By Melissa Noble
So what does a male orgasm feel like? Do orgasms differ drastically between the sexes? On our search to find out what exactly goes on in a man's head and body during sex, we first examined what we already know:
For starters, the male orgasm is significantly shorter, more intense and can, usually, only be experienced once during a single sex session. RIFT Platinum Women on the flipside, if properly stimulated, can pop out a series of orgasms with little recovery period. Secondly, the male orgasm unleashes a rush of drowsy hormones—norepinephrine, serotonin, oxytocin, vasopressin, nictric oxide and the hormone prolactin—making it next to impossible for men not to feel sleepy after sex. The Hands-Free Orgasm
But what exactly does a male orgasm feel like, we wonder. To find out, we asked a few bonafide, penis-owning individuals if they could put it into words that coveted five seconds of orgasmic bliss. What we found? The question was downright hard. Asking men to explain the male orgasm was akin to having them describe the color orange. Regardless, we managed to cull a few truths.
1. The brain shuts off, and then a moment of clarity arises.
Andrew, a 30-year-old computer programmer said that during sex he's in a trance-like, robotic state. While he's physically there, his mind wanders into deep horny forests, that if asked about, rift gold are just as ephemeral and hard to explain as the orgasm itself, but after he comes? "Everything makes sense for a split second. Like I'm seeing things clearly for the first time. That to me is the most powerful thing about orgasm, the moments afterward." The Myth Of The Male Orgasm
2. It's feeling of passing "energy."
Adam a 27-year-old set designer says his orgasms are different depending on whether he's masturbating or having sex. Masturbation for him results in an orgasm out of necessity, but when he comes inside a woman he explains it as almost spiritual. RIFT Platinum "I feel like I'm passing the core of my soul to someone," he said. When we thought he couldn't be serious, he concluded, "not to be cheesy, but its like sharing your energy with somebody. Being so close to someone during a very vulnerable period."
3. The intensity varies depending on how long he holds out.
Paul, a 23-year-old actor says his most intense and earth shattering climaxes happen after he's reached the edge and held out a few times. Rift Gold "There's a differences between just letting loose when you first feel the urge and challenging yourself to hold out. I'm a million times more exhausted after I've stopped and kept going."
2011年4月21日星期四
Bulls 88, Pacers 84: Deng, Korver and A Crunchtime Possession Send Chicago To A 3-0 Series Lead
The headlines will point to Derrick Rose's drive and layup with the game tied at 84 and 30 seconds left in the fourth quarter. They will espouse his leadership, his grittiness, his ability to make the big play with the game on the line.
But save for that hoop, which was ultimately the game-winner, the Bulls likely won Game 3 in Indiana in spite of the presumptive MVP. They were in fact his only two points in the second half.
Rose and Carlos Boozer combined for 6-28 shooting in a grind-it-out battle at Conseco Fieldhouse, which on most nights means the Bulls would walk away with the rare L. Boozer once again came up short when his team needed him most, missing two easy lay-ins in the first quarter before getting two fouls and sitting until late in the second quarter. Indeed it seems that Boozer's reputation for coming up small in the playoffs is well-earned, but it is no less infuriating to see a team play better once its 15 million dollar a year player is seated firmly on the bench.
But team leader Luol Deng and crunchtime sharpshooter Kyle Korver lifted the Bulls when they needed it most. Deng finished with 21 points, six assists and three rebounds, including 14 first-half points when no other Bull cracked double figures. Korver had 12 points on 5-6 shooting in only 19 minutes of floor time, including two huge three-pointers. He is now 7-8 from distance in the playoffs and has lifted his game when his team needs it most.
The series in now 3-0 in Chicago's favor, but it could just as easily by 0-3. The main difference between the two teams is that Indiana lacks a late-game scoring option, as evidenced by Danny Granger's prayer three-pointer on the game's final possession, and the Bulls' combination of Closer Rose and lock-down defense in the game's final minutes.
If the Bulls manage to stay within shouting distance, there is a sense that the late-game combination of Rose and D (D-Rose, get it? Okay I'm ashamed.) will always pull out the victory. For all the team's struggles in this series, and there have been many, when it has gotten to crunchtime Chicago has shown its superiority.
It bears mentioning that against better competition, the Bulls will need to play their best for more than five minutes per contest. However take nothing away from these Pacers, Rift Gold who played their hearts out for the third straight game, only to have it broken for the third straight time. While Granger failed to hit his final shot, he was stellar throughout the contest, finishing with 21 points. The Pacers destroyed the Bulls on the interior, outscoring Chicago 38-16., and received their fair share of home cooking refereeing (which, to be fair, the Bulls benefited from at the United Center).
Joakim Noah keyed the Bulls' defensive effort with a signature double-double of 11 points and 10 rebounds, to go with four blocks. Chicago held the Pacers to 38% shooting and only 11 assists on 84 points. The Bulls did struggle on the glass in the second half, a first for this series, as they were out-rebounded 27-20, but overall coach Thibodeau had to be pleased with the defensive performance.
It has been a new struggle for every game in this series, first with poor defensive rotations in Game 1, then turnovers in Game 2, RIFT Platinum and shockingly tonight, rebounding. And make no mistake, the Bulls offense has a serious case of the hiccups that must be ironed out if they are to advance beyond the second round of the playoffs.
But Chicago has something that the rest of the league fears, that makes the Bulls contenders when similar teams wouldn't be. There isn't a team in the league with a better finishing kick than this one. rift gold When Derrick Rose has the ball in his hands, Deng and Korver on the wings, and Noah working the offensive glass, the Bulls can get points when they need them late. And good luck to the team that tries to break through Thibs' defensive five of Rose, Brewer, Noah, Taj and Deng. The Pacers had a shot to win or take the lead tonight and they barely got the ball to the three-point line.
