidence-based policy making enunciati dal DPCM 21 novembre 2001 che ha introdotto i Livelli Essenziali di Assistenza (LEA).

1. “I LEA includono tipologie di assistenza, servizi e prestazioni sanitarie che presentano, per specifiche condizioni cliniche, evidenze scientifiche di un significativo beneficio in termini di salute, individuale o collettiva, a fronte delle risorse impiegate”.

2. “I LEA escludono tipologie di assistenza, servizi e prestazioni sanitarie che:

  • non rispondono a necessità assistenziali tutelate in base ai principi ispiratori del SSN;
  • non soddisfano il principio dell’efficacia e della appropriatezza, ovvero la cui efficacia non è dimostrabile in base alle evidenze scientifiche disponibili o sono utilizzati per soggetti le cui condizioni cliniche non corrispondono alle indicazioni raccomandate;
  • non soddisfano il principio dell’economicità nell’impiego delle risorse, in presenza di altre forme di assistenza volte a soddisfare le medesime esigenze”.

3. “Le prestazioni innovative per le quali non sono disponibili sufficienti e definitive evidenze scientifiche di efficacia possono essere erogate in strutture sanitarie accreditate dal Servizio Sanitario Nazionale, esclusivamente nell’ambito di appositi programmi di sperimentazione, autorizzati dal Ministero della Salute”.

Tali principi, se correttamente e uniformemente attuati, avrebbero potuto apportare uno straordinario contributo alla sostenibilità del SSN, perché attestano la volontà del legislatore di integrare le migliori evidenze scientifiche nelle decisioni di politica sanitaria, in particolare nel finanziamento di servizi e prestazioni sanitarie essenziali. Si afferma, infatti, che il SSN può rimborsare con il denaro pubblico solo gli interventi sanitari di documentata efficacia, facendo esplicito riferimento alle evidenze scientifiche. Viceversa, servizi e prestazioni sanitarie inefficaci, inappropriati o caratterizzati da una limitata costo-efficacia non possono rientrare nei LEA. Infine, in assenza di prove di efficacia definitive, in linea con una strategia di Ricerca & Sviluppo, l’erogazione di interventi sanitari innovativi deve essere circoscritta all’interno di specifici programmi di sperimentazione.

Di fatto, nel corso degli ultimi 11 anni, la progressiva resistenza delle autonomie regionali a riconoscere un decreto centralista, la mancata attuazione dei principi evidence-based e il ritardo nell’aggiornamento e nell’espansione degli elenchi di servizi e prestazioni hanno progressivamente ridimensionato il ruolo dei LEA. Nati come uno strumento per definire i criteri e monitorare l’appropriatezza di servizi e prestazioni sanitarie, oggi si limitano ad adempiere a una funzione esclusivamente finanziaria. Infatti, utilizzando la “griglia LEA”, un set di 21 indicatori per la verifica sintetica dell’adempimento sul mantenimento dei LEA, vengono individuate, rispetto all’impiego delle risorse assegnate, le Regioni virtuose (adempienti) e quelle dissennate (rinviate al Piano di Rientro).

Nel Decreto Balduzzi il Ministro ha dedicato ai LEA un intero articolo, ma – bando agli entusiasmi – si tratta solo di una dichiarazione di intenti che annuncia l’aggiornamento sia dei LEA (con riferimento a malattie croniche, malattie rare e ludopatia) entro il 31 dicembre 2012, sia del nomenclatore tariffario entro il 31 maggio 2013.

Se la storia è maestra di vita (DPCM 23 aprile 2008 sui “nuovi LEA” revocato da un Governo diverso da quello che lo aveva elaborato) ai LEA non rimane che confidare nel Monti-bis!

FonteCartabellotta A. La grande incompiuta dei LEA è madre della spending review? Il Sole 24 Ore Sanità 27 novembre – 3 dicembre: pag 20,22.

Medici meno esperti spendono di piu’ per cure e diagnosi @Medici_Manager

Roma, 5 nov. (Adnkronos Salute) – (EMBARGO ALLE 22.00) – Inesperienza e incertezze dei medici ‘nemiche’ della spending review. Secondo uno studio pubblicato su ‘Health Affairs’, infatti, le caratteristiche del medico influiscono direttamente sulle spese sanitarie. Infatti i camici bianchi con meno esperienza tendono a spendere molto più denaro nel trattamento dei pazienti, rispetto ai colleghi più navigati, spiegano i ricercatori della Rand Corporation e dell’Università di Pittsburgh.

Secondo gli studiosi questi risultati potrebbero avere implicazioni significative per i decisori in tempo di crisi, al momento di ‘disegnare’ reti di specialisti o di mettere in piedi programmi che premiano gli operatori sanitari che forniscono cure di qualità a un costo inferiore. “Questi risultati sono provocatori, e occorrono ulteriori esami” su questo tema, spiega Ateev Mehrotra, associato presso l’Università di Pittsburgh School e ricercatore della Rand Corporation, istituto di ricerca senza scopo di lucro. “Ma è possibile che un elemento guida dei costi sanitari stia nel fatto che i medici appena formati tendono a praticare una medicina più costosa”. In pratica, prescrivendo più esami diagnostici, o medicinali più cari, magari proprio perché meno esperti e sicuri rispetto ai colleghi che hanno alle spalle più anni di pratica.

Per disegnare l’identikit del medico più costoso per il servizio sanitario, i ricercatori hanno utilizzato i dati relativi a oltre un milione di persone residenti nel Massachusetts dal 2004 al 2005, costruendo i profili di ‘spesa sanitaria’ dei pazienti di oltre 12.000 medici dello stato americano. I costi sono stati valutati attraverso 600 tipi di “episodi di cura”, includendo la patologia di una paziente, la sua gravità e le procedure eseguite. Ebbene, la forbice più ampia nei costi si ha paragonando i dati dei ‘novellini’ con gli operatori con la maggiore anzianità di servizio. Si è visto che i medici che avevano meno di 10 anni di esperienza hanno costi complessivamente superiori del 13,2% rispetto ai colleghi con 40 o più anni di servizio.

Invece gli operatori con 10-19 anni di lavoro alle spalle hanno profili di costo più alti del 10% (rispetto ai colleghi più maturi), percentuale che per i medici con 20-29 anni di esperienza scende al +6,5% e per quelli con 30-39 anni del +2,5%.

