Friday, January 13, 2017

New Year. New Administration

With change always comes uncertainty. There are many political issues as stake in 2017, but one of the biggest is the fate of the Affordable Care Act.  At the moment, Republicans are lobbying to repeal the Act originally passed in 2010.  This past week, the U.S. Senate passed a budget blueprint, which was the first step in a possible repeal.  This blueprint paves the way for repealing or revising certain portions of the law.  The new administration has also vowed to make significant changes to the Affordable Care act through both executive power and legislative actions.

At this point, it is very hard to say what affect these changes will have on healthcare professionals and healthcare consumers.  Of course, the major concern is loss of insurance coverage to those who depend on the federal exchanges and subsidies.  Also largely at stake are early components of the Act, which allowed students to stay on their parent’s insurance until the age of 26 and most importantly blocked insurance companies from refusing to cover individuals with pre-existing conditions.

There are a few other portions of the law that many have come to rely upon, but others no little about.  These include:

1.  Calorie counts – Restaurants with 20 or more buildings are required to post the caloric content of food on their menus.

2.  Breast feeding rights – The Affordable Care Act requires organizations to provide several accommodations to mothers who are breast-feeding and also includes insurance coverage of certain equipment.

3.  Community Needs Assessments – Nonprofits healthcare organizations are required to perform community needs assessments every three years.

4.  Habilitative Care – In the past certain therapies were only covered by insurance for rehabilitative purposes (e.g., stroke or injury related).  The Affordable Care Act included coverage for habilitative therapy (e.g., speech therapy for a child born with autism).

5.  Prescription Drug Costs – the Affordable Care Act included better coverage for prescription drugs through Medicare. 

Other issues at stake include an increase in the federal deficit if individuals can opt out of purchasing health insurance.  Without the young and healthy to fund healthcare for the elderly and ill, the federal government will need to pick up the added cost.  In addition, it is unknown if states who expanded their Medicaid programs will opt to continue to offer coverage to those who no longer qualify.

Obviously, 2017 might prove to be as interesting as 2016.  Let’s hope the focus is on autonomy and utilitarianism.  Provide the greatest good to the greatest number of people while protecting the rights of our citizens.  It’s a large task.  

Provided by Valerie Connor, MA,CCC-SLP; MS CHES. Adjunct Faculty, Saint Joseph's College

Tuesday, December 13, 2016

A few pointers on how to be a successful Nursing Home Administrator!!

You have just received your Nursing Home Administrator License and have been offered your first opportunity to lead your own Facility. Here a couple of pointers that will help you be a success!!
First and foremost……..get yourself a really good Director of Nursing!! The right person in this vital position can and will make your new opportunity much more rewarding!!! How does one go about getting an excellent Director of Nurses…..if I knew the answer to that one, I would be able to retire and live life as a millionaire!!!

Second….know the Regulations!! The Surveyors will certainly know them (or at least they will know what regulations to cite). You will, therefore, need to respond in the event your Facility receives a citation. Of course, knowing the regulations up front should help in preparation for the survey. In addition, by being familiar with the regulations you should be able to provide a safer, more comfortable home for those in your care.

Third…..interact with the staff, residents and family members in your community!! How important is this to your success as a Nursing Home Administrator? Well, since you are now the team leader, I would say it is extremely important!!!

This is the Resident’s home and you need to make them feel comfortable in their own home!!! The Family members have entrusted your facility with taking care of those they love. They need to feel comfortable and confident that you consider their well-being to be first and foremost. The Staff are the front line in both caring for the residents and in turn, caring for the family members!!!

How does one go about interacting with staff, residents and family members? Make your-self available to meet and chat with all concerned. Make a sincere effort to involve the staff in the decision making process. Listen to the concerns expressed by those in your care!! Maybe what you think is a great idea or practice may not be as wonderful as you originally imagined. Does this mean that you should not follow your own ideas and thoughts? Absolutely not!!! But if you listen to those who have a contrary opinion, they just might raise an issue or concern that you had not originally thought about. Maybe if you alter your plans slightly, the result will be far greater.

 Always remember, one can accomplish more with the support and confidence of those you lead. A smile, a hello and a thank you can go a long way to show others your leadership strengths!!!
And of course………never be afraid to admit that you did something wrong and offer a most sincere apology!!!

