Leadership2 Essay Example | Topics and Well Written Essays - 5750 words

Leadership2 - Essay Example Bank Dhofar is one of the financial services firms growing at unprecedented rates in the Sultanate. The management team is proud of the quality of the services the bank offers. Project finance services, consumer banking, treasury services, and corporate banking are designed to satisfy the diverse needs of consumers, small and medium size businesses, and medium-size companies across the Sultanate. The history of incorporation of Bank Dhofar traces back to January 1990. By then, the bank was referred to as Bank Dhofar al Oman al Fransi. There were only two branches at Salaash and Muscat. During this time, Oman was still an absolute monarchy characterised by widespread autocracy. Bank Dhofar extended its network in 1992 by acquiring Bank of Credit and Commerce International from the Central Bank of Oman. The year 1999 saw the bank inaugurating the head office in the Commercial Business District. More improvements were witnessed when the bank purchased 16 commercial bank branches in 2000, mergered with Majan International Bank in 2002, obtained all regulatory and administrative approvals in 2003, and launched Maisarah Islamic Banking Services in 2013. Presently, Bank Dhofar is the second largest bank in Oman based on the market share. The bank has changed leadership styles over time to keep pace with the market dynamisms. The reputation concerning strong commitment to consistency and growth has helped boost the popularity of Bank Dhofar as financial institution. Managing employees across all branches requires fair, but strict leadership policies in order to avoid laxity at work and ensure that workers are highly motivated to work towards improved performance. Bank Dhofar has a vision of maintaining their status as the best bank in the Gulf. The vision will be achieved through delivering the best experiences to the bank’s customers and creating both personal and collective development

Raisin’ in the Sun Essay Example for Free

Raisin’ in the Sun Essay 1. WALTER: â€Å"You wouldn’t understand yet, son, but your daddy’s gonna make a transaction . . . a business transaction that’s going to change our lives. That’s how come one day when you ‘bout seventeen years old I’ll come home . . . I’ll pull the car up on the driveway . . . just a plain black Chrysler, I think, with white walls—no—black tires . . . the gardener will be clipping away at the hedges and he’ll say, â€Å"Good evening, Mr. Younger. † And I’ll say, â€Å"Hello, Jefferson, how are you this evening? † And I’ll go inside and Ruth will come downstairs and meet me at the door and we’ll kiss each other and she’ll take my arm and we’ll go up to your room to see you sitting on the floor with the catalogues of all the great schools in America around you. All the great schools in the world! And—and I’ll say, all right son—it’s your seventeenth birthday, what is it you’ve decided?! † (Act II, scene ii) Walter’s speech is addressed to Travis closing one of the most important scenes in the play and foreshadowing the climax of the novel. Walter is explaining that he is going to invest money choosing his own way instead of agreeing with other family members. Walter was working as a chauffeur to rich people and he had heard about benefits of investing. Walter becomes obsessed with this idea and he is dreaming about wealthy future describing luxurious cars he will have. He is sure that his dreams with inevitable come true and, therefore, he uses ‘will’, not ‘if’ in sentences. His dream is not fully materialistic as he sees chances to improve relations with his wife and Travis will study in the best colleges. In such a way Walter is growing to maturity when he thinks about his family, their provisions etc. 2. WALTER: â€Å" [W]e have decided to move into our house because my father—my father—he earned it for us brick by brick. We don’t want to make no trouble for nobody or fight no causes, and we will try to be good neighbors. And that’s all we got to say about that. We don’t want your money†. (Act III) Walter’s words are addressed to Mr. Linder after Walter reveals that liquor store has been stolen. Walter shows first signs of disobedience and disagreement as other family members don’t want to accept Mr. Linder buyout. This quotation shows that Walter has his own ideas, desires and beliefs. Moreover, he is willing to act as independent and self-sufficient personality. Walter shifts his priorities. He has changed as earlier he focused his attention on money only, but now he is taking care of his family. It is possible to say that he has become a man. References Hansberry, Lorraine. (2004). A Raisin’ in the Sun. USA: Vintage.