Nessuna associazione è stata trovata, invece, tra i costi e le altre caratteristiche dei medici, come ad esempio una segnalazione per negligenza o azioni disciplinari, o ancora le dimensioni della struttura in cui un medico ha lavorato. I ricercatori sostengono che la differenza rilevata dallo studio non suggerisce che i medici meno esperti, spendendo di più, finiscano per fornire una migliore assistenza medica. Anzi, sembrerebbe proprio che le cose non stiano così. “I nostri risultati non possono essere considerati definitivi, ma si sottolineano la necessità di comprendere meglio gli approcci della pratica medica e che cosa influenza questo comportamento,” dice Mehrotra.

Secondo gli studiosi sono diversi i fattori che possono spiegare i risultati ottenuti dalla ricerca. I medici appena formati possono avere più familiarità con nuove modalità di trattamento, più costose e high tech, rispetto ai vecchi medici. Inoltre, è possibile che la mancanza di esperienza e le incertezze dei ‘novellini’ si traducano in un approccio più aggressivo nella cura, fino a sfociare a volte nella medicina difensiva. Infine non è detto che, via via che i medici acquistano esperienza, il loro atteggiamento cambi: è possibile che le differenze rilevate dallo studio restino tali per tutta la carriera dei medici più giovani, dicono i ricercatori, convinti che nella formazione dei camici bianchi non possano più mancare elementi per renderli coscienti della responsabilità di essere anche buoni amministratori delle risorse sanitarie.

I social media nella strategia comunicativa delle associazioni no-profit: una miniguida all’uso (Parte II) @Medici_Manager

Eugenio Santoro, Laboratorio di Informatica Medica, Istituto Ricerche Farmacologiche Mario Negri

Nel corso di questi ultimi anni il ruolo dei social media è divenuto così importante che ormai numerose organizzazioni (anche quelle istituzionali) li usano abitualmente affiancandoli ai tradizionali mezzi di comunicazione. Nel precedente articolo (1) sono state illustrate le ragioni per le quali le organizzazioni no-profit, comprese quelle che operano in ambito sanitario e le associazioni di malati, dovrebbero prendere in considerazione di usare i social media nella loro strategia comunicativa. In questo articolo saranno proposti alcuni suggerimenti sulle modalità di impiego di Facebook e Twitter nel contesto delle organizzazioni no-profit, e illustrate le esperienze più significative.


L’obiettivo principale di Facebook (e di tutte le piattaforme di” social networking”) è quello di aggregare persone che hanno interessi simili creando le cosiddette comunità online (2). Le persone che frequentano Facebook hanno a disposizione strumenti che favoriscono l’interrelazione personale in Internet, la condivisione di informazioni e di file (per esempio immagini, filmati e diapositive), e la esposizione di pareri e giudizi (3).

La particolarità di Facebook risiede nel fatto che riesce ad offrire in un unico ambiente numerose funzionalità: dalla gestione della posta elettronica (il sistema di messaggistica di Facebook sta soppiantando la tradizionale posta elettronica), alla gestione dei profili e delle “amicizie”, dalla gestione delle immagini o dei video, a quella degli eventi, dalla gestione dei sondaggi online a quella dei feed RSS. Ogni ambiente di Facebook può inoltre essere personalizzato, dando la possibilità di creare pagine personali, pagine pubbliche e gruppi.

Un’associazione no-profit dovrebbe prendere in considerazione l’apertura di una pagina pubblica su Facebook per varie ragioni. Per esempio per rilanciare notizie provenienti dalla letteratura medica, da quella laica o dai congressi scientifici, o per riprendere notizie provenienti da altri portali/blog (partendo da quelli istituzionali) che trattano gli argomenti dell’associazione, o per rilanciare filmati e immagini pubblicati dalla associazione su altri social network (per esempio YouTube e Flickr), o ancora per pubblicare la rassegna stampa. Altri usi potrebbero inoltre riguardare l’attivazione di discussioni su argomenti di attualità, il lancio di campagne per la raccolta di fondi (particolarmente utile a questo scopo è la funzione “Causes”) e di sensibilizzazione su temi cari alla associazione, o semplicemente il richiamo di notizie e contenuti che appaiono sul sito web dell’associazione, dove, chi si collega, può ottenere degli approfondimenti.

Per creare una pagina pubblica su Facebook è necessario che il suo amministratore abbia un account valido sul noto social network. Una volta creata la pagina pubblica e definito il tipo (esistono varie tipologie, una delle quali espressamente pensata per le organizzazioni) e il nome, è necessaria una prima fase di configurazione per caricare il logo dell’associazione e le informazioni descrittive, per gestire le autorizzazioni di accesso alla pagina (i lettori possono lasciare commenti? Possono caricare immagini e video? Devono essere attivate limitazioni per età, paese, utente?) e per regolamentare gli aspetti amministrativi (esiste un unico curatore o più curatori?). Solo in una seconda fase si può dare inizio alla pubblicazione di contenuti e ad alimentare discussioni.

Usare i contatti email e le reti di “amicizie” può essere utile per invitare potenziali utenti interessati a diventare “fan” della pagina (attraverso il click del bottone “Mi piace”) affinché i contenuti pubblicati possano essere dirottati sui loro profili personali. Così come ricercare tra i gruppi su Facebook quelli che trattano argomenti affini e scrivere ai gestori di tali gruppi invitandoli a promuovere i contenuti della nuova pagina, può contribuire ad aumentare la visibilità dell’associazione.


Twitter è un formidabile mezzo di distribuzione delle notizie grazie alla rete di “followers”. Le notizie pubblicate su un canale Twitter possono essere infatti automaticamente riprodotti sui canali di Twitter di coloro che si sono registrati per seguirne gli aggiornamenti. Le notizie si distribuiscono così in maniera “virale” non appena queste sono pubblicate. Un’altra caratteristica è che chi vuole aggiornare la propria pagina di Twitter può usare non solo Twitter stesso, ma anche gli SMS. Analogamente, la distribuzione dei contenuti di un canale Twitter può avvenire attraverso le stesse modalità. E quest’ultimo aspetto, in particolare, che rende la notifica di una notizia assolutamente immediata e trans mediatica.

