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Monday, 16 May 2016

Princess Health and May 16th, 2016 Every Day. Princessiccia

Princess Health and May 16th, 2016 Every Day. Princessiccia

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May 16th, 2016 Every Day

Keeping a blog post short isn't always easy for me. Every day there's something I experience or something I'm reminded of--and these things, when they pertain to what this blog is all about, stimulate thoughts and ideas--and I'm a communicator, I want to share it right here, right now! But I often need to reel it in, be patient--be calm and get more rest!

Today had a rough start followed by an unexplained stomach ache midday that sent me home about an hour early. It was clearly something at lunch, I'm just not sure--everything was fresh. That's a wonderful benefit of eating the way I eat--it's much easier to key into direct food/body connections.

I felt much better by evening time--just in time for my Monday night support group conference call. I enjoyed a fantastic dinner--and had some fun with the tweets, too.

I maintained the integrity of my maintenance calorie budget, I remained abstinent from refined sugar, I exceeded my daily water goal and I made time for a great workout.

The day was rough in some ways and quite solid/smooth in others. How's that for balance?

Today's Live-Tweet Stream:








































Thank you for reading and your continued support,
Strength,
Sean

Princess Health and Health-care consumers get little help resolving complaints, columnist says, citing some horrific examples. Princessiccia

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By Trudy Lieberman
Rural Health News Service

Who protects consumers of health care?

Two recent emails from readers got me thinking about that question. I don�t mean consumers in their role as patients whose medical well-being is looked after by state medical boards and health departments that police doctors and hospitals. Those organizations don�t always do a perfect job protecting patients from harm, but at least they are in place.

But who protects patients when things go wrong on health care�s financial side? What happens when you receive a bill you didn�t expect and can�t afford to pay? What happens when insurers send unintelligible explanations of benefits you can�t understand? What about questionable loan arrangements to avoid medical bankruptcy? Consumers of health care are pretty much on their own.

From the 1960s though the 1980s when people complained, they got action from consumer organizations, government and even businesses that set up departments to handle complaints. That consumer movement is now but a flicker.

�We don�t have as many public-interest minded regulators, and officials who try to grab these issues by the horns and deal with them,� says Chuck Bell, director of programs for Consumers Union.

The emails I received show that although it�s an uphill battle to get redress, fighting back as an individual can get attention and may ultimately lead to better protections for everyone.

John Rutledge, a retiree, got snared in Medicare�s three-day rule by a hospital near his hometown Wheaton, Ill. At the end of March he took his wife, who was having breathing problems, to the hospital where she was held for three nights of �observation.� Patients must be in a hospital for three days as an in-patient before they are entitled to Medicare benefits for 100 days of skilled nursing home care, as I noted in a recent column.

Thousands of families have been caught when hospitals decide their loved ones are admitted for �observation,� a tactic that allows them to avoid repaying Medicare if government auditors find patients should not have been classified as �in-patients.� Playing the �observational� game is worth millions to hospitals but costs families tens of thousands of dollars when someone doesn�t qualify for Medicare-covered skilled nursing care.

Rutledge knew about the three-day rule. Both his doctor and a pulmonologist at the same medical practice recommended an in-patient stay, and Rutledge refused to sign a hospital document saying his wife was admitted for observation. Still, the hospital prevailed, claiming a consultant made the decision to keep her for �observation.�

Rutledge was stuck with a bill that, so far, totals over $15,000 for the skilled nursing care his wife did need. He said he had been a �significant donor� to the hospital foundation, and �I have told the foundation that what I spend as a result of �observation� will come out of what I planned to give them, starting with the annual gift.�

The second email came from Kathryn Green, a college history professor who lives in Greenwood, Miss. Green is fighting an air-ambulance company, which transported her late husband to a Jackson hospital after he suffered a fatal fall in their home. This �nightmare,� as she calls it, is a bill from the transport company that claims it�s outside her insurance network, and says she owes them $50,950.

�I am 63 and will have a devastated retirement if this is upheld,� Green told me.

Blue Cross & Blue Shield of Mississippi, the administrator for her insurance carrier the State and School Employees� Health Insurance Plan, paid $7,192 of the $58,142 the transport company billed. Blue Cross has told Green that she should be held harmless and should not be charged for the �balance after payment of the Allowable Charge has been made directly to that provider.�

Green is raising a ruckus and has taken her case to state and national media, members of Congress, the state attorney general, and the Mississippi Health Advocacy Program. The company has told her it will begin collection efforts.