Causes and Effects of Sea Pollution

Causes and Effects of Sea Pollution Nowadays, the sea pollution becomes a serious problem for the whole world. When technology in this world grows to be more advance, the sea pollution will become more serious. â€Å"Pollution is the introduction of pollutants into the environment to such a point that its effects become harmful to human health, other living organisms, or the environment.†(Pollution 2007) Sea pollution can cause many different problems. The problem inside that is damage the health and well of humans, plants and animals. Water from the sea is the primary source used by the human, animals and plants. So the sea is polluted will affect the organism in the sea and human was eating the organism in the sea. This will make the origination of serious disease to human and animals. When this problem was happen, this is damage the ecosystem in whole world. In some areas of the world, seas have become so polluted that ecosystems are in danger. Pure, the sea is unpolluted can balance the ecosystem of this wor ld. In this modern, many human have understood the problem of sea and other water pollution. Some of these human are taking steps to clean up the polluted sea. (TED Analysis Cases 2007) This will help the human to have clean sea and the sea life have clean habitat. But this must use many ways and high cost to clear the sea and the water, so most of the action cannot successfully be taking. Before the human clean up the polluted sea, they must understand all of the causes and effects of sea pollution. The sea pollution is caused by oil spill, ship pollution and sewage therefore the impact toward the sea are marine pollution, hypoxia and water quality. The first cause that leads to sea pollution is oil spill. â€Å"An oil spill is the unintentional release of a liquid petroleum hydrocarbon into the environment as a result of human activity.†(Oil spill 2007) The factory of petroleum often pollutes water bodies 1 in the form of oil. This is the mistake of human that they cannot control the oil spill from the factory. There was one estimate is that oil transported for every million ton is spilled one ton of oil. The oil mostly comes from tankers which wash out their holds at the same time as out at sea to save time in port. Enforcement of laws relating to the discarding of oil is difficult rests with the captain of each tanker to follow the law.   There was also have many case of accident was happen cause the sea pollution. For the case, â€Å"in January of 1993, an oil tanker ran aground off the Shetland Islands, Scotland in the United Kingdom. Oil from this tanker spilled into the sea water surrounding the Shetland Islands .† (TED Analysis Cases 2007) Other than that, the ship pollution was cause the sea pollution. Ship can pollute the sea in many ways. When the ship is shipping in the sea, it will discard some waste material like the oil. Most of the ship spill out the oil into sea. In this modern world, the quantity of the ship increase to use in the trade. So the increasing ship in the sea ports, pollution from the ship becomes more serious. Some of the ship will carry the chemical was spill out the chemical into sea. This is because the human cannot take the action to control the chemical spill out. The chemical was spill out is very poison. Even though it was only some chemical spill into the sea, but the chemical is pollute the sea seriously. The second cause that leads to sea pollution is chemical pollution. Usually this type of pollution is making by the unconscionable human. Some of the factory waste out released into the sea. Everyday there are many case of this type pollution. Enforcement of law relating to the discarding of chemical into sea is very difficult rest with the owner of the factory to follow the law. Owner of the factory did not use another way to discarding the chemical. This is because use another ways must use the high cost to solve that 2 problem. For example, if the factory wants to hide the chemical on the land, they must buy a big land to solve this problem. This is because this chemical will affect the health of human, plants and animals. The waste out by factory is very poisonous especially from the industrial of car, plastic and others. This chemical was waste are include the nitrogen, toxic and phosphorous compounds into the bodies of water. These chemicals do serious damage to marine life. Fo r the cases, â€Å"as recently as 1995, all of the factories in Hong Kong dumped their detergents, toxic chemicals, and waste water into the territorys port. This has caused serious water pollution in the Hong Kong port.† (TED Analysis Cases 2007) Other than that, waste released from the farm is the one of the cause sea pollution. The farm will discard the water after into the sea. For example, the chicken will discard the waste after use to wash the farm into sea. The water have use is very dirty and include some chemical, oil and toxin. Most of the owner of the farm did not discard the waste with true way. This is because the owner of the farm does not have more money to solve this problem. Another ways to handle the waste must use the high cost, the farm is only a small business. The profit of they get from the farm are only a few, that is not enough to handle the waste. Another cause is the sewage. There are many country was built the sewage pipeline because the human thought that the sea would reduce the sewage. (Sea Pollution 2007) If there are too much sewage discards into the sea, this will pollute the sea. In this modern world, there are many countries in development. Development of country has many of sewage. This is because develop the country will make built the bridge, building and others. The human will discard the sewage into the sea, so the sea pollution was become more serious in most of the country in entire world. For example, the Danes and 3 Swedes are built a bridge to their nations which can cross to make possible communication between the nations. (TED Analysis Cases 2007) When they built the bridge, they will flow the untreated sewage into the bodies of the sea. This is cause the sea pollution seriously. Some of the countries are no enough land; they will fill up the sea to build the house and the factory. For example, there was a case in Malaysia, which is Melaka State was fill up the sea to built the house, office and others. When they fill up the sea, the material inside that was pollute the sea. Other sewage is untreated trash which dumped by human into bodies of the sea. Trash is usually dumped by the households, restaurant and individuals. The trash will go into the sea by the sewage pipeline. Everyday there are many household and individual dumped the trash into bodies of the sea because the human have many things after use want to dump. Some of the trash that human dumped cannot dissolve by the water especially the trash make from the plastic such as fishing line, floats, plastic six pack holders and more. Those causes of sea pollution have many effect, one of them is marine pollution. The effects of the oil spill on marine life are the rare animal become extinct. The oil spill will make the oxygen in the sea decrease and make the sea become very dirty. After the oil spill pollutes the sea, the animals will move their habitat to other place. When they move to other place, they will easily to catch by the human. For the rare animals, it will become extinct. For example, the sea turtle move the habitat; it will go to another beach. This will make they easily catch by human. Some of the animals