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Single puzzle piece representing "The Patient Experience".

The Patient Experience

It was once said that only two things in life are certain: death and taxes. For Americans, today you'd have to add a third - health care.

Most of us are born in hospitals, and many of us die there. Wherever birth or death occurs, there are usually medical personnel on hand or in the offing. In between, it is to the health-care system that we turn when we are injured, become ill, or develop acute or chronic disease.

Sometimes, when we do so, the very processes that are supposed to help us fall short. Overwhelmingly, however, we are helped, our bodies made whole again, our pain managed, our distress relieved. Even when we can't be cured, we typically benefit from treatment that either extends and/or improves the quality of life.

In spite of this, many patients - even those whose outcomes are positive - find their experience unsatisfactory or even unacceptable. There's a lot of anger out there, a frustrating sense that the health-care system is run for the benefit of everyone but the patient and that any benefit to the patient is almost incidental.


Three interlocking puzzle pieces representing "The Provider Universe"

The Provider Universe

Health care is big business. In 2014, $3.0 trillion was spent on health care in the United States, 17.5% of the Gross National Product.

Providers range from the 2,000-bed hospital with its thousdands of employees and vendors to the drugstore pharmacist to the self-employed occupational therapist who works in the homes of clients.

As of May 2014, over twelve million people were employed in health care in the United States, not including self-employed individuals.

The most prominent entities in that universe as of 2014 are 708,000 physicians and surgeons, 2,750,000 registered nurses, and 5,600 registered hospitals.

Together, they perform medical miracles, helping millions of patients each year. Even as they do this, doctors, nurses, and hospitals are dealing with a tidal wave of accelerating change. To say they are feeling the pressure is an understatement. What's going on?


Four interlocking puzzle pieces representing "The Patient Experience" fitting into  "The Provider Universe"

The Book

Successful Patient: Step-by-Step Strategies To Get The Health Care You Need grew out of author Linda Hewitt's personal experiences with the American health-care system as both patient and advocate for family members.

Those experiences had good outcomes, but along the way there were obstacles to overcome, challenges to confront, and fears that proved groundless. Linda quickly realized that illness had drawn her into an alien world, one with its own arbitrary protocols and few guideposts.

Now, Linda has written the guidebook she wishes she'd had, a no-nonsense look at how to handle the patient experience in the provider universe as it exists today in health care and is likely to exist tomorrow.

Being sick is bad enough. Being sick and scared because you don't know what's coming next - and what to do about it - is worse. Successful Patient provides the tools to develop a personal health-care strategy to see you through.





Click above cover to order book!


Available April 30, 2018

On sale April 30, 2018!



Young Hispanic male in hospital bed - illustration for

WHO NEEDS HEALTH CARE? Sooner or later, just about everyone is injured or becomes ill. 83.2% of American adults had contact with a health-care professional in 2014.

WHAT ARE THE MOST COMMON ADULT DISEASES IN THE U.S.? The most common adult diseases, in alphabetical order, are:

  • Arthritis

  • Cancer

  • Diabetes

  • Heart conditions

  • Obesity

  • Stroke

In 2012, nearly 117 million adults in the U.S. were affected by one or more of these chronic conditions. Hypertension and high cholesterol - both stroke and heart-disease risk factors - also affect many Americans.


Mother holding her daughter with doctor holding clipboard in the background - illustration for

HOW MANY AMERICAN CHILDREN GO TO THE DOCTOR ANNUALLY? 92.4% of American children had contact with a health-care professional in 2014.

WHAT ARE THE MOST COMMON CHILDHOOD AILMENTS IN THE U.S.? The ten most common childhood ailments, in order, are:

  • Common cold

  • Respiratory synctial virus (RSV)

  • Roseola

  • Gastroenteritis

  • Hand-foot-mouth disease

  • Bright-red cheek rash

  • Strep throat

  • Influenza

  • Pinkeye

  • Pinworms


Female doctor explaining diagnosis for female patient - illustration for

HOW MANY AMERICANS WENT TO THE DOCTOR IN 2014? There were 928.6 million physician-office visits by Americans in 2014.

WHAT DO PATIENTS WANT IN A DOCTOR? According to, the top ten qualities that patients value in a doctor, in order, are:

  • Professionalism

  • Friendliness

  • Niceness

  • Ability to make patient feel comfortable

  • Helpfulness

  • Expertise

  • Empathy

  • Kindness

  • Ability and willingness to listen

  • Thoroughness


Female doctor looking at test result with young couple - illustration foir

WHAT DO PATIENTS NOT LIKE IN A DOCTOR? Doctor behaviors that patients dislike most:

  • Doesn't listen

  • Spends too little time with the patient

  • Is disrespectful

  • Keeps patient waiting

  • Rations care by refusing to recommend anything not sanctioned by the network(s) to which the doctor belongs

  • Puts the patient's interests last

WHAT DO DOCTORS NOT LIKE IN A PATIENT? Patient behaviors that doctors dislike most:

  • Late for appointments

  • Unrealistic expectations as to personal assistance from doctor's office

  • Failure to take medications and to admit this to the doctor

  • Self-diagnosis

  • Delaying doctor as the appointment ends

  • Expectation that treatment and/or medicine can eliminate the need for lifestyle changes

  • Failure to pay bill or make arrangements for payment in a timely manner


Emergency sign - Illustration for

WHO GOES TO THE EMERGENCY ROOM IN THE U.S.? 136.3 million Americans went to hospital emergency rooms in 2014. Hospital admission followed for 16.2 million, with 2.1 million going to a critical-care unit.

WHY DO AMERICANS GO TO THE EMERGENCY ROOM? The four most common complaints in American emergency rooms are: abdominal pain; respiratory infections; sprains and strains; and superficial injury.


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HOW MANY AMERICANS SPEND THE NIGHT IN THE HOSPITAL? In 2014, 7.3% of Americans were hospitalized.

WHY ARE AMERICANS HOSPITALIZED? In 2010, the ten most frequent reasons for hospitalization, in order, were:

  • Liveborn (newborn infant)

  • Pneumonia

  • Osteoarthritis

  • Congestive heart failure (nonhypertensive)

  • Septicemia

  • Mood disorders

  • Cardiac dysrhythmias

  • Chronic obstructive pulmonary disease and bronchiectasis

  • Complication of device (implant or graft)

  • Obstetrics-related trauma to perineum and vulva


WHY ARE AMERICANS SENT TO INTENSIVE CARE UNITS? Patients are admitted to the ICU because they need either close monitoring or special treatment in connection with one or more of the following situations: after a major surgical operation or serious head injury; problems with lungs that require ventilator support with breathing; heart and blood vessel problems (e.g., very low or very high blood pressure, a heart attack, or an unstable heart rhythm); chemical imbalance in the bloodstream; and/or a serious infection requiring specialized ICU care.

HOW MANY AMERICANS ARE ADMITTED TO INTENSIVE CARE UNITS? A 2013 study by George Washington University School of Public Health and Health Services (SPHHS) found that American ICU admissions jumped from 2.79 million in 2002-2003 to 4.14 million in 2008-2009. The ICU is not only the scene of highest mortality rates but also one of the most expensive medical settings, as well as one of the places where medical errors are most likely to happen because of the complexity of care.


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HOW SERIOUS A PROBLEM ARE HOSPITAL ERRORS? A 2013 study reported in the U.S. National Library of Medicine of the National Institutes of Health estimated that there are between 210,000 and 400,000 preventable adverse events per year in the U.S. that contribute to the death of hospitalized patients. More than 30% of hospital patients suffer some form of preventable harm during their hospital stay.

HOW OPEN ARE HOSPITALS ABOUT ERRORS? Patients who suffer harm while in hospital often cannot get information to help them understand what went wrong, even when the knowledge might help them make ongoing health-care decisions.


Older male patient in bed looking up at doctor angrily - Illustration for

SOME DOCTORS PRACTICE LAW AND MEDICINE. According to a 2013 Forbes article, more than 90% of U.S. physicians admitted to making some medical decisions based on avoiding lawsuits, as opposed to the best interest of their patients.