No matter the manner, the Bulls have a commanding 3-0 lead in their first round series and have a chance to earn some much-needed healing and practice time if they can close out the Pacers on the road Saturday. RIFT Platinum Ugly or not, Chicago is winning games as it is supposed to and growing up along the way. Hard to ask for much more from a young team just beginning to understand what it might take to be a champion.
But save for that hoop, which was ultimately the game-winner, the Bulls likely won Game 3 in Indiana in spite of the presumptive MVP. They were in fact his only two points in the second half.
Rose and Carlos Boozer combined for 6-28 shooting in a grind-it-out battle at Conseco Fieldhouse, which on most nights means the Bulls would walk away with the rare L. Boozer once again came up short when his team needed him most, missing two easy lay-ins in the first quarter before getting two fouls and sitting until late in the second quarter. Indeed it seems that Boozer's reputation for coming up small in the playoffs is well-earned, but it is no less infuriating to see a team play better once its 15 million dollar a year player is seated firmly on the bench.
But team leader Luol Deng and crunchtime sharpshooter Kyle Korver lifted the Bulls when they needed it most. Deng finished with 21 points, six assists and three rebounds, including 14 first-half points when no other Bull cracked double figures. Korver had 12 points on 5-6 shooting in only 19 minutes of floor time, including two huge three-pointers. He is now 7-8 from distance in the playoffs and has lifted his game when his team needs it most.
The series in now 3-0 in Chicago's favor, but it could just as easily by 0-3. The main difference between the two teams is that Indiana lacks a late-game scoring option, as evidenced by Danny Granger's prayer three-pointer on the game's final possession, and the Bulls' combination of Closer Rose and lock-down defense in the game's final minutes.
If the Bulls manage to stay within shouting distance, there is a sense that the late-game combination of Rose and D (D-Rose, get it? Okay I'm ashamed.) will always pull out the victory. For all the team's struggles in this series, and there have been many, when it has gotten to crunchtime Chicago has shown its superiority.
It bears mentioning that against better competition, the Bulls will need to play their best for more than five minutes per contest. However take nothing away from these Pacers, Rift Gold who played their hearts out for the third straight game, only to have it broken for the third straight time. While Granger failed to hit his final shot, he was stellar throughout the contest, finishing with 21 points. The Pacers destroyed the Bulls on the interior, outscoring Chicago 38-16., and received their fair share of home cooking refereeing (which, to be fair, the Bulls benefited from at the United Center).
Joakim Noah keyed the Bulls' defensive effort with a signature double-double of 11 points and 10 rebounds, to go with four blocks. Chicago held the Pacers to 38% shooting and only 11 assists on 84 points. The Bulls did struggle on the glass in the second half, a first for this series, as they were out-rebounded 27-20, but overall coach Thibodeau had to be pleased with the defensive performance.
It has been a new struggle for every game in this series, first with poor defensive rotations in Game 1, then turnovers in Game 2, RIFT Platinum and shockingly tonight, rebounding. And make no mistake, the Bulls offense has a serious case of the hiccups that must be ironed out if they are to advance beyond the second round of the playoffs.
But Chicago has something that the rest of the league fears, that makes the Bulls contenders when similar teams wouldn't be. There isn't a team in the league with a better finishing kick than this one. rift gold When Derrick Rose has the ball in his hands, Deng and Korver on the wings, and Noah working the offensive glass, the Bulls can get points when they need them late. And good luck to the team that tries to break through Thibs' defensive five of Rose, Brewer, Noah, Taj and Deng. The Pacers had a shot to win or take the lead tonight and they barely got the ball to the three-point line.
No matter the manner, the Bulls have a commanding 3-0 lead in their first round series and have a chance to earn some much-needed healing and practice time if they can close out the Pacers on the road Saturday. RIFT Platinum Ugly or not, Chicago is winning games as it is supposed to and growing up along the way. Hard to ask for much more from a young team just beginning to understand what it might take to be a champion.
2011年4月20日星期三
The old adage "sleep tight and don't let the bedbugs bite" is taking on new meaning this summer as bedbug infestations are on the rise, RIFT Platinum from Iowa to Seattle, Minnesota to New York City, CBS Early Morning News reports.
In fact, infestations are becoming so common that exterminators can barely keep up: Calls about bedbugs are up 71 percent, from one or two calls a year to 10 to 50 per week since 2001, says Missy Henriksen, vice president of public affairs for the National Pest Management Association. Health officials in Manchester, N.H., even started a Bedbug Action Committee tasked with bringing the issue under control.
Infestations are on the rise, experts say, because bedbugs hitch a ride on our clothes and hang out in our beds. And they are not only found in homes; more and more bedbugs are showing up in hotels, dormitories and places where people frequently travel. Even retailers are not immune: Victoria's Secret in New York City closed its doors for several hours to exterminate the nasty critters.
Bedbugs are many things, but one thing they are not, is a threat to your health. rift gold They are not disease vectors and are not considered a public health risk, according to entomologists at Purdue University's Public Health and Medical Entomology department. But their bites do tend to leave itchy welts on human skin, and some people experience an allergic reaction. What's more, bedbug sufferers say these persistent creatures wreak havoc on the psyche.
"Besides the 'icky' feeling of knowing bugs have crawled over you in your sleep, even after the infestation has been dealt with, people may still have a fear of falling asleep and feel anxiety about the whole experience," says Henriksen. "In some cases, furniture [and] clothes have had to be thrown away, increasing the costly toll of the problem."
Bedbugs are typically most active at night and tend to bite exposed skin while people are sleeping. The face, neck, hands and arms are the most common sites. RIFT Platinum Typically, the bites produce redness, swelling and itching, but if scratched, they can become infected, which is the most bodily damage they can cause. A particularity of bedbug bites is that they show up as multiples in a row.