move the habitat to other place but they will go to wrong way will make them to death. For example, the whale move the habitat but it go to sea is shallow, this will make it death. This is because the size of whale is big so it cannot go to the shallow. The whale is one of the rare 4 animals which we must protect them. So we cannot pollute the sea. Other than that, the steps taking by human to clea n up the sea was polluted will affect the habitat of the sea life. Oil spill can cause the human reluctant to buy marine product whether those product are stained. (Effect of marine oil spill 2007) This is because after the sea pollution, most of the human will thought the entire marine product was stained. The economic of the country will be decrease. Another effect of oil spill is damage the ecosystem in the sea. After oil spill pollute the sea, the oxygen in the sea will be decrease. So some of animals and plants in the sea was become extinct, this will affect the other animals cannot find their food to eat. The ecosystem is very important. So the human must taking steps to stop pollute the bodies of the sea. The second effect of the sea pollution is hypoxia. Hypoxia means the lack of oxygen from the air go in the bodies of the sea. Hypoxia will happen when the chemical pollution. The sea was polluting by chemical, oxygen difficult to go in the sea bodies. So suffocation of animals will happen. Most of the animals will move the habitat but have some of the animals cannot move, so they will be death. â€Å"In 1991, one million menhaden fish in North Carolinas Neuse River were killed in a Pfiesteria outbreak.† (Water pollution effects 2006) The sea floras decrease extremely because the sea flora in the sea cannot get the oxygen. Most of the sea floras cannot move the habitat, so that they only can wait for death. After all the sea life move and death, then that sea pollution will become more serious. This is because some of the sea life was death and their corpse is nobody to clear. After that, the human will infect by disease because the corpse of the sea life have many bacteria. If this situation is happen in a country, the economic of the country will decrease and the human at there will death. The economic will decrease is 5 because the sea food tainted by the sea pollution, the government must stop all the sea food business. Beside that, the tourist will cancel to go that country because of sea pollution and disease. Most of country will cancel business with that country because of the government afraid their citizen will infected by the disease. The third effect of the sea pollution is water quality. Every year, there are many countries close the beach. This is because water quality in many countries was become more serious after the sea pollution. The water quality is causes by the sewage, waste released from factory and others. Most of the human stay near at the beach, they will use sea water and play at the beach. This will make the human infected by the hepatitis, stomach aches, vomiting and more. For example, some of the state in Africa, there was many people infected by this disease because they do not know the dangerous of the polluted water. There was many cases was happen in most of the countries that their water quality was very poor. This was make the human stay at there was infected the disease. For the example case, â€Å"In 1993, high cryptosporidium levels in Milwaukees drinking water supply sickened more than 400,000 residents. Every year, seven million Americans are sickened by contaminated water.† (W ater pollution effects 2006)Poor of the water quality also usually make the skin cancer of the surfer. The surfer did not know the dangerous of the sea was polluted. After they go to surf at the sea, then they will easily to get the skin cancer. The government in most country was close the beach and the stop all the sea activities. This is because the government has known the dangerous of the sea pollution and worry about the image of the country. Image of the country is very important because the first image of the tourist will look the environment of that country. If the tourists have the bad image of the country will make the economic of that country will decrease. 6 As conclusion, the causes of sea pollution are oil spill, chemical pollution and sewage. Those will make many effects, which are marine pollution, hypoxia and water quality. Beside that, the economic of country, health of human and more also are effect by the sea pollution. This all effect was become more serious in most the country. So we must taking steps to solve the problem. There are many solutions to solve the problem of the sea pollution but there use the high cost and many steps. So the citizens must co-operate with the government to solve this entire problem. The government gives the education to the citizen start from the primary school. The education must include the important of the sea, the dangerous of the sea pollution and more. This will make the citizens learn more and know the dangerous of the sea pollution from young. After that, they will co-operate with the government to taking steps and processes to clean up the sea. Clean up the sea is a ways to solve this prob lem but the human must concentrate about the marine life. This is because the processes of clean up the sea will affect the habitat of the marine or make them death. Other than that, the government uses the law to take action to the owner of the factory for no obey the law. The government can increase the penalty to the owner of the factory make the sea pollution to make them afraid and they will obey the law. Another solution that able to reduce the sea pollution is that, the government should organize sea activities. As a result, people will realize that the sea is a wonderful and mystery element and they will try to do least harmful action to the sea. Therefore, sea pollution will be able to reduce. References Effect of marine oil spill 2007. Retrieved: November 13, 2007, from http://www.itopf.com/effects.html Oil spill 2007. Retrieved: November 15, 2007, from http://en.wikipedia.org/wiki/Oil_spill Pollution 2007. Retrieved: November 14, 2007, from http://en.wikipedia.org wiki/Pollution#Sources_and_causes TED Analysis Cases 2007. Retrieved: November 14, 2007, from http://www.american.edu/ted/projects/tedcross/xseap17.htm Water pollution effects 2006. Retrieved: November 16, 2007, from http://www.grinningplanet.com/2006/12-05/water-pollution-effects.htm

Internet Pornography, the ACLU, and Congress Essay -- Cyberporn Essay

