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Exam Code: OCN Practice exam 2022 by team
OCN Oncology Certified Nurse - 2022

Exam ID : OCN
Exam Title : Oncology Certified Nurse (OCN®)
Questions : 165
Duration : 3 hours
Exam Type : multiple-choice

Test Content Outline (Effective 2020)
I. Care Continuum - 19%
A. Health promotion and disease prevention (e.g., high-risk behaviors; preventive health practices)
B. Screening and early detection
C. Navigation
D. Advance care planning (e.g., advance directives)
E. Epidemiology
1. Modifiable risk factors (e.g., smoking, diet, exercise, occupation)
2. Non-modifiable risk factors (e.g., age, gender, genetics)
F. Survivorship
1. Rehabilitation
2. Recurrence concerns
3. Financial concerns
4. Employment concerns
5. Insurance concerns
6. Family and social support concerns
7. Sexuality concerns
G. Treatment-related considerations
1. Delayed-onset side effects
2. Chronic side effects
3. Secondary malignancies
4. Follow-up care
H. End-of-life care
1. Grief
2. Bereavement
3. Hospice care
4. Caregiver support
5. Interdisciplinary team
6. Pharmacologic comfort measures
7. Non-pharmacologic comfort measures
II. Oncology Nursing Practice - 17 %
A. Scientific basis
1. Carcinogenesis
2. Immunology
3. Clinical trials (e.g., research protocols)
B. Site-specific cancer considerations
1. Pathophysiology
2. Common metastatic locations
3. Diagnostic measures
4. Prognosis
5. Classification
6. Staging
7. Histological grading
C. Scope, standards, and related issues
1. Standards of care (nursing process)
2. Legal (including documentation)
3. Accreditation (e.g., The Joint Commission)
4. Self-care (e.g., managing compassion fatigue)
D. Standards of professional performance
1. Ethics (e.g., patient advocacy)
2. Education
3. Evidence-based practice (e.g., Putting Evidence Into Practice (PEP) guidelines) and research
4. Quality of practice
5. Communication
6. Leadership
7. Collaboration
8. Professional practice evaluation
9. Resource utilization
10. Environmental health (e.g., safety, personal protective equipment, safe handling)
III. Treatment Modalities - 19%
A. Surgery
B. Blood and marrow transplant
C. Radiation therapy
D. Chemotherapy
E. Biotherapy
F. Immunotherapy
G. Vascular Access Devices (VADs) for treatment administration
H. Targeted Therapy
IV. Symptom Management and Palliative Care - 23%
A. Etiology and patterns of symptoms (acute, chronic, late)
B. Anatomical and surgical alterations (e.g., lymphedema, ostomy, site-specific radiation)
C. Pharmacologic interventions
D. Complementary and integrative modalities (e.g., massage, acupuncture, herbal supplements)
E. Palliative care considerations
F. Alterations in functioning
1. Hematologic
2. Immune system
3. Gastrointestinal
4. Genitourinary
5. Integumentary
6. Respiratory
7. Cardiovascular
8. Neurological
9. Musculoskeletal
10. Nutrition
11. Cognition
12. Energy level (i.e., fatigue)
V. Oncologic Emergencies - 12%
A. Disseminated intravascular coagulation (DIC)
B. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
C. Sepsis (including septic shock)
D. Tumor lysis syndrome
E. Hypersensitivity
F. Anaphylaxis
G. Hypercalcemia
H. Cardiac tamponade
I. Spinal cord compression
J. Superior vena cava syndrome
K. Increased intracranial pressure
L. Obstructions (bowel and urinary)
M. Pneumonitis
N. Extravasations
VI. Psychosocial Dimensions of Care - 10%
A. Cultural, spiritual, and religious diversity
B. Financial concerns (including available resources)
C. Altered body image
D. Learning styles and barriers to learning
E. Social relationships and family dynamics
F. Coping mechanisms and skills
G. Support
1. Patient (i.e., individual and group)
2. Caregiver (including family)
H. Psychosocial considerations
1. Anxiety
2. Loss and grief
3. Depression
4. Loss of personal control
I. Sexuality
1. Reproductive issues (e.g., contraception, fertility)
2. Sexual dysfunction (e.g., physical and psychological effects)
3. Intimacy

Oncology Certified Nurse - 2022
Medical Certified PDF Download
Killexams : Medical Certified PDF obtain - BingNews Search results Killexams : Medical Certified PDF obtain - BingNews Killexams : What to Do When Your Doctor Doesn't Take Medicare

Not all doctors accept Medicare for the patients they see, an increasingly common occurrence. This can leave you with higher out-of-pocket costs than you anticipated and a tough decision if you really like that doctor.

So what happens when you sign up for Medicare only to learn it's a no-go at your favorite doctor? Fortunately, you have some options.

Key Takeaways

  • If you choose a doctor who accepts Medicare, you won't be charged more than the Medicare-approved amount for covered services.
  • A doctor can be a Medicare-enrolled provider, a non-participating provider, or an opt-out provider.
  • Your doctor's Medicare status determines how much Medicare covers and your options for finding lower costs.

What Is Medicare?

Medicare is a federal government–sponsored program that provides health insurance for American citizens ages 65 and over. President Lyndon B. Johnson signed Medicare into law on July 30, 1965. By 1966, 19 million Americans were enrolled in the program.

Now, more than 50 years later, that number has mushroomed to over 60 million—more than 18% of the U.S. population. As more baby boomers reach age 65, enrollment is expected to hit 81 million in 2035. It’s no wonder that Medicare benefit payments totaled an estimated $796 billion in 2019.

Annual open enrollment for Medicare runs from Oct. 15 to Dec. 7 every year.

If your long-time physician accepts assignment, this means they agree to accept Medicare-approved amounts for medical services.

Medicare Part A pays for inpatient hospital stays. Most participants don't pay a monthly premium for Part A since they paid into it via taxes, and there are no coinsurance costs for 60 days or less for hospital stays. However, the annual deductible for Part A is $1,484 for 2021 and $1,556 for 2022.

Medicare Part B covers doctor's visits, tests, physical therapy, and flu shots. For most individuals, the Medicare Part B premium is $148.50 per month for 2021 and $170.10 per month for 2022. The Part B annual deductible is $203 for 2021 and $233 for 2022.

Can Doctors Refuse Medicare?

The short answer is "yes." Thanks to the federal program's low reimbursement rates, stringent rules, and grueling paperwork process, many doctors are refusing to accept Medicare's payment for services.

Medicare typically pays doctors only 80% of what private health insurance pays. While a gap always existed, many physicians feel that Medicare reimbursements haven't kept pace with inflation in the past several years, especially the rising costs of running a medical practice. At the same time, the rules and regulations keep getting more onerous, as do penalties for not complying with them. 

Most American physicians participate in Medicare and "accept assignment" (what Medicare pays) for their services without additional charges. However, if your doctor is non-participating or has opted out of Medicare, here are five options.

1. Stay Put and Pay the Difference

If your doctor is what's called a non-participating provider, it means they haven't signed an agreement to accept assignment for all Medicare-covered services, but can still choose to accept assignment for individual patients. In other words, your doctor may take Medicare patients but disagrees with the program's reimbursement rates. These non-participating providers can charge up to 15% over the official Medicare reimbursement amount.

If you choose to stick with your non-participating doctor, you'll have to pay the difference between the fees and the Medicare reimbursement. Plus, you may have to cough up the entire amount of the bill during your office visit. If you want to be paid back afterward, either your doctor will submit a claim to Medicare, or you may have to submit it yourself using Form CMS-1490S.

Let's say, for example, your doctor's bill comes to $300, and Medicare pays $250. This means you'll have to pay the $50 difference, plus any copay, out of pocket, assuming your doctor agrees to the program's reimbursement rates. This can add up quickly over time. However, you may be able to cover these extra expenses through a Medigap insurance policy, aka Medicare Supplement Insurance. Provided by private insurers, it is designed to cover expenses not covered by Medicare.

2. Request a Discount

If your doctor is what's called an opt-out provider, they may still be willing to see Medicare patients but will expect to be paid their full fee—not the smaller Medicare reimbursement amount. These docs accept no Medicare reimbursement, and Medicare doesn't pay for any portion of the bills you receive from them. That means you are responsible for paying the total bill out of pocket.

Opt-out physicians are required to reveal the cost of all their services to you upfront. These doctors will also have you sign a private contract saying you agree to the opt-out arrangement.

Of course, you can always try to negotiate a discount. It's not uncommon for physicians to lower their rates for established patients. As a courtesy, they may also offer extended payment plans if you require a series of expensive treatments or procedures.

3. Visit an Urgent Care Center

Urgent care centers have become a popular place for people to go for their healthcare needs. There are now more than 9,000 urgent care centers in the U.S. These centers may also operate as walk-in clinics. Many provide both emergency and non-emergency services, including the treatment of non-life-threatening injuries and illnesses, as well as lab services.

Most urgent care centers and walk-in clinics accept Medicare. Many of these clinics serve as primary care practices for some patients. If you need a flu shot or you've come down with a relatively minor illness, you may consider going to one of these clinics and save the doctor visits for the big stuff.

4. Ask Your Doctor for a Referral

If you simply cannot afford to stick with your doctor, ask them to recommend the next best doctor in town who does accept Medicare. Your current doctor has probably already prepared for this eventuality and arranged to transfer Medicare patients to another physician's care.