Entomologists say the bugs' presence has nothing to do with cleanliness, but the insects do produce small brown or red dots on sheets. And getting rid of them is not easy or cheap.
How do you spot a bedbug? Adult bedbugs are about 1/4-inch long, oval, reddish brown and wingless. Their bodies are very flat, and they possess long, slender legs and antennae, according to the Purdue scientists.
Bedbugs can travel easily -- from beds to sofa cushions, from room to room and even home via suitcases from travel. Once an infestation develops, whether in a home, a hotel or even a movie theater, bedbugs are extremely difficult to remove and require the experience of a pest professional. Bedbugs can live for a year or more without eating and can withstand a wide range of temperatures, from nearly freezing to almost 113 degrees Fahrenheit, says Henriksen.
And since it is the height of travel season (the resurgence of bedbugs is tied largely to international travel), Rift Gold it is important for travelers to know what to look for in hotels. The NPMA offers these tips:
* Pull back the hotel bed sheets and inspect the mattress seams, particularly the corners, for telltale brownish or reddish spots.
* Thoroughly inspect the entire room before unpacking. Do not put your luggage on the bed.
* If you change rooms but choose to stay in the same establishment, be sure your new room is not adjacent to the potentially infested room.
* Use a large plastic bag to store your luggage.
In fact, infestations are becoming so common that exterminators can barely keep up: Calls about bedbugs are up 71 percent, from one or two calls a year to 10 to 50 per week since 2001, says Missy Henriksen, vice president of public affairs for the National Pest Management Association. Health officials in Manchester, N.H., even started a Bedbug Action Committee tasked with bringing the issue under control.
Infestations are on the rise, experts say, because bedbugs hitch a ride on our clothes and hang out in our beds. And they are not only found in homes; more and more bedbugs are showing up in hotels, dormitories and places where people frequently travel. Even retailers are not immune: Victoria's Secret in New York City closed its doors for several hours to exterminate the nasty critters.
Bedbugs are many things, but one thing they are not, is a threat to your health. rift gold They are not disease vectors and are not considered a public health risk, according to entomologists at Purdue University's Public Health and Medical Entomology department. But their bites do tend to leave itchy welts on human skin, and some people experience an allergic reaction. What's more, bedbug sufferers say these persistent creatures wreak havoc on the psyche.
"Besides the 'icky' feeling of knowing bugs have crawled over you in your sleep, even after the infestation has been dealt with, people may still have a fear of falling asleep and feel anxiety about the whole experience," says Henriksen. "In some cases, furniture [and] clothes have had to be thrown away, increasing the costly toll of the problem."
Bedbugs are typically most active at night and tend to bite exposed skin while people are sleeping. The face, neck, hands and arms are the most common sites. RIFT Platinum Typically, the bites produce redness, swelling and itching, but if scratched, they can become infected, which is the most bodily damage they can cause. A particularity of bedbug bites is that they show up as multiples in a row.
Entomologists say the bugs' presence has nothing to do with cleanliness, but the insects do produce small brown or red dots on sheets. And getting rid of them is not easy or cheap.
How do you spot a bedbug? Adult bedbugs are about 1/4-inch long, oval, reddish brown and wingless. Their bodies are very flat, and they possess long, slender legs and antennae, according to the Purdue scientists.
Bedbugs can travel easily -- from beds to sofa cushions, from room to room and even home via suitcases from travel. Once an infestation develops, whether in a home, a hotel or even a movie theater, bedbugs are extremely difficult to remove and require the experience of a pest professional. Bedbugs can live for a year or more without eating and can withstand a wide range of temperatures, from nearly freezing to almost 113 degrees Fahrenheit, says Henriksen.
And since it is the height of travel season (the resurgence of bedbugs is tied largely to international travel), Rift Gold it is important for travelers to know what to look for in hotels. The NPMA offers these tips:
* Pull back the hotel bed sheets and inspect the mattress seams, particularly the corners, for telltale brownish or reddish spots.
* Thoroughly inspect the entire room before unpacking. Do not put your luggage on the bed.
* If you change rooms but choose to stay in the same establishment, be sure your new room is not adjacent to the potentially infested room.
* Use a large plastic bag to store your luggage.
Mark Hominick, a nine-year MMA veteran who will be fighting for his first major title in less than two weeks when he meets Jose Aldo at UFC 129, is finally cashing in.
And fittingly enough for the Ontario-born Hominick, a Canadian organization is backing him for the biggest fight of his career.
The Hamilton Tiger-Cats of the Canadian Football League announced on Wednesday that they had "entered a partnership" with the native of Thamesford, Ontario. Rift Gold In other words, the Ticats will be one of Hominick's sponsors for his UFC featherweight title fight.
As part of the partnership, Hominick will also be featured at 'MMA Night' at Hamilton's Ivor Wynne Stadium on July 16 when the Ticats host the Saskatchewan Roughriders.
According to a release by the team, Hominick will wear a Ticats hat as he enters the cage and will bear the team's logo and Web site on his shorts during the fight.
"I am very excited about this partnership with the Tiger-Cats," Hominick said at a press conference on Wednesday. "I can't wait to enter the octagon, in Canada, with millions of CFL and Ticats fans cheering me on. I am grateful for the Ticats support and look forward to representing the black and gold with pride."
Tom Wright, UFC Canada's director of operations, served as CFL commissioner from 2002 to 2007, however, RIFT Platinum he told MMA Fighting on Wednesday that he had nothing to do with the deal.
"A savvy move by a good marketing organization to line up with a great Canadian like Mark – purely coincidental with my years as Commish," Wright said.
The NBA's Sacramento Kings have been a long-time sponsor of UFC welterweight Diego Sanchez.