Se una associazione di pazienti vuole usare Twitter è necessario che attivi un account su questa piattaforma. Al momento della registrazione (ma questo può avvenire anche in seguito) è possibile selezionare gli argomenti di interesse e individuare così persone o istituzioni che li trattano così da “seguirle” nel tempo. Quando decidiamo di “seguire” qualcuno, ogni volta che questa persona invierà un messaggio sulla sua pagina, questo apparirà automaticamente sulla nostra home page di Twitter e, se da noi condivisa (re-twittata nel gergo di twitter), sarà a disposizione di quelli che ci “seguono”. Una volta attivato, l’associazione potrà usare il profilo su Twitter non solo per rilanciare notizie provenienti da altri canali, ma anche per rilanciare quelle ha pubblicateo sul proprio sito web, pubblicarne di nuove, porre domande alle persone che lo “seguono”, oppure rispondere alle domande che da questi vengono poste.


Uno degli esempi di impiego di social media è quello proposto dalla associazione “MacMillan Cancer Support”. Una sezione del loro sito web ( ) ospita infatti 4 strumenti basati rispettivamente su Facebook, su Twitter, su Flickr e su YouTube.

Il canale aperto su Facebook permette di diffondere le attività dell’associazione a migliaia di utenti di Facebook. Inoltre, attraverso l’area su Facebook gli utenti possono vedere filmati e fotografie caricate dai sostenitori dell’associazione e dalla stessa associazione, oppure semplicemente accedere alle ultime notizie prodotte. Attraverso Twitter, oltre a rilanciare notizie pubblicate sul proprio sito web, l’associazione attiva campagne per la raccolta di fondi, lancia eventi di cui è organizzatrice e arruola volontari disposti a lavorare per conto dell’associazione. L’associazione sfrutta anche il canale aperto su Flickr per pubblicare le fotografie scattate nel corso di campagne per la raccolta fondi o di eventi nei quali l’associazione e i suoi volontari sono stati coinvolti. E come un album fotografico, le fotografie si possono catalogare, condividere e segnalare ad altri. Infine, attraverso il canale aperto su YouTube, si possono vedere i filmati che l’associazione ha prodotto per attivare campagne per la raccolta di fondi, per documentare come spende i soldi raccolti, per presentare l’attività di supporto ai malati di cancro o per raccogliere le loro testimonianze.

Molto simili sono gli strumenti messi a disposizione dalla Alzheimer Association ( , l’organizzazione che riunisce i malati di Alzheimer negli Stati Uniti.

Anche le associazioni di pazienti italiane hanno iniziato a utilizzare i social media per questi scopi. Tra le esperienze più interessanti si possono citare quella della Associazione Italiana Sclerosi Multipla (, probabilmente la più attiva in Italia nel settore dei nuovi media tra le organizzazioni no-profit, e quella dalla Associazione Italiana per la Ricerca sul Cancro ( ). Sulle homepage dei rispettivi siti web si trovano i collegamenti ai canali di social media che tali organizzazioni hanno deciso di inserire nella loro strategia comunicativa.

– Santoro E. I social media nella strategia comunicativa delle associazioni non profit: una miniguida all’uso – Parte 1. Partecipasalute 2012.
– Santoro E. Web 2.0 e social media in medicina: come social network, wiki e blog trasformano la comunicazione, l’assistenza e la formazione in sanità. Seconda edizione. Il Pensiero Scientifco Editore, Roma 2011.
– Santoro E. Facebook, Twitter e la medicina. Il Pensiero Scientifco Editore, Roma 2011.

Ultimo aggiornamento: 02/10/2012

I social media nella strategia comunicativa delle associazioni no-profit: una miniguida all’uso (Parte I) @Medici_Manager

Eugenio Santoro, Laboratorio di Informatica Medica, Istituto Ricerche Farmacologiche Mario Negri


Il web 2.0 è quella parte di Internet alla quale chiunque può liberamente accedere attraverso l’impiego di un software gratuito al fine di condividere informazioni e collaborare per creare nuova conoscenza, e nel quale gli utenti siano al tempo stesso produttori e fruitori dell’informazione (1).

E’ quindi non solo un insieme di tecnologie, ma un nuovo modo di “stare” in Internet, nel quale la voce del cittadino, unita a quella di altri come lui, può contribuire a generare domande e, per quanto possibile, ad ottenere delle risposte.

Tra gli strumenti del web 2.0, cominciano ad assumere una importanza fondamentale i cosiddetti social media (2). Il loro ruolo è divenuto così centrale che ormai qualunque organizzazione impegnata a fare informazione e a comunicare li usa abitualmente affiancandoli ai tradizionali mezzi di comunicazione. Il loro impiego parte dalla constatazione che ormai gli utenti di Internet trascorrono molto del loro tempo sui social network e sui blog. Chi fa informazione non può quindi limitarsi a pubblicare i propri contenuti sul sito web istituzionale, ma deve usare canali alternativi per diffonderli là dove è più facile che vengano letti, condivisi, discussi e rilanciati verso altre piattaforme sociali.


Le associazioni no-profit possono avvantaggiarsi dall’uso dei social media per diverse ragioni. Innanzitutto possono sperimentare canali complementari ai loro siti web per raggiungere i potenziali interessati alle tematiche di cui l’associazione si occupa, spiegare loro in che cosa queste consistono, aggiornarli tempestivamente sulle iniziative intraprese, fare sentire la propria voce rispetto a certi problemi o determinate politiche sanitarie.

Le potenzialità aggregative di questi strumenti consentono poi di allargare la rete sociale degli interessati, fino a coinvolgerli direttamente nelle attività dell’associazione. Le potenzialità “sociali” dei social media contribuiscono inoltre a condividere facilmente con altri le informazioni che riguardano l’associazione, favorendo in questo modo una diffusione “virale” dei messaggi distribuiti dalla organizzazione no-profit. Infine, tali strumenti, se usati in modo adeguato, consentono di attivare delle campagne di raccolta fondi efficaci ed economiche.

Non è un caso, quindi che il 74%, 46% e 43% delle associazioni no-profit americane è rispettivamente presente su Facebook , YouTube e Twitter, tre dei più importanti social media.


