Rank and File Reporting - Donald Trump

The first containment - Coronavirus - New York State - Rank and File Reporting - Donald Trump

Coronavirus Containment Order New York National Guard

Kiss her goodbye, you're locked down, by order of New York State and enforced by the National Guard -

War down the street - One World Government - Shadow Government - Above Ground Civil War - Our Presidents People

The young veterans knew what to do, they started talking and then they started walking, gathering at predetermined locations for (relation work), but these guys knew it was for enhanced urban and rural combat training.

It was evident enough that traditional America was in grave danger and seven years ago a couple of guys in Portland got together and started thinking how they could save their families, property and liberties from increased socialist pressures.

They had some little ideas - they felt the urge for adventure and romanticized about another conservative President of the United States -

Their ideas were pushed out on blogs and social media pages and a little at a time they got bigger, then bigger again.

A money connection developed instantly, from Seattle. The money people considered their ideas as a social opportunity as these young Army veterans in Portland made a lot of sense to a lot of people.

Americans, traditional constitutionally centered citizens were feeling stuck and these two Portland guys increasingly described the ultimate indignity forced upon a nation, the indignity was the disgrace of socialism.

After the conservative President was removed by the socialists the nation went stagnant again and the mood of the nation was like watching an old Western, good guys and bad guys and the badmen had won the nation.

Young men and woman, determined not to become pawns in the many political socialists games were feeling lost but the anonymous web site (Achieve Identity Distinction) gave them hope and was receiving over twenty million hits a day and still growing.

The New York Times described the web site (Achieve Identity Distinction) as a unreliable destination for old fashioned patriotic radicals and nut jobs that buried guns and food in their backyard.

The web site was crotchety, fussy and mostly unreliable until the money guys showed up from Seattle. They laid two boxes tapped up cardboard boxes filled with cash on the scratched up folding table of Andy Ledger, the owner of www.AchieveIdentityDistinction.Com and a folder with names and phone numbers for business and web developers and consultants.

It was a crucial test for Andy Ledger as his living room was the world headquarters for his web community.

Andy would go shopping and spent the next week end calling names listed in the folder.

Andy had been on a bumpy road after leaving the Army as he watched the United States create socialist poverty, restrict property ownership, impose tariffs between the states, shut down all coal power generation, limited oil fired power plants, free trade college for everybody, mandated electric vehicles, sprawling restrictions across the economy from the size of milk cartons, the speed limits in every town, city and village, required military service, wealth limitation, tax increases across every income stream and there was no end in sight.

He had never seen one million dollars in cash.

The two guys in Seattle told Andy Ledger, the founder of (Achieve Identity Distinction) that social change and war making were alike, it was like an assembly line process on a bank loan installment plan.

Andy knew these money guys from all their T.V. commercials concerning their National Truck Stop Motels, Restaurants and fueling depots.

Their company (Parkway Truck Yards) owned hundreds of giant tractor trailer overnight truck stops, truck stop motels, truck stop full service buffets and restaurants, truck and trailer washes, truck maintenance and mechanical centers and they always sponsored low cost hot-dog stands at local trucking company terminals across the nation.

If you were in the trucking industry you knew all about Parkway and so did your friends.

Every truck driver in America recognized the giant gleaming bird logo of Parkway Truck Yards swooping low over a pure mountain river in the Northwest grabbing up the trout fish for dinner.

Andy Ledger was not a college graduate - he joined the Army and spent his restless years fighting North Korea ... Andy didn't know why he was so restless. It was like he lived in a ghost town - empty buildings - shadows - stories - dark nights and storms.

At war's end Andy Ledge came home and was considered one of the young veterans at thirty four years old. During the war with North Korea, which was backed up by China, the military drafted up to 55 years old.

North Korea was sent back to the middle ages and six million U.S. Military troops were sent home.

Everything sucked.

.

Illegal Aliens (brown people) are a commodity - just like a black slave was property prior to the Civil War in America.

Illegal Aliens (brown people) are a commodity - just like a black slave was property prior to the Civil War in America.  It's sad now, that we understand that people are used as industrial commodities - people are bought and sold - salaries and wages - working conditions - benefits - but the illegal aliens and natural born black citizens bear most of the pain...

The Democratic Socialists are experts at granting little promises to brown and black people but withholding big favors unless these same brown and black people pledge allegiance to the DNC Democratic Socialist Party.