Now go forth, smile and offer a friendly greeting to everyone you come in contact with today!!!

 Submitted by Charlie Carrozza, Adjunct Faculty, Saint Joseph's College

Wednesday, November 16, 2016

Right to Die

During the November election, Colorado residents voted to approve Proposition 106, The End of Life Options Act.  I happened to be in Denver this past summer when grassroots activists were pounding the pavement requesting signatures on the petition.  When I was approached, I disappointed the young activist when I told him that my signature wouldn’t help because I’m from Iowa.  However, as I walked away, I wasn’t sure if I would have wanted to sign the petition or not.  Even after teaching the legal and ethical issues surrounding end of life decisions for nearly 10 years, I’m still on the fence on this issue.

On the one hand, I am a huge proponent of patient autonomy.  It is my firm belief, from a legal and ethical standpoint, that patients should be informed of all their treatment options and be able to choose treatment options without prejudice or bias from healthcare professionals.  However, as more states choose to legalize physician-assisted suicide, it becomes clear that not all patients are offered the same choices.  Their choices are limited by geography.

Physician-assisted suicide statutes have been passed in Oregon, Washington, Vermont, California, Colorado, and the District of Columbia.  In addition, court cases have legalized a patient’s right to end their own life in Montana and possibly New Mexico (pending new regulations).  So, if you live in one of those states, have a diagnosis of a long-term illness with a prognosis of six months or less to live AND meet a slew of other qualifications, you can obtain a prescription for a lethal dose of medication to end your own life on your own terms.  In many cases, the patients will obtain the prescription and never take the medication – more of a safety blanket, if you will.

As a huge proponent of patient autonomy, I feel that any law that gives patients more control is a step in the right direction.  However, after reading Atul Gawande’s book “Being Mortal,” I was swayed in a different direction.  If physician-assisted suicide is the best choice that we can offer patients at the end of life, are we failing our duty to balance beneficence and nonmaleficence?  If ending a life on purpose is the best way to keep a patient comfortable in the end stages of a terminal illness, we might really be focusing on the wrong issues.

That being said, as healthcare administrators, it’s important to know and understand the law in your state.  If your state has legalized physician-assisted suicide, it is your legal and ethical duty to make sure patients are aware of that option.  Hospice facilities should have information on the option and educate patients on the availability.  Many religious institutions might not feel comfortable doing this, but failing to inform patients of their options would be a violation of the Patient Self-Determination act, which protects patients’ right to know ALL treatment options.

If you are not familiar, take a few minutes to learn more about your state’s position on physician-assisted suicide today:


Submitted by Valerie Connor, MA CCC-SLP, CHES, Adjunct Faculty, Saint Joseph's College

Thursday, September 29, 2016

Navigational Thinking & Being Older

We see things not as they are, but as we are.
-H.M. Tomlinson

Navigational Thinking is an effective strategy for recalibrating perspective. It
offers aging adults a process to create a more useful attitude about being older.
Navigational thinking mimics the strategy that pilots use during an in-flight
emergency. Pilots resist the natural response to panic by focusing their attention
on a set of predetermined questions that lead them to useful thinking about the
best course of action to save not only their lives, but also the lives of the
passengers who are counting on them.

Although Navigational Thinking acknowledges a decline in outlook is a normal
response to upheaval of being older, it insists that a course correction is not only
possible but is necessary to preserve quality of life.

Navigational Thinking is designed to capitalize on the unique opportunity aging
adults have to orchestrate a different outcome. To accomplish this, it provides
them with a new thinking ritual they can use to change the internal discussion
they are having about their experiences. It taps into the cognition-emotion
connection in the brain and redirects the emotional intensity of being older into a
more useful, positive perspective.

Navigational Thinking is comprised of three reframing questions that increase
control and facilitate legacy. They can be used at any time and in any situation.
This is not a quick fix that will magically transform a negative attitude back into
first half optimism. Rather, Navigational Thinking is a rebalancing tool for the
distorted thinking that being older creates, a cognitive reframing system that
slowly begins to restore a more sustainable and nurturing perspective.

Navigational Thinking questions can be asked in any order. All three questions
begin to reverse the myopia of “problem fixation” that a negative attitude imposes
on aging adults by redirecting their focus to new insights, choices, and solutions.
The questions have no right or wrong answers; they are not a test. They offer a
starting point for a new internal conversation. Like all cognitive strategies, they
are most effective when written down, reconsidered, annotated, and shared on a
regular basis.