In both cases there�s a legislative solution. The three-day rule can be fixed by counting all the time a patient spends in the hospital whether they�re classified as an �in� or as an �observational� patient. The ambulance problem can be fixed by changing the 1978 airline deregulation law that prevents states from interfering with fares, services, and routes. But money and politics block the federal changes that would help people like Rutledge and Green.

�It�s like playing a game of health-insurance roulette,� Bell says. �Your coverage exposes you to these gaps that have been normalized. It�s become the way of doing business.� A resurgent consumer movement could change all that.

What consumer problems have you had with balance billing? Write to trudy.lieberman@gmail.com.
Princess Health and Kentucky Center for Economic Policy report warns about impact of Bevin's proposed Medicaid changes. Princessiccia

Princess Health and Kentucky Center for Economic Policy report warns about impact of Bevin's proposed Medicaid changes. Princessiccia

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By Danielle Ray
Kentucky Health News

A research group with a liberal outlook warned Monday that Republican Gov. Matt Bevin should be careful in changing the state Medicaid program.

The Kentucky Center for Economic Policy said the state�s expansion of Medicaid eligibility under Democratic Gov. Steve Beshear has increased health screenings and job growth in health care.

Tobacco counseling and interventions increased 169 percent from 2013 to 2014, the first year of the expansion, the report noted. Influenza vaccinations went up 143 percent and breast cancer screenings increased 111 percent, it noted.

In addition, Medicaid expansion brought Kentucky health-care providers nearly $3 billion through mid-2015 and resulted in a 4.6 percent job growth in the health-care sector from 2014 to 2016, according to the report.

�No matter how you look at Medicaid expansion in Kentucky, it�s clear it has had a positive effect on access to health care that will improve our state�s economy and quality of life,� Jason Bailey, executive director of KCEP, said in a news release.

However, Bevin says the state can�t afford to have more than a fourth of its population on Medicaid and is seeking a waiver from the federal government to make changes in the program, such as �skin in the game� for beneficiaries: co-payments, deductibles or health savings accounts, as used in a year-old experiment in Indiana, which he has cited as an example.

The KCEP reports says the Medicaid waiver Bevin is seeking could result in additional costs to recipients and benefit changes. Arkansas was the first state to design a Medicaid expansion using such a waiver. So far, five other states have implemented similar waiver-based programs.

Waiver programs differ from standard Medicaid expansion in that they utilize some or all of the following: health savings accounts, a cost-sharing account to be used for health care expenses; lockouts, periods in which recipients who have been dis-enrolled for failure to pay premiums are barred from re-enrolling; and premium assistance, the use of Medicaid funds to buy private insurance plans.

These waivers are designed to grant states the freedom to enact experimental programs within Medicaid, so long as the programs continue to reflect the overall goal of Medicaid, increasing coverage of low-income individuals and improving overall health care, as well as efficiency and stability of health care programs that serve that population.

The Foundation for a Healthy Kentucky, which convened a meeting of Medicaid stakeholders last week, is holding off on making judgments of the proposed waiver program. �We believe that diverse input is essential to sustaining these gains, and to continue improving our health care system and health outcomes in Kentucky,� said Susan Zepeda, president of the foundation.

Zepeda said research the foundation has funded has shown a greater decrease in the number of Kentuckians who lack health insurance than any other state, which she attributes largely to Medicaid expansion adding about 400,000 Kentuckians to the rolls.

More than 1.4 million Kentuckians are enrolled in Medicaid, 39 percent of whom are children. Nearly 32 percent are enrolled under the expansion: childless adults in households that earn less than 138 percent of the federal poverty line, currently $33,000 for a family of four.

The KCEP report also asserts that Kentucky�s Medicaid benefits are on par with those of other states, specifically that 12 out of 13 of Kentucky�s optional benefits are also covered in at least 40 other states and territories. Kentucky Medicaid only covers services that are deemed medically necessary.

KCEP noted that Medicaid is a partnership in which the federal government funds a minimum of half of traditional Medicaid spending in each state, with poorer states receiving a larger federal match. In Kentucky, the federal share is about 70 percent. For people covered by the expansion, the federal government is paying the full cost through this year, but the state will pay 5 percent in 2017, rising in annual steps to the law�s limit of 10 percent in 2020.