Illegal Immigration - Illegal Aliens - Wetbacks (1950 terminology) Can there really be 60 Million illegal aliens in the United States right now? Many experts agree on one thing.. the government always lies about the problem..

“illegal alien” is the term used in federal law"

Democrats want illegal aliens.

Big Business want illegal aliens.

Serious studies put the number of illegal aliens inside America today... considerably higher then you hear about on your favorite news tonight. 60 million illegal aliens is not our of the realm of possibilities.

WalMart - Target - Best Buy - hires an illegal alien through a temp agency and taxpayers feed them... you are paying for everything...

At the low end, a Massachusetts Institute of Technology and Yale study last year put the number of illegals at 22 million.

Yet Bear Stearns investment bank had it at 20 million back in 2005,

and Pulitzer Prize-winning investigative reporters Donald L. Barlett and James B. Steele reported in 2004 that 3 million illegals were crossing each year —

so simple math would put it at well over 60 million today

Grass Cutting Mechanicsburg PA $10

Grass Cutting Mechanicsburg PA $10

Holy Spirit Hospital Camp Hill Pennsylvania Holy Spirit Hospital Left alone to die? Geisinger has no firm grasp on prosperity, just ideas, regardless of people, Holy Spirit Hospital Camp Hill Pa should be draped in black, the color of death, a huge coffin suspended by Geisinger strings.. How

Geisinger Holy Spirit Hospital, Holy Spirit Hospital, Geisinger, Holy Spirit Hospital Camp Hill Pa, Dr. Ryu, Jaewon Ryu, Harvard, Walmart, 

Geisinger is huge — it has 13 hospital campuses, two research centers, a medical school, and a commercial health plan — and is famously innovative. Its best-practice approaches have been widely adopted, and it is spearheading one of the largest DNA-based precision-health projects in the world. So it’s little surprise that Geisinger is a pioneer in another area, so-called centers of excellence (COE) destination-care programs. In these arrangements, employers such as Walmart, Lowe’s, and McKesson fly employees to selected COEs for complex care — with remarkable results.

HBR’s Gardiner Morse spoke with Dr. Ryu about the benefits and challenges for providers of embarking on COE programs, and their implications for both employers and insurers. Following are edited excerpts of their conversation.

JAEWON RYU

Geisinger Holy Spirit Hospital, Holy Spirit Hospital, Geisinger, Holy Spirit Hospital Camp Hill Pa, Dr. Ryu, Jaewon Ryu, Harvard, Walmart,

Why is Geisinger engaging in these arrangements with employers to fly their employees in for care?

Partly it’s about growth. Being a destination-care provider for employers like Walmart allows us to reach a patient population that isn’t already getting its care within Geisinger and is beyond our backyard. So it’s a good way for us to expand the scope and reach of what we’re doing.

But it also aligns really well with how we deliver care. We’re big believers in developing best-practice protocols and then designing workflows to deliver them. We have developed care protocols for many clinical scenarios, including areas like cardiac surgery, spine surgery, chronic obstructive pulmonary disease, diabetes management, and many others, and they yield the best combination of quality and patient experience. It’s a program that began years ago, and we’ve been refining the protocols and adding new ones ever since. It’s a chassis, if you will, that these new centers-of-excellence programs can easily build on. We have the resources, culture, and processes already in place to develop, say, a joint-replacement bundle with an employer. And doing that reinforces our culture and processes. There’s a positive feedback loop.

Where does the destination-care program fit in that feedback loop, reinforcing how people work?

We’ve seen that sometimes after you go live with a protocol you can get what we call “beach erosion,” where over time people can become less diligent or deliberate about making sure everyone follows the protocol. Being one of the centers of excellence for employers in programs like these helps prevent that erosion because it’s yet another area where the protocols are applied. It keeps us on top of our game, as employers are paying close attention to how we perform. So the program reinforces their consistent use.

What would you say to other providers who maybe don’t have smooth-running protocols like Geisinger’s about the risks of these types of programs?