1. What is the big picture of being older?
The years forever fashion new dreams when old ones go. God help the one
dream man…Robert Goddard
Aging brings with it losses and recovery. This is not a new experience for aging
adults who are veterans of life’s give and take. Yes, being older has painful
setbacks, but at the same time it mobilizes new channels of courage and
resiliency in a world where time is no longer vague or intangible. It also fosters a
deeper gratitude for family and friends who anchor love and support. Aging
adults are free to savor both the past and an amplified present with just enough
time to make a difference.

2. What are my choices in being older?
Ever tired. Ever failed. No matter. Try again. Fail again. Fail better…Samuel
Aging takes its toll. It is easy to become defeated by losses and setbacks.
Withdrawal and isolation are common is a society that venerates youth and sees
aging as pathology. Despite these emotional and cultural headwinds, being older
still offers the opportunity to dance with circumstances. Aging adults are free to
set the agenda and see what happens. They are equally free to change their
minds, be out of character or reclaim a dream. The same is true for
disengagements and amends. It is also possible to do nothing and dance with
the gift of each day. Aging changes many things but choice survives it all.

3. What can I learn from being older?
The wiser mind mourns less for what age takes away than what it leaves
behind…William Wordsworth
Aging leaves in its wake lessons about being older. First and foremost, aging
adults come to understand that life is hard for everyone. This transformative
insight paves the way for an inclusive empathy through patience and kindness.
Second, aging adults have come far enough to see that life always works out of
its own volition, an insight that marks the limits of their control over life’s drama.
Aging adults are called to adopt a new perseverance that is less apologetic about
being older and more accepting of the opportunity life presents without fanfare or
limits each day.
Contributed by David Solie, Adjunct Faculty, Saint Joseph's College

Tuesday, September 13, 2016

Happy National Assisted Living Week!

The week of September 11-17, beginning with Grandparents’ Day, is designated as the week to honor assisted living.  This year’s theme is Keep Connected.  In 2005, 2% of older adults used social media; today, 35% do.  It seems Granny is keeping up with the times!

Social media plays a great role in the lives of many seniors, including residents of assisted living.  By staying connected with family members who live far away, they don’t feel as disconnected and lonely.  Family members at a distance also appreciate staying “in the loop” with their loved one’s care and lifestyle.  One of my residents was reassured to Skype with her grandson while he was deployed in Afghanistan. 

The field of assisted living continues to evolve, primarily in response to market demands.  There is no standard definition of assisted living due to this ambiguity.  For this reason, those potential residents and their families should determine what services they require now, and are likely to require in the next few years.  Costs will vary greatly depending upon the services offered.  If the loved one can still be independent with many household tasks, can he/she perform them?  If the person loses that ability, then can staff supplement and provide assistance? 

A valuable guide to help in evaluating needs and making decisions can be found at

During this special week of recognition, let’s express appreciation to the caregivers in assisted living, and recognize the valuable accomplishments that our assisted living residents have made.  May our understanding and provision of assisted living services continue to evolve to meet the needs of our beloved seniors!

Contributed by Philip C. DuBois, CNHA, FACHCA

Program Manager, Long Term Care Administration, Saint Joseph's College

Thursday, September 01, 2016

Gender Issues?

On May 13th, President Obama issued a directive to public schools requiring them to allow transgender students to use the bathrooms and lockers of the gender to which they associate.  If a school did not cooperate, the President threatened to take away their federal funding.  Last week, U.S. District Judge Reed O’Connor heard arguments against this directive and put a temporary stop on the order.  Several other states are suing the President on this issue.

The arguments surround two issues.  First is federal overreach – opponents of the directive claim that the directive came without time for input and that the President did not follow the appropriate rule-making process.  The second issue is terminology.  Title IX prohibits discrimination based on sex, but the word “gender” is not utilized.

Likely, this decision will be appealed and we will hear more about it in the coming months.  In the meantime, healthcare facilities can be proactive about future transgender issues.   Here are a few suggestions from the American Medical Student Association:

1.  Have a gender-neutral bathroom at your facility.  Many facilities already have bathrooms designated for family use – these could also be used as gender-neutral bathrooms. 

2.  When asking for gender on a health history form, leave a blank so that people can fill in their choice, rather than only offering two choices.