The full KCEP report is at http://kypolicy.org.

Sunday, 15 May 2016

Princess Health and May 15th, 2016 Epiphany Day Anniversary. Princessiccia

Princess Health and May 15th, 2016 Epiphany Day Anniversary. Princessiccia

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May 15th, 2016 Epiphany Day Anniversary

From my "Epiphany Day" post on May 15th, 2014:

I'm a great person worthy of love regardless of my size and appearance. I have my mind, sense of humor, talents, a big heart, loads of compassion for others and so very much more. And none of it is diminished with weight gain or increased with weight loss. 

I am me, always.

And my journey will continue toward a healthier weight because I want to live, I want to move easier, I want to experience the freedom a healthy body weight provides. Regardless of how this journey goes, I believe I just discovered one of my greatest personal freedoms of all.

From this blog on May 19th, 2014:

If we tether our identity, self-worth, definition of success and happiness to anything that naturally fluctuates or can change dramatically, then we're in for a roller coaster ride of emotional unrest.

I've always attached my self-worth to my weight. Well, until now of course. I've often talked about potential and not living up to potential. But here's the thing: Potential is tied directly to the constant qualities within us and if our focus is on the pursuit of happiness in every direction except within, then those qualities aren't allowed to flourish, to grow--to give life to the potential within us all.

This whole thing makes me want to take the best care I can. I've never felt more determined to return to a healthy weight. It's what I need physically. What I need emotionally isn't affected by weight loss. And making that distinction provides a nice inner calm, a peace.


The question to determine these inner qualities needing attention and love is: What are the qualities in me that remain regardless of my weight, regardless of my financial situation, regardless of my relationship status, regardless of my professional success--what about me stays the same when all of these other things can and do change?  My heart, soul, sense of humor, natural compassion for others, likes and dislikes, pride in parenting, artistic talents, selflessness, humility, etc. Have you made your list?  And when these constants are cared for and loved, watered, so to speak--they grow, they flourish--and they give us what we need to experience emotional freedom, the freedom and ability to claim our happiness come what may.
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Today was my two anniversary of "Epiphany Day."

I no longer base my self-worth and identity on anything that fluctuates. Gaining weight never made me a worse person and losing weight never made me a better person. The deep inner qualities that are the very foundation of me, didn't change. Those inner qualities were ignored for far too long because I was constantly distracted by the natural fluctuation of things outside of myself--and I made those things the source of my self-worth and identity. I abruptly stopped doing that on May 15th, 2014.

In the two years since "Epiphany Day," I've successfully lost the relapse/regain weight--plus some, I'm doing well in maintenance mode, I started doing stand-up again--just because it's in me and I must--no other reason, I started doing speaking engagements again, I have more support interactions and I freely envision/dream of what I want to do and where I want to go. I've been happy in the face of challenges, I've been calm amid stress and I've truly embraced ME on levels I didn't know existed. And now I know, regardless of the ups and downs of life--I can always be happy. And I can genuinely feel good about me. And with this, I know--I will be okay.

I picked up my grandson this afternoon. We shopped for him a pair of shoes--and pretty much destroyed the kids section of a local shoe store. I offered to help reorganize and the offer was politely declined. With every new pair he tried, he sprinted up and down the aisle until we found one pair that was the fastest. It was so much fun!

After our shoe adventure, we made our way to Stillwater for a belated Mother's Day dinner with mom.

It was a beautiful evening--and really, just a wonderful day.

Today-- I maintained the integrity of my maintenance calorie budget, I remained abstinent from refined sugar, I participated in several support exchanges and I exceeded my daily water goal. That's a solid day. I'll aim for another, tomorrow.

I'll let the Tweets take it the rest of the way...

Today's Live-Tweet Stream:


































Thank you for reading and your continued support,
Strength,
Sean
Princess Health and Rogers says House Republicans want $622 million for Zika; McConnell, Senate plan $1.1 billion; Obama wants $1.9 billion. Princessiccia

Princess Health and Rogers says House Republicans want $622 million for Zika; McConnell, Senate plan $1.1 billion; Obama wants $1.9 billion. Princessiccia

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UPDATE, May 16: The Republican package totals $622 million. May 17: Obama calls that "woefully inadequate," says he would veto it.