SOME DOCTORS GET BONUSES FOR COST CONTROLS. Patients don't like doctor bonuses for cost controls, especially when they're not disclosed and are not associated with quality measures.


Older African-American couple with wife comforting husband, who is in hospital bed - Illustration for

DOES ETHNICITY MATTER? Patients wonder if they'll be treated differently because of their ethnicity, whether due to prejudice or provider failure to understand the language the patient speaks.

WHAT ARE OTHER POSSIBLE CAUSES OF DISCRIMINATORY TREATMENT? Other concerns voiced by patients as possible cause of discriminatory treatment:

  • Being female - too many doctors have difficulty taking women's health concerns as seriously as they do those of men

  • Being obese - some overweight patients say that doctors don't want to see beyond their size

  • Daring to disagree with doctor's diagnosis - many patients say that once they ask or say anything that indicates any other than total agreement the doctor either backs away or treats them aggressively


Young female doctor having serious discussion with male patient in exam room - Illustration for

PATIENTS DON'T LIKE BEING THREATENED WITH CONSEQUENCES. Patients don't like it when physicians use fear-based messages instead of information in an attempt to get them to modify lifestyle behavior.


Older male doctor holding pill bottle as he explains its label to young Hispanic female patient - Illustration for

HOW MANY AMERICANS TAKE PRESCRIPTION DRUGS? A 2013 Mayo Clinic study revealed that 70% of Americans take at least one prescription drug. More than half of Americans take two prescription medications, and 20% take at least five prescription medications.

WHAT ARE THE MOST COMMONLY PRESCRIBED DRUGS? The most commonly prescribed drugs are antibiotics, antidepressants, and opioids. Other frequently prescribed drugs are vaccines, cholesterol-lowering drugs, and anti-asthma drugs.


Row of prescription-drug containers - Illustration for

WHAT IS PRESCRIPTION DRUG ABUSE? Abuse is the misuse of prescription drugs in one of these ways:

  • Using a drug that isn't prescribed for the patient and/or the patient's condition

  • Using a drug in the wrong quantities or at the wrong intervals

  • Using a drug simply for the experience of taking the drug, e.g., it provides a high or a feeling of pleasure or some other desired sensation

Prescription drug abuse is a serious societal issue because it harms not only abusers but also those with whom they work, live, and share the highway.

WHAT ARE THE MOST COMMONLY ABUSED MEDICATIONS? The medications most commonly abused are:

  • Pain relievers

  • Tranquilizers

  • Stimulants

  • Sedatives

Some abused medications are bought on the street, but others are provided by friends or relatives or are simply removed from family medicine cabinets where they're kept because another occupant of the house has a prescription for the drug.

WHAT IS THE SIGNIFICANCE OF DRUG ABUSE FOR LEGITIMATE ACCESS TO DRUGS? Some prescription drugs are abused in such significant numberes that the DEA (Drug Enforcement Administration) aggressively investigates the issue, making physicians reluctant to prescribe those medications even though seriously ill patients, particularly those suffering from cancer, need them to control excruciating pain.


Crumpled thousand-Dollar bill lying on heavily grained wooden background - Illustration for

WHAT ARE OUT-OF-POCKET HEALTH-CARE EXPENSES? OOP expenses include any money spent by patients on deductibles, co-pays, and health-related services or devices that are not fully paid for by the patient's employer, insurance plan, or other third-party payer.

HOW MUCH DO AMERICANS PAY IN OUT-OF-POCKET EXPENSES? In 2014 Americans paid $329.9 billion in out-of-pocket expenses for uninsured health care, deductibles, and co-pays.

WHAT KINDS OF HEALTH-RELATED EXPENDITURES ARE OUT-OF-POCKET? Of the $329.9 billion Americans paid in out-of-pocket health-care costs in 2014, these were the categories of expenses:

  • $78.3 billion for "other medical products"

  • $54.0 billion for "physician and clinical services"

  • $45.7 billion for "dental services"

  • $44.7 billion for "prescription drugs"

  • $41.2 billion for "nursing care facilities"

  • $21.3 billion for "other professional services"

  • $7.4 billion for "home health care"

  • $5.9 billion for "other health care"


WHAT ARE THE MEDICAL DATA BREACHES THAT MAKE PATIENTS WORRY? As records become increasingly digitized, patients are particularly concerned about (1) medical ID theft by hackers breaking into the computer networks of insurers and providers, including not only physician offices and hospitals but also device manufacturers and Big Pharma, and (2) the revelation of personally compromising and/or embarrassing information through the misuse of electronic health records (EHRS).

WHAT ARE THE REASONS FOR MEDICAL ID THEFT? Medical ID theft may be financial in nature, instigated by criminals intending to sell the patient's ID to re-sellers targeting consumers wanting free health care or to fraudulent providers who will bill insurance companies or Medicare for "services rendered" to the patient whose identity was stolen. It may even be undertaken for the purpose of blackmail. The consequences of medical ID theft are far-reaching. When a patient's medical ID is used by someone else, any diagnosis the fraudulent patient receives, treatment they're given, drugs they're prescribed, etc., goes into the electronic health record (EHR) of the original patient, thereby defeating the EHR's purpose of maintaining an accurate record of a specific patient's medical situation. What makes medical ID theft particularly troubling is that American health care is tied to the patient's Social Security number, which can be fraudulently misused for many purposes, not just health care.

WHAT DO PATIENTS WORRY ABOUT IN CONNECTION WITH THE MISUSE OR THEFT OF EHRs? Electronic Health Records are rapidly becoming the norm as providers comply with mandates to keep all patient records in a consistent, digitized form that can be shared across the entire provider universe. This improves health care in that it makes possible faster, better diagnosis, avoids duplication of treatment, and lessens the chance of errors in treatment. Records are meant to follow a patient throughout life, and their privacy is controlled by law. Patients are encouraged to be totally candid with health-care providers about any issues that could affect health, which leads to descriptions of substance abuse, sexually transmitted diseases, family discord, and other personal dysfunction. This is not the kind of information a patient wants in the wrong hands, and patients worry that access to EHRs may not be as strictly controlled as it should be.

HEALTH CARE IS THE INDUSTRY AMERICANS LOVE TO HATE. There are many things about American health care that a lot of people would like to change for one reason or another. No objective observer could call it perfect. At the same time, for most people, most of the time, it works as intended, giving patients access to the care they need, when they need it, and getting them back to their normal lives in short order. When we are injured or ill, we commit ourselves to the system, hoping that we are in the hands of highly trained professionals dedicated to their calling who want to do their best for us. Most of the time, we're right.


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WHO PROVIDES HEALTH CARE? Over twelve million people work in American health care. According to the Occupational Outlook Handbook issued by the U.S. Department of Labor/U.S. Bureau of Labor Statistics, in order, these are the fifteen most numerous health-care occupations in 2014:

  • Registered nurses - 2,751,000

  • Nursing assistants and orderlies - 1,545,200

  • Home health aides - 913,500

  • Licensed practical and licensed vocational nurses - 719,900

  • Physicians and surgeons - 708,300

  • Medical assistants - 591,300

  • Pharmacy technicians - 372,500

  • Dental assistants - 318,800

  • Medical and clinical laboratory technologists and technicians - 328,200

  • Pharmacists - 297,100

  • Emergency medical technicians and paramedics - 241,200

  • Radiologic and magnetic resonance imaging technologists - 230,600

  • Physical therapists - 210,900

  • Dental hygienists - 200,500

  • Medical records and health information technicians - 188,600

WHAT QUALIFIES HEALTH-CARE PROFESSIONALS TO PROVIDE CARE? Most medical occupations have specific and sometimes extensive educational qualifications and require some form of licensing or registration. Also, most of those who choose health care as a job do so because they feel a genuine calling to help others and/or confront the challenges posed by disease.