Internet Porn, the ACLU, and Congress      Ã‚  Ã‚   Ashcroft vs. ACLU, 00-1293, deals with a challenge to the Child Online Protection Act (COPA), which Congress passed in 1998. The law, which is the subject of this essay, attempts to protect minors from exposure to Internet pornography by requiring that commercial adult websites containing "indecent" material that is "harmful to minors" use age-verification mechanisms such as credit cards or adult identification numbers.(Child) An earlier version of the law -- the 1996 Communications Decency Act -- was struck down as an unconstitutional restriction of free speech when challenged by the ACLU; the 1998 version attempted to address the constitutional concerns by limiting its scope to commercial websites, and carving out an exception for material that has "serious literary, artistic, political or scientific value for minors." (Communications) COPA makes adult website operators liable for criminal sanctions -- up to $50,000 in fines and six months in jail -- if children are able to access material deemed "indecent," by "contemporary community standards," for those under 16. This raises the sticky issue of what "community" should set the standard for the global world of the Internet. No one has been prosecuted under COPA; the ACLU brought suit as soon as the law was passed, and a federal judge in Pennsylvania agreed to block enforcement. The Third Circuit upheld the injunction, ruling that COPA's reliance on community standards improperly allows the most conservative communities to dictate what should be considered indecent. The ACLU represents a number of plaintiffs who publish materials online, including an art gallery, Salon.com magazine, a bookstore, and the producer of a... ...rmful to minors on the Web, Beeson responded: "There isn't any way to make it a crime to display material harmful to minors on the Web." A decision from the Supreme Court is expected sometime in the spring of 2002. This case does not directly address the issue of how the community standards requirement applies to determining whether online material is obscene (speech that does not receive First Amendment protection) rather than merely indecent (harmful for minors but protected for adults). The court's ruling will nonetheless be significant in terms of the future of the "community standards" test for obscenity online. WORKS CITED: Child Online Protection Act. http://www.epic.org/free_speech/censorship/copa.html Communications Decency Act. http://www.epic.org/CDA/cda.html "Legal Challenge to COPA" http://www.epic.org/free_speech/copa/complaint.html

The Person I Dislike

The Person I dislike Hate is a very strong word. So it feels a little awkward to say that I hate a particular person. But there are certain types of people who are easy to be disliked. There are lots of people I met in my life, it is not necessary that I like all of them. I categorize the people in three types. One that I like most, second one I don’t like and the third one who has no impression at all in my life. It is a natural phenomenon that we can’t be friendly or alien to all people to whom we met.Of course here are always some good reasons behind as why we like or dislike someone. For me, such people include hypocrites, people who abuse women and children, people who gossip and backbite, and people who are greedy. In my personal opinion, it is very awkward to hate person solely on the basis of their physical appearance or on such things at which they have no control for example their face, color, height, race or religion etc. However, there are many other good re asons that you can hate a person or group of person that is their character or deeds.I dislike Mr. Tindu more than anything in the world. He is related to my father and is forty years old. Tindu is a mean, contemptible fellow. Tindu is an educated person but behaves like an illiterate person. He is dead to all sense of shame and very talkative. I saw Tindu arguing with Majid it looks that some fight is going on. Tindu often talks tall and freely indulges in self-praise. He talks ill of others behind their back and very selfish. Tindu told me uncle Baber likes to gamble and drink whisky and then he met uncle in front of me saying uncle never drinks.Tindu enjoys nobody's confidence. To feel superior to others is in his nature. Tindu does not give respect his parents. Tindu has a habit of cursing and yelling. I saw him to cursing them out for no reason and openly defy them. Tindu has no respect for woman and never think that a woman gave him birth. He is a man of loose morals and have no ethics. Tindu has no love for his motherland. He is not an American by birth but act like that. He is migrated from Pakistan and belongs to a middle class family. Tindu lacks of civic sense.He is very quarrelsome and fought with my brother in law in a marriage ceremony. Tindu does not extend a helping hand even to his relatives and friends in trouble. He laughs at the miseries and troubles of others. Tindu have bad credit. Two years ago he borrowed money from my father never give back. He makes fun of everybody, even the beggars on the street. Tindu loves to smoke marijuana and drink whisky. He cannot be calm always speak loudly to enforce his ideas. Thus he brought a slur to his family.He never does anything worthy of a gentleman. He is seldom fair and square in his dealings with others. Because of his greediness, Tindu makes money by foul means. He is working as inspector in hosiery. He deliberately rejects the stuff and sales that stuff in open market. Hypocrite can easily be disliked. Because of uncle Baber I knew that Tindu talks ill of others behind their back. Although hate is difficult to express in words, to dislike someone is natural. One must avoid that rogue. I dislike Tindu because he is a jerk!

Love of country? Essay

Frederick Douglass’s speech â€Å"If I Had A Country, I Should Be A Patriot† delivers a blasting reproach on the discrimination of the African American and why he feels indignant about his country and being unwilling to call himself a patriot. Similar to Langston Hughes’s â€Å"I, Too, Sing America† , both employ a chord informative structure and a canting tone simple enough for the audience to incite a reaction from the audience to plead for freedom in America. Both authors though in different times face the challenges of racism and being an African American in the â€Å"Republic† of America. Douglass explains that even under natural rights there is no spot sacred in America that can secure his right of liberty. He orates â€Å"This is your land of the free†, your â€Å"home of the brave† to symbolize the ambivalence and optimism for freedom being an African American in America at that juncture and that America must be envisioned as the sentimental identity of the African American slave. â€Å"I never knew what freedom was till I got beyond the limits of the American eagle†. Douglass tries to explain that the idea of being a patriot in America differs from the reality currently going on in his time persuading his listeners to acknowledge the humanity in dehumanizing the institution of slavery. In Langston Hughes’s poem his first stanza details how he is treated unequally. â€Å"I am the darker brother; they send me to eat in the kitchen, when company comes but I laugh and eat well and grow strong.† He demonstrates that the nation he considers himself to belong under the constitution does not treat him as a superior but an inferior. The sentiment of this quote internally depicts that he feels equal to the other race. Unlike Douglass who is encouraging the people to realize their rights, Hughes is waiting for the opportune moment to rebel. The last four lines of Hughes’s poem â€Å"Besides, They’ll see how beautiful I am and be ashamed – I, too, am America† corresponds with Douglass’s insight of hope and using inequality to unmask inequality in America and orating that his race integral to the very existence of America. Hughes orates that he will endure the racial despair with hopefulness in the American promise of justice for all. Douglass and Hughes are judging that there’s no greater danger to the advancement of the African American than the country and its spirit of alienation. This will always steer up to a revolution in a country. America should be a land true to natural love of liberty and its moral humanity and guide its united people to a moral progress. They found a reason to love and identify with this country despite injustices their people had suffered continued to suffer in their days as they waited for the alternate solution.