House Republicans' funding to fight the Zika virus will be about half the $1.9 billion President Obama requested, but still "adequate," U.S. Rep. Hal Rogers of Kentucky's Fifth District, chair of the House Appropriations Committee, said Friday.

Dierdre Walsh and Ted Barrett report for CNN, "Ever since they sent the request to Capitol Hill, the White House has complained that Republicans are ignoring a public health crisis and need to sign off on more money soon, especially before the potential risks from the mosquito-borne virus increase with the summer months."
    Rogers told reporters the bill he plans to introduce Monday will provide "less than a billion" for Zika but will be "adequate funding to face the problem." Also, "the money will be targeted for agencies to spend right away," Walsh and Barrett report. Rogers said the House could vote on the bill as early as Wednesday, May 18.

    "Rogers and other congressional Republicans said they hadn't acted before now because the Obama administration wasn't giving Congress the details on how they would spend" the money, CNN reports, "and they were working through their own analysis on how much the various agencies needed to deal with the immediate needs. House conservatives also demanded that any new money for Zika needs to be paid for with cuts to other programs."

    His bill is "fully offset" with cuts, Rogers said, but he declined to say where, "saying his committee was still finalizing those details," CNN reports. "But the White House and congressional Democrats argue in these cases Congress doesn't traditionally specify cuts to pay for additional funding. An unnamed Democratic aide on the appropriations staff told the network, "We don't offset emergency funding, period. And this is the definition of a public health emergency."

    Meanwhile, Senate Majority Leader Mitch McConnell, R-Ky., and Democrats in that chamber "worked out a bipartisan $1.1 billion Zika proposal that they plan to attach to a separate spending bill" and scheduled it for a vote Tuesday, May 17, CNN reports. "The Senate will also vote on two competing proposals -- one from the two Florida senators, Bill Nelson, a Democrat, and Marco Rubio, a Republican. It would fully fund the President's request. The second is from Sen. John Cornyn, R-Texas, that would provide about $1 billion and be offset with cuts elsewhere. Those last two proposals are not expected to pass."
    Princess Health and Air ambulances save lives in rural Kentucky, but are costly; Junction City buys Air Evac memberships for everyone in town. Princessiccia

    Princess Health and Air ambulances save lives in rural Kentucky, but are costly; Junction City buys Air Evac memberships for everyone in town. Princessiccia

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    Medical helicopters are especially important to rural Kentucky because they get people to the medical care they need quickly, but this service comes at a cost that many can't afford, Miranda Combs reports for WKYT.

    Air Evac Program Director Donald Hare told WKYT that "the average cost of a flight is around $32,000 and insurance pays, on average, $8,000 and $12,000 of that cost," Combs writes.

    "About 14 to 16 percent of our flights are people with no insurance whatsoever and don't have the ability to pay for that flight," Hare said, noting that they try to work with people to set up a payment plan in this situation.

    Jim Douglas, the mayor of Junction City, told Combs that his city council has decided to buy memberships with Air Evac Lifeteam, which has a hub in the Danville Airport, for everyone in the city to cover them if they need to use the service. He said more than 60 people were flown out of Boyle County on a medical helicopter last year.

    "It could be a lifesaving thing," Douglas told Combs, and said it will "cost the city just under $12,000," Combs writes. And while he said he fully expected some people to use the service for non-emergency reasons, he asked,  "But who's to make the call? I wouldn't want to."

    Michael Bentley, a paramedic, assured WKYT that most of their transfers are emergencies.

    "We generally get called out to the sickest of the sick patients. We're generally not going out to 'Joe that stubbed his toe on the refrigerator at home.' Our patients are major trauma type patients or cardiac events that have happened to these patients," Bentley told WKYT.

    Adam Tubbs, an EMT in Nicholas County, told Combs that medical flights were important because it takes "precious time by ground to get to an emergency call" in such a large rural county. He noted that, on average, they call for air ambulances several times a week. The Nicholas County Hospital closed more than one year ago.