Sono molti i tipi di filmati che un’associazione no-profit in ambito sanitario potrebbe produrre e caricare su YouTube. Le testimonianze di malati sono da sempre un ottimo veicolo per avvicinare malati simili e portarli così a conoscenza della presenza e delle attività dell’associazione. Così come quelle di medici, specialisti, opinion leader, rappresentanti delle istituzioni. Fondamentali allo scopo di promuovere l’associazione e aggregare persone interessate alle sue finalità e alle sue attività sono i filmati che riguardano l’associazione stessa, come per esempio quelli relativi a campagne da essa promosse o organizzate. Particolare attenzione deve essere posta nel caricare filmati di TG o di programmi televisivi in quanto su questi (come su molti altri non di proprietà) vige il diritto d’autore.

Per caricare un filmato su YouTube occorre richiedere un “account” (fatto di una login e di una password). Una volta attivato è possibile aprire un canale per l’associazione e configurare il sistema (per esempio per decidere se a caricare i filmati deve essere una persona o un gruppo di persone). Il caricamento è piuttosto facile in quanto YouTube accetta numerosi formati standard. Affinchè, siano efficaci dal punto di vista dei contenuti i filmati dovrebbero essere chiari (il linguaggio usato deve essere sufficientemente comprensibile all’utente medio di YouTube) e soprattutto brevi. E’ poi consigliabile associare al filmato caricato un numero elevato di tag (le parole chiave decise dall’autore) perché è attraverso la ricerca di questi che gli utenti di YouTube arrivano al filmato e quindi al sito dell’associazione. Se poi i tag scelti riescono ad identificare in modo preciso l’argomento è ancora meglio. Così come suggerito per i blog, è importante che i filmati siano continuamente caricati sul canale aperto di YouTube, perché questo genera nuovo interesse e quindi nuovi utenti.

Una volta attivato il canale, è importante segnalare la pubblicazione di un nuovo filmato su tutti i media usati dall’associazione (pagina pubblica su Facebook, profilo istituzionale su Twitter, blog, sito web, social network vari), o ancora meglio, incorporarne il codice (su YouTube esiste un apposito campo chiamato “codice da incorporare”) affinchè sia immediatamente fruibile partendo da essi. Altrettanto importante è segnalare sul canale di YouTube dell’associazione i link agli altri social media. Essendo di fatto un social network, il canale di YouTube potrebbe contribuire alla loro diffusione in rete. Una volta caricati, YouTube fornisce degli strumenti per misurare la popolarità dei video in termini di numero di visualizzazioni e di numero dei commenti lasciati. Tali strumenti, insieme alla possibilità di accedere al contenuto dei commenti (ma in fase di configurazione del canale si può decidere di impedire agli utenti di lasciarli) e ad altre statistiche accessibili attraverso il link “statistiche e dati” consentono un continuo monitoraggio dell’andamento dei filmati pubblicati e del canale.


La forza dei blog, oltre alla possibilità di generare spazi di discussione, sta nella possibilità di distribuire automaticamente verso altri blog, siti web e social network i post e i commenti pubblicati. Ciò avviene tramite appositi strumenti (come i feed RSS, i profili su Twitter, le pagine pubbliche di Facebook) che possono essere attivati configurando la piattaforma che gestisce il blog. Questa sorta di disseminazione delle attività è quanto di più occorre alle associazioni di pazienti per diffondere i propri contenuti e allargare la cerchia dei propri sostenitori. A ciò occorre aggiungere che i blog possono integrare filmati di YouTube e immagini o fotografie di Flickr o di Instagram (due database di immagini condivise noti agli utilizzatori delle tecnologie web 2.0 e spesso definiti anch’essi come social media) lasciando che i rispettivi file restino memorizzati nei database di origine. Per le loro potenzialità i blog sono usati dalle associazioni no-profit (soprattutto quelle di pazienti) per attivare collaborazioni, condividere informazioni tra persone che soffrono delle stesse malattie, per fare formazione e informazione, per promuovere eventi e raccolte fondi, per pubblicare la rassegna stampa.

Per aprire un blog un’associazione no-profit può utilizzare piattaforme gratuite che hanno il pregio di essere facilmente configurabili. Tra queste le più note sono WordPress ( e Blogger ( Una volta registrati, è possibile scegliere, tra i vari formati, come configurare il blog e quali strumenti attivare, oltre a definire le politiche di accesso. Eseguite queste operazioni il blog è pronto per essere riempito di contenuti. Perché gli utenti lo usino è però necessario che il blog sia adeguatamente promosso. Inserire un ampio richiamo sul sito web dell’associazione piuttosto che sulla sua area su Facebook o su Twitter può essere di aiuto.

– Santoro E. I social media nella strategia comunicativa delle associazioni non profit: una miniguida all’uso – Parte 2. Partecipasalute 2012.
– Santoro E. Web 2.0 e social media in medicina: come social network, wiki e blog trasformano la comunicazione, l’assistenza e la formazione in sanità. Seconda edizione. Il Pensiero Scientifco Editore, Roma 2011.
– Santoro E. Facebook, Twitter e la medicina. Il Pensiero Scientifco Editore, Roma 2011.

Ultimo aggiornamento: 02/10/2012 


The changing NHS @DGFoord @Medici_Manager

The NHS in England is in the middle of the biggest reorganisation since its creation.

There has been intense political debate – but many patients are still unclear about what it will mean. Here we look at the main changes.

The NHS is a very large and complex organisation. Most parts will be affected in some way.

But the biggest changes are about who makes decisions and who spends the money.

New organisations are being created and others abolished.

And the legal responsibility for managing most of the NHS budget will be handed over in April 2013 to some of these new organisations locally and nationally.

Local councils are also being given a bigger role in influencing health services.

In the long term, the NHS may look very different – but for the moment patients going to see their GP or going into hospital may see little visible difference.

Who plans and buys treatment for patients?

Graphic showing how clinical commissioning groups fit into the new NHS structure

At the moment, 152 bodies called primary care trusts (PCTs) control local spending on dentists, hospital operations and tests, and medicines – accounting for 80% of NHS spending. They are mostly made up of health managers.

Some care may be provided by private health companies, or charities.