Accountable Care Organizations, Bundled Payments, and Health Reform Essay

With the enactment of the Patient Protection and Affordable Care Act (PPACA) in March 2010, health care reform has become the law. The legislation will extend health care coverage to more citizens, stabilize health insurance markets, enhance regulation and consumer protection, and improve the affordability and quality of health care in the United States. Changes in payment system of health care proposed by PPACA have led to the development of Accountable Care Organization (ACO). This paper will address how ACOs and the bundled payments system will impact the future of health care. See more: Strategic Management Process Essay The ACO is a health care organization which provides accountability for quality, cost, and care for medical beneficiaries with single entity providers that are responsible for delivering care. The ACO-model builds on the Medicare Physician Group Practice Demonstration and the Medicare Health Care Quality Demonstration, established by the Medicare Prescription Drugs Improvement and Modernization Act of 2003. Under the Affordable Care Act, the U.S. Department of Health and Human Service (HHS) released new rules that benefit doctors, hospitals, and other health care providers of better care for Medicare patients through ACOs on March 31, 2011(U.S. Department of Health & Human Services, 2001). According to the Centers for Medicare & Medicaid Services’ (CMS) administrator Donald Berwick, MD, â€Å"An ACO will be rewarded for providing better care and investing in the health and lives of patients. ACOs are not just a new way to pay for care but a new model for the organization and delivery of care† (Penton Media., 2011). The new model, which is called the â€Å"Pioneer Accountable Care Organization,† is to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries  (Medicare Parts A and B) and reduce unnecessary costs through establishing a shared savings program, which promotes accountability for Medicare FFS beneficiaries. It requires coordinating care for services provided under Medicare FFS and encourages investments in infrastructure, and it redesigns care processes. Regarding the differences, the Pioneer ACO payment model incorporates a population-based payment in the third year of the ACO’s Participation Agreement. This population-based payment will replace fifty percent of the FFS payments (McDermott & Emery, 2011). The Pioneer ACO model is estimated to save Medicare as much as $430 million over three years by coordinating with private payers to reduce costs for Medicare beneficiaries and improve health outcomes. An ACO may engage in either a Shared Savings Program or in the Pioneer ACO model. In addition, the Pioneer ACO model is separated from the Medicare Shared Savings Program for Medicare beneficiaries by the Advance Payment Initiative (Center for Medicare and Medicaid Innovation Center, 2011). ACOs require the ability to manage cost and quality for patients across the continued extent of care and across different associational settings. They also require the capability to plan budgets and resources needed to allocate payments, and the commensurable size of primary care providers for Medicare patients’ populations assigned to the ACOs (at least 5,000 Medicare or 15,000 commercial patients). According to the Journal of the American Medical Association, doctors Shortell and Casalino recommend a three-tiered system of qualification for ACOs (Shortell, S. and Casalino, L., 2010). The tiers will be based on the degree of financial risk acceptable for ACOs and the degree of financial rewards that can be completed by performance targets. In the first tier, ACOs will receive FFS payment with shared savings for providing quality care at lower than the expenditure targets. In the second tier, ACOs will receive bundled payments and episode of care based payments for managing costs and achieving benchmarks. They will be accountable for care that meets these criteria. In the third tier, ACOs will receive partial and global capitation payments. Under a three tiered structure, ACO providers will submit a three-year plan to the HHS or CMS for achieving qualification status at the varied levels. The U.S Department of Health and Human Services (HHS) announced the â€Å"Bundling Payment for Care Improvement Initiative† to coordinate payments for services delivered across an episode of care, such as a cardiac bypass or a hip replacement, on August 23, 2011 (Vendome Group, LLC, 2011). The definition of bundled payments refers to a single payment for all care related to an entire treatment or condition. Bundled payments, also called episode-base payments or case-rate payments are considered as a mechanism for improving both cost and quality, such as currently exist with Geisinger Proven Care and the Prometheus Payment system (Dark,Cedric., 2011). Bundled Payments do benefit physicians and hospitals if patients complete their medical treatments within a certain time period because it will save the physicians and hospitals additional costs. However, it is a disadvantage for physicians and hospitals if the treatment takes longer than the traditional time because it will cost more money to care for patients. Unfortunately, its emphasis is less about improving care and more about reducing the financing for medical care (Gorman Health Group Blog, 2011). This means hospitals, physicians, and other practitioners will have to take their own approach to improving the delivery of healthcare, which should benefit Medicare patients. The goal of the initiative is to increase efficiency of care, improve quality of care, and lower costs. This initiative consists of four different bundled payment models. The first three bundled payment models are retrospective payment arrangements based on patients’ historical data. However, the fourth model is proposed for the future. Centers for Medicare & Medicaid Services (CMS) make a single bundled payment to the hospital for all services during inpatient stays for hospitals, physicians, and other medical professional specialists. In the first model, the episode of care is the length of time the inpatient stays in the acute care hospital. Medicare pays the hospital a discounted payment based on the payment rates established under the Inpatient Prospective Payment System (IPPS), which starts at zero percent for the first six months and then rises to a minimum of two percent in the third year, based on the IPPS. Physicians are paid under the Medicare Physician  Fee Schedule. Hospitals and physicians are to share in any costs. This model benefits Medicare patients by reducing their costs, but not hospitals and physicians because they must share in any expenditures. The second model, which is also based on IPPS, is different from the first model because it includes