    The cost of these air transports has become such a problem that Rep. Tom McKee, D-Cynthiana, filed a bill during the last legislative session calling for a study of air-ambulance charges. The bill passed out of the House, but did not make it out of committee in the Senate.
    Princess Health and New Jersey Confidential: the Almost Secret Membership of the RWJ Barnabas Health Board. Princessiccia

    Princess Health and New Jersey Confidential: the Almost Secret Membership of the RWJ Barnabas Health Board. Princessiccia

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    A Hospital System Tries to Hide its Board of Trustees

    The US Internal Revenue Service mandates disclosure of the membership of boards of trustees of non-profit corporations.  Nonetheless, as reported by New Brunswick (NJ) Today, the leadership of the newly formed RWJ Barnabas Health system has been doing their best to keep the membership of its board of trustees secret.

    The new organization created to function as the state's largest hospital chain is refusing to tell the public who serves on their Board of Trustees,...

    To elaborate,

    The two hospital networks officially combined to form a new conglomerate, the state's second largest employer, in a deal that was finalized on March 31.

    But since then, the new group has refused to identify its board members, after stalling for nearly two weeks.

    'Thank you very much for your interest. It is a policy at RWJBarnabas Health not to share the names of the Board of Trustees" read a peculiar April 12 email response from an anonymous address affiliated with Barnabas, B4@barnabashealth.org.

    The anonymous email address has not responded to follow up inquiries from this newspaper, including one urging them to make the 'smart choice' and 'be transparent.'

    This goes against at least the spirit of the law.

    'If the organization has been recognized by the IRS as tax-exempt under one of the subsections under 501(c), there are a number of documents that organizations must make available that would include board lists,' said the leader of the Center for Non-profits.

    The initial application, and the three most recent annual filings, must be made available for inspection or copying by members of the public at their place of business, according to the IRS.

    In general, any organization that files a Form 990... must make its three most recent Form 990's and its Form 1023 available for public inspection without charge at its principal place of business,' reads the Center's website.

    'All parts of the return, schedules and attachments must be made available during regular business hours at the organization's principal office and at any regional offices having 3 or more employees.

    There is an exception to the requirement if a non-profit chooses to make the documents widely available by posting them on the internet.

    The anonymous email address that cited the policy of having a secret board, and the media contacts listed on the press release announcing the merger between RWJ and Barnabas, have not responded to questions about whether their healthcare organization is in compliance with the IRS rules regarding making the forms available to the public.
    This obviously also is a remarkable rebuff to those in health care who advocate maximum transparency.

    A Futile Attempt at Secrecy

    Some good investigative reporting by New Brunswick Today penetrated the flimsy veil set up by hospital system leadership. The system chairman turns out to be one Jack Morris:

    Documents provided by the NJ Department of Treasury show that controversial developer Jack Morris was made the Chairman of the RWJ Barnabas board.

    Morris is a close friend and ally of former State Senate President and convicted felon John Lynch, Jr., who ruled New Brunswick as Mayor from 1978-1990, and some contend still is a key player in statewide politics.

    Morris had previously served as Chairman of the Robert Wood Johnson University Hospital (RWJUH) Board of Directors. Morris is also tied to Cooper Hospital Chairman George Norcross, the state's most notorious unelected political boss.

    The vice-chairman is actually Marc Benson.

    another real estate mogul was named the RWJ Barnabas board's Vice Chair, according to the documents, which were filed with the State Treasurer in November 2015, nearly half a year before the merger was finalized.

    Marc Berson founded the Millburn-based 'Fidelco Group' in 1981, a 'private investment owner-developer of residential, commercial, retail, and industrial properties in New York, New Jersey, Florida and Ohio,' according to a press release announcing his election as Chairman of the Barnabas Health Systems board in 2014.

    As for the rest of the board, they are,

    The other 18 secret board members are:

    Robert L. Barchi, (Rutgers University, New Brunswick)
     James C. Salwitz, MD (Robert Wood Johnson University Hospital, New Brunswick)
    Murdo Gordon (Bristol-Myers-Squibb, Princeton)
    Susan Reinhard (AARP Public Policy Institute, Washington, DC)
    Nicholas J. Valerani (West Health Institute, La Jolla, CA)
    John A. Hoffman (Wilentz, Goldman, & Spitzer, Woodbridge)
    Alan E. Davis, Greenbaum (Rowe, Smith & Davis LLP)
    Robert E. Margulies, Esq. (Margulies Wind, Jersey City)
    Kenneth A. Rosen (Lowenstein Sandler PC, Roseland)
     Lester J. Owens (J.P. Morgan Chase, New York, NY)
    James Vaccaro (Manasquan Savings Bank, Wall)
    Albert R. Gamper, Jr. (Caliber Home Loans, Inc., Far Hills)
    Anne Evans-Estabrook (Elberon Development Corporation)
    Gary Lotano (Lotano Development, Inc., Toms River)
    Steve B. Kalafer (Flemington Car and Truck Country, Flemington)
    Brian P. Leddy (former Chairman of RWJUH Rahway, Cranford)
    Joseph Mauriello (formerly of KPMG, Chester)
    Richard J. Kogan (formerly of Schering-Plough Products, Inc., Short Hills)
    Why the Futile Effort to Make Board Membership Secret?