Hospital exterior with sign in foreground - Illustration for

HOW MANY HOSPITALS ARE THERE? According to the American Hospital Association, in 2014 there were 5,627 registered hospitals in the U.S., including community, government, psychiatric, long-term care, and institutional hospitals. Some are used by a specific population, but 4,926 community hospitals are open to the general public. Hospitals offer inpatient services that require overnight stays, anesthesia, and/or the use of sophisticated diagnostic and surgical equipment. Their outpatient facilities are designed to deliver services that don't require overnight stays.


Elegant hospital lobby - Illustration for

HOSPITALS GO UPMARKET. Once rather forbidding, bare-bones spaces, hospitals are now more user-friendly, with lobbies that resemble nicer versions of airport concourses. In part, this is because studies show that pleasant surroundings lower the stress level of patients and family members. In part, upgrading facilities is down to competition from independent ambulatory care centers capable of offering many of the same services once provided only by hospitals.


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HOSPITAL ROOMS ARE BOTH HIGH-TECH AND HOMEY. The Spartan hospital room of old is rapidly giving way to spaces that not only accommodate both patients and visitors more comfortably but also incorporate a wide variety of network-connected devices, electronic monitoring equipment, and treatment options, not to mention adjustable beds that move with a patient throughout his or her hospital stay.


Operating room with barebones setup and big overhead light - Illustration for

OPERATING ROOMS CAN BE CONFIGURED AS NEEDED. Today's ideal operating room offers a comprehensive lighting scheme as well as plenty of space for whatever kind of procedural and monitoring setup the surgical team requires for a particular surgery.


Four-person surgical team operating on patient on table - Illustration for

SURGICAL TEAMS ARE ASSEMBLED AS NEEDED. The surgical team provides care in the preoperative stage, during the surgery, and throughout the postoperative period. The composition of the team will vary according to the nature of the surgery, but will always include at least one surgeon and an anesthesiologist with advanced training for his or her role.

WHICH SURGERIES ARE PERFORMED MOST OFTEN IN THE U.S.? Of the 40-50 million surgeries performed annually in the U.S., in order these are the ten most common:

  • Cataract removal

  • C-section for surgical delivery of baby

  • Joint replacement

  • Circumcision

  • Broken bone repair

  • Angioplasty and atherectomy to open coronary arteries clogged with plaque and to remove the plaque

  • Stent procedure to keep artery open following angioplasty

  • Hysterectomy

  • Gallbladder removal

  • Heart-bypass surgery


THERE ARE MORE PLACES TO GET HEALTH CARE. Walk-in clinics, for example, sometimes known as urgent-care or immediate-care clinics, provide professional-level care for minor ailments or injuries, are generally less expensive, and - best of all - do not require appointments. They're often located in popular shopping areas. According to the American Academy of Urgent Care Medicine, there are approximately 9,300 stand-alone urgent-care clinics in the U.S., and 50-100 new clinics open every year.


Stressed-out doctor at desk staring at computer - Illustration for

WHY ARE DOCTORS IN PRIVATE PRACTICE SO STRESSED?  This isn't the medicine they signed up for. Not so long ago, doctors in private practice enjoyed near-autonomy and, once established, a more-or-less guaranteed lifetime of patient flow, community respect, and good earnings as they practiced the kind of medicine in which they found satisfaction. Today, they've been turned into managers of a complex business enterprise, thanks to a combination of high costs, payer demands, growing competition, increasing patient expectations, rapidly advancing medical technologies, legislative requirements, and regulatory mandates. Although the profession is still highly regarded by the public at large and earnings can be significant, many currently practicing physicians say they would not encourage their children to go into medicine.


African-American nurse comforting older patient in hospital bed - Illustration for

NURSES ARE THE HEART AND SOUL OF MEDICINE. They're also its face, as - at over two-and-a-half million strong - registered nurses are by far the most numerous health-care occupation. Drawn to nursing by a strong desire to serve, higher-than-usual empathy, high energy, and intellectual curiosity, nurses were once considered the handmaidens of physicians, women who kept their mouths shut as they comforted the patient and did what they were told by the doctor. Now, their numbers include men, and - women and men alike - they find themselves in a world that offers more opportunities even as it requires that they master multiple skills and knowledge-sets required by ever-changing technologies. Nurse practitioners, for example, can now fulfill many of the functions once performed only by MDs. Disturbingly, however, many nurses say that they are overworked, underpaid in relation to their skills, and disrespected in relation to doctors.


HEALTH CARE IS A FLEET OF PROVIDERS FLOATING ON INFORMATION TECHNOLOGY. Computers - and their software - have been important in the offices of most health-care providers for decades, used for internal recordkeeping and billing. Today, because of legislation, regulation, payer requirements, and criminal activity, their importance extends to the core of the provider universe. The most critical IT challenges facing health care relate to: (1) ICD-10; (2) EHRs (electronic health records); and (3) security.

WHAT IS ICD-10? This is a disease-classification reporting format that must now be used for all provider billing to Medicare, Medicaid, and insurance companies. Issued by the World Health Organization (WHO), it replaced ICD-9, the former reporting format, in 1999. Unlike most industrialized nations, the U.S. did not switch to ICD-10 but continued to update ICD-9. This mattered because ICD-9 did not fully reflect medical advances, which led to its being imprecise in ways that contributed to coding errors and interfered with the accurate sharing of consistent information in a fast and efficient manner. A particular concern was that ICD-9 coding would not be current enough to support electronic health records (EHRs). In 2009, as part of the Health Insurance Portability and Accountability Act (HIPAA), federal mandate required that health-care providers switch to ICD-10 for reporting purposes. The long-term goal is the reduction of costs, paperwork time, and administrative hassle, not to mention improvements in patient care and an accelerated revenue cycle for providers. The deadline for switching without penalty was October 1, 2015, and many providers are still struggling to get there because the short-term reality has been a confusing transition period involving expensive software, time-consuming staff training, and unexpected system problems. Failure to switch to ICD-10 means lost or delayed revenue for providers, and a faulty switch has the same result.

WHAT ARE EHRs? EHRs are electronic health records. Meant to follow a patient throughout his or her life, across the entire provider universe, EHRs should theoretically include in one master data set every detail of the individual's medical complaints, diagnoses, treatment, and aftermath. The goals of the required transition to EHRs include:

  • Allowing patients and their providers fast access to accurate, complete, consistently maintained health records

  • Helping providers make better and faster diagnoses

  • Protecting patients from unnecessary or duplicative procedures or drug prescriptions

  • Increasing patient-provider engagement in the patient's overall health care

  • Improving public health

  • Facilitating the exchange of clinical information among the professional members of the multi-provider health-care team

The goals are worthwhile, but getting from the current variety of recordkeeping methods and information technologies to this clean, streamlined, consistent electronic system that can interact with every other provider's system is complicated. In addition to the inevitable software purchase and staff training, all the provider's records must be transferred into the new system, including "nonstandard information" - the contents of old paper files, Rolodex cards, and other odds and ends - as well as existing computer records which were themselves sometimes patched together when previous systems were combined. Mandated by the American Recovery and Reinvestement Act of 2009, the implementation date was the start of calendar year 2015. A lot of providers still aren't fully in compliance, and the result is a reduction in Medicare reimbursements - the reduction rate for 2016 is 2%, and it rises each year.

WHY IS SECURITY SUCH AN ISSUE FOR HEALTH CARE? Information technology poses a security risk for health-care providers in several ways and for several reasons. The reasons for provider vulnerability relate to:

  • The amount of detailed financial and other information that health-care providers store about patients and employees, information that has solid market value and that can be readily resold

  • The large number of potential users with a right or need to access patient and other information, often from private devices with little or no security guards in place

  • Outdated or inadequate firewalls and virus-detection on hospital or physician-office servers

  • The growing sophistication of hackers

The motivations for hacking include:

  • The re-selling of patient data on the dark web for purposes of identity fraud

  • Blackmail of providers via the use of ransomware by which the provider's IT system is shut down until it pays whatever sum the hacker wants

  • Blackmail of patients who are targeted because of certain kinds of information in their electronic health records (EHRs) - this is suspected to be behind the theft of hospital and insurance-company information from areas with a lot of U.S. defense contractors

Apart from the logistical and criminal implications, breaching provider IT systems undermines public confidence in the credibility and integrity of the health-care system and its ability to protect patient information.