3.  Use gender-neutral language when discussing a patient’s partner.

4.  Be aware of health disparities and inequalities that occur in the transgender population. 

For more information, please see: 


Contributed by Valerie Connor, MA, CCC-SLP, CHES Adjunct Faculty, Saint Joseph's College

Monday, August 08, 2016

Design Thinking in Healthcare

What exactly is design thinking?  Basically, it is a problem-solving process adapted from the design field to create, develop or improve a product, service or process.  While design thinking seems logical for many industries (think of automobile design or mobile technology), its application to health care might not come so easily.

Design thinking takes the perspective of creation or improvement and applies it to services, products and experiences. Natalie Nixon, a nationally recognized leader in design thinking, outlines elements of design-thinking theory:  observe and understand, brainstorm and create, prototype and test and finally, implement.  (Nixon, 2013).

Applying this process to health care has many possibilities.  It doesn’t have to be grand but could be used to develop innovative processes to serve patients or new delivery approaches.  It could be as simple as designing walkways for aging adults to creating interactive robots to assist nurses.

If you are interested in reading more about design thinking, here are two good articles introducing the concept: 
Design Thinking by Tim Brown in the June 2008 issue of Harvard Business Review and Viewing Ascension Health from a Design Thinking Perspective by Natalie W. Nixon from the Journal of Organization Design 2(3): 22-28, 2013.  (Referenced above.)

Nixon, N.  (2013).  Viewing Ascension Health from a Design Thinking Perspective.  Journal of Organization Design 2(3):  p. 22-28.

Contributed by Dr. Becky Urbanski, Adjunct Faculty for Saint Joseph's College

Tuesday, August 02, 2016

Abortion from a LEGAL Perspective

The following is a legal discussion of the issue of abortion. It is does not intend to address the ethical issues.

Abortion.  It’s a heated topic in most years and a red hot topic during presidential election years.  There are common misconceptions about laws surrounding abortion, so sometimes it is good to step back and look at the issues.

Roe v Wade:  In this landmark case, the Supreme Court ruled that a women’s right to privacy extends to making decisions about her fetus – including the right to have an abortion.  The right is completely autonomous in the first trimester and then states have limited rights to restrict during the second and third trimester.  (Third trimester abortions are illegal in most states).  The case also granted the states the right to place other restrictions, such as parental consent for minors.  The key issue in Roe v. Wade is privacy – not the legality or moral implications of abortion.

Conscience Clause: This federal regulatory law allows healthcare facilities and healthcare professionals to opt out of procedures that they find morally questionable.  To this end, most healthcare facilities with Catholic affiliation will not perform sterilization procedures or abortions.  Because this is a regulatory law, it can change when we have a federal administration change.  For example, during the Bush administration, the Conscience Clause included pharmacists and allowed them to refuse to fill morning after pill prescriptions.  When Obama was elected, his administration removed that component because they felt it put an undue burden on patients seeking that contraceptive alternative.  States have the ability to expand the conscience clause allowances (see resource below).

These issues will most likely be touched upon in upcoming presidential debates.  One of the key issues centers on the fact that the next president will appoint at least one new Supreme Court Justice, and likely several others, during his/her tenure.  The thought from both sides is to promote a Justice who supports their side: Pro-life vs Pro-choice.  However, the history books have shown that the issue is not really the sanctity of life.  It is allowing patients the right to make private decisions about their healthcare options.  Just as in Montana vs. Baxter, the Supreme Court ruled that an individual’s right to privacy extends to the right to die with dignity.  The right to privacy is as precious to U.S. citizens as the right to free speech.   It is unlikely that any sworn protector of the Constitution would feel otherwise.


 Provided by Valerie Connor, MA CCC-SLP, CHES; Adjunct Faculty, Saint Joseph's College

Monday, July 18, 2016

Mental Health & Substance Use

CMS finalized their ruling on mental health and substance use for Medicaid and CHIP on March 29, 2016. The goal for CMS was to strengthen access to mental health and substance use services to ultimately align themselves to that of private/commercial insurance companies. The overall goal of the program was to make the services for mental health and substance use similar to those of medical and surgical services offered to their beneficiaries.