Just because you are eligible for Medicare doesn't mean you have to enroll in all four parts. If you have other health insurance—for example, you're still working and can remain covered by your employer's group plan—you may want to stick with that plan. Medicare Advantage Plan networks are another alternative to investigate. Physicians in those HMO-like plans have agreed to accept the network's fees.

5. Search Medicare's Directory

There are still plenty of doctors who take Medicare. You can find them in Medicare’s Physician Compare directory, a comprehensive list of physicians and healthcare providers across the nation. Once you pinpoint a provider, call to make sure they’re still taking on new Medicare patients. After all, this can change on a dime.

Another approach is to check the best local hospitals and see if any physicians on their staff are taking Medicare patients. When you get names, research them online to learn about their backgrounds.

The CARES Act of 2020

On March 27, 2020, President Trump signed a $2 trillion coronavirus emergency stimulus package, called the CARES (Coronavirus Aid, Relief, and Economic Security) Act, into law. It expanded Medicare's ability to cover treatment and services for those affected by COVID-19. The CARES Act also:

  • Increases flexibility for Medicare to cover telehealth services.
  • Authorizes Medicare certification for home health services by physician assistants, nurse practitioners, and certified nurse specialists.
  • Increases Medicare payments for COVID-19–related hospital stays and durable medical equipment.

For Medicaid, the CARES Act clarifies that non-expansion states can use the Medicaid program to cover COVID-19–related services for uninsured adults who would have qualified for Medicaid if the state had chosen to expand. Other populations with limited Medicaid coverage are also eligible for coverage under this state option.

Does Every Doctor Accept Medicare?

No. Because of a number of factors, like lower reimbursement rates, paperwork, and regulations, some doctors choose to opt out of Medicare.

What Do I Do If My Doctor Does Not Accept Medicare?

You can choose to stay and cover the costs out-of-pocket, but this is not an affordable option for most Americans. Instead, you can ask your doctor for a referral to another healthcare provider that does accept Medicare, do your own research, or visit an urgent care facility. Most urgent care offices accept Medicare.

Why Do Doctors Refuse to Take Medicare?

Medicare is not always cost effective for doctors. It typically pays doctors only 80% of what private health insurance pays.

The Bottom Line

Thanks to plummeting reimbursement rates, ever-tightening rules, and cumbersome paperwork, many doctors are dropping Medicare. If you recently enrolled in Medicare only to find that your long-standing doctor doesn’t accept it, you have a number of options.

Whether you choose to stick with your cherished physician and pay the potentially exorbitant price or switch to a doctor who does accept Medicare, it’s important to carefully crunch the numbers before you make a final decision. Also, review your own medical situation and whether you need your current doctor—or someone with similar expertise—because of a specialized health issue.

Fri, 01 Apr 2016 04:45:00 -0500 en text/html
Killexams : Geographic Variation in Medicare Home Health Expenditures


Objectives: To quantify geographic variation in home health expenditures per Medicare home health beneficiary and investigate factors associated with this variation.

Study Design: Retrospective study design analyzing US counties in which at least 1 home health agency served 11 or more beneficiaries in 2016. Several sources of 2016 national public data were used.

Methods: The key variable is county-level Medicare home health expenditures per home health beneficiary. Counties were grouped into quintiles based on per-beneficiary expenditures. Analyses included calculation of coefficients of variation, computation of the ratio of 90th percentile to 10th percentile in expenditures, and linear regression predicting expenditure. The control variables included characteristics of patients, agencies, and communities.

Results: Significant variation in home health expenditures was identified across county quintiles, with a 90th-to-10th-percentile expenditure ratio of 2.5. The percentage of for-profit agencies in the lowest quintile was 15.7 compared with 81.7 in the highest quintile of spending. Unadjusted spending differed by $3864 (95% CI, $3793-$3936), compared with $3611 (95% CI, $3514-$3708) in the adjusted model, between counties in spending quintiles 1 and 5. Although state fixed effects explained nearly 20% of the variation in home health expenditures, 42% of the variation remained unexplained.

Conclusions: Home health care exhibits considerable unwarranted variation in per-patient expenditures across counties, signifying inefficiency and waste. Given the expected growth in home health demand, strategies to reduce unwarranted geographic variation are needed.

Am J Manag Care. 2022;28(7):322-328.


Takeaway Points

Existing research on home health expenditures uses home health data more than 2 decades old. US home health expenditures rose by 113% between 2000 and 2016, from $8.5 billion to $18.1 billion. The Medicare program has implemented several policies in the past decade to combat the growth in expenditures. This study finds the following:

  • A 2.5-fold spending difference per beneficiary exists between the 90th and 10th spending percentiles.
  • Patient characteristics explained only 16% of the variation in home health expenditures.
  • More than 40% of spending variation remained unexplained in the study, suggesting substantial inefficiency and waste in the home health care program.


Unwarranted variation in the utilization of health services, or variation not related to differences in patient needs or conditions, is pervasive across health care settings in the United States.1,2 Unwarranted variation in services typically leads to increased health care spending without a concomitant improvement in health care outcomes.3 Reducing unwarranted variation in health care services is necessary to Excellerate efficiency in both public and private health care delivery systems.4 Concerns over program inefficiency and variation in health care spending led to a 2013 Institute of Medicine (IOM) report that documented the extent of variation in service utilization and expenditures in Medicare. The IOM report found that at least 36% percent of variation in regional spending was unwarranted—not explained by differences in disease burden or severity among patients.1 The IOM report also raised serious concerns with services provided in postacute and long-term care settings, finding that variation in postacute care spending alone accounted for 73% of the total observed variation in Medicare spending.1

Home health care is a critical component of postacute and long-term care services in the United States, which, despite extensive variation, remains understudied.5,6 As of 2017, more than 12,000 Medicare-certified home health agencies participated in the program, delivering care to more than 3 million beneficiaries.7 The number of beneficiaries is expected to increase due to the aging US population and policy changes by CMS.8

Medicare home health expenditures increased 113% from $8.5 billion in 2000 to $18.1 billion in 2016 in part due to the implementation of Home Health Resource Groups (HHRG), a prospective payment system that replaced the Medicare fee-for-service (FFS) mechanism previously used to reimburse home health agencies.7 With the increasing number of participating home health agencies, beneficiaries served, and expenditures under HHRG, information describing the extent of variation in home health care is needed to help policy makers and other stakeholders identify potential reforms.

This study describes regional variation in US home health spending to better understand unwarranted variation. Additionally, the study seeks to identify the sources of variation in home health care spending to inform policy makers on strategies to reduce unwarranted variation.

Conceptual Framework

The conceptual framework is based on the literature describing home health utilization, which is a function of patient, home health agency, and community characteristics. In addition to age and gender, evidence has shown that dual-eligible Medicare and Medicaid beneficiaries use more home health resources.9 The CMS Hierarchical Conditional Category (HCC) risk score, a score assigned to patients based on health status and health conditions, is associated with health care consumption and used to adjust payment for private insurance plans that cover Medicare beneficiaries under Medicare Part C.10 Agency characteristics include ownership type (for profit, not for profit, government) and whether market entry took place during the era of the HHRG prospective payment system implemented in 2000.11,12 The number of primary care physicians in the community affects coordination between physicians and home health professionals and the timeliness of care received.13 Competition among home health agencies, skilled nursing facilities, and hospitals also affects patient choice about the use of home health vs other long-term care services.14


Study Design and Study Sample

This is a retrospective study design that aggregated home health agency data at the county level to examine variation. Analysis of service variation commonly relies on specific geographic areas, such as hospital referral regions, health service areas, or counties.4 The county was used as the geographic unit for analysis because the majority of Medicare home health beneficiaries receive care from agencies in their home county.15 The study trial consists of all Medicare-certified home health agencies serving 11 or more beneficiaries in 2016 across all 50 states and the District of Columbia.

Data Sources

Data sources included the 2016 Medicare Provider Utilization and Payment Data files: the Public Use File Home Health Agencies (PUF HHA) file, the Provider of Services (POS) file, the Home Health Compare (HHC) file, and the Area Health Resources File (AHRF). The PUF HHA file contains agency-level information, including provider identification number, the total Medicare standard payment amount for beneficiaries who receive at least 5 home health visits during their episode of care (non–Low Utilization Payment Adjustment [non-LUPA] beneficiaries), and summarized characteristics of the beneficiaries per home health agency. These include the mean age of beneficiaries, the percentage of dual-eligible beneficiaries, and the mean HCC risk score for patients served. The HHC file provides the agency’s initial date of the contract with CMS and ownership type. The AHRF provides state and county Federal Information Processing Standards (FIPS) codes for each county and details for county-level community characteristics, such as the number of primary care physicians, nursing home beds, and long-term hospital beds. Medicare wage adjustment per county based on Social Security Administration (SSA) state and county codes are available in the Medicare Wage Adjustment files.

Dependent Variable

The dependent variable is county-level Medicare standard home health expenditure per home health beneficiary because it eliminates geographic factors incorporated by Medicare to adjust provider payment. Per-beneficiary payments were calculated by aggregating agency-level Medicare standard payment amounts at the county level as the numerator and agency-level unique Medicare non-LUPA home health beneficiaries as the denominator.