Computer terminal in medical examination room - Illustration for

HOW IMPORTANT IS INFORMATION TECHNOLOGY AS A TREATMENT TOOL? Information technology is already important in treatment rooms because it allows doctors and nurses to access patient records to confirm past diagnoses, treatments, and prescriptions. It will become increasingly important for this purpose as electronic health records (EHRs) come online across the provider universe. Also, CPOE (Computerized Physician/Provider Order Entry) requires computer entry of all information relating to patients and represents a major change in the recording of patient histories, diagnoses, and treatment plans. In terms of rapid and accurate diagnosis, however, the most valuable role of computers may come with the growing use of clinical decision support, which gives medical personnel access to focused, well-organized information incorporating the latest research, best practices, and decision-making support related to the patient's specific health problems. CPOE and clinical decision support can lower costs, reduce medical errors, and encourage treatment based on evidence.


WHO CONTROLS AND REGULATES MEDICAL SERVICES AND PRODUCTS? Because of its life-or-death function, the amount of money spent on it by public authorities at different levels, and its resulting political importance, the health-care industry is controlled through legislation and regulation by local authorities, the states, and/or the federal government. Together, these authorities work with providers to keep health care safe, effective, and reliable. Professional associations also have influence over standards. The least visible - and perhaps most powerful - influencers, however, are industry members who contribute to political campaigns and pay for the lobbyists who represent the health-care industry with state and federal legislators and regulators.

WHAT DO LOCAL AUTHORITIES CONTROL IN THE HEALTH-CARE INDUSTRY? Local authorities control health-care industry issues that fall within their jurisdictions, such as:

  • Investigation of workplace-related injury or illness

  • Response to workplace violence and criminal behavior directed toward or committed within the hospital or medical-office environment

  • Issuance of business licenses to health-care providers whose function requires them

  • Inspection of restaurant and certain other premises for hygiene and safety

  • Inspection of health-care facilities for conformity to fire codes

  • Issuance of building permits for health-care facilities

WHAT DO THE STATES CONTROL IN THE HEALTH-CARE INDUSTRY? States have control over many aspects of health care, such as:

  • Physician licensing

  • Nurse registration

  • Issuance of professional licenses to certain other medical occupations, as required by state law

  • The number of hospital rooms, operating rooms, etc., that can be built

  • State-owned hospital facilities

  • Schools of medicine in state-owned universities

  • Regulation of health insurance, including all private insurers

  • Authority to set up insurance exchanges to comply with health-insurance market reforms, such as the Affordable Care Act, and also to exercise primary enforcement authority over health-insurance issuers

  • Regulation or oversight of certain aspects of workplace health and safety and investigation of accidents

  • Legislation defining medical liability and medical malpractice

  • Investigation of criminal activities relating to health care, such as fraud and inappropriate behavior by health-care practitioners

WHAT DOES THE FEDERAL GOVERNMENT CONTROL IN THE HEALTH-CARE INDUSTRY? The federal government touches almost every aspect of the health-care industry through legislation and a wide array of departments, bureaus, and agencies that regulate the industry and/or enforce legislation affecting it. Some of the most prominent federal entities involved include:

  • CDC (Centers for Disease Control)

  • CMS (Centers for Medicare & Medicaid Services)

  • DEA (Drug Enforcement Administration)

  • DHHS (Department of Health and Human Services)

  • FBI (Federal Bureau of Investigation)

  • FDA (Food & Drug Administration);

  • FTC (Federal Trade Commission)

  • OSHA (Occupational Safety and Health Administration)

Some of the areas of responsibility for the federal government in the field of health care include:

  • Administration of Medicare and Medicaid

  • Approval of new drugs and medical devices

  • Assistance with and enforcement of the move to electronic health records (EHRs)

  • Enforcement of HIPAA, which gives patients rights over their health information and sets rules as to who can have access to health information

  • Enforcement of laws and regulations pertaining to controlled substrances

  • Innovation as to the improvement of health-care delivery systems and how they're paid for

  • Investigation of health-care fraud, with jurisdiction over both federal and private insurance programs

  • Regulation of advertising that promotes health-care products or services

  • Setting and enforcing workplace standards relating to health and safety, as well as providing training, outreach, education, and assistance in meeting those standards

Where there is overlap between local, state, and federal functions, the federal government may play either a lead or a supporting role in relation to the local and state governmental authorities, according to the nature of the issue.

HOW MUCH INFLUENCE DO LOBBYISTS HAVE OVER LEGISLATION AND REGULATION AFFECTING THE HEALTH-CARE INDUSTRY? Lobbyists have significant influence over health-care legislation and regulation. This is because of the large amount of time and money they spend lobbying state and federal legislators and regulators. In 2015, according to the Center for Responsive Politics (whose numbers come from the Senate Office of Public Records), the Health sector spent $510,319,585 on lobbying, second only to Miscellaneous Business, which spent $525,094,565. Five of the top fifteen individual lobbying spenders were in the health-care sector, including:

  • #3 BlueCross/BlueShield ($23,702,049)

  • #4 American Medical Association ($21,930,000)

  • #7 American Hospital Association ($20,687,935)

  • #9 Pharmaceutical Research and Manufacturers of America ($18,920,000)

  • #15 CVS Health ($15,230,000)

Some lobbying is educational, relating to governmental action or policy on general health issues, but much of it is an attempt to influence or control what government does affecting the corporation or association's specific interests and profit models.


WHY IS MEDICARE SO POWERFUL A PLAYER IN THE HEALTH-CARE INDUSTRY? Medicare - administered by CMS (Centers for Medicare and Medicaid Services) - has both the motivation and the power to make the most transformational changes in the health-care industry. Its motivation is that it is the largest single payer of health-care expenses in the U.S. and that its client population is exploding, thanks largely to the mass of Baby Boomers reaching retirement age. It's forced by political reality to maximize patient benefit for monies spent. Also, it is specifically charged with leading innovation in health care. Its power derives not only from its legislation-mandated administrative and enforcement responsibilities, but also from its willingness to pursue innovation in the interest of keeping the program sustainable. The most important Medicare initiatives have the joint goal of (1) improving the quality of health care delivered to patients and (2) making care more cost effective. To this end, Medicare is transitioning to care-delivery models like ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) and bundled billing. Through these and other means, it is providing incentives to health-care providers who meet or exceed quality/cost targets and penalizing those who do not. The end result of these initiatives is a move away from fee-for-service and toward pay-for-performance. This represents an elemental shift in that it threatens long-established income models for providers who prove unable to meet the new standards.



  • Changing payer rules about how care must be delivered and billing must be handled, particularly the move away from unbundled toward bundled billing

  • Change from fee-for-service to pay-for-performance

  • Negotiating apportionment of payments between care providers in ACOs (Accountable Care Organizations)

  • Payment that arrives in stages, sometimes many months after service is performed - if quality-of-outcome targets are not met, the second payment may not arrive at all or may be significantly reduced

  • Insurance-company pressure to accept tightly negotiated fees or be excluded from the company's network of providers

  • Loss of patients who are insured by a company that has excluded the provider from its network

  • Growing competition from new kinds of care-delivery venues, such as walk-in clinics

  • Consolidation creating larger, more powerful competitors

  • Difficulty of collecting out-of-pocket expenses from patients to cover deductibles, co-pays, and uninsured treatment

  • Rising costs


CONSOLIDATION IS HAPPENING ALL OVER. It's not universal yet, but it happens so often that it sometimes seems as if every kind of concern is seeking cover by joining forces. Hospitals and even networks of hospitals merge. Independent doctors join other practices or sell their practices to hospitals. Pharmaceutical firms buy each other out. Companies that issue health insurance have seen so much merger activity that only a handful of major concerns remain.