The rest, controlled nationally, includes things like specialist care.

From April 2013 PCTs will be replaced by more than 200 GP-led organisations called Clinical Commissioning Groups (CCGs).

They will be responsible for closer to 60% of the NHS budget. Every GP surgery has to belong to a CCG, although in reality only a small number of GPs will take responisbility for deciding what local services to fund.

Ministers believe GPs will be more responsive to the needs of patients as they have day-to-day contact with them. This, the theory goes, will make the NHS more efficient and improve the quality of care.

New organisations will be able to offer CCGs support on buying and planning health services.

Who directs the funding?

Graphic showing how clinical commissioning groups will direct funding in the new NHS structure

CCGs will decide whether or not to pay for any hospital care a GP thinks they need – as PCTs do now.

The government says CCGs will be better placed to decide on local priorities because more doctors and nurses will be involved.

Some GPs are keen to get more involved in these decisions – but others fear factoring in costs will compromise the doctor-patient relationship.

Most care is provided by NHS organisations, but some routine operations are carried out by private companies – but paid for by the NHS.

Under the new system a regulator called Monitor will be given the job of making sure there is a level playing field for private companies and charities to compete with NHS organisations to provide care.

The government says Monitor will also have to ensure competition does not affect the service patients receive.

How is the NHS run?

Graphic showing the NHS's new management structure

The health secretary sets policies, such as waiting times, for the NHS.

Currently, the Department of Health then passes these down through 10 strategic health authorities and then to the PCTs who have to ensure they are implemented.

Under the new system the clinical commissioning board will take charge of overseeing the NHS from the Department of Health.

Instead priorities will be given to a new NHS Commissioning Board, based in Leeds but with four regional and 50 local offices around England.

It will control a significant part of the overall budget so that it can plan and buy specialist services and will also be charged with ensuring CCGs do not overspend their budgets.

Local councils are to have more of a role in tackling public health problems, such as obesity, in their area – and new health and wellbeing boards will help link this work with that of the CCGs.

A national body called Healthwatch, with local groups, is being set up to enable patients to have their say about the NHS.

Overall structure of the new NHS in England

Flow diagram of the new structure of the NHS in England

Coaching Introverts @helenbevan @ReadyToManage @Medici_manager


Introverts are getting a great deal of attention recently, in part due to Susan Cain’s popular book, “Quiet: The Power of Introverts,” published last year and this year’s Scientific American article, The Power of Introverts: A Manifesto for Quiet Brilliance. In the past, introverts tended to be criticized as less, somehow, in need of being “fixed” or “brought out of their shell” by extroverts. This perception may have arisen from lack of knowledge and is explored in this article by examining how introverts might best be coached in the workplace as one factor among many in coaching skill-building.

First, we’ll tackle a few basic questions before moving on to specific coaching strategies. This initial groundwork looks at these questions: what is an introvert? how does an introvert generally relate to the world? and finally what percentage of the world is introverted versus extraverted?

What is an introvert?

According to Carl Jung, the psychologist who defined the terms introversion and extraversion in the language, Introversion is all about drawing energy from the internal world of thoughts and ideas, preferring depth and pausing for thought. Jung would say that the unconscious preoccupation of introverts is therefore privacy. Extraversion, on the other hand, is about drawing energy from the world of people, things, and activities, and dealing in breadth rather than depth. Jung would say that the unconscious preoccupation of extraverts is therefore access to people. Introverts then tend to focus on their own inner world of ideas and experiences. They direct their energy and attention inward and receive energy from their internal thoughts, feelings and reflections. They tend to enjoy quiet for concentration and do not mind working on one project for a long time. They usually prefer working alone and develop their ideas through reflection.

People who prefer introversion are energized when they are involved with the ideas, images, memories, and reactions that are a part of their inner world. Introverts often prefer solitary activities or spending time with one or two others with whom they feel an affinity, and they often have a calming effect on those around them.

Introverts often take time to reflect on ideas that explain the outer world. With their orientation to the inner world, introverts truly like the idea of something, often better than the something itself, and ideas are almost solid things for them.

So, in summary, people who prefer introversion are likely to:

  • Be mainly private and contained
  • Enjoy being calm and “centered” or reserved (preferring reflection in general). This means they tend to reflect before acting or speaking
  • Feel comfortable being alone and like solitary activities
  • Prefer fewer, more intense relationships socially (and may need time to recover from heavy socializing)
  • Sometimes spend too much time reflecting and may not move into action quickly (usually wanting to understand things thoroughly before acting)
  • Often like quiet space in which to work or concentrate
  • Sometimes forget to check with the outside world to see if their ideas really fit their experience (as they are drawn to inner world of thoughts and ideas)

To contrast the introvert with the extravert, the following table may help (and, you will notice that both lists start and end with how extraverts and introverts use energy: 

Extraversion Introversion
  • Energized by what goes on in the outer world
  • Need to talk to clarify what they think
  • Can be seen as accessible and understandable
  • Difficult for them to just sit and listen
  • Often work to change the world
  • Interests often have breadth
  • Interaction
  • Multiplicity of relationships
  • Expenditure of energies
  • Energized by what goes on in their own inner world
  • Need to reflect and clarify internally before they talk
  • Can be seen as subtle and difficult to know well initially
  • Work quietly, often without interruption
  • Often work to understand the world
  • Interests often have depth
  • Concentration
  • Limited relationships
  • Conservation of energies

How does an introvert generally relate to the world?

Quiet people may be introverted but this is not always the case, as extraverts can be quiet for a short period and some introverts can adopt more extraverted and non-quiet behaviors for a period. We can tune into the language that introverts tend to use to get a better idea of when individuals may have a greater preference for introversion. Hence, we might hear statements such as:

  • “I have to reflect on that” (although they may just do this and say nothing!)
  • “I have had one or two close friends most of my life.”
  • “I can usually concentrate/focus pretty well.”
  • “I prefer not to make speeches/presentations/talking in public.”
  • “Let me think about it and I’ll have an answer for you tomorrow.”
  • “I’d rather do it on my own.”