Key Measures

Quintiles of county-level spending per Medicare home health beneficiary and how quintile assignment relates to the characteristics of patients, providers, and the community are the key measures of interest. Home health agencies behave differently based on when they entered the market in relation to the implementation of HHRG in 2000, as profitable practices in the prospective payment system differed from those in the previous FFS payment system.9 Thus, a measure of tenure as the percentage of home health agencies entering the market before 2000 in each county is included. The percentages of agencies that were government owned and for profit per county, as well as an indicator of agencies operated as part of home care chains, were drawn from the POS file. A link between the wage adjustment file and the PUF HHA data set was created by utilizing a crosswalk between SSA and FIPS codes. For community characteristics, a county-level Herfindahl-Hirschman Index (HHI) of competition was calculated as the sum of the squared market share based on the number of home health beneficiaries served by each agency. Finally, the number of primary care physicians per 1000 population, the number of nursing home beds and long-term hospital beds per 1000 population, and county-level median household income were included at the county level.

Analytical Approach

Counties were divided into quintiles based on Medicare home health expenditures per home health beneficiary. Counties in quintile 1 had the lowest expenditures; those in quintile 5 had the highest. Additionally, the coefficient of variation (COV) and the ratio of the 90th to 10th percentile for all variables were used to analyze variation in expenditures within and across each quintile.

Ordinary least square regression models were used to assess factors associated with geographic variation in home health expenditure per home health beneficiary. The first model included only 4 dummy variables for counties in quintiles 2 to 5, with those in quintile 1 serving as the reference group. Each iteration of the model successively added patient, agency, and community characteristics. The changes in R2 in each subsequent model show how much variation in home health expenditure per beneficiary is explained by adding patient, agency, and community characteristics.

Counties in each quintile include state effects that influence expenditures. To estimate geographic variation resulting from state-level fixed effects, we excluded the dummy variable for quintiles and added patient, agency, and community characteristics successively and analyzed models with and without state-level fixed effects. Statistical analysis was conducted with Stata 14.2 (StataCorp).


The PUF HHA file contains information on 10,046 home health agencies that served 11 or more patients in the United States in 2016. A total of 1925 of 3141 counties in the United States had at least 1 agency in the PUF HHA file and were included in our analysis. Counties not included in the study were more likely to be rural, with lower population levels and lower median incomes.

Table 1 presents the mean of county-level Medicare home health expenditures per home health beneficiary and county-level patient, agency, and community characteristics of the study trial across quintiles of Medicare home health expenditure. On average, overall Medicare expenditures were $5050 per home health beneficiary, ranging from $3440 in quintile 1 to $7305 in quintile 5. The within-quintile 90th-to-10th-percentile ratio of expenditures was 2.5, and the same ratio for the HCC scores was 1.13. Approximately 30.4% of patients were dual-eligible Medicare and Medicaid beneficiaries, representing 25.8% of beneficiaries in quintile 1 vs 37.6% in quintile 5. Overall, non-White beneficiaries comprised 14.6% of the sample, but this ranged from 8.7% in quintile 1 to 22.5% in quintile 5. Agencies included in the study had an mean HCC score of 2.1. Across quintiles, agency HCC score ranged from a low of 2.0 in quintile 1 to a high of 2.2 in quintile 4. The majority (50.3%) of agencies in the study were for profit; 17.1% were government agencies. Major differences were observed across quintiles in agency ownership. Counties in quintile 1 had the lowest percentage of for-profit agencies (15.6%) but had the highest percentage of government-owned agencies (35.1%). Counties in quintile 5 had the highest percentage of for-profit agencies (81.6%) but the lowest percentage of government-owned agencies (6.7%). Overall, tenured agencies that entered the market before HHRG implementation made up approximately 40% of the study sample; they were 43.3% of agencies in quintile 1 and 34.0% of agencies in quintile 5. Overall, 22.5% of agencies in the trial operated as branches of home health chains, with the highest proportion of chain agencies in quintile 5 (30.5%) and the lowest in quintile 1 (11.2%). Medicare wage adjustments were higher in lower quintiles, with quintile 1 at a wage adjustment of 0.90 and quintile 5 at 0.81. Counties in the study had an mean of 0.2 long-term hospital beds, 0.6 physicians, and 0.4 nursing beds per 1000 population. Median household income was $50,792, and the mean HHI score was 7146.

Figure 1 provides a visualization of the extent of variation in county-level home health expenditure per beneficiary by quintiles. Intraquintile variation was low, with quintiles 1 (COV = 0.1) and 5 (COV = 0.14) exhibiting the highest variation. However, the overall COV for mean expenditures per beneficiary in all study counties was 0.3, indicating substantial overall variation across quintiles. The overall 90th-to-10th-percentile ratio of 2.5 indicates that the 90th percentile mean expenditure is 2.5 times that of the 10th percentile. Figure 2 adds context to the results, identifying counties by quintile of per-patient expenditure by color on a map. The South, particularly Texas, Oklahoma, and Louisiana, has a higher concentration of high-expenditure counties. The New England and West Coast regions have higher concentrations of low-expenditure counties. Counties colored in gray were not included in the study due to a lack of eligible agencies for analysis.

Table 2 provides results from models adjusted for selected variables based on our conceptual framework. Coefficients are first presented in dollar spending for each quintile of per-patient expenditure in an unadjusted model and are then adjusted as we add patient, agency, and community characteristics (the results are available in eAppendix A [eAppendices available at]). In the unadjusted model, unexplained spending differences ranged from $758.28 (95% CI, $686.83-$829.73) between quintiles 1 and 2 up to $3864.70 (95% CI, $3793.25-$3936.16) between quintiles 1 and 5, with an R2 of 0.87; R2 remained unchanged after adding beneficiary, agency, and community characteristics to the model.

State policies and other characteristics likely influence expenditures for home health at the county level. To estimate state effects on variation, we excluded dummy variables for county quintiles and applied the models with and without state fixed effects (Table 3). The R2 between models with (0.50) and without (0.16) state fixed effects changed to 0.58 and 0.39 once agency and community characteristics were added, representing a percent difference reduction from 212.5% to 48.7%. However, the full model with state fixed effects explained only 58% of the variation (the results are available in eAppendix B).


The IOM report on spending variation identified postacute care as the primary driver of spending inefficiency in Medicare, with postacute care accounting for approximately 70% of the variation in patient-level Medicare spending. The home health industry is an integral component of postacute care for Medicare beneficiaries and provides services to 3.5 million beneficiaries annually through more than 12,000 contracted home health agencies. This study provides new information on the extent of spending variation that exists among home health beneficiaries. A prior study suggested that the source of variation in home health services utilization stems from differences in organizational behavior, local resources, or Medicaid factors,16 but in the present study, these measures had a marginal impact on explaining variation. Excluding the 3 states with the highest rates of variation (Texas, Oklahoma, and Louisiana) resulted in a drop in the 90th-to-10th-percentile ratio from 2.5 to 2.0, indicating persistent unexplained variation. And although these 3 high-utilization states opted not to expand Medicaid, a sensitivity analysis exploring the possible impact of Medicaid expansion on home health utilization showed that Medicaid expansion status was not statistically significant in state-level fixed effects or random effects models. After adjusting for patient, agency, and community factors, a difference of more than $2500 remained between per-beneficiary home health expenditures in quintiles 1 and 5, and more than 40% of the variation remained unexplained by the models in the study, an indication of waste and inefficiency in the home health care delivery system.

Several characteristics of beneficiaries, physicians, and agencies likely contribute to this observed variation. To receive services, the Medicare Home Health Benefit requires beneficiaries to meet 3 criteria: being homebound, requiring intermitted skilled care, and receiving a physician referral through a face-to-face encounter assessment.17 Beneficiaries bear no cost sharing and can receive unlimited 60-day episodes of home health care with physician recertification.17 Without beneficiaries sharing financial responsibility for episodes of home health care, cost does not influence beneficiary decision-making about whether another episode of care is needed, what actions they can take themselves to Excellerate their conditions, and what home health providers can do for them.

Although physicians are required to conduct a face-to-face assessment in order to refer their patients for home health care,18 latest evidence shows that the majority of physicians spend less than 1 to 2 minutes completing the referral form, do not change the referral form once home health professionals submit the renewal certification, and fail to ask home health professionals to clarify any information in the form.13 This physician certification mechanism leaves room for home health agencies to induce unnecessary demand.

At the agency level, home health agencies require only small capital assets to enter and operate in the market and can easily adjust operating systems to maximize profit margins.19 Cabin and colleagues found that for-profit agencies were more costly but provided lower quality of care compared with not-for-profit agencies.11 Under the HHRG, Kim and Norton also found that for-profit agencies that entered the market after 2000 were more financially incentivized to provide therapy visits that yielded high margins than agencies established before the HHRG implementation.12 The success of these new market entrants influenced for-profit peers to adopt similar practice patterns and pursue profitable therapy visits. In addition to for-profit agencies and peer effects, medical fraud is an issue in the home health industry. According to a report by the US Government Accountability Office, home health agencies exhibited the highest rate of medical fraud among all types of health care providers, accounting for more than 40% of medical fraud in the nation in 2010. Although fraud may contribute to unwarranted variation,20 it is not a major source of variation in health care delivery identified by the IOM.1


There are limitations to the study. First, the study analyses rely on data from just 1925 of 3141 US counties due to limitations in the PUF HHA file, which suppresses agencies providing services to 10 or fewer patients in the calendar year. Should the behavior of agencies in counties excluded be different from that of those in our study, our results would not generalize to them. Second, our data include only patient risk factors for gender, race, age, dual eligibility, and CMS HCC score. Other health and social risk factors, such as measures of activities of daily living and the capability and availability of informal caregivers, may affect how often home health professionals visit their patients,21,22 for which our models could not control. Finally, the county, based on the location of the home health agencies, is our geographic unit of measurement. Although the majority of beneficiaries seek care from home health agencies located in their residential county,15 our data do not allow us to distinguish expenditures at the patient level, and some beneficiary spending will be captured in the county of the home health agency rather than their county of residence.