inpatient and post-acute care from either 30 or 90 days following discharge. This bundled payment includes physicians’ services, post-acute care, readmissions, and other related services, which can be clinical laboratory services, medical equipment, prosthetics, orthotics, other supplies, and Part B drugs. The minimum discount is three percent for the first 30 to 90 days after discharge and two percent for more than 90 days. The Medicare enrollee is to share the costs if the total payments are less than the target price. However, the provider will be responsible for payment coverage if the total payments exceed the target costs. This model uses an incentive discount for Medicare patients to spend less time in rehabilitation versus the first model which has no early rehabilitation discount. However, this model does not give an advantage to hospitals and physicians because it encourages Medicare patients to leave medical services sooner. The third model begins at discharge from an acute facility if less than 30 days are spent in rehabilitation. These bundled payments are the same as the second model with the exception of a discounted rate, which Medicare enrollees are required to set up instead of CMS, since CMS has not indicated an expected discount for medical service (Becker, Epstein & Green, P.C, 2011). In the fourth model, which is the only perspective model, hospitals will receive a single bundled payment from CMS that covers all medical services by hospital, physicians, and other medical professional specialists. The minimum discount will be three percent of the estimated total costs for the episode care (Proskauer Rose, 2011). The bundled payments are more hospital-centric than ACOs’ program. However, ACOs’ focus will be on how hospitals and physicians will share reimbursements in a post-fee-for-service payment system. Therefore, Medicare beneficiaries will benefit the most but hospitals and physicians will not. Future ACOs include: Integrated Delivery Systems, Multispecialty Group Practice (MSGP), Hospital Medical Staff Organization (HMSO), Physician-Hospital Organizations (PHO), Interdependent Practice Organization (IPO), and the Health Plan Provider Organization or Network (Charles DeShazer, 2011). However, most physicians work in very small practices that would not likely have the resources to develop the capacities to be an ACO. In an ACO-based health care organization, these small practices would either merge into new or already existing specialty group practice, or would engage in an ACO that facilitates clinical integration among small practices. Many physicians may still prefer smaller practices, and under comprehensive healthcare reform may continue to exist. In ACOs completely based on the quality and cost of care, the market may decide whether virtually integrated systems can succeed in competition with systems where physicians are merged into large group practices. Moreover, specialist physicians are creating medium sized or even larger single specialized groups. However, a single specialty group cannot serve as an ACO for full patients care but can be an essential element of an ACO or can be a crucial source of medical care through referrals. In Integrated delivery systems (IDS), medical care is coordinated and reimbursed within the system to make patient care more efficient while improving access to and the quality of the care received. Some examples are: Cleveland Clinic, Henry Ford Health System, Mayo Clinic, Scott & White Clinic, and so on. However, a recent report indicates that challenges may still remain. IDS face lack of compensation from health insurance providers for care coordination services as well as difficulties in finding specialty care, such as mental health care and changes in management and physician cultures in adopting the new organization (United States Government Accountability Office, 2011). The promising advantages of the multispecialty group practice (MSGP) model were recognized in 1932. As stated in the Physician’s Advocate(2008), â€Å"These advantages include having the resources to redesign care processes, take advantage of economies of scale to implement electronic medical records, form health care teams, obtain database feedback on performance gaps, and make the changes needed to improve care† (Physician’s Advocate, 2008). Some evidence indicates that multispecialty group practices do make the most of recommended care management processes like electronic information technology, as well as sharing in quality improvement medical services. Therefore, MSGPs provide better quality care for preventive measures involving screening tests and diabetes management than smaller forms of practices. Moreover, studies also indicate lower Medicare spending on patients related to multispecialty or hospital associated groups than other patients. However, it is unlikely that MSGPs will become the major organization form in the United States health care system since it is so expensive to implement. HMSO, more than 800,000 physicians that currently practice in the United States are members of hospital medical staffs (Carroll, 2011). The hospital medical staff organization can serve as ACOs for either inpatient or outpatient care. Studies indicate that most physicians have primary relationships with a single hospital to form a stronger partnership entity between physicians and their primary hospital (Fisher and et al., 2006). Hospitals have resources to support adopting electronic medical records (EMR), provide performance and accountability data, and assist quality improvement support for physicians. Bundled payments for specific medical conditions or episodes of sickness, such as a coronary artery bypass graft (CABG), hip or knee replacement (Massachusetts Medical Society, 2008) will provide incentives for hospitals and physicians to work together to reduce Medicare costs (Welch, WP and ME Miller, 1994). This model will have future advantages for chronic illness treatment as we ll as episodes of care since physicians and hospitals work together closely to monitor patients’ long term care. However, the HMSOs encounter challenges including leadership of the diverse cultures of hospitals and physicians and legal restrictions to obtain sharing (Primary Care Associates., 2008). An alternative of the MSGP model is the PHO. Hospitals and physicians work together to ensure cost-effective and steady system delivery of medical services and the provisions of the health care services to the patients. There are approximately one thousand PHOs in the United States and most are managed organizations with the goals of achieving and managing the quality  and cost of care (Nixon Peabody LLP., 2010). Under the Affordable Care Act, the contracting PHO model can emerge into an entity that will manage the quality and cost of care. Without meeting