That’s the ultimate question for any system that wants to embark on this journey. For us, it made sense because it was already ingrained as our approach to care, so there weren’t the same start-up costs and culture-change challenges that you might see in an organization that didn’t already have the culture and protocols in place. Also, we like reimbursement models like bundles where we’re taking risk, because we tend to do better with those in driving overall value than we do under an episodic, per-widget model. But that’s part of the calculus for any provider. Do you have the culture and operational programs and processes in place to succeed with this kind of model?

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There’s a huge opportunity for a provider that doesn’t yet have these capabilities fully in place to pursue direct arrangements with employers as a way to jump-start the shift. Delivering value is the direction that health care is going — whether to patients, employer groups, the payers you’re partnering with, or the government. Building the chassis I’ve been talking about positions any health system better for what’s coming in the future, and what is in many ways already here. In time, every system is going to need to have this capability, and this kind of program is a way to get started.

I’m assuming doing programs like these reflects well on a provider?

Well, it can help the provider tell the story about the value they’re offering. For instance, we work hard at making sure that we’re not doing unnecessary procedures, so we find that a significant number of patients referred to us for a surgical procedure actually don’t need it after all. We take a lot of pride in that because it shows that we’re focused first and foremost on determining what is the best care rather than on how many procedures we can do. Data from Walmart shows that more than half of their employees referred to centers-of-excellence programs like ours for spine surgery end up not needing it. It can be more work to convince a patient that they don’t need a procedure, but doing that results in the best care.

Let’s talk about the challenges. This can’t be easy.

That’s right. Make no mistake — even if you have the chassis in place there’s still a lot of work you need to do on the culture to go live with a program like this. We were lucky — we had a running start, if you will. But even so, it’s not something you turn on overnight. We’ve been on this journey for more than a decade. It takes constant work and vigilance. For instance, even when you recruit physicians you need to make sure they are brought along into our organizational approach and don’t introduce unwarranted variation into how we approach care.

It also requires constant attention to make sure your protocols are up-to-date and to assure that everyone’s aligned with them. It turns out that if you follow evidence-based best practices reliably, great things happen for patients. So you need physician leadership that is committed to pursuing these protocols and tracking performance, and updating them as the science changes.

What’s an example?

Well, the conventional wisdom that many doctors were taught in medical school was that patients should have nothing by mouth in the hours preceding surgery, and should be eased back on a clear liquid diet after surgery. So essentially you’d starve them before and starve them after surgery.

But so-called enhanced-recovery-after-surgery, or ERAS, protocols showed that patients do better if you give them enriched-nutrient shakes before and after. Complication rates go down, length of stay goes down, and they’re up and mobile more quickly. It runs counter to the traditional teaching and so it makes some physicians uncomfortable, but we incorporated this into our own protocols and it’s how we do many elective procedures now. It’s easier to launch an approach like this systematically when your culture embraces the need to continuously seek better ways to do things and to do them more consistently.

Making sure everyone is on board and aligned must require real transparency about performance. How does that work at Geisinger?

We’re firm believers in transparency. Data is probably more visible here than you’d see at just about any other health system.

Let me give you a snapshot of what that transparency looks like. A few years ago, we launched a primary care redesign program that focuses on closing gaps in care. If you’re due for your mammogram or a colonoscopy, how often are we making sure that you get those preventive services? We track this at the level of individual providers. If you walk into any one of our primary care sites today, there would be a whiteboard where the whole team huddles every morning and the name of every provider in that clinic is listed on it. It has information about their appointment availability and also a score for how they’re doing on closing care gaps, including any missed opportunities they might have had. Nurses are also listed there, with information about how effectively each is setting up patients for those care-gap actions. It’s taken some work to get us to this point, and admittedly the transparency can be uncomfortable at first. But it helps us reinforce and support each other in driving for the best outcomes. And I think we could do even more.

How do you manage the discomfort that this transparency must cause? If a doctor isn’t performing well, and it’s visible to the team, that must create tension all around.

Well, partly there’s a socialization that makes it acceptable. Transparency is part of our culture, but it does take a little time to get used to it. We really try not to do this in an embarrassing or “gotcha” kind of way. There’s a lot of pre-processing and vetting with the clinical leaders and the teams around what we’re going to measure and how we will track it, so people are more aware of the process and reasons for it. We try to do it in a very objective way — we’re asking, “What can we do to learn from each other and improve the overall game?” We look at data such as the rate at which patients within a given primary care panel are landing in the emergency room or how often our emergency medicine physicians are ordering CT scans for non-serious head trauma, and look for outlier behavior. Sometimes the outlier behavior is justified. But shame on us if we’re not asking why there are outliers.