    It is certainly striking that a big non-profit hospital system would try to conceal the membership of its board of trustees.  One might think the leadership should be proud of the board members, and the board members would be happy to advertise their community service.

    This did not seem to be the case here.  Once more we see how the new overlords of health care reflexively seem to choose secrecy over transparency, deliberately creating the anechoic effect which we have frequently discussed.

    Perhaps the board wanted to avoid undue attention to the political connections of its new chairman, one of which  was to a"convicted felon," and another of which was to Mr Norcross, whose apparent conflicts of interest in his role in the governance of a former UMDNJ hospital were discussed here. Parenthetically, an article in NJ.com on the merger noted that this new hospital system is a descendant of the now dissolved University of Medicine and Dentistry of New Jersey, UMDNJ (look here), an organization whose extensive troubles kept Health Care Renewal very busy in past years.

    Perusing the list of the members of the board reveals two people with pharmaceutical connections that could be conflicts of interest, a few people with health care affiliations, but no obvious affinity for the patients and public in New Jersey whom the new hospital system is supposed to serve, and many lawyers and business people with no obvious affinity for the values of health care professionals.

    However, as summarized by the National Council for Nonprofits,

    the board of directors have three primary legal duties known as the 'duty of care,' 'duty of loyalty,' and 'duty of obedience.'

    ...

    In sum, these legal duties require that nonprofit board members:

    Take care of the nonprofit by ensuring prudent use of all assets, including facility, people, and good will; and provide oversight for all activities that advance the nonprofit�s effectiveness and sustainability. (legal 'Duty of due care')

    Make decisions in the best interest of the nonprofit corporation; not in his or her self-interest. (legal Duty of loyalty')

    Ensure that the nonprofit obeys applicable laws and acts in accordance with ethical practices; that the nonprofit adheres to its stated corporate purposes, and that its activities advance its mission. (legal 'Duty of obedience')

    So it is not obvious that these board members are particularly familiar with the nuances of the mission of a large academic hospital system, which includes delivering excellent patient care that puts individual patients first, particularly ahead of board members' self interest, and of its academic role, seeking and disseminating the truth.  One wonders what sort of governance this sort of board will provide.  Maybe the hospital leadership wanted to forestall such questions by keeping board membership as obscure as possible.

    Speaking of the anechoic effect, while the new RWJ Barnabas Health system will be a very major player in NJ health care, and while trying to keep the board members of a non-profit health care system is rather a remarkable action, so far, only one local newspaper, and now your humble blogger seem interested.  This is yet another example of the anechoic effect.

    Comments

    We have been writing now for a long time about the tremendous and growing dysfunction of US health care.  Some now obvious reasons for its problems are poor leadership of ever larger and more powerful health care organizations, and failure of existing governance bidues to exercise stewardship over these organizations.  We have discussed numerous previous problems with boards of trustees of non-profit health care organizations here.  We have noted that board member may have conflicts of interest, and are often rich business executives who may be more interested in preserving the power and wealth of their fellow executives, including those generic managers who know often run large health care organizations, than defending vulnerable patients.  These problems are compounded by the anechoic effect: information and opinions which might offend those currently in power and who stand to benefit most from the current system is kept very quiet, treated as a taboo subject, that is, made to have no echoes.  This new case again suggests that these problems are not going away.

    How many times must we say this?....   True US health care reform would vastly increase transparency, not just of prices, but of leadership and governance.  True US health care reform would put the operation of US health care organizations more in the hands of people who have knowledge and experience in health care, and are willing to be transparent and accountable to support health care professionals' values.  Furthermore, oversight and stewardship of these organizations should represent the patients and public which the organizations are supposed to serve. 


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