the needs of all physicians, this model has the advantage and the incentive of improving performance. With the HMSOs, the hospital will provide resources for EMR, performance reporting, quality improvement, and process management support. However, PHOs must be clinically integrated to avoid anti-trust laws (Casalino, Lawrence P., 2006). A fifth model is the Interdependent Practice Organization (IPO), which is an advancement for those physicians who practice in small organizations or who do not wish to be part of larger organizations for delivering care. The interdependent practice organization is based on an association of physicians in numerous independent practices. IPOs are capable of providing high quality, better care, although most of these organizations are loosely organized (Rittenhouse and et al., 2004). The future IPO model requires strong leadership, administration, and enough patients across individual practices to support financing of technology infrastructure and management systems. IPO models might be attractive to physicians practicing in rural areas. With given sufficient incentives, existing IPOs can became independent organizations by strengthening their management structure and developing a solid shared culture of performance improvement. These requirements are challenges since IPOs are composed of many small practices. The last model, the Health Plan-Provider Organization or Network (HPPO/HPPN) is similar to the IPO. It is based on an association of independent physician practices. The health plan will be the major financial assets to encourage a more cost-effective health care delivery system. Many have capabilities in disease management, electronic information technology implementation, and quality improvement entities that can be used effectively in collaboration with physicians. Some physician practices may participate with health plans rather than local hospitals. Health plans can be part of a smaller physician’s practice and become the unit of accountability of performance. However, the success of this model will depend on an individual physician’s leadership (Shortell and et al., 2008). The Centers for Medicare & Medicaid Services (CMS) released final rules and new opportunities for financial support for doctors, hospitals, and health care providers to work together to improve the care of Medicare patients by adopting ACOs on October 20, 2011. The new rules provide for a new voluntary Medicare Shared Savings Program. Providers will be able to participate in an ACO and share in the savings with Medicare. ACOs will reward providers for reducing the costs and meeting quality measures, such as reducing hospital readmissions or emergency room visits. Providers will begin to share in savings based on how they perform in thirty-three quality measurements in the second and third performance years. Medicare beneficiaries will be a part of the ACO system when they form. Moreover, community health centers and Rural Health Clinics (RHCs) will be allowed to participate in the ACO programs (Galewitz, Phil and Jenny Gold., 2011). To appeal to providers, CMS will provide physician-owned and rural providers early access to the expected saving of up to $170 million dollars, so providers can start ACOs right away. At the same time, the Antitrust Division of the Department of Justice issued the entire final rules that will allow providers to participate in the Medicare Shared Savings Program. In addition, the final rules will no longer require a mandatory antitrust review for collaborations as a condition of entry into Shared Saving Program (Department of Justice, 2011). Electronic health record (EHR) usage is no longer a condition of participation to prompt more RHCs and other programs to join (Center for Medicare and Medicaid Innovation Center, 2011). Moreover, CMS will assist agencies in monitoring the care and quality of performance of ACOs. The program will save up to $940 million dollars over four years (U.S. Department of Health & Human Services, 2001). Patients or Medicare beneficiaries are encouraged to select an ACO as their medical center. ACOs can be used for result-based payments, public report purposes, and claim-based payments which retrospectively allow patients to join who have not adopted ACOs. This advances patients’ choices and encourages ACOs to coordinate their patients’ care to treat patients equally. Because physicians are not required to be part of ACOs, physicians  can still be paid with the Shared Saving Programs used by Medicare, Medicaid, and other commercial health plans. They also can be eligible to achieve quality-based rewards. In addition, physicians and hospitals that are part of ACOs can have both obtainable rewards for improving quality and controlling costs; however, there is more inevitable risk. Furthermore, bundled payments for certain services and procedures, using a combination of capitation, result-based payments, and readmissions, gain sharing between physicians and hospitals tha t can be adopted within ACOs. Physicians also can benefit from the assistance that ACOs can provide with electronic health records and with implementation of established processes to improve quality and efficiency. Health reform will be needed in laws and regulations for the Stark law, anti-kickback statuses, fraud and abuse, anti-trusts, scope of practices, and the corporate practice of medicine. However, the final rules were relaxed and established waivers for the physicians’ self-referral law, the federal anti-kickback status, and certain penalties to encourage the participation in the Medicare Shared Saving Program and the Advance Payment Initiative (FierceHealthcare, 2011). Therefore, more medical providers will be regulated by the programs. In the past, healthcare leadership has relied on organizational structure to deliver higher quality at lower costs, which has not succeeded in improving neither efficiency nor performance. In fact, they have increased the problems that they intended to address. Neither diagnostic related groups (DRG) nor Health Managed Organizations created a shared achievement for all parties. Provider profit motivation lacked the pressure of medical beneficiaries to protect quality while minimizing costs. While each DRG and resource based relative-value unit encouraged providers to focus on provision without interventions, HMOs and other managed providers encouraged providers to minimize intervention, regardless of whether managing could delay the quality or completeness of patient care (Numberof, 2011). Ignoring the minimal role that patient demand plays in driving market completion among providers, the current and past medical health care system has decreased accountability for quality of medical care. ACOs were established to fix the inadequate accountability for wasteful  spending and quality