WHAT'S THE SIGNIFICANCE OF CONSOLIDATION? Consolidation has consequences for patients, the health-care industry, and insurance companies. For patients, consolidation usually means increased prices, fewer treatment options, and decreased access to health care. For the health-care industry, consolidation means decreased competition, increased management challenges, and power shifts. For insurance companies, consolidation within the insurance industry means higher profits and more power over providers, especially independent doctors intimidated by the possibility of being left out of the insurance-company's "narrow networks" and encouraged by insurance companies to use cheaper alternatives to hospital care for their patients.


MEDICAL TECHNOLOGY IS ADVANCING AT A DIZZYING RATE. In the last few decades, the health-care industry has produced dramatic advances in diagnostics and treatment. Some of this has meant years more of life for patients diagnosed with once quickly terminal conditions; some has facilitated once-impossible cures. In some situations, conditions that would have meant disability or death have been thwarted by joint replacements or organ transplants. Some advances have facilitated provider operations. Advances in computer technology have given us electronic health records (EHRs), mHealth, telemedicine, patient access to health-care portals, remote monitoring tools, sensors and wearable technology, wireless communication, real-time locating services, biometric identifiers, and pharmacogenomics/genome sequencing. The net effect of all this has been increasingly to facilitate provider accuracy and to tailor treatment to the individual patient.

MEDICAL MIRACLES IN THE PROCESS OF ARRIVING OR ALREADY ON THE HORIZON. The trend toward the personalization of medicine is but a jumping-off point for what's about to happen or is visible on the horizon. According to The Medical Futurist and other futurist authorities, the most striking of these leaps forward include:

  • Augmented reality - e.g., a digital contact lens that measures blood glucose levels from tears, which has the potential to change diabetes management

  • Medical 3D printing using bioink based on the patient's own body chemistry to create organs and other body parts less likely to be rejected by the patient's body as incompatible

  • Behavior-change motivators - e.g., a pill bottle that glows red when a dose is missed

  • Behavior monitors - e.g., tiny digestible sensors in pills that transmit pill digestion data to physicians and family members (health insurance companies will find these useful to determine patient compliance with doctor's orders)

  • Real-time diagnostics - e.g., the intelligent surgical knife that detects chemicals and can immediately identify whether tissue is malignant

  • Multi-function radiology capable of detecting a variety of medical problems, biomarkers, and symptoms at the same time

  • In silico clinical trials enabling the switch from long and expensive trials that require human and/or animal testing to tiny microchips that can be used as models of human cells, organs, or whole physiological systems

  • Digestible and wearable sensors and tattoos capable of measuring important health data and transmitting it to the cloud - the most advanced could send alerts to medical systems when an emergency medical event is taking place - and could even call an ambulance if needed

  • Changes in medical education as more powerful cameras and greater bandwidth enable a surgeon to perform an operation using a virtual reality camera, with the output transmitted anywhere in the world

  • Also affecting medical education will be the use of virtual dissection tables and anatomical models that allow for the visualization of solutions before implementation

  • Robot assistants for everything from human-sized robots performing routine tasks like delivering supplies in hospitals to nanorobots capable of entering the body's systems and performing delicate surgical interventions from within

  • Optogenetics, which is the use of light to control cells in living tissue, providing radically different therapy solutions. One application of this still-on-the-horizon technique is the generation of false memories in humans of taking drugs. Given the placebo effect, this could revolutionize the need to use drugs such as pain killers, tranquilizers, and stimulants.

  • Artificial intelligence to support physician decision making

  • Use of genome sequencing and genetics to prevent and cure diseases

Probably the most generally transformational of medical advances has to do with patient empowerment. The convergence and combination of developments in communication, research, and technique will give patients access to information and even certain processes that they can use to control, or at least influence the shape of, individual health care.


EPISODES OF ILLNESS OR INJURY WERE ONCE TREATED AS ONE-OFF EVENTS FOR WHICH EACH PROVIDER INVOLVED CHARGED SEPARATELY FOR SERVICES DELIVERED - WHATEVER THE OUTCOME, BUT THAT'S CHANGING. Several needs are coming together with enhanced capabilities of recordkeeping and communication to enable new delivery models for health care. Health-care costs have increased unacceptably over the last few decades even as quality issues remain. Payers concluded, in effect, that they were oftentimes subsidizing substandard care. New delivery models, combined with new billing requirements, aim to incease quality and cut costs. The delivery models being tried most frequently, with prompting from Medicare, are patient-focused, as follows:

  • Accountable Care Organizations (ACOs) are those in which a group of providers join forces to treat a patient. The providers bill the payer together, usually through a hospital or independent physician. When the bill is paid the monies received are divided between all the entities in the ACO according to the agreed-upon formula. In this kind of arrangement, a percentage of the bill is not paid until the quality of the outcome can be determined, usually months after the service is performed. If the quality outcome is not satisfactory, the payer may withhold some or all of the unpaid percentage of the ACO's bill. In effect, this pay-for-performance model replaces the traditional fee-for-service approach.

  • Patient Centered Medical Homes (PCMHs) focus on the organization and delivery of health care. The PCMH term refers not to an actual place but to a virtual home in which all the patient's health-care providers know not only the individual's name but everything else about his or her health history, current status, and treatment preferences. This enables the team of providers to work together to deliver truly comprehensive care that is coordinated across the provider universe. Within that context, patients enjoy shorter waiting times for emergencies, longer office hours, and 24/7 telephone or email access to a member of the care team. The goal of the PCMH is to deliver higher quality care at less cost and to encourage patients to take more responsibility for and have more control over their health and health-care treatments. The goal is to get rid of one-episode, one-provider thinking and combine everything to do with the patient's care in a sharable, continually updated format.

The move to EHRs (electronic health records) facilitate both these approaches. Other models will doubtless be tried over time, but the core aims of all will be generally the same:

  • To give patients better-quality care

  • To enable providers to make faster and more accurate diagnoses and treatment plans

  • To engage patients and their families more fully in the health-care process

  • To lower costs for payers


African-American doctor with patient (child), with nurse in background - all smiling - Illustration for

PATIENTS WANT A HEALTH-CARE SYSTEM THAT SATISFIES THEM - HOW DOES THE U.S. STACK UP? According to Becker's Hospital Review, a 2012 survey indicated that 77% of U.S. patients are satisfied with their health care. This compares favorably with other developed countries - the next closest satisfaction levels were India at 76% and Germany at 72%. Americans were most satisfied with their physicians, nurses, pharmacists, and hospitals, each of which received a satisfaction rating of over 82%. Pharmaceutical companies, however, scored only 63%, insurers only 57%, and government only 54%. Satisfaction relates not only to outcome but to the process that produced it, with patients giving high marks to providers perceived to be ethical, reasonable in cost, highly professional, and respectful in their treatment of the patient.


HOW BIG A PROBLEM IS MEDICAL ERROR? According to researchers at Johns Hopkins Medicine, medical errors are the third leading cause of death in the U.S. The 2016 Johns Hopkins study estimates that more than 250,000 Americans die from medical errors each year. Only heart disease and cancer kill more (about 600,000 each), and respiratory disease, the fourth leading cause at 150,000, doesn't kill as many. Medical errors are underreported as a cause of death, the study says, because current coding captures the underlying cause of death as the condition that led the patient to seek treatment, not the error that actually precipitated death.