Despite these limitations, our findings have policy implications. First, the Medicare program is a primary payer of home health for older patients and has the purchasing power to set payment rates. However, states regulate the home health market, which influences agency practice patterns. For example, states with certificate-of-need regulations consume less home health care and have lower growth in home health expenditures than those without.23,24 Findings from this study indicate a large effect of state regulatory policies and characteristics on overall spending, with approximately 20% of the observed variation attributable to state fixed effects. These findings indicate that the Medicare program should work with states to address geographic variation through market regulation.

Second, although face-to-face physician assessment encounters are required by policy, evidence in the literature indicates that the physician referral system should be strengthened, either through incentivizing physicians to perform more meaningful assessments or through assignment of legal responsibility to physicians to certify the referral process. Finally, for individual beneficiaries, increasing cost-consciousness through co-pays when accessing the Medicare Home Health Benefit—as recommended by the Medicare Payment Advisory Commission to CMS25—could reduce unnecessary preference-sensitive home health care utilization.

The demand for home health care is expected to continue to grow, given both the preference to stay home and the changing demographics of the country.26 Reducing unwarranted variation is key to strengthening the Medicare home health care benefit. In 2020, CMS implemented a new payment system, the Patient Driven Groupings Model, which eliminates the number of therapy visits from the payment equation.7 We recommend strengthening the physician referral system, adding co-pays for each episode of home health care, and improving collaboration between states and the Medicare program to ensure that the home health care delivery system provides sustainable, efficient, high-quality care to beneficiaries in need.

Author Affiliations: Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences (RFS, ALML, HFC, JMT), Little Rock, AR.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RFS, HFC, JMT); acquisition of data (RFS); analysis and interpretation of data (RFS, HFC, JMT); drafting of the manuscript (RFS, ALML, HFC, JMT); critical revision of the manuscript for important intellectual content (RFS, ALML, HFC, JMT); statistical analysis (RFS, HFC); administrative, technical, or logistic support (ALML, JMT); and supervision (HFC, JMT).

Address Correspondence to: Robert F. Schuldt, PhD, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205. Email:


1. Institute of Medicine. Variation in Health Care Spending: Target Decision Making, Not Geography. The National Academies Press; 2013. doi:10.17226/18393

2. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4):273-287. doi:10.7326/0003-4819-138-4-200302180-00006

3. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288-298. doi:10.7326/0003-4819-138-4-200302180-00007

4. Wennberg JE. Tracking Medicine: A Researcher’s Quest to Understand Health Care. Oxford University Press; 2010.

5. Talaga SR. Medicare home health benefit primer: benefit basics and issues. Federation of American Scientists. March 14, 2013. Accessed January 10, 2020.

6. Newquist DD, DeLiema M, Wilber KH. Beware of data gaps in home care research: the streetlight effect and its implications for policy making on long-term services and supports. Med Care Res Rev. 2015;72(5):622-640. doi:10.1177/1077558715588437

7. Medicare Payment Advisory Commission. Home health care services. In: Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission; 2019:225-248. Accessed December 4, 2019.

8. Knickman JR, Snell EK. The 2030 problem: caring for aging baby boomers. Health Serv Res. 2002;37(4):849-884. doi:10.1034/j.1600-0560.2002.56.x

9. Joynt Maddox KE, Chen LM, Zuckerman R, Epstein AM. Association between race, neighborhood, and Medicaid enrollment and outcomes in Medicare home health care. J Am Geriatr Soc. 2018;66(2):239-246. doi:10.1111/jgs.15082

10. Pope GC, Ellis RP, Ash AS, et al. Diagnostic cost group hierarchical condition category models for Medicare risk adjustment. CMS. December 21, 2000. Accessed March 13, 2020.

11. Cabin W, Himmelstein DU, Siman ML, Woolhandler S. For-profit Medicare home health agencies’ costs appear higher and quality appears lower compared to nonprofit agencies. Health Aff (Millwood). 2014;33(8):1460-1465. doi:10.1377/hlthaff.2014.0307

12. Kim H, Norton EC. Practice patterns among entrants and incumbents in the home health market after the prospective payment system was implemented. Health Econ. 2015;24(suppl 1):118-131. doi:10.1002/hec.3147

13. Boyd CM, Leff B, Bellantoni J, et al. Interactions between physicians and skilled home health care agencies in the certification of Medicare beneficiaries’ plans of care: results of a nationally representative survey. Ann Intern Med. 2018;168(10):695-701. doi:10.7326/M17-2219

14. Li Q, Rahman M, Gozalo P, Keohane LM, Gold MR, Trivedi AN. Regional variations: the use of hospitals, home health, and skilled nursing in traditional Medicare and Medicare Advantage. Health Aff (Millwood). 2018;37(8):1274-1281. doi:10.1377/hlthaff.2018.0147

15. Franco SJ. Medicare home health care in rural America. Policy Anal Brief W Ser. 2004;(1):1-4.

16. Welch HG, Wennberg DE, Welch WP. The use of Medicare home health care services. N Engl J Med. 1996;335(5):324-329. doi:10.1056/NEJM199608013350506

17. Medicare & home health care. CMS. Updated September 2020. Accessed November 9, 2021.

18. Patient Protection and Affordable Care Act, Pub L No. 111-148 (2010) Sec. 6407. Accessed March 13, 2020.

19. Medicare Payment Advisory Commission. Home health services. In: Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission; 2011:173-199. Accessed January 10, 2020.

20. Health care fraud: types of providers involved in Medicare, Medicaid, and the Children’s Health Insurance Program cases. US Government Accountability Office. September 2012. Accessed March 13, 2020.

21. Osakwe ZT, Larson E, Andrews H, Shang J. Activities of daily living of home healthcare patients. Home Healthc Now. 2019;37(3):165-173. doi:10.1097/NHH.0000000000000736

22. Cho E, Kim EY, Lee NJ. Effects of informal caregivers on function of older adults in home health care. West J Nurs Res. 2013;35(1):57-75. doi:10.1177/0193945911402847

23. Polsky D, David G, Yang J, Kinosian B, Werner R. The effect of entry regulation in the health care sector: the case of home health. J Public Econ. 2014;110:1-14. doi:10.1016/j.jpubeco.2013.11.003

24. Rahman M, Galarraga O, Zinn JS, Grabowski DC, Mor V. The impact of certificate-of-need laws on nursing home and home health care expenditures. Med Care Res Rev. 2016;73(1):85-105. doi:10.1177/1077558715597161

25. Medicare Payment Advisory Commission. Home health care services. In: Report to the Congress: Medicare Payment Policy. Medicare Payment Advisory Commission; 2017:229-253. Accessed September 10, 2019.

26. Fixing to stay: a national survey on housing and home modification issues. AARP. May 2000. Accessed March 22, 2019.

Wed, 13 Jul 2022 01:00:00 -0500 en text/html
Killexams : Legal and Professional Issues for Nurses: A Nurse Attorney Answers
  • How Specific Should an Employment Contract Be? A nurse practitioner negotiating an employment contract wants it to specify her work hours. Is this a reasonable request?

    Ask the Expert, March 2019

  • 'Outside' Income-Producing Activities Forbidden Should you accept an employment contract that forbids having a second source of income?

    Ask the Expert, March 2019

  • If Parents Don't Comply, What Should Clinicians Do? Is it too soon to call child protective services to report possible medical neglect?

    Ask the Expert, February 2019

  • Can a Nurse Practitioner Take a Locum Tenens Position? Before agreeing to cover for a physician on leave, NPs and medical practices should be aware of Medicare's fee-for-time compensation rule.

    Ask the Expert, February 2019

  • How Much Should a Collaborating Physician Be Paid? Healthcare attorney Carolyn Buppert provides a roadmap for calculating how much a collaborating physician should be paid.

    Ask the Expert, January 2019

  • Can I Be a 'Nurse Coach' Across State Lines? A registered nurse in California wants to serve clients in other states as a certified nurse coach. Is it legal?

    Ask the Expert, October 2018

  • I Believe I'm a Victim of Ageism. What Recourse Do I Have? A 52-year-old RN who has been unable to find a job believes that she is a victim of age discrimination.

    Ask the Expert, October 2018

  • Finish Documentation on a Patient Visit Within 48 Hours? An employer requires providers to complete documentation within 48 hours--even on Friday.

    Ask the Expert, September 2018

  • What Can a Nurse Do? Healthcare attorney Carolyn Buppert provides a decision-making framework about how to answer critical scope-of-practice questions. obtain a useful PDF.