Outside of observing language clues we might also see the following general behaviors:

  • Often require a lot of time alone (but can often tune out very effectively and hence be alone in a crowd).
  • Dislike interruptions.
  • Can’t be easily pressured into talking about an issue until ready (may take quite a long time).
  • Is often intense and passionate even though it may often not show, seeming to take life very seriously.
  • Must generally understand a thing before trying it.
  • Generally think carefully before speaking or acting.
  • Often very good listeners.
  • Generally dislike small talk.

What percentage of the world is introverted versus extraverted?

It is popularly thought that introverts are only 25-30% of the total population. However, the managers of the Jungian based Myers-Briggs Type Indicator (or MBTI®) have more recently reported that in a population of hundreds of thousands of assessment-takes the split is 51:49 in favor of Introverts. For the purposes of this article we are going to assume that there is approximately the same amount of introverts as extraverts or it is a 50:50 split. An article on this subject can be found at the “Thoughtful self-improvement” site at 

Coaching the introvert

Now that we have understood more about introverted preferences, let’s turn our attention to how best to coach an introvert. Perhaps the best place to start is to look at the kind of frustrations and/or goals that introverts are likely to have in the workplace. Although this is both an incomplete and non-specific list below are ten of the most common ones:

1.  A wish to boost overall ability to interact (often confused with external show of confidence and self-esteem) – introverts (and not exclusively of course) may suffer from low self-esteem where they have become over-introspective and/or when they have lost confidence in their inner means to cope with their work environment. A coach may therefore need to help them to develop greater confidence (often by getting them to give more of their assistance and advice to others).

2.  A wish to contribute more in important workplace discussions and/or decisions – Extraverts may well become impatient with introverts in significant discussions when important decisions have to be made (especially when time is pressing) so an introvert may feel unheard or sidelined. However, introverts can typically be much more effective in difficult problem-solving situations and when complex issues need to be thought through and a coach can help in getting introverts to better promote these skills as a key step in important discussions or before key decisions are made. 

3.  A wish for a greater connection to others – Introverts can feel incompetent or unskilled in communicating and connecting with others (despite their need to spend time alone to think and reflect on a regular basis). A coach may therefore need to help them to develop approaches to connect with other people.

4.  A wish to overcome apparent shyness (at least to some degree) – Shyness may be a sign of introverts under-developed social skills and/or under-developed sense of self. There is a huge difference between an introvert who requires quiet time and an introvert who avoids people wherever possible. The former is taking necessary time and keeping his or her energy “battery” charged whereas the latter is being avoidant and potentially not helping him or herself and the team of which he or she is a part. A coach may therefore need to help an introvert to develop the ability to enjoy limited socializing that is commensurate and comfortable for the introvert’s overall temperament. 

5.  A wish to be less “perfectionistic” at times – Most introverts want to evolve thinking such that the output of their thinking is as near perfect as possible. But if this goes too far, the perfectionism may negatively impact the introvert and others (and create a sense of slowing things down unnecessarily). Coaching can help here by providing a more objective perspective on the introvert’s introspection and by identifying a way of being at least somewhat more pragmatic when time and circumstances demand it. 

6.  A wish to deal more effectively with the dominance of extraverts in the workplace – Most introverts see extraverts to be more assertive and even pushy, confident (perhaps overly so) and prone to jump-around a lot. This approach often puts them “in-charge” of tasks and projects (even if they are not the official leader). This can be irritating to an introvert, especially if he or she is the knowledge expert and he or she may therefore just withdraw and let the extravert “dig his/her own grave”. A coach therefore needs to work with the introvert to find common ground with the extravert by not withdrawing and getting information to them in different ways-such as ahead of time in writing or quietly on a one-on-one basis after a discussion.

7.  A wish to work more effectively in the fast-paced work climate that is often required – Today’s work environment often requires work to meet difficult to achieve deadlines. A coach can work with an introvert to help develop different ways to contribute that meet the pressure of a deadline, or sometimes show why changing a deadline (to allow for deeper thinking perhaps) may create a better result.

8.  A wish to promote their own agenda and needs at work and when networking – While an extravert will not be slow at putting him or herself forward, the introvert may find self-promotion to be extremely difficult. Here a coach can work with an introvert to pre-identify/pre-prepare important issues and contributions that should be made, so that they can put forward in pithy and impactful ways in more public environments.

9.  A wish to more effectively contribute effectively in meetings – Extraverts will often call meetings, chair them and do most of the talking (it is after all an extraverted communication format with lots of people talking about lots of things in a fixed time period). An introvert may never therefore feel totally comfortable in this climate but a coach can work with an introvert to ask questions of others and communicate both before and after to ensure their input is heard. This helps to emphasise that their input is important and insightful and worth sharing. (this in turn boosts their confidence in themselves/ their ability. They may need strong encouragement and strategies for getting their ideas on the table and to realize that an idea does NOT have to be carefully crafted before it is put into the outside world.

10. A wish to put themselves forward strongly enough to lead projects and even gain promotion – Introverts will put themselves forward for jobs they think they are capable of doing but may not see themselves to be the forceful leader that is required. A coach can therefore work with an introvert to increase confidence in his or her own ability and give them strategies for leadership that are a comfortable fit for his or her temperament. 

So, how should a coach relate to an introvert?

All of the above often boils down to one major issue – communication. Of course, both extraverts and introverts have helpful and hindering behaviors, as the table below illustrates:

Communicating – Extraversion and Introversion

Potentially helpful Potentially hindering
Extraversion  being outgoing and sociable; being spontaneous and enthusiastic; enjoying talking through ideas with peers and the people you manage; demonstrating energy overwhelming people; finding listening difficult; wanting to get to action too quickly; being easily distracted; appearing to have a ‘butterfly’ approach
Introversion  a reflective style which allows people space; listening attentively; concentrating on what is happening below the surface; staying calm appearing withdrawn or moody; lacking in social confidence; seeming over-intense; disliking large meetings; appearing lacking in presence

A coach can help an introvert in at least three of the four boxes in the above table. This is not only with the potentially hindering behavior of the extravert and introvert but also in helping the introverted individual to promote him or herself in the more positive ways that he or she can contribute to the team.  To do this there are effective strategies for a coach to adopt, as well as approaches to avoid as follows:

Effective coaching strategies to adopt with Introverts Coaching approaches to avoid with Introverts
Allow an introvert time to “mine” his or her internal feelings and thoughts-this means being more patient in general Don’t spend time on small talk
Always operate in a calm and considerate manner (avoiding too much gesticulation or histrionics) Don’t introduce multiple points one after the other or overwhelm with a lot of unrelated data
Listen carefully using occasional paraphrases to check for understanding Avoid “jumping in” too quickly and completing sentences or thoughts for introverts
Introduce points one at a time and allow them to be fully discussed Try to discourage too much introspection or unhelpful “wallowing” in an issue
Ask searching questions about complex issues Get them to respond to statements or questions immediately
Let silence reign and allow time for answers Don’t push for action too early
Encourage the introvert to partner with others (but perhaps just one or two people) on tasks and projects on a limited basis Don’t push them to be more extraverted
Allow them to talk about details or minor points (these may be more important than at first appears) Encourage them into group or team coaching
Assign homework and reading between sessions for study and reflection Don’t let a session ramble on too long-it will overwhelm the introvert who will want to escape.