Of course, from time to time you have differences of opinion about the accuracy of the data or to whom they’re attributed. And if there’s any question about their applicability at the level of individual providers we’ll focus instead on the team. So we might identify teams that are behaving differently than others. That might be a good thing, or it might indicate a need for change — but let’s have that discussion. I think that’s the key: The data isn’t the be all and end all, but it can serve to start the discussion, and framing it that way helps get acceptance.

Let’s move on to the bigger picture. What kind of impact do you think programs like yours, where employers contract directly for care, will have at a national level?

I think programs like these are going to grow because they address the cost and quality problems employers are struggling with. But destination care for defined episodes like spine surgery is only a piece of where I think the industry is migrating. The broader approach that I expect we’ll see a lot more of is employers directly partnering with providers for the totality of care for their employees — taking care of the whole person, and the whole employee population. In other words, an employer contracting directly with a provider in a prepaid model to take care of a population. We’re already seeing some movement in this direction.

There will be some tension between employers seeking high-value care in these types of programs and consumers’ desire for choice. You may get better value when an entity like Geisinger partners directly with an employer like Walmart, but, to get that, employers need to direct their employees to a smaller network of providers selected based on performance. If an employer wants to preserve employees’ ability to have a phone book of providers to choose from, there’s going to be a trade-off between employee choice and better value, since a lot of providers may not be as focused on quality and value in the ways we’re talking about here.

How are commercial insurers responding to all this? I’d think they’d see it as a threat — but there’s probably an opportunity in this for them too.

I think that’s right. On the surface, it looks like a threat because it disintermediates them from the role they currently play in the relationship between employers and health care providers. But the opportunity for them is that insurers are good at identifying and contracting with quality provider networks. And they’re good at pricing. Those capabilities will be very important as the industry moves this way. Even if the traditional role of the commercial insurer changes, employers still need to rely on someone to identify high-value providers and negotiate prices and develop contracts. Currently, third-party administrators do this, but it’s a space commercial insurers are well positioned to move into.

What do you think the employer’s role should be in moving employees toward higher-value networks?

I think they should be encouraging that shift, and some like Walmart are, for instance, by giving employees a broad choice of providers but telling them they’ll need to pick up more of the cost if they choose a provider that’s not a Walmart center of excellence. A challenge is that employees’ and even employers’ perception of quality and value aren’t always aligned with reality. Sometimes people equate fancy facilities with great quality, and of course those things aren’t always correlated. But employers need to be looking at providers’ data and driving people toward the best ones.

What’s next for Geisinger?

We’re looking to expand the centers-of-excellence, destination-care model to make it available to other employers as well. There’s a scattering of local employers that are potentially interested in going down this path. That’s the beauty of how the model was built. It can be adapted to serve local markets, and we get the opportunity to deliver care in the way we think is best, and we grow. The employer and employee/patient get value. I think that’s a nice win-win-win.

Any final words of advice for employers?

Employers have an important role to play in getting better value out of their health care dollars. They have a tremendous opportunity to reward providers that deliver value. The more employers seek out and contract directly with the best providers, the more traction these types of programs will get — and everyone benefits.THE BIG IDEA

About the author: Gardiner Morse is a senior editor at Harvard Business Review.

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Holy Spirit bleeding cash, triggering talk of layoffs Geisinger Holy Spirit Hospital -

Central Pa. hospital bleeds money, triggering talk of a sale

Posted May 11, 2018   Geisinger Holy Spirit Hospital, Holy Spirit Hospital, Geisinger, Holy Spirit Hospital Camp Hill Pa, Dr. Ryu, Jaewon Ryu, Harvard, Walmart, 

File photo of Geisinger Holy Spirit Hospital near Camp Hill in Cumberland County. (PennLive archives)

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By David Wenner | dwenner@pennlive.com

Fierce competition among central Pennsylvania hospitals has Geisinger Holy Spirit in Cumberland County bleeding red ink.

In 2017, the hospital near Camp Hill had an operating margin of minus 6 percent, meaning it lost $6 for every $100 worth of medical care. Its malady seems long term: Both income and patient volume are down from a few years ago, with that drop coinciding with the opening of a competing hospital just five miles away.