UFC 129 will mark the first major MMA event in Ontario since the province legalized the sport on Jan. 1, 2011. rift gold It will also shatter the North American MMA record for tickets sold (55,000) and live gate ($11 million).
"The popularity of MMA in Southern Ontario and in particular the Hamilton area is no secret," Ticats president Scott Mitchell said. "We look forward to working with Mark to promote an exciting game on July 16th featuring great MMA fighters and thousands of MMA enthusiasts. RIFT Platinum As an exciting, tough, local Canadian athlete, Mark embodies many of our organization's characteristics. We are glad to be in Mark's corner as he contends for the featherweight title and we know our fans in the TigerTown region will be behind him."
And fittingly enough for the Ontario-born Hominick, a Canadian organization is backing him for the biggest fight of his career.
The Hamilton Tiger-Cats of the Canadian Football League announced on Wednesday that they had "entered a partnership" with the native of Thamesford, Ontario. Rift Gold In other words, the Ticats will be one of Hominick's sponsors for his UFC featherweight title fight.
As part of the partnership, Hominick will also be featured at 'MMA Night' at Hamilton's Ivor Wynne Stadium on July 16 when the Ticats host the Saskatchewan Roughriders.
According to a release by the team, Hominick will wear a Ticats hat as he enters the cage and will bear the team's logo and Web site on his shorts during the fight.
"I am very excited about this partnership with the Tiger-Cats," Hominick said at a press conference on Wednesday. "I can't wait to enter the octagon, in Canada, with millions of CFL and Ticats fans cheering me on. I am grateful for the Ticats support and look forward to representing the black and gold with pride."
Tom Wright, UFC Canada's director of operations, served as CFL commissioner from 2002 to 2007, however, RIFT Platinum he told MMA Fighting on Wednesday that he had nothing to do with the deal.
"A savvy move by a good marketing organization to line up with a great Canadian like Mark – purely coincidental with my years as Commish," Wright said.
The NBA's Sacramento Kings have been a long-time sponsor of UFC welterweight Diego Sanchez.
UFC 129 will mark the first major MMA event in Ontario since the province legalized the sport on Jan. 1, 2011. rift gold It will also shatter the North American MMA record for tickets sold (55,000) and live gate ($11 million).
"The popularity of MMA in Southern Ontario and in particular the Hamilton area is no secret," Ticats president Scott Mitchell said. "We look forward to working with Mark to promote an exciting game on July 16th featuring great MMA fighters and thousands of MMA enthusiasts. RIFT Platinum As an exciting, tough, local Canadian athlete, Mark embodies many of our organization's characteristics. We are glad to be in Mark's corner as he contends for the featherweight title and we know our fans in the TigerTown region will be behind him."
Health Psychology
In 1977 George Engel published a seminal article titled ‘‘The Need for a New Medical Model,’’ in which he advocated for a multidisciplinary biopsychosocial model of health that incorporates psychological and social dimensions of well-being. This signaled the emergence of health psychology as a subdiscipline; the following year, the Health Psychology section of the American Psychological Association was established. Like other social and behavioral sciences,rift gold the field of health psychology developed partly in response to the rise of chronic disease and to the role of personal health habits in the etiology and Social Science Contributions to Public Health:
management of conditions such as cancer, heart disease, and diabetes. In addition, new models for understanding the complexity of contextual factors in the illness process enlarged the scope of analysis and intervention. The biopsychosocial model emphasizes the interplay of biological, psychological, and social factors in illness, and gives importance to multiple determinants and macro-level processes (Taylor, 2006). For example, stress and social support have been increasingly recognized as contributing factors in health. This broad view is compatible with the ecological perspective of public health.
rift gold
Important contributions from health psychology include the study of health behaviors such as smoking and exercise; research on stress, social support, and immune function; interventions for addictions; the relationship between mental illness and physical illness; and practical approaches to the management of chronic illness.
Some particular areas of note include studies of Type A behavior, hostility, and heart disease; health promotion strategies such as smoking cessation and weight management; methods for enhancing sexual health such as safer sex practices to reduce sexually transmitted infections; and psychosocial factors in the progression of cancer. As noted previously, social psychological models of health behavior change have dominated the public health field of health promotion and education.
management of conditions such as cancer, heart disease, and diabetes. In addition, new models for understanding the complexity of contextual factors in the illness process enlarged the scope of analysis and intervention. The biopsychosocial model emphasizes the interplay of biological, psychological, and social factors in illness, and gives importance to multiple determinants and macro-level processes (Taylor, 2006). For example, stress and social support have been increasingly recognized as contributing factors in health. This broad view is compatible with the ecological perspective of public health.
rift gold
Important contributions from health psychology include the study of health behaviors such as smoking and exercise; research on stress, social support, and immune function; interventions for addictions; the relationship between mental illness and physical illness; and practical approaches to the management of chronic illness.
Some particular areas of note include studies of Type A behavior, hostility, and heart disease; health promotion strategies such as smoking cessation and weight management; methods for enhancing sexual health such as safer sex practices to reduce sexually transmitted infections; and psychosocial factors in the progression of cancer. As noted previously, social psychological models of health behavior change have dominated the public health field of health promotion and education.
Equity in Health Services
The problem of equity with respect to health services is and remains a serious problem in American society. In a free market system lacking national health insurance, those personswho are economically disadvantaged are also medically disadvantaged when it comes to obtaining quality services. The United States has a two-track system of health-care delivery divided into a private track and a public track. The public track is a system of welfare medicine supported by public health insurance, especially Medicaid (for the poor) but also Medicare (for the elderly).