The Affordable Care Act was instrumental in increasing access for patients so that more people could get the help that they need with regards to the challenges they are experiencing in their lives. The final rule allows services to be enhanced for approximately 23 million people enrolled in Medicaid Managed Care Programs, Medicaid Alternative Benefit Plans, and CHIP. The final ruling keeps the flexibility for the states to manage this process, and at the same time, guaranteeing that Medicaid enrollees are able to access these important services.  

Through this final rule, insurance plans must disclose information on mental health and substance use disorder benefits upon request. These requests will include the criteria that is used to determine medical necessity. In addition, the states are required to disclose the reason for any denial of payment for these services for their Medicaid beneficiaries. CMS introduced several initiatives to help states transform their existing programs to be better capable of meeting the needs of their beneficiaries. 

They are as follows as listed in the final rule:

·         In 2014, CMS launched the Innovation Accelerator Program, a new strategic and technical support platform designed to improve delivery systems for beneficiaries that are high need and high cost.
·         CMS issued guidance to states on a new section 1115 demonstration opportunity to develop a full continuum of care for beneficiaries with a substance use disorder, including coverage for short-term residential treatment services not otherwise covered by Medicaid.

·         In response to the growing prescription opioid abuse epidemic, CMS recently released information on effective safeguards and options to help address over-prescribing of opioid pain medications.
·         CMS disseminated important information regarding screening and early intervention services for children and youth who have or may have a mental illness or substance use disorder, including best practice information for the delivery of medication-assisted treatment as well as services and supports that can address first psychiatric episodes to reduce the likelihood of ongoing hospitalizations, involvement with police and courts, and increase the chances of keeping families intact.  

As we can see, the epidemic that society and our healthcare system are facing is not going unnoticed. However, continued enhancement to behavioral health and substance use disorders needs to take place, not only at the federal level, but at the private/commercial level as well. Most importantly, a clear and easily understandable set of rules and guidelines, along with ease of communication between payer and patient, would be helpful for all parties involved.

Submitted by Kevin Harrington, Full-Time Faculty, Saint Joseph's College

Thursday, June 30, 2016

Is Linking Patient Satisfaction to Reimbursement Feasible?

In 2006, the Centers for Medicare and Medicaid (CMS) instituted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a survey which serves as a standard measure of patient satisfaction.  HCAHPS became mandatory in 2007 for facilities who receive Inpatient Prospective Payment System (IPPS) funds and wished to be eligible for full payment.  This was further solidified when the Hospital Value Purchasing Program (VBP) was instituted as part of the Patient Protection and Affordable Care Act (PPACA) in October, 2012.  This affects Medicare payments; however, it is projected to be applied to Medicaid and the Children’s Health Insurance Program shortly—the process was piloted in 2015.

The survey is administered usually anytime from 48 hours to 42 calendar days post discharge.  That is a large window and distance can skew results both positively and negatively.  The most honest response is likely to occur shortly after discharge. If a patient becomes incapacitated and goes into long-term care, the family members will complete the survey. 

HCAHPS consists of 32 questions that ask how often a patient experienced a critical aspect of hospital care. The questions from the March 2016 version are as follows:

Scale: Never Sometimes Usually Always
During this hospital stay:
1.  How often did nurses treat you with courtesy and respect?
2.  How often did the nurses listen carefully to you?
3.  How often did nurses explain things in a way you could understand?
4.  After you pressed the call button how often did you get help as soon as you wanted?

Questions 5-7 are questions 1-2 repeated asking about the physician in lieu of the nurse.

8.  How often were your room and bathrooms kept clean?
9.  During this hospital stay how often was the area around your room quiet at night?
10-11.  If a bedpan was used, how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
12-13.  If pain medicine was administered, how often was your pain well controlled?
14.  How often did the hospital staff do everything they could do to help you with your pain?
15-16. If new medicine was administered, how often did the hospital staff tell you what the medicine was for?
17.  How often did hospital staff describe possible side effects in a way you could understand?

Questions 18-20 are demographic in nature and yes/no questions regarding written discharge info.

21.  Patients are requested to rank the hospital stay from 1-10 with zero being the worse possible stay.

22-32 Demographic questions with the most important being would the patient recommend the hospital to others.