Holy Spirit's downturn is all the more alarming since most hospitals are enjoying a financial golden age. That's due to more people having health insurance because of the Affordable Care Act, and the surge of baby-boomers getting things like heart bypasses and joint replacements. All of Holy Spirit's hospital neighbors -- or rather competitors in today's aggressive health care landscape -- are enjoying much better health.

UPMC Carlisle, known as Carlisle Regional Medical Center until last year, posted a 10.77 percent operating margin in 2017. That means it had $10.77 left over for every $100 it was paid for caring for patients. UPMC Pinnacle, centered just across the river in Harrisburg and owner of the recently-built hospital near Holy Spirit, had a 10 percent operating margin. Penn State Health Milton S. Hershey Medical Center had an 11 percent margin.

How healthy are central Pa. hospitals? Here are their vital signs

The cause of Holy Spirit's condition seems obvious: the opening of UPMC Pinnacle West Shore in 2014. The newer hospital cost $120 million and has all private rooms and an emergency room built to handle 36,000 visits per year. Moreover, it has a prime location just off Interstate 81 and Route 944, providing easy access for vast sections of Cumberland and Perry counties and substantial populations to the east and north.

In 2013, the last full year before the opening of West Shore, Holy Spirit had a 62 percent occupancy rate, matching the state average, according to data from the Pennsylvania Department of Health. In 2016, the most recent year available, Holy Spirit had a 52 percent occupancy rate, more than ten percent less than the state average. Holy Spirit cared for 10,404 patients in 2016, down from 13,136 the year before West Shore opened.

The health department data lumps all the UPMC Pinnacle hospitals together, and doesn't break out the occupancy rate for West Shore. However, UPMC Pinnacle's overall occupancy rate was 69 percent in 2016, well above the state average.

Emergency room visits at Holy Spirit fell from nearly 47,000 in 2013 to 40,790 in 2016. Meanwhile, combined ER admissions at UPMC Pinnacle rose from 115,361 in 2013 to 141,184 in 2016.

As most people know, health care keeps getting more expensive and America's health care bill keeps growing. As a result, virtually all hospitals see their revenues rise from one year to the next.

But Holy Spirit's revenues have fallen, from $304 million in the fiscal year that ended shortly after the opening of West Shore, to $287 million in 2017.

"These losses are quite serious," said Stephen Foreman, an associate professor of economics and health administration at Robert Morris University. Still, he noted that, averaged over the past three years, Holy Spirit loss is only minus 0.57 percent, which he called "Not great but not a disaster."

David Sarcone, an associate professor at Dickinson College and a health care expert, agrees West Shore hospital has had a major negative impact on Holy Spirit, and one that will be hard to reverse. He points out that hospitals costs are largely fixed -- they need to be staffed at a certain level regardless of whether they are busy, for example.

The opening of PinnacleHealth West Shore Hospital in 2014 appears to have drained revenues from Geisinger Holy Spirit near Camp Hill. .Joe Hermitt, PennLive

"Once the volume of services drops below a financial break even, things can get very ugly very quickly from a financial perspective," he said.

Now, there's talk in Harrisburg-region health care circles that Geisinger is looking to unload Holy Spirit, and rumors of discussions with Penn State Health and others.

Geisinger Holy Spirit declined to answer specific questions about the revenue and volume drop offs, or whether Geisinger is looking to sell Holy Spirit.

Kyle Snyder, Geisinger Holy Spirit's chief administrative officer, said in a written statement, "With all the moves in the Harrisburg region, it is not surprising that there is speculation about what may be next for Geisinger Holy Spirit."

He also said "we talk regularly with other organizations to explore ways in which we can work together to better serve our patients and community." Also, Snyder said while the quality of care is good at Holy Spirit, "we must continue to focus on making improvements to our financial position."

Penn State Health declined to specifically address whether it has an interest in buying or joining with Geisinger Holy Spirit.  "Cumberland County remains an important focus," wrote spokesman Scott Gilbert, who also added "we are exploring a range of options to enhance patient access to Penn State Health Services and providers close to home."

It makes sense that Penn State Health, the parent of Penn State Hershey Medical Center, would be among those willing to talk to Geisinger Holy Spirit. It too is feeling pressure from UPMC Pinnacle, which last year bought Carlisle Regional Medical Center as well as three hospitals in York and Lancaster counties. That was right before Pinnacle merged with UPMC, Pennsylvania's largest health care system.