Public health insurance has provided access to the American health-care delivery system for the poor, but the character of the services rendered – that of welfare medicine – has not changed dramatically. The urban poor have historically been dependent on public hospitals rift gold and clinics rather than private hospitals and practitioners for providing patient care. And that is still the case today for many of the poor and near-poor as physicians, pharmacists, and hospitals have joined banks, supermarkets, and department stores in migrating out of inner-city areas where the poor are concentrated. Vladeck (1983: 9) describes a pattern that has remained unchanged for years: Apart from whatever esthetic differences such a pattern might imply, the fact remains that the poor – and to an even greater extent, the near-poor, who lack even the limited access to private physicians Medicaid provides – have no continuing relationship with individual physicians. This means that access to other services resides in the hands of bureaucratic strangers. The poor and nearpoor are more likely to be admitted to hospitals through emergency rooms than a scheduled admission, and more likely to be sicker when they are admitted. They are more likely to be treated by a foreign medical graduate, or a house staff physician still in training (or both) than a fully trained American graduate. Their drug prescriptions are written by physicians with less personal knowledge and understanding of the patients’ characteristics and problems, and they are likely to be seen on a follow-up visit by a physician other than the one who treated them originally.
The rural poor likewise have problems of access to health care as medical facilities and health practitioners may not be available locally. And the rural poor (as other people living in rural areas) also may be more likely to be treated by foreign medical school graduates. This situation is brought on by the doctor shortage in these areas caused by a reluctance of many American-trained physicians to work in small communities. Another segment of society particularly affected by problems of equity is the large number of Americans – over 16% of the population – who do not have health insurance. The largest proportion of persons (about 70%) without health insurance in 2003 were those whose family income was $50 000 or less. Most individuals and families without health insurance make too much money to qualify for Medicaid but still struggle financially. Many of them work for small businesses that cannot afford to offer health insurance to their employees. Not only does not having health insurance prevent or delay getting care for immediate health problems, but a lack of insurance over time has a strong negative cumulative effect on a person’s health (Quesnel-Valle´e, 2004). Without health insurance or available cash, people can be rift gold and are turned away from hospitals and sent elsewhere. Ultimately, they may be sent to ‘hospitals of last resort,’ which are generally public hospitals under the jurisdiction of city, county, or state governments. These hospitals are the ones that accept patients other hospitals refuse to treat because of an inability to pay for services.
Public health insurance has provided access to the American health-care delivery system for the poor, but the character of the services rendered – that of welfare medicine – has not changed dramatically. The urban poor have historically been dependent on public hospitals rift gold and clinics rather than private hospitals and practitioners for providing patient care. And that is still the case today for many of the poor and near-poor as physicians, pharmacists, and hospitals have joined banks, supermarkets, and department stores in migrating out of inner-city areas where the poor are concentrated. Vladeck (1983: 9) describes a pattern that has remained unchanged for years: Apart from whatever esthetic differences such a pattern might imply, the fact remains that the poor – and to an even greater extent, the near-poor, who lack even the limited access to private physicians Medicaid provides – have no continuing relationship with individual physicians. This means that access to other services resides in the hands of bureaucratic strangers. The poor and nearpoor are more likely to be admitted to hospitals through emergency rooms than a scheduled admission, and more likely to be sicker when they are admitted. They are more likely to be treated by a foreign medical graduate, or a house staff physician still in training (or both) than a fully trained American graduate. Their drug prescriptions are written by physicians with less personal knowledge and understanding of the patients’ characteristics and problems, and they are likely to be seen on a follow-up visit by a physician other than the one who treated them originally.
The rural poor likewise have problems of access to health care as medical facilities and health practitioners may not be available locally. And the rural poor (as other people living in rural areas) also may be more likely to be treated by foreign medical school graduates. This situation is brought on by the doctor shortage in these areas caused by a reluctance of many American-trained physicians to work in small communities. Another segment of society particularly affected by problems of equity is the large number of Americans – over 16% of the population – who do not have health insurance. The largest proportion of persons (about 70%) without health insurance in 2003 were those whose family income was $50 000 or less. Most individuals and families without health insurance make too much money to qualify for Medicaid but still struggle financially. Many of them work for small businesses that cannot afford to offer health insurance to their employees. Not only does not having health insurance prevent or delay getting care for immediate health problems, but a lack of insurance over time has a strong negative cumulative effect on a person’s health (Quesnel-Valle´e, 2004). Without health insurance or available cash, people can be rift gold and are turned away from hospitals and sent elsewhere. Ultimately, they may be sent to ‘hospitals of last resort,’ which are generally public hospitals under the jurisdiction of city, county, or state governments. These hospitals are the ones that accept patients other hospitals refuse to treat because of an inability to pay for services.
Health System of United States
The existing health-care delivery system in the United States is a conglomerate of health practitioners, agencies, and organizations, all of which share the mission of healthcare delivery but operate more or less independently. The greatest portion of all patient services, approximately 80%, is provided in offices and clinics by physicians who sell their services on a fee-for-service basis. About two thirds of all active physicians – some 480 000 practitioners out of a total of 717 500 – are involved in direct patient care in an office- or clinic-based practice,rift gold while the remainder are mostly residents in training, or fulltime staff members of hospitals.
The next most prominent form of health-care delivery consists of services provided by hospitals.With the exception of tax-supported government institutions, hospitals, like physicians, charge patients according to a fee-forservice system. Nonprofit hospitals charge patients for hospital services using the standard of recovering the full cost of services provided and meeting the hospital’s general expenses. Profit-making or proprietary hospitals not only calculate the cost of services rendered but also operate to realize a profit from those services. Nonprofit and profit-making hospitals rely heavily on third-party sources, either private health insurance or government agencies, to pay most or all of a patient’s bill.