WHAT CONSTITUTES MEDICAL ERROR? There are several general kinds of medical error, as follows:

  • An unintended act (either of commission or omission)

  • The failure of a planned action to be completed (an error of execution)

  • The use of a wrong plan to achieve an aim (an error of planning)

  • Deviation from the process of care (either of commission or omission)

Some relatively common errors include:

  • Misreading medical tests or imaging results

  • Failure to incorporate the results of medical tests or imaging studies when diagnosing or making treatment plans

  • Misinterpreting the results of examination, tests, and imaging to reach a wrong diagnosis due to a lack of judgment

  • Surgery on the wrong part of the body

  • Leaving foreign objects in the body during surgery

  • Prescribing or administering incorrect medication

  • Failure to follow treatment plans

  • Failure to maintain proper hygiene

  • Miscommunication with the growing number of U.S. patients who do not speak English as their primary language

The most serious form of medical error is referred to as "Never Events." The National Quality Forum (NQF) defines "Never Events" as errors in medical care that (1) are clearly identifiable, preventable, and serious in consequences for patients and (2) indicate basic problems in a facility's safety and credibility.


WHAT IS HEALTH-CARE FRAUD? Health-care fraud is criminal activity that occurs in the form of both provider and patient schemes. Provider schemes include:

  • Billing for care not rendered

  • Filing duplicate claims for the same service

  • Altering dates, description of service, or identities

  • Miscoding a bill so that a non-covered service becomes a covered service

  • Maximizing payment by intentionally upcoding diagnoses, procedures, devices, or equipment

  • Prescribing unneeded medication

  • Prescribing drugs for purposes other than those for which they have been approved by the FDA when the prescription will be paid for by Medicare or Medicaid

  • Using unlicensed staff

  • Accepting or giving kickbacks for referrals

  • Waiving patient co-pays

  • Prescribing additional or unnecessary treatment

  • Unbundling bill items for which payer requires bundlled billing, with the result that the total fragmented bill is higher

Patient schemes include:

  • Providing false information on applications for programs or services

  • Forging or selling prescription drugs

  • Using medical transportation benefits for other purposes

  • Lending the patient's insurance card or using another's insurance card

PROVIDERS AND PATIENTS GET AWAY WITH HEALTH-CARE FRAUD BECAUSE IT IS HARD TO DETECT IN TIME FOR THE PAYER TO REJECT FRAUDULENT CLAIMS LEGALLY. Congressional legislation requires that legitimate claims be paid within thirty days. This short time frame and the number of fraudulent activities make it difficult for the primary entities charged with the investigation of health-care fraud - the Federal Bureau of Investigation, the U.S. Postal Service, and the Office of the Inspector General - to do what's necessary to stop payment in time. If a provider is uncovered and prosecuted, however, a successful prosecution can end with incarceration, fines, clawing back of fraudulent billing amounts, and a possible loss of the right to practice in the medical industry.

HOW BIG A PROBLEM IS HEALTH-CARE FRAUD? In 2012, Donald Berwick, former head of CMS (Centers for Medicare and Medicaid Service), and Andrew Hackbarth of the RAND Corporation, estimated that health-care fraud added $98 billion or approximately 10% to annual Medicare and Medicaid spending and as much as $272 billion throughout the U.S. health system. Detection, investigation, and prosecution are difficult because of the thirty-day payment requirement and the numbers involved - it's estimated, for example, that Medicare contractors submit 4.5 million claims daily. As investigations have become more intense, the perpetrators of fraud have become more sophisticated, learning from the past mistakes of other fraudsters, sometimes relatives or business associates who have worked the same scam in another geographic location. Health-care fraud has become so attractive that, according to The Economist, some criminals are switching from cocaine trafficking to prescription-drug fraud because it's lucrative, it's safer, and the penalties are less.


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WHAT IS PRESCRIPTION-DRUG ABUSE AND WHY DOES IT MATTER? The right prescription drug can make the difference between life and death and vastly improve the quality of life. Unfortunately, drug abuse is a huge problem. Drug abuse occurs when individuals:

  • Take extra doses of a legitimately prescribed drug either accidentally or deliberately

  • Take drugs prescribed for someone else

  • Take a drug not for medical reasons but for its mind-altering or energy-affecting qualities

Prescription-drug abuse leads to many problems for abusers, but it also creates issues for providers and patients. It's commonly accepted that the DEA (Drug Enforcement Administration) actively discourages providers from prescribing frequently abused drugs, which can lead to providers electing not to prescribe the most effective drug for patients but rather the drug that won't draw attention from the DEA. This means that patients in need of serious pain relief from diseases like cancer may sometimes find it difficult to get the drug they need from their doctor.


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HOW BAD ARE DOCTOR-NURSE SHORTAGES? According to a 2016 physician workforce report released by the Association of American Medical Colleges, "the physician shortage is real, it's significant, and the nation must begin to train more doctors now if patients are going to be able to receive the care they need when they need it in the near future." Here are some troubling facts relating to physician shortages:

  • One-third of physicians are now over the age of fifty-five, meaning there will be a bulge of retirements in the next ten to fifteen years.

  • As more Americans gain access to health care, more physicians will be needed.

  • In 2014, forty-five states had fewer psychiatrists relative to their populations than they had in 2009, despite the large number of American adults reporting a mental illness.

  • By 2025, there's an estimated shortfall of (1) between 14,900 and 35,600 primary care physicians and (2) between 37,400 and 60,300 non-primary care specialties. In particular, the number of surgical specialists is likely to decline, especially those who treat diseases more common to older people, such as cancer.

Doctor shortages mean longer wait times for appointments and longer drives to reach an available provider, especially in already underserved areas that find it hard to attract doctors even when they're in ample supply.


As for nursing shortages, according to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the January 2012 issue of the American Journal of Medical Quality, the RN shortage is projected to spread across the country between 2009 and 2030, with the greatest shortages projected to be in the South and the West. Here are some troubling statistics relating to nurse shortages:

  • Registered nursing is projected to be one of the fastest growing occupations between now and 2022, with 2.71 million RNs in 2012 increasing to 3.24 million in 2022, an increase of 19%

  • The Bureau of Labor Statistics (BLS) projects the need for 525,000 replacement nurses by 2022, in addition to the 526,800 additional nursing positions that will open up. The replacement issue is so critical because, as with doctors, a significant percentage of current RNs are approaching retirement age.

  • Only 55% of currently registered nurses meet the educational standards that experts say are needed to handle the increased demands of the rapidly evolving, technologically sophisticated health-care workplace.

When patients think of medicine, it is doctors and nurses of whom we think first. That probably won't change, but we should probably be getting ready for other occupations to take over some of their responsibilities if the current and anticipated shortages can't be remedied.

WHY IS THERE A SHORTAGE OF DOCTORS? There's no one reason for the growing shortage of doctors, but the biggest culprit seems to be a shift in supply and demand. Changing demographics are driving a huge increase in demand.

  • According to Janis Orlowski, M.D., Chief Health Care Officer at Association of American Medical Colleges (AAMC), "The number of people over the age of 65 is expected to go up by 40-45% within the next ten years."

  • Older people usually require more health care for both acute and chronic conditions.

  • Another demographic driver has to do with changes in the populations that now have access to health care, thanks to the Affordable Care Act (ACA) of 2010. Before ACA, there were approximately 44 million Americans without health insurance. Now, with more Americans insured, more will seek care because they can.

  • People who have gone without adequate health care tend to have greater immediate medical needs for a wider variety of ailments. They're also more likely to have developed chronic conditions that require ongoing care.

Even as demand for doctors soars, there is no anticipation under current conditions of a corresponding increase in the number of new doctors qualifying to practice. Also, the aging physician work force means that the next ten years could see as many as one-third of current practitioners retire.

WHY IS THERE A SHORTAGE OF NURSES? There are many reasons for the current and projected shortage of nurses, among them:

  • Poor working conditions - long hours, too much overtime, badly spaced shifts, co-worker bullying, too little input into hospital policies, and inadequate pay in relation to responsibilities

  • Short-staffing - practice in some hospitals of having an inadequate number of nurses to maintain proper nurse-to-patient ratios

  • Inadequate resources for nursing research and education - each year tens of thousands of would-be nurses are denied education because there aren't enough faculty members to teach them

  • An aging nursing workforce

  • Expanded career options for women, coupled with nursing's predominantly female nature

  • Increasing complexity of health care that requires a higher degree of education, which means that training takes longer

  • Lack of empowerment, coupled with a lack of respect

  • Growing number of patients using hospital facilities

Some states and the federal government have taken baby steps toward rectifying the shortage, but with little effect so far.