    Ask the Expert, September 2018

  • Must NP Preceptors Duplicate a Student's Documentation? CMS doesn't require physician teachers to do so, but does this rule apply to advanced practice nurse and physician assistant preceptors?

    Ask the Expert, August 2018

  • Can RNs Perform Cosmetic Procedures? And if so, what is required to make this practice legal?

    Ask the Expert, July 2018

  • Can I Get Out of a Noncompete Agreement? If So, How? In responding to this question, attorney Carolyn Buppert explains why you shouldn't enter a noncompete agreement in the first place.

    Ask the Expert, June 2018

  • A Wrong Turn: Fraudulent Documentation How big a deal is it to chart a task, such as patient repositioning, when it wasn't done for lack of time?

    Ask the Expert, May 2018

  • Can I Be Forced to Work at an Affiliate Hospital? A nurse is unhappy about being forced to drive to another city to work when census is low in her hospital.

    Ask the Expert, May 2018

  • Prescribe for Family, Friends, or Colleagues? Why Not? A healthcare attorney answers a common question: Is it a good idea to write prescriptions for family, friends, or colleagues?

    Ask the Expert, April 2018

  • Are Pre-Signed Prescriptions a Good Idea? Even Legal? Can I fill in a pre-signed prescription for a patient in the physician's absence? What if I'm also a prescriber?

    Ask the Expert, April 2018

  • How Should I Document an On-Call Patient Consultation? When the clinician takes call and is unable to access the electronic record, how should the call and the clinician's advice be documented?

    Ask the Expert, March 2018

  • How Much Should Clinicians Be Paid for Being On Call? Use these questions to decide how much you should be compensated for on-call hours.

    Ask the Expert, February 2018

  • Nurses and Social Media: Guard Your Career and Your Reputation Nurses have a lot to offer, and social media is an outlet for their wisdom. Here are four ways to protect professional reputation while taking advantage of social media.

    Ask the Expert, February 2018

  • I'm on Medical Marijuana. Can I Be Fired for Positive Drug Test? Can a nurse with a marijuana medical-use card work without repercussion from a positive employee drug screen?

    Ask the Expert, February 2018

  • Tue, 18 Aug 2020 09:04:00 -0500 text/html
    Killexams : What Is Google Stack?

    What Is Google Stack?

    Google Stack is a document-scanning and -filing app. It digitally photographs and stores receipts, bills, and other papers as PDFs, organizing them into different categories. Free to download, it is available exclusively for Android phones and tablets in the United States.

    Key Takeaways

    • Google Stack is a document-digitizing and -filing app, launched by Google in March 2021.
    • The app is free but available exclusively for Android users.
    • Google Stack uses artificial intelligence to scan and store papers as PDFs, organizing them into customizable categories.
    • Users can search their stacked docs in various ways, including by a store name, a bill’s due date, or a sum of money.
    • Copies of Google Stack documents also can be stored on a user’s Google Drive.

    How Google Stack Works

    Launched on March 30, 2021, Google Stack was created by Area 120, the in-house incubator of Google, owned by Alphabet Inc. (GOOG and GOOGL).

    The team leader for Stack was Christopher Pedregal, creator of Socratic, an education app that Google acquired in 2018.

    To use Stack—once it’s downloaded from the Google Play store—you begin by photographing a document. The app will scan it, title it for you, and suggest the right category, or “stack” (get the name now?), for you to store it in, based on details within the doc. You can also import and scan existing PDFs or photos of documents already on your Android smartphone.

    The stacks have names, such as Bills, Receipts, Banking, House, IDs, Vehicles, Insurance, Legal, Medical, Tax, and Travel. If you don’t like the preset suggestions, you can change the file name, slot the doc into another stack, or create a category of your own. You can put a PDF into more than one stack, and you can edit a file’s appearance (crop, color) as well—though the app automatically does a lot of digital enhancement. One professional app reviewer was particularly impressed by Stack’s ability to gather information from and categorize a highly crumpled receipt.

    Google Stack Strong Points

    Scanning apps have been around for a while. The biggest deal with Stack’s is its organizing function—the way that it “reads” a document and files it.

    Stack makes extensive use of Google’s DocAI tool, a Cloud-based technology for document analysis.

    This ability to analyze and zero in on key data also allows you to search for your stacked docs in various ways: by a store name, a bill’s due date, a sum of money, etc. The app also enables full-text searches within a doc.

    Another of Stack’s selling points is its ability to sync with Google Drive; you can opt to automatically save a copy of your stacked documents there, for access on a desktop or laptop. That way, your scans will always be available, should you ever decide to stop using Stack—or should Google discontinue it, as some cynics say it will.

    Reactions to Google Stack

    Stack receives largely favorable reviews on the Google Play store. As of March 4, 2022, the app has a 4.7-star rating (out of five) from 5,746 reviewers. “Simple, easy to use and intuitive” and “the naming and the categories are awesome!” are typical kudos. Complaints have centered on crashes/upload delays and difficulty in moving PDFs between stacks or re-sorting them within stacks.

    Some responders have expressed big data concerns, given Stack’s affiliation with the Google Workspace (formerly G-Suite) family. One CNET comment reads: “And what will Google do with all of your important scanned documents? Don’t be surprised if you receive oddly coincidental advertising after using this app.”


    The number of Stack installs, as of March 4, 2022.

    Google Stack Competitors

    Document-scanning and -digitizing services are not new: CamScanner, one of the oldest, dates back to 2011. Some of the leading mobile apps that Google Stack is competing with include:

    • Microsoft Office Lens for iPhone and Android, which lets you save to OneNote or OneDrive
    • Tiny Scanner, with versions for iOS and Android devices
    • Adobe Scan for iOS and Android, which can upload PDFs or JPEGs to Adobe Document Cloud


    Is Google Stack Safe?

    Stack uses Google’s advanced security and sign-in technology to protect documents. For extra safeguarding, you can require a scan of your face or fingerprint every time that you unlock the app.

    How Do I Use Google Stack?

    First, you sign in to the Google Stack app, using your Google account. Then tap on the + button in the bottom-right corner of the screen. You can scan and import items in three ways: the PDF option for already-digitized files, the Gallery option if it’s a photo, or the Camera option to create a digitized version of an real document. Using Camera is akin to taking any smartphone pic: Place the paper on a well-lit, even surface, hold the phone steady, and tap the Scan button. The app automatically crops and sharpens the image.

    Where Are Google Stack Documents Stored?

    Google Stack documents are stored in the app itself, organized into different categories (the “stacks”). You also can opt to have copies of the docs saved to your Google Drive.

    Wed, 18 May 2022 22:52:00 -0500 en text/html
    Killexams : How To Get A Medical Marijuana Card In New York State: A Step-By-Step Guide

    For many years I thought my friends with medical marijuana cards were just looking for a legal loophole to get high and goof around—and for the most part I was right. But I had never considered it before. Besides, I was perfectly happy with my stash of relatively low-dose recreational cannabis, which I started taking sometime in 2017 when my lower back pain became untenable.

    Then I injured my back (again) during a particularly intense month of contact combat training with fighters twice my size. It had been years since it last happened and I was in a panic. But I’ve been here before: the debilitating pain, the inability to move, and just all-around physical misery. And let me tell you: That kind of excruciating pain is not something anyone would ever want to live through again—or regularly, for that matter.

    When I wasn’t hoovering Aleve, CBD gummies and low-dose THC edibles to ease the constant pain, I was seeing a chiropractor, doing physical therapy thrice a week, and slathering myself with CBD topicals. On occasion, I even had to rely on a cane to get around.

    Managing this latest bout of pain was also helped by the budtenders I had the pleasure of meeting in Nevada and California: They certainly knew their stuff. But the more I learned about cannabis and how my ailing body responds to it, the more I realized that it was time to see a professional about a medical marijuana card.

    But here’s the thing—I wasn’t looking to get high. And I didn’t want a card just so I could shop locally in Manhattan. So I didn’t go to one of those rent-a-New-York-doctor sites, say the right things for ten minutes, and get a card mailed to me. Instead, I did what I always do whenever I hunt for a new doctor: I asked a good friend in the cannabis industry to recommend a reputable doctor. I did my due diligence and took the medical part of medical marijuana seriously. I gathered whatever pain-related medical documents I had that, just in case they’d be handy.

    And I would recommend this approach to anyone. Plus, the entire process was fairly painless—and efficient. My doctor was beyond helpful: Thanks to his recommendations and guidance on dosing, I’ve been experiencing lower pain and fewer flareups. And between medical-grade cannabis (which typically has a higher dosage) and regular mobility drills coupled with core strengthening exercises, I’m already on my way to a (mostly) pain-free life.

    And you can do it too. Here’s how.


    Cannabis was partly decriminalized in New York State in mid-2019. But that certainly doesn’t mean that anybody can walk around with joints and go all out at the park. (Public consumption is still illegal, FYI.) Also: New York State has one of the most stringent requirements for its residents to acquire a medical marijuana card—meaning, if you’re not suffering from a debilitating disease, chronic pain, opioid abuse, PTSD, cancer, Parkinson’s diseases, or anything that can seriously affect your wellbeing and ability to function on a day-to-day basis, there’s a good chance you’re not going to be granted the right to use medical marijuana legally. So, if you have one of these qualifying conditions and you think cannabis could greatly Excellerate your quality of life, proceed to step number two.