Besides office-based medical practices and hospitals, the other types of organizations involved in the delivery of health care to the American public are official agencies, voluntary agencies, health maintenance organizations, preferred provider organizations, allied health enterprises in the business community, and traditional healing services. Official agencies are public organizations supported by tax funds, such as the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, the U.S. Public Health Service, and the Food and Drug Administration, which are intended to support and conduct research, develop educational materials, and provide services designed to minimize public health problems. Official agencies also have the responsibility for the direct medical care and health services required by special populations like reservation Indians, the military, veterans, the mentally ill, lepers, tuberculosis patients, alcoholics, and drug addicts.
Voluntary agencies are charitable organizations, such as the Multiple Sclerosis Society, the American Cancer Society, the American Heart Association, and the March of Dimes, who solicit funds from the general public and use them to support medical research and provide services for disease victims.
Health maintenance organizations (HMOs) are managed care prepaid group practices in which a person pays amonthly premium for comprehensive health-care services. HMOs are oriented toward preventive and ambulatory services intended to reduce rates of hospitalization. Under this arrangement, HMOs derive greater income from keeping their patients healthy and not having to pay for their hospital expenses than they would if large numbers of their subscribers were hospitalized. There is evidence that HMOs and other managed care organizations reduce hospital use and produce lower overall medical costs than the traditional open-market fee-for-service pattern (Wholey and Burns, 2000). Most of the savings are due to lower rates of hospitalization, but surgical rates and other fees may be lower for HMO populations. Physicians participating in HMOs may be paid according to a fee-for-service schedule, but many are paid a salary or on a capitation (set amount per patient) basis. Membership entitles patients to receive physicians’ services, hospitalization, laboratory tests, X-rays, and perhaps prescription drugs and other health needs at little or no additional cost.
There are some disadvantages to HMOs, namely, that patients (especially at night or on weekends) may be treated by whoever is on duty rather than their personal doctor, and a patient may need a referral from his or her primary care practitioner to consult a specialist. HMOs have attracted considerable attention because of their cost control potential and emphasis on preventive care. The number of HMOs and their enrollment have been rapidly increasing in the last few years. In 1970 there were 37 HMOs serving 3 million people; in 2003 there were 454 HMOs enrolling 71.8 million people. The peak year was 1999, when there were 651 HMOs with 81.3 million enrollees, or 31% of all Americans. The failure to meet expenses or make profits, along with patient dissatisfaction, has caused a decline in the number of both HMOs and patients, leaving HMOs with some 24.6% of the population as their clients. Included in this percentage are patients seen by individual practice associations (IPAs) which are solo practitioners or small groups of physicians who contract independently with HMOs to provide care to patients enrolled in their plans.
Preferred provider organizations (PPOs) are a form of managed care health organization in which employers who purchase group health insurance agree to send their employees to particular hospitals or doctors in return for discounts. PPOs have the advantage of being imposed on existing networks of hospitals and physicians without having to build clinics or convert doctors into employees. Doctors and hospitals associated with a PPO are expected to provide their usual services to PPO members, but lower charges are assessed against the members’ group health insurance. Thus, the health-care providers obtain more patients and in return charge less to the buyer of group insurance.
Allied health enterprises are the manufacturers of pharmaceuticals and medical supplies and equipment
which play a major role in research, development, and distribution of medical goods. Traditional healing services are healing options outside biomedicine that constitute forms of complementary and alternative medicine (CAM). CAMrefers to the use of treatments that are not commonly utilized by the medical profession, such as visits to chiropractors, faith healers, folk healers, acupuncturists, homeopaths, naturopaths, and the use of dietary supplements to cure or prevent disease. CAM also includes ayurveda, aromatherapy, shiatsu, crystal healing, biofeedback, and various other nonmedical techniques. The National Center for Complementary and Alternative Medicine was established by the U.S. Congress in 1992 to facilitate research, evaluate, and disseminate information on CAM techniques. The proportion of the population who use CAMis not known, although it is popular among some people (Baer, 2001). However, in relation to other health professionals, CAM practitioners occupy a marginal position in U.S. health-care delivery. The majority of Americans have health insurance benefits provided through their place of employment and paid for by contributions from both the employee and employer. In 1984, some 96% of all insured workers were enrolled in traditional health plans that allowed them to choose their own doctors and have most of their costs for physician and hospital services covered in an unmanaged fee-for-service arrangement. However, this situation changed dramatically because of soaring costs of health care and limitations being placed on the insurance benefits provided. By 1998, only 15% of all insured workers had unmanaged fee-for-service health plans, while the remainder had managed fee-for-service plans in which utilization was monitored and prior approval for some benefits, like hospitalization, was required. The day in which doctors and their patients decided just between themselves what care was needed without considering cost appears over, as financial concerns are increasingly influencing how patients are cared for.
Some features of the health-care delivery system in the United States remain unchanged. The system is pluralist, that is, it has more than one major client. It serves a substantial private sector, the elderly and the poor with government-sponsored health insurance, and a large uninsured population. But there has also been widespread change. As employers, both government and private corporations are the major purchasers of health services and so dominate health policy. Managed care is now the primary form of medical practice. This development means
that more people with private health insurance are limited in their use of health services to a particular managed care network, such as an HMO or PPO. Physician practice has shifted away from its historical roots in self-employment toward group and salaried arrangements that are better positioned to meet the current demands on providers stemming from both the change to managed care and the growth of medical technology (Gold, 1999). Physician incomes are increasing less rapidly than in the past, and professional autonomy is declining as well.
Given the magnitude of these changes – the reorganization of medical practice into managed care, along with constraints on income and autonomy – it is not surprising, as Gold (1999: 14) points out, that the satisfaction of physicians with their work situation has decreased. However, as Warren and her associates (1998: 364) explain,
‘‘Whereas physicians twenty years ago may have been horrified at the prospect of managed care, physicians now accept it as the rules of the game – at least in areas in which high percentages of patients belong to such plans – and recognize that the price of refusing to play by those rules is bankruptcy.’’