In October, 2012 CMS began withholding 1% of hospital’s Medicare reimbursement in case patient satisfaction scores did not meet thresholds.   By 2018 a total of 2% will be withheld. Through a complicated set of measures and calculations, reimbursement incentives are calculated.  The calculations can be found at
This ultimately results in up to 30% of a facility’s reimbursement being tied to patient satisfaction which is measured by the HCAPHS.  If the patient does not answer these questions positively, reimbursement will be significantly affected. Hospitals nationally will be compared with one another; thresholds will be set for each reporting period based on the 50th percentile and the high performers nationally.  In areas where most hospitals do very well, small changes can have a very significant impact and result in reduced reimbursement.

Most likely everyone can agree patient satisfaction is important.  But does patient satisfaction with care equate to quality of care?  A patient can be very happy with his hospital stay, yet he may have not received the best clinical medical care.  What a patient wants is not always what he/she truly needs.

There are a plethora of confounding variables surrounding this issue.  These issues include health literacy, language barriers, but most importantly perceptions. If you look at the rating system (Always, Usually, Sometimes, Never) and questions 1-2 and 5-7 about nurses and physicians treating the patient with courtesy and listening, there are potential perception issues.  How much is usually?  Is it 7 out of 10 interactions?  It may in fact be to the ones who created the survey, but is it to the patients?  A patient could interpret a few instances within 100 interactions as either always, usually or sometimes depending on the patient’s perspective that particular day.  If a nurse is in a room talking with Patient A when suddenly she is called away to her patient down the hall by a colleague, the patient she was talking to may perceive this as a negative interaction and mark the nurse down on listening.  Yet she might have been called away because a patient coded; because of HIPAA, Patient A has no right to know this.  The nurse can apologize for being called away for an emergency, but Patient A may view her emergency as more important than Patient B’s even if she just wanted someone to talk to and Patient B was dying. 

Let’s look at question 4.  The key to this question is “as soon as you wanted it.”  There is a big difference between a patient who rings the call button to have someone close the drapes compared to someone that rings it in an emergency.  Yet some patients expect immediate response to their every request as those who have worked in health care can attest. 

The question surrounding pain management is particularly problematic when considering patient perceptions.  Pain is real and we all feel it differently; however, those who are drug-seekers and drug abusers may likely note their pain was never controlled because they want higher level of narcotics.  Yet these patients may be included in sampling if they do not have a psychiatric diagnosis.

In general, it is very likely a facility can have numerous patients in their population that are dissatisfied because necessary medical treatment and intervention was outside a patient’s comfort zone.  Medical procedures can hurt, medicine tastes bad and may not work as expected.  Health care is an art and not a science because each individual is different.  Patients who just had surgery do not want to get out of bed right afterward, but this yields better outcomes and recovery even if satisfaction is decreased. A patient who is morbidly obese may consider true information delivered in a polite and respectful manner (such nutrition and weight counseling, or cautionary information about increased mortality rates) as bullying and this will impact how the patient may rate satisfaction with the facility and caregivers.  Yet this was truly the right thing to do for the patient even if he/she does not view it as such.  Advice that conflicts with a patient’s desires and wants is not always viewed positively by a patient.

Alexandra Robbin on April 17, 2015 reported in the Atlantic that some hospitals some hospitals have gone to extreme measures to get good patient satisfaction scores.  These includes things as valet parking, custom meals, VIP lounges, and a 5-star hotel feel.  However, this will only drive up the cost of health care ultimately.  County hospitals that serve large populations of undocumented aliens (such as in my home state of Texas) and those without health insurance are already losing uncompensated care reimbursement under the PPACA.  Yet they still do this compensated care. These facilities usually have a large population of Medicare and Medicaid patients.  This patient satisfaction requirement will cause these facilities to once again tighten their purse strings when there is little left to cut which could, in fact, negatively impact quality of care even more.

Patient satisfaction is important. Patients should be treated respectfully and should have their conditions and care explained to them in a way they can understand.  However, for guidance and perspective on such incentivized systems we can look to our secondary education system.  Since No Child Left Behind was enacted which has an incentivized payment for performance system, the U.S. has continued to lose intellectual ground compared with other countries in its secondary schools.  The poor performing schools with low scores were penalized and were given less funding while high performing schools were rewarded with additional funding.  The poor schools got poorer and the educational gap continued to widen.  Disparity already exists in health care.  Time will only tell if this incentivized system will widen the gaps.

Submitted by Dr.  Colleen Halupa, Adjunct Faculty, Saint Joseph’s College