    Decades ago, there was such a stigma surrounding cannabis use. The word “stoner” carried with it visions of unkempt misfits unbothered by ambition, the business of life, the rat race, or “the establishment.” But no longer. These days, more and more people are taking cannabis as a means to Excellerate their health—not to get zonked. After all, the plant is known for its anti-inflammatory and neuroprotective properties. According to BDSA, an analytics firm that focuses on the cannabis industry, “the worldwide [cannabis] market will more than triple from $14.8 billion in 2019 to $46.8 billion in 2025.” A staggering growth projection. And for New York residents, finding a professional couldn’t be easier: The New York State Medical Marijuana Program lists a robust number of registered participating healthcare professionals in all 62 counties—many of whom are not just doctors, but nurse practitioners and physician’s assistants as well.  


    Choosing a doctor for the purposes of learning how to treat your condition with the help of medical marijuana is very much like picking a therapist: You’ve got to have rapport. And as a patient, you need to feel that you’re in good hands. Once you’ve picked a physician from New York’s list, schedule an appointment and talk about whatever it is that ails you. (In my case, I emailed my doctor my lumbosacral MRI and X-ray results shortly before our appointment to help move things along—and to deliver him a good idea of what he’s dealing with.) During the consultation be as detailed as possible, especially when answering questions related to your symptoms, medical history, and general lifestyle. This will help the doctor “prescribe” a suitable cannabis product for you. And by “prescribe,” the physician will help determine the starting dose you need, the best delivery method for your body, and the frequency with which you ought to be partaking. The whole process typically doesn’t last an hour if you’re an obvious candidate—and once the appointment is over, your doctor will then prepare your medical marijuana patient certification, which will be emailed to you in PDF form. And of course, this is where you pay your doctor’s professional fee.


    It won’t take long for the certificate to reach your inbox. (Mine showed up in three days.) As soon as it’s in your hands double check each field on the form—there’s no room for any sort of error, so if you find one, ask your doctor to make the necessary corrections. The certificate should contain important personal information: the medical condition that qualifies you to be part of the state’s medical marijuana program, your patient certification number, your doctor’s DEA registration number and New York State practitioner number, your dosing recommendation, and the expiration date (which is exactly one year from the issue date). I recommend printing at least two copies: One to keep on file and one to have with you at all times, since you need to present your certificate in addition to your medical marijuana card when visiting a dispensary.  


    This bit is very important and I cannot stress this enough. Having an NYS ID will make all the difference when applying for a medical marijuana card. So if you don’t already have one, get yourself a personal New York State government account via the state’s official ID site and keep your username and password safe. Remember, this is the exact same login credential that allows you sign up for a multitude of state services across the board: educational programs, health resources, DMV services, tax assistance, and a whole lot more. So if you’ve lived in New York for long enough and have a driver’s license or state ID, there’s a good chance you already have an account. Plus, if you’ve ever applied for unemployment insurance, you certainly have one—because there’s no way you can certify claims without a MY NY account. So double (and triple) check to make sure you don’t sign up twice. Go over your data to validate its accuracy, otherwise it could cause delays or complicate your application and registration. Beyond that, it’s just good idea for every New Yorker to have a singular account you can use to easily access your personal data and process whatever you need to get done on the state level—your account is not solely meant to authorize cannabis for legal medical use.


    From here on out, everything is going to be easier than surviving the disaster that was 2020—including the four years we had to endure with our twice-impeached former president. Anyway, enough about that: Now that you have your New York ID, whether it’s a driver’s license or a non-driver ID card, simply visit and log in. Just make sure you do not use Safari, which is incompatible with New York State’s platform. (I used Chrome.) From there, consult the second section of your NYS Medical Marijuana Program patient certification and follow every single directive accurately on page three. And make sure there are no typos: Your name, date of birth, address, and patient certification number all have to tally up with the information on your doctor-provided paperwork. Errors and falsifications will cause major delays—it could take weeks or it could take a few months, depending on whatever discrepancies there may be. You’ll notice that there’s a section called “Supporting Documentation,” which allows you to upload paperwork. But you can ignore it for as long as you have your NYS identification number: That particular field is meant for individuals who reside in New York but need to show proof of residency, mainly because their state ID is from somewhere else—or they simply do not have the required ID.

    So there’s no need to upload any of your medical documents, your patient certification, your license, or even your photograph. (The powers that be will use the existing image it has on file from your ID.) So it’s important to note that you must enter your nine-digit NYS ID without dashes or spaces. And once you’ve done that you’ve essentially completed your registration. NB: If your condition is so severe that you’re not always able to go to the dispensary yourself, you can designate a caregiver after your registration is approved.


    If all goes well (no typos were made; your nine-digit NYS ID was successfully verified) you’ll have your temporary card almost immediately after registration. A prompt will appear at the very end of the process and it will enable you to obtain the card, which will be valid for a month. Print a few copies and have one with you at all times (in addition to the medical marijuana certificate with your doctor’s signature), in case you need to visit a dispensary immediately. Again, you need both the card and the certificate to enter a dispensary.


    It should take you no time at all to receive your “real” medical marijuana card in the mail. More often than not, it takes less than two weeks. Personally, mine arrived exactly one week after the day I registered. Note that the card only lasts a year and you will a few need periodic follow-ups with your doctor to see how your treatment is going—and whether your dose needs to be calibrated further. To renew it, deliver your doctor ample time and schedule a renewal appointment at least a month before your medical marijuana card expires.


    There are less than 20 medical marijuana dispensaries in New York City. But there are more in other counties, which you can find here. Do your research and pick one that suits you—in terms of what they carry and what your physician recommended you take. For instance, if you were advised to try sublinguals go to dispensary that carries a number of them so you’re able to enjoy a number of options. Remember: Take both your card and certificate. You will not be able to purchase medical cannabis in New York without both. One good thing to remember is that while your doctor may recommend certain methods of THC delivery via the certificate (such as edibles, sublinguals, or buccal sprays), the dispensary’s “pharmacist” or budtender may (and can) ultimately recommend something completely different. All this is legal. If you’re not comfortable with whatever the dispensary recommends, most doctors will let you call them right there and then—so you don’t end up spending money on something that could be too strong or too weak for you. Cannabis isn’t cheap, so it’s always good to proceed with good advice.


    In some instances, even in the middle of a pandemic, travel may just be unavoidable. And the last thing you need is to be without pain relief in a distant city. Here’s a helpful list that explains where you can purchase medical marijuana with a New York State card—and just what the parameters are. Many will let you make purchases, while others will only allow for you be in possession of what you already have. Each state is obviously different. Hawaii, for instance, will let out-of-state qualified visitors register online up to three months in advance. But whatever you do, make sure to never fly with cannabis on you.

    Sun, 31 Jan 2021 08:07:00 -0600 Karla Alindahao en text/html
    Killexams : The NCBI dbGaP database of genotypes and phenotypes

    Cite this article

    Mailman, M., Feolo, M., Jin, Y. et al. The NCBI dbGaP database of genotypes and phenotypes. Nat Genet 39, 1181–1186 (2007).

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    Thu, 13 May 2021 15:00:00 -0500 en text/html
    Killexams : Music could be a powerful tool to help mothers promote infant development

    Professor Shannon de l'Etoile knows the impact of a mother's lullaby.

    As a young music therapist in Colorado, de l'Etoile saw that when disadvantaged mothers were encouraged to sing to their babies, they were amazed by the positive responses they received. She quickly realized that music could be a powerful tool to help mothers learn more about their infants and to build a relationship with their new child.

    Soon, de l'Etoile began researching the practice, called infant-directed singing, and learned its wide range of returns. Chief among them, infant-directed singing helps babies learn to regulate their emotions, which allows them to later navigate socialization, school, and the professional world, according to de l'Etoile, who has spent her career studying the habit.

    If a mother can sing in a way that captures the infant's attention, it can help them tap into those brain structures that they need to develop for self-regulation."

    Professor Shannon de l'Etoile, board-certified music therapist and associate dean of graduate studies, University of Miami Frost School of Music

    Yet, while singing to infants is something most mothers do naturally-;without even realizing the benefits-;for those in difficult circumstances, infant-directed singing may not be as instinctive, de l'Etoile observed. She has noticed that mothers impacted by depression, domestic violence, or substance exposure may need encouragement and guidance to provide this unique form of caregiving.

    "Infant-directed singing is a way that mothers communicate with their babies that most infants can recognize and respond to. But to be most effective, the mother needs to be attentive and sensitive to infant cues," said de l'Etoile. "For some moms that may not be happening and that impacts the infant."

    But because infant-directed singing is so advantageous, de l'Etoile is working with the College of Arts and Sciences Department of Psychology's flagship early intervention program at the Linda Ray Intervention Center to create a coaching program that will guide mothers in the practice.

    Recently, de l'Etoile's efforts received support from the GRAMMY Museum Grant Program, a division of the National Academy of Recording Arts and Sciences. This funding will sponsor her pilot study to train mothers of infants at the center in the critical caregiving skill. The study is one of just six scientific research projects that earned funding from the organization this year.