Thus, many physicians have had to make the adjustment to managed care, and the revenue, especially capitation fees, from this type of practice now constitutes a growing percentage of physician incomes.
Traditionally, doctors and hospitals have been paid on a fee-for-service basis. This method of payment is consistent with the principle of the open market, in which the consumers of health care, like the consumers of other products, are free to choose which health-care providers offer the best services at prices they can afford. Highquality services and affordable prices are supposed to result from competition among providers. Theoretically, physicians who are incompetent or who charge excessive fees and hospitals with lower-quality services would be driven out of the market by more competent, reasonably priced, and more effective physicians and better hospitals. To eliminate or reduce free choice would supposedly undermine the incentive of physicians and hospitals to satisfy patients.
The fee-for-service system is a highly attractive situation for doctors. It allows physicians to decide how much money they should charge for their services, how many patients they should have, how many hours they should work per week, what branch of medicine they should specialize in, and where they should practice medicine. The market, professional ethics, and sense of duty to their patients are supposed to block any desire to make as much money as possible.
Fee-for-service health-care delivery, however, is not a good example of a competitive marketplace. The fundamental law of the marketplace is supply and demand. When the supply of a product exceeds the demand for it, prices should drop. However, that law does not apply to medicine because physicians define what patients need and provide their services at prices they, their employers, or the federal government set. Therefore, doctors and hospitals create their own demand. Organized medicine has traditionally opposed changing the fee-for-service system because of the advantages it provides the profession. Yet fee-for-service discriminates against those people who are unable to pay the fees,rift gold making them dependent on welfare or charity. It also contributes to increased costs through high fees and the unnecessary duplication of technology and services by various providers and hospitals seeking to gain or maintain income.
Rising costs and lack of universal access to quality care finally forced changes, beginning with Medicare and Medicaid in the 1960s, and continuing today with the dominance of managed care systems charging a set capitation fee to patients each month. However, as noted, managed care constraints have eroded, leading to higher contributions for health insurance benefits on the part of both employers and employees, as well as higher costs for the care itself. Not surprising, the number of people without health insurance continues to increase. Light (2004) depicts the American health-care delivery system as the most costly, inefficient, wasteful, and inequitable system of health care in the industrialized world, while Mechanic (2004) describes it as disorganized and irrational. ‘In the final analysis,’ states Mechanic (2004: 83), ‘fault is in the failure of the United States to introduce a rational system of universal health care.’
The next most prominent form of health-care delivery consists of services provided by hospitals.With the exception of tax-supported government institutions, hospitals, like physicians, charge patients according to a fee-forservice system. Nonprofit hospitals charge patients for hospital services using the standard of recovering the full cost of services provided and meeting the hospital’s general expenses. Profit-making or proprietary hospitals not only calculate the cost of services rendered but also operate to realize a profit from those services. Nonprofit and profit-making hospitals rely heavily on third-party sources, either private health insurance or government agencies, to pay most or all of a patient’s bill.
Besides office-based medical practices and hospitals, the other types of organizations involved in the delivery of health care to the American public are official agencies, voluntary agencies, health maintenance organizations, preferred provider organizations, allied health enterprises in the business community, and traditional healing services. Official agencies are public organizations supported by tax funds, such as the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, the U.S. Public Health Service, and the Food and Drug Administration, which are intended to support and conduct research, develop educational materials, and provide services designed to minimize public health problems. Official agencies also have the responsibility for the direct medical care and health services required by special populations like reservation Indians, the military, veterans, the mentally ill, lepers, tuberculosis patients, alcoholics, and drug addicts.
Voluntary agencies are charitable organizations, such as the Multiple Sclerosis Society, the American Cancer Society, the American Heart Association, and the March of Dimes, who solicit funds from the general public and use them to support medical research and provide services for disease victims.
Health maintenance organizations (HMOs) are managed care prepaid group practices in which a person pays amonthly premium for comprehensive health-care services. HMOs are oriented toward preventive and ambulatory services intended to reduce rates of hospitalization. Under this arrangement, HMOs derive greater income from keeping their patients healthy and not having to pay for their hospital expenses than they would if large numbers of their subscribers were hospitalized. There is evidence that HMOs and other managed care organizations reduce hospital use and produce lower overall medical costs than the traditional open-market fee-for-service pattern (Wholey and Burns, 2000). Most of the savings are due to lower rates of hospitalization, but surgical rates and other fees may be lower for HMO populations. Physicians participating in HMOs may be paid according to a fee-for-service schedule, but many are paid a salary or on a capitation (set amount per patient) basis. Membership entitles patients to receive physicians’ services, hospitalization, laboratory tests, X-rays, and perhaps prescription drugs and other health needs at little or no additional cost.
There are some disadvantages to HMOs, namely, that patients (especially at night or on weekends) may be treated by whoever is on duty rather than their personal doctor, and a patient may need a referral from his or her primary care practitioner to consult a specialist. HMOs have attracted considerable attention because of their cost control potential and emphasis on preventive care. The number of HMOs and their enrollment have been rapidly increasing in the last few years. In 1970 there were 37 HMOs serving 3 million people; in 2003 there were 454 HMOs enrolling 71.8 million people. The peak year was 1999, when there were 651 HMOs with 81.3 million enrollees, or 31% of all Americans. The failure to meet expenses or make profits, along with patient dissatisfaction, has caused a decline in the number of both HMOs and patients, leaving HMOs with some 24.6% of the population as their clients. Included in this percentage are patients seen by individual practice associations (IPAs) which are solo practitioners or small groups of physicians who contract independently with HMOs to provide care to patients enrolled in their plans.