And finally, how should an introvert relate to his or her coach?

If an introvert is dealing with an introverted coach, then there may be a more comfortable relationship. However, even here the coach may be pushing quite hard towards outcomes. Where the coach is an extravert, this pushing may be even more apparent however, and it is therefore up to the introverted person to play his or her part in managing the relationship to get the most from the experience. Here are therefore a few ways in which this can be done:

  • Always bring a notepad/journal to a coaching session – take notes and keep a record of thoughts/feelings for yourself.
  • Ask your coach for direct and candid feedback.
  • Speak up when you need more time to reflect on what has been asked of you or when a subject warrants it, or when you have a more important concern to discuss.
  • Specifically let your coach know when you are starting to share your private views–the ones that you keep to yourself in usual circumstances.
  • Let your coach know directly if you are not comfortable in sharing some information or you prefer not to answer a question that has been put to you.
  • When working with a highly extravert coach be prepared to apply a metaphorical “hammer” from time to time to get his or her attention.
  • After your coaching session, keep a running record of brief notes on what you thought after you have had time to ponder things – write down what you are learning.
  • Make a list of new questions or issues and bring it with you to your next coaching session.
  • Try and be as willing as possible to attempt something new or different that you may not otherwise consider. Small stretch tasks will eventually help to make bigger stretches.
  • Talk to new colleagues and build new relationships as you become comfortable in doing so when being coached – start with other introverts. Relate the experience to your coach.
  • Take the whole coaching journey step-by-step and let things unfold as slowly as you like. Your coach at your pace, you do not have to work at theirs. 


Introverts have much to bring to any workplace. In general they are more effective than extraverts at focusing or concentrating on important issues, thinking deeply about them and coming up with new, different or well thought through ideas (often noticing or picking up important details that extraverts may miss entirely). They may need a little more time and space to perform this role, and may need assistance in teasing out their ideas, but results usually make this extremely worthwhile. The more that extroverts therefore become knowledgeable about introverts, the less tension and misunderstanding there will be among the two and the higher overall workplace productivity will become. To finally summarize, if you don’t know what an extravert is thinking you haven’t been listening but if you don’t know what an introvert is thinking, you haven’t asked. And as a final contrast, albeit with tongue in cheek, the table below from counseling group New Reflections leaves no doubt about the differences.

An Introverts Versus Extraverts Lexicon

WORD  Extrovert’s Definition  Introvert’s Definition 
Alone, adj. Lonely. Enjoying some peace and quiet.
Book, n.  1) Doorstop.
2) Paperweight.
1) Source of comfort.
2) Safe and inexpensive method of travelling, having adventures, and meeting interesting people.
Bored, adj.  Not frantically busy. Stuck making small talk, and unable to escape politely.
Extrovert, n.  A nice, normal, sociable person. Never surprises you with anything weird. A boisterous person who may be very nice, but who is somewhat exhausting to spend time with. Usually not too deep, but fun.
Free time, n.  A time when you do group activities. (See Introvert’s Definition of work.) A time when you read without interruption until you’re in danger of going blind.
Friend, n.  Someone who makes sure that you’re never alone. Someone who understands that you’re not rejecting them when you need to be alone.
Good manners, n.  Making sure people aren’t left all by themselves. Filling in any silences in a conversation. Not bothering people, unless it’s necessary, or they approach you. (Sometimes you can bother people you know well, but make sure they aren’t busy first.)
Home, n.  A place to invite everybody you know. A place to hide from everybody you know.
Internet, n.  1) Another medium for advertising.
2) A place where geeks with no life hang out.
A way to meet other introverts. You don’t have to go out, and writing allows you to think before just blurting something out.
Introvert, n.  One of those who like to read. Moody loners. Be careful not to tick them off; some of them are serial killers. One who shows a perfectly natural restraint and caution when meeting new people. One who appreciates solitude. Often, one who enjoys reading and has a philosophical turn of mind.
Love, n.  Never having to do anything alone. Being understood and appreciated.
Music, n.  Background noise. Something with a tune and lyrics which may be moving and intelligent, or may be drivel.
Phone, n.  Lifeline to other people – your reason for living. Necessary evil, and yet another interruption. Occasionally useful, but mostly a nuisance.
Reading, v.  A chore that a teacher makes you do when you’re a kid. You have to do it in secret and pretend you don’t really do it, or people think you’re strange.
Shell, n.  Something you find on the beach. What people relentlessly nag you to come out of. Why do you have to leave it, if you’re happy there?
To go out, v.  Requires at least two people, and the more the better. Constant chatter, loud music, sports, crowds, and food consumption are all fun components of going out. Can be done alone or with others. Enjoyable if there’s some point to it; i.e., in order to see a band, a movie, a play, or perhaps to have a stimulating discussion with one or two close friends.
Work, n.  Having to read, write, listen, or concentrate on anything. Being pestered every five minutes about something trivial, and not allowed to concentrate.

From: New Reflections Counseling, Inc

Related Resources

Where the Candidates Stand on Medicare and Medicaid @ProPublica @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by Suevon Lee ProPublica, Sept. 14, 2012

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together make up nearly a quarter of all federal spending. With total Medicare spending projected to cost $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the hot-button issues of the campaign.