The moves gave the former PinnacleHealth scale and reach hospitals systems say has become necessary to their survival.

Penn State Health also needs more scale -- that's why it planned to merge with Pinnacle a few years ago, until government regulators objected. Since then, it's been in major growth mode, although much of its expansion has been concentrated in the Berks and Lancaster counties.

With a stronger foothold in Cumberland County, Penn State Health could use its reputation as an academic medical center and offerings, including a broad range of organ transplants, to draw more patients from Cumberland and Perry counties. In fact, the aging populations of Cumberland and Perry were a major factor in Pinnacle's decision to build West Shore Hospital even when, based on occupancy rates at Holy Spirit and Carlisle Regional, there was no glaring need for the hospital.

Further, the surge of Cumberland and Perry residents entering their Medicare years played a role in attracting Geisinger to Holy Spirit in the transaction that became final in late 2014. At the time Geisinger decided to acquire Holy Spirit, Penn State Hershey and Pinnacle had yet to announce their merger plans. UPMC was nowhere to be seen in the Harrisburg region.

Penn State Health, parent of Penn State Hershey Medical Center, wouldn't say whether it has any interest in acquiring or joining with Geisinger Holy Spirit Dan Gleiter | dgleiter@pennlive.com

Holy Spirit, a Catholic hospital that opened in 1963, has plenty of people who feel an attachment, especially in the immediate Camp Hill area. But it also has factors working against it that are hard to overcome. It's landlocked and much of the structure dates back to the original construction. It's also not ideally located, with people having to make their way through congested Camp Hill to reach it.

Those factors are likely a likely a turnoff for older people, especially given the ease of reaching West Shore Hospital via I-81 or Route 944, also known as Wertzville Road.

Holy Spirit's financial situation has changed dramatically since becoming part of Geisinger. Still another attraction for Geisinger was the prospect of using Holy Spirit and its network of doctors to grow its health insurance company, Geisinger Health Plan, in the Harrisburg region. But that hasn't materialized to any great extent, with the plan having about 582,000 members, up from 467,000 in late 2014.

Geisinger, true to its initial promises, has made improvements at Holy Spirit, including adding 100 doctors and spending $32 million to expand the ER and add a Level II trauma center. But the market has changed dramatically with the entry of an aggressive giant such as UPMC, and the urgency on the part of Penn State Health to expand.

Foreman, the Robert Morris University expert, believes it's possible for Geisinger Holy Spirit to turn the situation around. However, he said it would take major steps such as dropping money-losing services, mounting a multi-year campaign to convince patients it's the area's best hospital, and recruiting popular doctors from UPMC Pinnacle.

Asked about the plausibility of selling Holy Spirit, Foreman said, "Who would buy it? Who would pay money to compete with UPMC Pinnacle?"

Still, Foreman believes it's possible Penn State Health would have an interest, mainly because of the patient referrals that would come from owning the system. And while the Federal Trade Commission shot down a merger with Pinnacle, Foreman suggested the FTC might react differently if the hospital being acquired is viewed as "failing."

Dickinson College's Sarcone said, "It appears that [UPMC Pinnacle] through aggressive marketing and the investment in new facilities basically took market share away. Reestablishing patient preference revealed in physician referral patterns will be expensive and time consuming."

Sarcone doubts an aging hospital with a declining patient volume would attract many potential buyers. Still, he believes Penn State Health might be the exception. Holy Spirit has a heart center, an urgent care center, a network of doctors and an inpatient mental health unit. "Holy Spirit has valuable assets that would fit nicely with Hershey's needs ... that's something to think about," he said.

Whatever the future of Geisinger Holy Spirit, it could have significant consequences for health care consumers in central Pennsylvania. When Penn State Hershey and Pinnacle tried to merge, the government objected on grounds the merged entity could raise prices and reduce quality, with many consumers having no alternative.

The subsequent fallout seemed ideal, resulting in three major health systems, Geisinger, UPMC Pinnacle and Penn State Health, competing to be the top choice for Harrisburg region residents. That's an unusual level of competition for a region the size of the Harrisburg region. In that light, the loss or diminishment of a major player would surely be felt.