WHAT ARE POSSIBLE SOLUTIONS FOR DOCTOR-NURSE SHORTAGES? Here are possible solutions to the worsening doctor-nurse shortage:

  • Devise ways to train more nurses and doctors more quickly. This might include creating more instiututions of training, modifying the training curriculum to take advantage of new technologies, and/or breaking the MD training curriculum into segments that will allow non-specialist doctors to go into basic practice more quickly but that will require them to pursue ongoing training on a regular basis.

  • Increase federal support for a larger number of physician residencies.

  • Involve nurses more in the setting of policies and processes affecting how they must perform their medical duties and interact with patients and co-workers.

  • Make use of advancing technology to relieve nurses of as many routine activities as possible. For example, robots could be designed to fulfill certain functions, and more sophisticated monitoring equipment could eliminate some cut-and-dried tasks.

  • Spend more resource on patient education and preventative medicine so that not as many patients reach the point where they require the intensive attention necessitated by disease or injury. PCMHs (patient centered medical homes) can play a key role here.

  • Expand the role played by nurse practitioners and physician assistants. Nurse practitioners (NPs) are advanced practice registered nurses (APRNs) who have at least a master's degreee and extra medical training and who have qualified to practice by passing a natonal examination. Physician assistants (PAs) must also earn a master's degree and take a national certification examination. Both must pursue ongoing education and be licensed by the state in which they want to practice. Both must be recertified periodically. Their training is supposed to qualify both NPs and PAs to provide most of the services provided by doctors, including examination, diagnosis, treatment plans, and prescribing drugs. Most states require that both NPs and PAs perform these services under the supervision or authority of doctors. A growing number of states allow NPs - who are required to have more training than PAs and have completed a residency - to practice independently.

Powerful interests oppose or will oppose most of the above because they threaten entrenched systems and profit models. The opposition is often justified by the claim that the issue isn't so much shortages as inefficient use and distribution of resources.


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NOT ENOUGH DOCTORS ARE GOING INTO PRIMARY CARE. This is particularly significant because the primary care physician is the first point of contact for most patients who develop medical needs. Essentially, primary care is the portal to American health care. It is to the office of this type of physician that patients typically take their undiagnosed ailments, and it is this office that decides the next step. This makes the estimated shortage of between 15,000 and 35,000 primary care physicians by 2025 significant for both patients and the rest of the health-care industry. The principal reason that fewer doctors are training for primary care appears to be financial. Specialists can make millions of dollars more over the course of a professional lifetime. The shortfall in primary care physicians will probably be alleviated to some extent by the growing use of nurse practitioners (NPs) and physician assistants (PAs) to perform many of the functions traditionally handled by these physicians.


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HEALTH CARE IS PARTICULARLY VULNERABLE TO WORKPLACE VIOLENCE. According to the Occupational Safety and Health Administration (OSHA), U.S. health-care workers are four times more likely to be the targets of workplace violence than those in other industries. Data from the Bureau of Labor Statistics (BLS) indicates that attacks on health-care workers account for almost 70% of all nonfatal workplace assaults causing days away from work. The violence may range from verbal abuse to spitting to physical attacks involving scratching, kicking, biting, strangling, even being tackled while walking down hospital corridors. And the violence doesn't end with minor attacks. Health-care workers are sometimes stalked, robbed, and even murdered by assailants first encountered on the job.

HOSPITALS ARE THE SETTING FOR MOST HEALTH-CARE RELATED WORKPLACE VIOLENCE INCIDENTS. Hospitals provide a natural setting for the development of potentially violent situations.

  • Patients and their families are already under stress. Anything unexpected, particularly if unpleasant or perceived as disrespectful, may trigger outbursts.

  • Hospitals try to reassure patients that everything possible will be done to help them and ease their discomfort. If this doesn't happen as quickly as the patient wants or in the way the patient expects, the patient may respond violently.

  • Hospitals usually have no way of knowing when patients and their visitors have a history of violence and so do not know when to take extra precautions.

  • Patients are sometimes medicated in a way that releases natural inhibitions or clouds judgment. This makes them more likely to strike out at those attempting to help them.

  • The physical layouts of hospitals often offer settings in which patients feel they can act out without observation. People are more likely to behave inappropriately when they think they aren't being seen.

  • Hospital employees are sometimes inadequately trained in how to recognize situations likely to become violent and how to de-escalate them.

  • Hospitals do not always have systems in place to support employees subjected to violent behavior. Some, in fact, tolerate a culture of victim blaming in which employees are made to feel that they "must have done something wrong" to attract that kind of behavior.

  • Hospital employees regularly confront situations with the potential to call forth inappropriate responses to patients and co-workers. While few go as far as the handful of doctors and nurses who have been caught murdering patients, there appears to be a growth in workplace bullying of co-workers.

Making a potentially dangerous setting even riskier is the fact that there is often minimal security, and - even when there is adequate security - many hospitals keep its presence relatively invisible as a matter of policy.

NURSES ARE PARTICULARLY VULNERABLE TO WORKPLACE VIOLENCE. It seems inherently contradictory to think of nurses in connection with workplace violence, for theirs is a caring occupation generally appreciated by those whose best interests they serve. So, why are nurses so exposed to workplace violence? The basic reason is that nurses are the hospital employees with whom patients and their families most often come into contact. Nurses become targets, in essence, because they are there. Also, the nursing profession remains overwhelmingly female, and angry people are more likely to become violent with females than with males. There's also the fact that many patients aren't comfortable showing hostility to their doctors, but have no problem in venting it on nurses, who in effect serve as surrogate targets. According to The Online Journal of Issues in Nursing: A Scholarly Journal of the American Nurses Association, this is an issue that's complicated by two seemingly contradictory attitudes:

  • A health-care culture resistant to the idea that nurses are vulnerable to patient-related violence

  • The nursing profession's acceptance that a certain amount of violence is part of the job

Added to this is the fact that some hospitals tolerate a culture in which nurses are automatically blamed for the violence perpetrated against them, the implicit policy being that the nurse must have been remiss in some way to become involved.


Young female surgeon sunk in despair onto hospital corridor floor - Illustration for

BURNOUT IS PART OF LIFE FOR HEALTH CARE. Health-care occupations suffer a high rate of burnout. Most who work in the industry are drawn to it because they want to help others and because they value the meaning their work brings to their lives and those of others. Yet, their very commitment makes them vulnerable to burnout because, by its nature, health care can fail both them and those they work to help. Surgeons lose one patient too many in spite of their best efforts. Physicians weary of coping with the non-medical issues that occupy much of their time, and find the growing restrictions on how they practice medicine disheartening. Nurses are discouraged by unrealistic nurse-to-patient ratios, stressful working conditions, and the lack of respect and recognition they receive for the role they play. Administrators wonder how many more changes can be incorporated without implosion of the hospital environment. The list goes on. The impact of burnout can be significant. At the least, it can make the health-care professional pull back emotionally or psychologically as a self-protective measure. At most, burnout can lead to individuals electing to change jobs, whether to move from one health-care employer to another or to leave the industry altogether. This is significant because every trained health-care professional who is no longer able to remain in the industry and give 100% affects patient care, provider efficiency, and the public good.