With the candidates slinging charges, we thought we’d lay out the facts. Here’s a rundown of where the two candidates stand on Medicare and Medicaid:


Big Picture

Earlier this year, the Medicare Board of Trustees estimated that the Medicare hospital trust fund would remain fully funded only until 2024. Medicare would not go bankrupt or disappear, but it wouldn’t have enough money to cover all hospital costs.

Under traditional government-run Medicare, seniors 65 and over and people with disabilities are given health insurance for a fixed set of benefits, in what’s known as fee-for-service coverage. Medicare also offers a subset of private health plans known as Medicare Advantage, in which roughly one-quarter of Medicare beneficiaries are currently enrolled. Obama retains this structure.

The Obama administration has also made moves that it says would keep Medicare afloat. It says the Affordable Care Act would extend solvency by eight years, mainly by imposing tighter spending controls on Medicare payments to private insurers and hospitals.

In contrast, Rep. Paul Ryan, Mitt Romney’s running mate, has proposed a more fundamental overhaul of Medicare, which he says is on an “unsustainable path.” On hiscampaign website, Romney says that Ryan’s proposals “almost precisely mirrors” his ideas on Medicare. But he’s been fuzzy on other aspects of the plan.

A Romney-Ryan administration would replace a defined benefits system with a defined contribution system in which seniors are given federal vouchers to purchase health insurance in a newly created private marketplace known as Medicare Exchange. In this marketplace, private health plans, along with traditional Medicare, would compete for enrollees’ business. These changes wouldn’t start until 2023, meaning current beneficiaries aren’t affected – just those under 55.

Under the Romney-Ryan, the vouchers would be valued at the second-cheapest private plan or traditional Medicare, whichever costs less. Seniors who opt for a more expensive plan would pay the difference. If they choose a cheaper plan, they keep the savings.

Who’s covered

In the current system, people 65 and over are eligible for Medicare, which Obama has said he would keep for now.

Romney has proposed raising the eligibility age for Medicare beneficiaries from 65 to 67 in 2022, then increasing it by a month each year after that. In the long run, he wouldindex eligibility levels to “longevity.” Ryan’s budget plan proposesraising Medicare eligibility age by two months a year starting in 2023, until it reaches 67 by 2034.

Many others looking to keep Medicare solvent have also proposedraising the age of eligibility.

The Congressional Budget Office estimates that raising the minimum age from 65 to 67 would reduce annual federal spending by 5 percentBut it would also result in higher premiums and out-of-pocket costs for seniors who would lose access to Medicare.

Obama’s health care law also adds some benefits for seniors, such as annual wellness visits without co-pays, preventive services like free cancer screenings and prescription drug savings.

Proposed Savings

The Affordable Care Act is projected to reduce Medicare spending by $716 billion over the next 10 years. These reductions, as detailed by Washington Post’s Wonkblog, will come mostly from reducing payments to hospitals, nursing homes and private health care providers.

While Ryan criticized such spending cuts in his speech at the Republican National Convention, his own budget proposed keeping these reductions.

“The ACA grows the trust fund by giving more general revenue to the Treasury, which then gives the trust fund bonds. But it then uses the money from those bonds to expand coverage for low- and middle-income people,” explains Dylan Matthews on Washington Post’s Wonkblog.

Romney hasn’t really come up with a solid answer: he previously said he would restorethe $716 billion savings that the health care law imposes. Per this New York Timesstory, the American Institutes for Research calculates this would increase premiums and co-payments for Medicare beneficiaries by $342 a year on average over the next 10 years.

For more on where the candidates stand on the $716 billion, the private health policy Commonwealth Fund offers this helpful explanation.

Caps on Spending

Both Obama and Ryan have set an identical target rate that would cap Medicare spending at one-half a percentage point above the nation’s gross domestic product.

But they have different ideas on mechanisms to achieve it.

The Affordable Care Act establishes a 15-member Independent Payment Advisory Boardthat, starting in 2015, would make binding recommendations to reduce spending rates. As Jonathan Cohn points out in the New Republic, the commission is prohibited from making any changes that would affect beneficiaries.

Ryan has proposed hard caps on spending and derided this panel of appointed members as “unelected, unaccountable bureaucrats.” When laying out his plan in a 2011 memo, Ryan wrote that to control spending, “Congress would be required to intervene and could implement policies that change provider reimbursements, program overhead, and means-tested premiums.”

Romney hasn’t stated clear proposals for imposing a cap on spending.


Big Picture

Though, it’s far less discussed on the campaign trail, Medicaid actually covers more people than Medicare. The joint federal-state insurance program for the poor, the disabled, and elderly individuals in long-term nursing home care currently covers about 60 million Americans.  The Affordable Care Act has expanded Medicaid coverage further. Beginning 2014, Medicaid will include people under 65 with income below 133 percent of the federal poverty level (roughly $15,000 for an individual, $30,000 for a family of four). This was estimated to cover an additional 17 million Americans as eligible beneficiaries.

In June, however, the U.S. Supreme Court ruled that states could opt out of the Medicaid expansion. A ProPublica analysis estimated that the 26 states that challenged the health care law, and thus may possibly opt out, would account for up to 8.5 million of those new beneficiaries.

Romney and Ryan would overhaul this current system by turning Medicaid into a system of block grants: the federal government would issue lump sum payments to the states, who would determine eligibility criteria and benefits for enrollees. These grants would begin in 2013.

Effects on spending

The Congressional Budget Office estimates that Medicaid expansion under the new health care law would cost an additional $642 billion over the next 10 years.

Under the Ryan plan, federal Medicaid grants would be adjusted only for inflation, but not health care costs, which grow at a much higher rate. The CBO estimates Ryan’s plan would save the federal government $800 billion over the next 10 years. Another study conducted by Bloomberg News shows that the block-grants could decrease Medicaid funding by as much as $1.26 trillion over the next nine years.

Actual Impact                                                                                                     

The New York Times points out that more than half of Medicaid spending goes toward the elderly and disabled. An Urban Institute analysis estimates the Ryan plan would result in 14 million to 27 million fewer people receiving Medicaid coverage by 2021.

Though rarely mentioned by any of the candidates, Medicaid costs are soaring to cover the elderly who require long-term nursing care. As the Times’ details how, states saddled by high Medicaid costs have begun turning to private managed care plans to blunt the cost.