Preferred provider organizations (PPOs) are a form of managed care health organization in which employers who purchase group health insurance agree to send their employees to particular hospitals or doctors in return for discounts. PPOs have the advantage of being imposed on existing networks of hospitals and physicians without having to build clinics or convert doctors into employees. Doctors and hospitals associated with a PPO are expected to provide their usual services to PPO members, but lower charges are assessed against the members’ group health insurance. Thus, the health-care providers obtain more patients and in return charge less to the buyer of group insurance.
Allied health enterprises are the manufacturers of pharmaceuticals and medical supplies and equipment
which play a major role in research, development, and distribution of medical goods. Traditional healing services are healing options outside biomedicine that constitute forms of complementary and alternative medicine (CAM). CAMrefers to the use of treatments that are not commonly utilized by the medical profession, such as visits to chiropractors, faith healers, folk healers, acupuncturists, homeopaths, naturopaths, and the use of dietary supplements to cure or prevent disease. CAM also includes ayurveda, aromatherapy, shiatsu, crystal healing, biofeedback, and various other nonmedical techniques. The National Center for Complementary and Alternative Medicine was established by the U.S. Congress in 1992 to facilitate research, evaluate, and disseminate information on CAM techniques. The proportion of the population who use CAMis not known, although it is popular among some people (Baer, 2001). However, in relation to other health professionals, CAM practitioners occupy a marginal position in U.S. health-care delivery. The majority of Americans have health insurance benefits provided through their place of employment and paid for by contributions from both the employee and employer. In 1984, some 96% of all insured workers were enrolled in traditional health plans that allowed them to choose their own doctors and have most of their costs for physician and hospital services covered in an unmanaged fee-for-service arrangement. However, this situation changed dramatically because of soaring costs of health care and limitations being placed on the insurance benefits provided. By 1998, only 15% of all insured workers had unmanaged fee-for-service health plans, while the remainder had managed fee-for-service plans in which utilization was monitored and prior approval for some benefits, like hospitalization, was required. The day in which doctors and their patients decided just between themselves what care was needed without considering cost appears over, as financial concerns are increasingly influencing how patients are cared for.
Some features of the health-care delivery system in the United States remain unchanged. The system is pluralist, that is, it has more than one major client. It serves a substantial private sector, the elderly and the poor with government-sponsored health insurance, and a large uninsured population. But there has also been widespread change. As employers, both government and private corporations are the major purchasers of health services and so dominate health policy. Managed care is now the primary form of medical practice. This development means
that more people with private health insurance are limited in their use of health services to a particular managed care network, such as an HMO or PPO. Physician practice has shifted away from its historical roots in self-employment toward group and salaried arrangements that are better positioned to meet the current demands on providers stemming from both the change to managed care and the growth of medical technology (Gold, 1999). Physician incomes are increasing less rapidly than in the past, and professional autonomy is declining as well.
Given the magnitude of these changes – the reorganization of medical practice into managed care, along with constraints on income and autonomy – it is not surprising, as Gold (1999: 14) points out, that the satisfaction of physicians with their work situation has decreased. However, as Warren and her associates (1998: 364) explain,
‘‘Whereas physicians twenty years ago may have been horrified at the prospect of managed care, physicians now accept it as the rules of the game – at least in areas in which high percentages of patients belong to such plans – and recognize that the price of refusing to play by those rules is bankruptcy.’’
Thus, many physicians have had to make the adjustment to managed care, and the revenue, especially capitation fees, from this type of practice now constitutes a growing percentage of physician incomes.
Traditionally, doctors and hospitals have been paid on a fee-for-service basis. This method of payment is consistent with the principle of the open market, in which the consumers of health care, like the consumers of other products, are free to choose which health-care providers offer the best services at prices they can afford. Highquality services and affordable prices are supposed to result from competition among providers. Theoretically, physicians who are incompetent or who charge excessive fees and hospitals with lower-quality services would be driven out of the market by more competent, reasonably priced, and more effective physicians and better hospitals. To eliminate or reduce free choice would supposedly undermine the incentive of physicians and hospitals to satisfy patients.
The fee-for-service system is a highly attractive situation for doctors. It allows physicians to decide how much money they should charge for their services, how many patients they should have, how many hours they should work per week, what branch of medicine they should specialize in, and where they should practice medicine. The market, professional ethics, and sense of duty to their patients are supposed to block any desire to make as much money as possible.
Fee-for-service health-care delivery, however, is not a good example of a competitive marketplace. The fundamental law of the marketplace is supply and demand. When the supply of a product exceeds the demand for it, prices should drop. However, that law does not apply to medicine because physicians define what patients need and provide their services at prices they, their employers, or the federal government set. Therefore, doctors and hospitals create their own demand. Organized medicine has traditionally opposed changing the fee-for-service system because of the advantages it provides the profession. Yet fee-for-service discriminates against those people who are unable to pay the fees,rift gold making them dependent on welfare or charity. It also contributes to increased costs through high fees and the unnecessary duplication of technology and services by various providers and hospitals seeking to gain or maintain income.
Rising costs and lack of universal access to quality care finally forced changes, beginning with Medicare and Medicaid in the 1960s, and continuing today with the dominance of managed care systems charging a set capitation fee to patients each month. However, as noted, managed care constraints have eroded, leading to higher contributions for health insurance benefits on the part of both employers and employees, as well as higher costs for the care itself. Not surprising, the number of people without health insurance continues to increase. Light (2004) depicts the American health-care delivery system as the most costly, inefficient, wasteful, and inequitable system of health care in the industrialized world, while Mechanic (2004) describes it as disorganized and irrational. ‘In the final analysis,’ states Mechanic (2004: 83), ‘fault is in the failure of the United States to introduce a rational system of universal health care.’
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