WHAT DOES U.S. HEALTH CARE COST? According to CMS (Centers for Medicare and Mediacid Services), over two-and-a-half trillion dollars was spent on health care in the U.S. in 2014, as follows:

  • 38% - $971.8 billion on "hospital care"

  • 24% - $603.7 billion on "physician and clinical services"

  • 12% - $297.7 billion on "prescription drugs"

  • 6% - $155.6 billion on "nursing care facilities"

  • 6% - $150.4 billion on "other health care"

  • 4% - $113.5 billion on "dental services"

  • 4% $103.3 billion on "other medical products"

  • 3% - $84.4 billion on "other professional services"

  • 3% - $83.2 billion on "home health care"

WHO PAYS FOR U.S. HEALTH CARE? These are the six primary sources of funding and the amount they paid in 2014:

  • $867.9 billion - Private insurance (private companies issuing health-care insurance policies)

  • $680.7 billion - Medicare (federal health-insurance program for people 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease)

  • $444.9 billion - Medicaid (jointly funded, federal-state health-insurance program for low-income and needy people, covering children, the aged, blind, and/or disabled and other people eligible to receive federally assisted income maintenance payments)

  • $329.9 billion - Out-of-pocket (individual consumer paying for uninsured health-care expenses, as well as for deductibles and co-pays)

  • $233.6 billion - Other payers (self-funded employer health plans or medical reimbursement programs or any other health-care payer not otherwise listed)

  • $105.9 billion - Other public insurance (insurance coverage written by government bodies at any level or operated by private agencies under government supervision and control, not including Medicare and Medicaid)

Medicare's importance as a payer will grow as Baby Boomers age into coverage, but the most noticeable trend here will probably be the ongoing growth of out-of-pocket expenditures that will, to one extent or another, be borne by all ages of patients.


Copyright 2017 . ArbeitenZeit Media . All Rights Reserved


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Available April 30, 2018!


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Coming soon!


With SUCCESSFUL PATIENT in hand, you'll be ready to move step by step through the health-care process knowing what to expect, the questions to ask, and what your personal decisions and preferences can affect. The book doesn't guarantee that you'll get everything you want but that you are more likely to have a successful outcome with less stress and uncertainty. Think of it as a travel guide into the world of medicine.


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A lot is going on the world of the physician, especially the physician in private practice. Much of it improves your care, but some of it can affect your experience at the doctor's office in ways that seem confusing and even counterproductive. SUCCESSFUL PATIENT tells you how to prepare to get the best result from your visit and what to expect.


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Nurses do a lot more than take doctor's orders and pat patient's hands. They're in the forefront of using technology and new knowledge-sets to benefit the entire health-care process. SUCCESSFUL PATIENT takes you into today's world of nursing, sharing how nurses affect patient care and giving tips on how to maximize their talents for your benefit.


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There are many different kinds of ambulance and other medical-transport services, operating under different rules and wildly varying cost structures. SUCCESSFUL PATIENT tells you why it's important to know, before you call an ambulance, what's going to happen next.


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Hospitals are facing what amounts to a revolution in care delivery even as they continually readjust procedures and staffing to take advantage of medical advances to give patients the best of today's medical capabilities. SUCCESSFUL PATIENT tells you what's going on and how to prepare for and maximize the value of your hospital stay.


Whether preparing in advance of need, already experiencing symptoms, going to the doctor, getting a diagnosis, making treatment decisions, going to the hospital, having surgery, ordered to therapy, or researching a health issue, you'll find SUCCESSFUL PATIENT a useful resource.




Chapter One. No One Expects The Unexpected


Chapter Two. The Transformation of U.S. Health Care


Chapter Three. American Health Care Today


Chapter Four. Turmoil & Patient Consequences




Chapter Five. What's The Point of Strategy?
Chapter Six. You & Them, Not You Vs. Them
Chapter Seven. Getting Real With Strategy
Chapter Eight. Tips For Creating A Strategic Framework



Chapter Nine. Health Care Strategy Starts With You
Chapter Ten. In Advance Of Need
Chapter Eleven. When Symptoms Develop
Chapter Twelve. When You Go To The Doctor
Chapter Thirteen. When The Doctor Orders Tests
Chapter Fourteen. When You Get A Diagnosis
Chapter Fifteen. When You Must Make Care Decisions
Chapter Sixteen. When You Go To The Hospital
Chapter Seventeen. When You Go Home
Chapter Eighteen. When Therapy Is Prescribed
Chapter Nineteen. If Something Goes Wrong
Chapter Twenty. What If The Silver Bullet Misses Its Mark?
Chapter Twenty-One. Ongoing Coordination


Chapter Twenty-Nine. Avoid Nasty Surprises
Chapter Thirty. What If Your Insurance Won't Cover What Your Doctor Orders?


Chapter Thirty-One. How Care Is Billed Varies


Chapter Thirty-Two.Negotiating A Medical Bill/em>


Chapter Thirty-Three. Concierge & Other Non-Standard Practice Models




Chapter Thirty-Eight. Where Information Comes From Matters


Chapter Thirty-Nine. General Health Issues


Chapter Forty. Specific Diseases


Chapter Forty-One. When Things Go Wrong


Chapter Forty-Two. Patient Advocacy


Chapter Forty-Three. Miscellaneous


Chapter Forty-Four. Sites Rating Providers






Linda Hewitt is an award-winning communications consultant and author of over forty titles, mostly related to economics, finance, and cultural history. She is married to writer and artist Robert Hewitt, with whom she lives in the mountains of northwestern North Carolina. Together, they enjoy acting as cat staff, painting, and collecting old books, art, and Staffordshire Blue. Click here to read about the health event that inspired Linda to write SUCCESSFUL PATIENT.



ArbeitenZeit Media (ABZ) publishes both fiction and nonfiction titles in the combination of media its research indicates will be most useful to the target market. SUCCESSFUL PATIENT: Step-By-Step Strategies To Get The Health Care You Need will be published April 30, 2018, in hardback, trade paperback and ebook formats.


Kindle Format:

ISBN-10: 1-941168-25-6

ISBN-13: 978-1-941168-25-7

Price: TBD


Trade Paperback Format:

ISBN-10: 1-941168-26-4

ISBN-13: 978-1-941168-26-4

Price: TBD


Hardback Format:

ISBN-10: 1-941168-32-9

ISBN-13: 978-1-941168-32-5

Price: TBD


Library of Congress Control Number (LCCN): 2017911192

Copyright 2017 . ArbeitenZeit Media . All Rights Reserved


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by Linda Hewitt

Publisher: ArbeitenZeit Media

Hardback ISBN-13: 978-1-941168-29-5
Trade Paperback ISBN-13: 978-1-941168-27-1
Kindle eBook ISBN-13: 978-1-941168-28-8
Library of Congress Control Number: 2017905998



Chapter One. The Purpose Of This Book
Chapter Two. Where We Get Health Care
Chapter Three. Who Provides Health Care
Chapter Four. What Health Care Costs, Who Pays & For What
Chapter Five. Why Health Care Costs So Much In The U.S.
Chapter Six. Who Regulates, Influences, & Legislates Various Aspects Of Health Care?
Chapter Seven. The Scope & Nature Of American Health Care
Chapter Eight. Medical Advances, Medical Miracles
Chapter Nine. Medical & System Failures
Chapter Ten. Medical Error
Chapter Eleven. Ourcomes - For Patients, Providers, Payers
Chapter Twelve. Why It Sometimes Seems As If The American Health-Care System Is Set Up To Benefit Everyone But Patients
Chapter Thirteen. Major Challenge: Medical Advances & New Technology
Chapter Fourteen. Major Challenge: Information Technology
Chapter Fifteen. Major Challenge: Emerging Care-Delivery Models & Reimbursement
Chapter Sixteen. Major Challenge: Patient Empowerment
Chapter Seventeen. Major Challenge: The Political-Football Factor
Chapter Eighteen. Physicians Caught In A Perfect Storm
Chapter Nineteen. Hospitals Having A Challenging Day
Chapter Twenty. Nurses In An Identity Crisis
Chapter Twenty-One. Morphing Roles In The Provider Universe
Chapter Twenty-Two. What The Changing Provider Universe Means For Patients
Chapter Twenty-Three. A Typical Health Episode Today & Tomorrow
Chapter Twenty-Four. The Dream, The Promise & The Likely Reality
Appendix A. Acronyms Used In The Book
Appendix B. Useful Online Resources: A Selection
Successful Patient: Step By Step Strategies To Get The Health Care You Need by Linda Hewitt


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