    For close to three decades, the Linda Ray Intervention Center, which serves children from birth to age 2, has been the site of some of the most cutting-edge research in the nation. That research focuses on the developmental needs of at-risk infants and how to best support mothers in building secure bonds with their children.

    "We want to deliver moms and caregivers these tools they can use, so that they can feel empowered to help their babies thrive," de l'Etoile said. "Building self-regulation at an early age is so important because it helps children deal with adversity. Children who don't regulate well are lacking in resilience, and they may have problems later in life, like obesity, addiction, and aggression."

    De l'Etoile and the center's executive director, Isabel Chica, are now in the process of identifying and training staff members at the center, who will coach mothers for a month in the most beneficial ways to sing to their infants. The process includes watching and recording mothers as they sing to their infants and then demonstrating to these mothers how they can be sensitive to their infants' emotions while singing. Mothers will be able to notice if the infant is benefiting because the baby will gaze longer at the mother and reach a contented state.

    Chica believes the project is a great fit for the center.

    "One of our main goals is to provide families with opportunities to learn new strategies and techniques that support positive parent-child interactions, and this pilot may strengthen parenting skills as well as a parent's ability to help their child self-regulate," Chica said. "We believe this is a great way for healthy attachments to develop between parent and child."

    As part of the study, after each mother completes the training, de l'Etoile will work with the Frost School's music engineering program to analyze recordings of the mother's voice. Ideally, the analysis will reveal changes over time in the mother's ability to modify their singing according to the infant's emotions. Videos of the babies will also be analyzed to determine engagement with the mother over time, tracked through their gaze (whether they are focused on the mother), as well as their level of comfort, revealed in the baby's facial cues.

    "For an infant to make progress toward self-regulation, they need focused attention on the mother. And they also need to have achieved an optimal level of arousal where they are not excited, or fussy, but comfortable," she said.

    The project also signals a new frontier for de l'Etoile, who in the past has documented how infant-directed singing occurs naturally, in both typical and clinical populations, including mothers with post-partum depression and infants with Down syndrome. In this project, she is providing a community-based, infant-directed singing intervention and is thrilled to work with the Linda Ray Intervention Center.

    For more than two years, de l'Etoile has been working closely with center staff to develop the program so that it aligns with the needs of their families. The staffers will soon begin coaching some of the mothers, and both Chica and de l'Etoile are eager to begin.

    "We want this project to have a lasting legacy and impact, not just for us to have positive outcomes but to create a model for how a program like this could be implemented in other early intervention facilities," de l'Etoile said.

    Wed, 03 Aug 2022 11:59:00 -0500 en text/html
    Killexams : PGIMER Releases Information Brochure For ICMR JRF 2022, Check out all exam details

    Chandigarh: Postgraduate Institute of Medical Education & Research (PGIMER) has released the information brochure for ICMR Junior Research Fellowship (JRF) exam for 2022.

    The last date for filling out the online application form will be 28th August 2022. The candidates seeking admission to the entrance exam must submit their application in the prescribed format available online with the prospectus on the website http// No candidate should register more than one application.

    The candidates must ensure that the photo/signature is uploaded according to the instructions provided in the prospectus. Failure to do so may result in the rejection of applications. They will receive the acknowledgement of successful online registration on their registered email.

    The candidates willing to apply will have to pay the following application processing and examination fee –

    1. Fee for General/EWS/OBC - Rs. 1500 +Transaction charges as applicable

    2. Fee for SC/ST - Rs. 1200 +Transaction charges as applicable

    3. Fee for PwBD/Transgender - Exempted from payment of a fee

    The candidates must deposit the fee online through the payment gateway available at ICMR-JRF 2022 application portal. The fee can be paid starting from today till 29th August 2022. PGIMER has requested to avoid payment through UPI. The cost of the application form includes the fee for the entrance exam, which is non-refundable, and no correspondence in this regard will be entertained.

    The candidates are advised to read the information brochure and instructions carefully before starting online registration and ensure that no column is left blank. In the event of rejection of the application form, no correspondence/request for reconsideration will be entertained. They should obtain and take a print of the application form and retain a copy of the application form till the award of the fellowship.

    The candidates should keep a few identical photographs in reserve during entrance examinations/admission. Any deviation or discrepancy between real appearance at the examination time and facial appearance in the photograph pasted on the application/admit card will make the candidate liable for rejection.

    The candidates should take two printouts of the online application form by logging in with their login ID and password. Affix the same passport-size photograph (which was uploaded with the online form) on it and keep it safe with them.

    The candidates must upload scanned copies of certificates/documents supporting their educational qualifications, marks, date of birth, category etc. Suppose the candidates fail to upload scanned copies of the requisite documents as above. In that case, their candidature will be cancelled, and they will not be allowed to participate in subsequent stages of the selection/admission process.

    Educational Qualification –

    MSc /MA or equivalent degree (subject areas mentioned in Section 5.1, pg. no. 7) with a minimum of 55% marks for General/EWS candidates and 50% for the SC/ST/OBC and PwBD candidates.

    A candidate who is appearing/has appeared in the final year (IV/VI Semester, whichever is applicable, and final year where Semester system is not there) of M.Sc./MA or equivalent examination during the session (2021-22) can also apply for the exam as RA (Result Awaited). Such candidates will have to submit the attestation format (given in annexure-I duly certified by the Head of the Department/Institute over their signature and rubber stamp (with address and name) where they are appearing in the final year examination. However, such candidates shall be admitted to the exam provisionally and shall be considered eligible for JRF only after they submit proof of having passed the Master's Degree examination with the requisite percentage. The MSc/MA or equivalent degree mark sheet must be submitted to ICMR, latest, by 31st December 2022; otherwise, candidature selection will automatically be forfeited.

    The age limit for admission to the eligibility test is 28 years as on 30-09-2022 (upper age limit relaxable up to five years in case of candidates belonging to SC/ST, PwBD and female candidates, three years in the case of OBC category.

    Syllabus –

    1. As prescribed by UGC.

    2. A trial question paper for ICMR JRF Examination is available on the ICMR website

    Reservations of Seats –

    1. ICMR provides Reservation for Scheduled Caste (SC), Scheduled Tribe (ST), Other Backward Classes (OBC) - Non-Creamy Layer (NCL), wherever applicable and admissible as per instructions from the Government of India.

    2. All candidates, irrespective of category, may be considered against General category vacancies, subject to fulfilment of parameters for General candidates. However, only candidates belonging to that community will be considered against the vacancies earmarked for specific categories (SC/ST/OBC).

    3. For availing reservation, SC/ST/OBC candidates should furnish Caste Certificate from competent authorities as per the format given in Annexure-II (for SC/ST candidates) and at Annexure-III (for OBC-NCL candidates) at the time of submission of documents.

    4. As per provisions (Chapter VI Clause 32) of the Rights of the Persons with Disabilities Act 2016, 5% of seats shall be reserved for PwBD who are Indian Nationals. The reservation will be provided on a horizontal basis, as per their rank in order of merit in the Entrance Exam.

    5. In reference to the Department of Personnel & Training (DOPT), GoI, order no. 36039/1/2019- Estt (Res) dated 31.01.19, 10% reservation for EWS category will be given only to the General Category candidates.

    Summer of JRF examination –

    1. Mode of Examination - Computer Based Test (CBT)/Online

    2. Duration of Examination - 02 hours (two hours), i.e. 120 minutes

    3. Date of Examination - Friday, 23rd September 2022

    4. Number of Shifts - 01 (One), Afternoon shift- 2.00 P.M. to 04.00 P.M

    5. Location of Examination Centers - Tentatively, 20 cities in India

    6. Language of Paper - English

    7. Type of Examination - Objective Type

    The exam will consist of one paper of two hours duration. The paper will consist of two Sections. The Aptitude Section (Section A) will have 50 questions on (i) scientific phenomena in everyday life, (ii) general knowledge in Sciences, and (iii) common statistics. All these questions would be compulsory, with each question carrying 1 mark. The subject Specific Section (Section B & C) would pertain to (B) Life Sciences and (C) Social Sciences. Each area of sections B & C would have 100 questions, and the candidate will attempt any 75 questions in the predesigned area of Section B or C. The system will not allow the candidate to attempt more than 75 questions in the online Computer-based exam. Candidates must also indicate the option for Section B or C in the application form.

    Each question carries one mark. Negative marking @ 0.25 will be made for each wrong answer. The questions in both Sections would appear in English only. The qualifying marks will be 55% obtained in both the Sections (A+B or C) for General Category & EWS and 50% for SC/ST/OBC and PwBD. The exam will be held in the following streams: (1) Aptitude test (common for all), (2) Life Sciences (3) Social Sciences.

    Subjects covered under Life Sciences include microbiology, physiology, molecular biology, genetics, human biology, biotechnology, biochemistry, bioinformatics, biophysics, immunology, pharmacology, nursing, zoology, botany, environmental Sciences and veterinary Sciences (excluding Agriculture Extension/ Soil Sciences etc.)

    Subjects covered under Social Sciences include psychology, sociology, anthropology, social work, home Sciences, statistics and Public health/Health economics (excluding others).

    The answer keys for the ICMR-JRF examination will be uploaded on the ICMR New Delhi website after 3 days of the exam. The answer key will contain the right answers to the questions.

    Tentative test centres –

    1. Ahmedabad (Gujarat)

    2. Bengaluru

    3. Bhopal

    4. Bhubaneswar

    5. Chandigarh (Tricity)

    6. Chennai

    7. Dehradun

    8. Delhi

    9. Guwahati

    10. Hyderabad

    11. Jodhpur

    12. Jammu

    13. Kolkata

    14. Lucknow

    15. Mumbai

    16. Noida

    17. Patna

    18. Pune

    19. Thiruvananthapuram

    20. Varanasi

    Admit cards for accepted registration/application forms will only be uploaded on the website. Suppose the status of the registration/application form or admit card is not available on the website. In that case, the candidates should immediately write an email to the Registrar, PGIMER, on email: or contact 0172-2755561, 67 along with full particulars of the registration form.

    To obtain the admit card, the candidates will have to visit the PGIMER website: or ICMR website: and click the same link 'ICMR-JRF Exam–2022', which will take them to the same portal where they had filled their online application form. The candidates need to Click on the 'Login' button to log in with their login ID and password. Click on 'PRINT ADMIT CARD' to obtain and print your admit card.

    Intimation about when to obtain the admit card will be sent to the candidates' registered mobile number/email. Roll Numbers/Admit Cards for appearing in the entrance examination will be available for obtain to eligible candidates approximately 10 days before the entrance exam date.

    The candidates should note that their candidature is provisional. No candidate will be admitted to the test unless they hold the admission certificate for the test. The mere fact that an acknowledgement card/admission certificate has been issued to the candidates will not imply that the ICMR has finally accepted their candidature. Candidates may note that the verification of eligibility conditions of a candidate concerning the documents as may be called for will be taken up only after the candidate has qualified for the exam.

    The award of JRF by the ICMR after successfully passing the examination will be subject to verification of documents, i.e. proof of age and qualifying mark sheet/degree in MSc/MA (Final) or equivalent exam, with requisite percentage of marks and also SC/ST/OBC/PwBD/EWS certificates, if the candidate belongs to any of these categories.

    Fellowship will be initiated from the date of PhD enrolment (generally within one year from the date of issue of JRF award letter), and it will be treated as the date of joining, the total duration being five years or submission of PhD thesis (whichever, is earlier). A total of 150 Fellowships would be awarded.

    The candidates selected for the JRF program of ICMR would be permitted to enrol for the PhD program in biomedical/health research subjects of any University/Medical College recognized by the UGC/MCI. The duration of JRF will initially be limited until two years, carrying a monthly stipend of Rs. 31000 plus House Rent Allowance (HRA) as applicable per Govt. rules and an annual contingency grant of Rs. 20000 per annum.

    The progress of research work would be evaluated annually through annual progress reports (APR). On completion of two years as a JRF, the monthly stipend of a fellow may be increased to Rs. 35000 plus HRA from 3 rd year onwards based on an assessment of the candidate's research progress/achievements and upgradation report recommendation as submitted by the Institute's Assessment Committee.

    In the event of the Committee not recommending upgradation, the fellow will continue as JRF with a stipend of Rs. 31000/- per month for the 3rd year, or the ICMR may terminate the fellowship. The duration of SRF may be for a maximum duration of three (03) years. Thus, the total tenure as JRF plus SRF shall not exceed 05 (five) years or until the submission of PhD thesis (whichever is earlier).

    Selected candidates must join their respective fellowships on the prescribed date as indicated in the award letter issued by ICMR. The selection of those who fail to join by the specified date shall automatically stand cancelled.

    To view the notice, click on

    Sat, 30 Jul 2022 20:30:00 -0500 en text/html
    Killexams : FMGE June 2020 Result Out At; Less Than 10% Pass
    FMGE June 2020 Result Out At; Less Than 10% Pass
    FMGE June 2020 Result Out At; Less Than 10% Pass

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    The result of FMGE 2020 June session has been announced by National Board of Examinations, or NBE, today, September 12, 2020. The result FMGE 2020 June session has been released in the PDF format. Applicants had to secure the minimum qualifying marks -- 150 out of 300 in FMGE result 2020. Candidates who have appeared in the examination can visit the official website— and obtain the FMGE result 2020. The Foreign Medical Graduates Examination is conducted for candidates who have earned their medical degrees abroad but wish to practice in India.

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    According to official result document, out of 17,789 candidates who appeared in FMGE 2020 June session, only 1,697 or 9.94% students have managed to pass. As many as 13,790 candidates could not qualify in the entrance examination.

    Follow these steps to obtain FMGE result of June session 2020. Candidates can tap on the link below and obtain the FMGE result 2020.

    1. Go to the official website of the National Board of Examinations at http://website—

    2. Click on the second link in the notice section which says "Result of FMGE screening test"

    3. On the page that opens, click on "Click here for view result" and obtain the PDF file

    Foreign medical graduates who have been listed in the FMGE Result 2020 and qualified the examination of the June session will be issued a provisional/permanent registration from State Medical Council to practice medicine in India.

    The schedule of the issuance of FMGE 2020 pass certificate will be updated by NBE on its official website.

    FMGE is conducted nationwide for Indian Nationals or OCIs to secure registration certification to practice further medicine in India. The FMGE exam is held biannually— June and December. NBE held the exam for FMGE 2020 June session on August 31, 2020.

    Sat, 12 Sep 2020 07:43:00 -0500 en text/html
    Killexams : Wearable Healthcare Devices Market is anticipated to register US$ 30 Billion by 2026

    [319 Pages Report] A new report says the wearable healthcare devices market is anticipated to grow at a CAGR of 13% from $16 billion in 2021 to $61 billion by 2032.

    A report from Future Market Insights observes that the worldwide wearable healthcare market is expected to reach $30 billion by 2026. From 2022 to 2032, it is predicted to increase at a compound annual growth rate (CAGR) of 13%.

    The wearable healthcare devices market is expected to be influenced by the rise of businesses such as home healthcare and remote patient monitoring devices. In addition, the wearable healthcare devices market is projected to be impacted by an increased focus on fitness and healthy lifestyle orientation.

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    The COVID-19 pandemic has elevated the importance of wearable medical devices in the healthcare market. As a result, various firms working on wearable medical devices from across the world are joining the wearable healthcare devices market, where wearable medical equipment can detect early warning symptoms of viral infection. For example, the Ava Bracelet, originally designed as a fertility tracker, is now being utilized to aid in the fight against the coronavirus. This wristband monitors heart rate variability, breathing rate, and skin temperature and can monitor viral symptoms. As a consequence of this, the demand for wearables is anticipated to grow.

    In the wearable healthcare devices market, the adoption of new sophisticated tools and technologies such as AI and 5G is predicted to deliver high wearable healthcare devices growth potential.

    In deciding compensation for mobile healthcare, national agencies play a significant role. Federal regulations in several EU member states define medical treatment in terms of the patient and doctor’s physical presence, which has an impact on payments for mobile and remote healthcare solutions. Such regulations slow the adoption of wearable healthcare devices in the healthcare sector.

    Clinical device manufacturers in the United States and Europe confront significant hurdles from patent reform and patent trolls. Patent trolls are firms that buy patents to collect royalties from businesses that purportedly infringe on patents owned by patent assertion entities or non-practicing organizations (NPEs). The key to success in the fast-developing clinical-grade wearable business is to protect patients.

    For in-depth insights, obtain a PDF Brochure –

    The pharmacy category held the highest proportion of the wearable healthcare devices market in 2020. The wearable healthcare devices market expansion is being driven by an increase in the elderly population and, as a result, an increase in the incidence of chronic illnesses.

    Diagnostic instruments dominated the wearable healthcare devices market. However, the category is likely to grow as people become more aware of the capacity of neurological wearables to continually measure people’s cognitive abilities. At the same time, they go about their daily lives.

    Due to the rising intake of therapeutic devices, the therapeutic device sector is expected to grow at the quickest rate throughout the forecast period.

    Smartwatches, which allow for monitoring a variety of indicators such as mobility, respiration rate, pulse rate, and Bluetooth and cloud connection, are expected to drive wearable healthcare devices market growth in this category throughout the forecast period.

    Due to the rise in prevalence of cardiovascular disease, diabetes, and cancer in this area.

    “The rises in chronic illnesses that require regular monitoring, as well as the development of modern healthcare infrastructure, are expected to propel wearable healthcare devices market expansion throughout the forecast period.”

    For in-depth competitive analysis Buy Now –

    Key Takeaways:

    · The diagnostic instruments category held the largest wearable healthcare devices market share, accounting for 62.5% of total sales.

    · The strap/clip/bracelet category dominated the wearable medical devices market, accounting for 51.2% of total sales.

    · The home healthcare sector dominated the wearable healthcare devices market, accounting for 53.5% of total revenue.

    · North America held the largest wearable healthcare devices market share, accounting for 38.1% of total sales.

    About FMI:

    Future Market Insights (ESOMAR certified market research organization and a member of Greater New York Chamber of Commerce) provides in-depth insights into governing factors elevating the demand in the market. It discloses opportunities that will favor the market growth in various segments on the basis of Source, Application, Sales Channel and End Use over the next 10-years.

    Contact Us:
    Future Market Insights,
    Unit No: 1602-006,
    Jumeirah Bay 2,
    Plot No: JLT-PH2-X2A,
    Jumeirah Lakes Towers,
    United Arab Emirates
    For Sales Enquiries:

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