of patient care. The PPACA provisions are consumer based solutions; however, they do not allow patients to have fully informed choices about their coverage and medical care (Numberof, 2011). Employers, who contract with insurers, apply with providers; therefore, accomplishment is limited. However, many physicians are reluctant to assume accountability for patient outcomes, since they admit that outcome is directly under the behavioral control of the patient. Furthermore, it seems that provider contracts could be integrated to a successful ACO in a shared savings program; providers continue to receive funding for each service they perform. Even with the possibility of a bonus from shared-savings, maintaining the FFS system boosts providers into continuing delivering an excess of services. In addition, ACOs, which are a single untested model, are largely hospital based. Eligibility requirements are larger and more involved for ACO organizations. Larger organizations are able to consolidate their markets; however, this consolidation may result in less competition. Therefore, large delivery organizations may become too big to fail but will increase advantages for patients. Without competition, the organizations might have little incentive to reduce the costs or improve quality of medical care. Enduring health reform has to cover the uninsured without exception or conditions. As Victor Fuchs, professor at Stanford University mentions â€Å"It [Enduring health reform] must improve efficiency in medical practice by providing physicians with the information, infrastructure, and incentive they need to deliver cost effective care† (Fuchs, 2010). Information will come from the electronic health records, a process that will be amped up by the HITECH Act, which is part of the American Recovery and Reinvestment Act of 2009 (Leyva, Carlos and Deborah Leyva, 2009). Electronic health records will benefit providers with more accurate real-time data on patients as well as provide analyses on drug responses and provide support to improve the quality of medical care. Health information Exchange (HIE) can enhance information from a wide databases and allow that information to be shared through various technology by providers. This allows related patient information to be shared withi n EMR with the provider who needs that information (Southern New Hampshire Health System, 2011). Furthermore, the  Patients Centered Outcomes Research Institute (PCORI) will offer physicians and patients new information of varied medical technology. Atul Grover, chief advocacy officer for the Association of American Medical Colleges, notes â€Å"It will be an evidence synthesis that really considers different populations and different diseases and tries to get more information to clinicians as they go about doing their daily work† (Marathon Medical Communications, Inc, 2010). The integration of the PCORI will enhance information so that physicians and patients can choose the appropriate test and treatment based on the patients’ condition. Moreover, infrastructure reform will enhance horizontal collocation within providers and monitor patients consistently. Health care reform strengthens greater integration through the redesign of delivery systems such as medical homes and ACOs for physicians. Recent studies suggest that better coordination of care can reduce readmission rates for major chronic sicknesses (Hernandez, AF, 2011). In addition, the PPACA will give incentives for hospitals to support proven practices that essentially reduce their rates (Foster, 2010). Likewise, the PPACA’s pilot program involving bundling payments will bring physicians and hospitals an incentive to allocate care for patients with chronic illnesses. Most essentially, PPACA admits that health reform that brings ACOs as the delivery system is an ongoing process requiring continuous adjustment. The PCORI will develop new medical tests, drugs, and other treatment that will provide continuously updated information for physicians and patients. Over the next decade, similarly, the Innovation Center in the Centers for Medicare and Medicaid will be establishing and evaluating new policies and programs that will enhance the quality of care for Medicare beneficiaries and reduce costs. PPACA not only will expand health care coverage to millions of Americans but also will enact many policies to reduce the amount of costs for health care by bringing ACOs as the delivery system, which will reduce the costs of health care over time. By enacting ACOs as a Primary Care Provider (PCP), PPACA provides the most effective medical care support possible. Moreover, by adopting the bundled payment approach, physicians, hospitals, and other providers will be able to reduce the costs for Medicare beneficiaries.  Therefore, the public should embrace the new health care proposal to reduce their costs and improve the quality of their medical care. References Becker, Epstein & Green, P.C (2011) â€Å"HEALTH REFORM: CMS Innovation Center Announces Four Models in Bundled Payments for Care Improvement Initiative,† Retrieved from http://www.ebglaw.com/showclientalert.aspx?Show=14876 Carroll, Aaron. (2011, June 3). â€Å"Meme-busting: Doctors are all leaving Canada to practice in the U.S.,† Retrieved from http://www.washingtonpost.com/blogs/ezra-klein/post/meme-busting-doctors-are-all-leaving-canada-to-practice-in-the-us/2011/06/03/AGVdAuHH_blog.html Casalino, Lawrence P. (2006) â€Å"The Federal Trade Commission, Clinical Integration, and the Organization of Physician Practice,† Journal of Health Policy, Politics, and Law, Retrieved from http://www.ftc.gov/os/comments/aco/2006jhppl.pdf Center for Medicare and Medicaid Innovation Center (2011) â€Å"Pioneer ACO Application,† Retrieved from http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco-application/index.html Center for Med icare and Medicaid Innovation Center (2011) â€Å"final ACO rule,† Retrieved from http://www.cms.gov/aco/downloads/Appendix-ACO-Table.pdf Department of Justice, the Antitrust Division and the Federal Trade Commission (2011) â€Å"Background Documents,† Retrieved from http://www.justice.gov/atr/public/health_care/276458.pdf DeShazer, Charles. (2011) â€Å"Accountable Care Organization (ACO) Tutorial,† Retrieved from http://www.slideshare.net/cdeshazer/accountable-care-organization-aco-tutorial Dark, Cedric (2011) â€Å"Quality over Quantity: Reforming Payment,† Retrieved from http://www.policyprescriptions.org/?p=2066 FierceHealthcare, (2011) â€Å"CMS, OIG to relax self-referral, anti-kickback laws with ACO waivers,† Retrieved from http://www.fiercehealthcare.com/story/cms-oig-relax-self-referral-anti-kickback-laws-aco-waivers/2011-10-21 Foster, David. (2010) â€Å"Healthcare Reform: Pending Changes to Reimbursement for 30-Day Readmission,† Retrieved from http://thomsonreuters.com/content/healthcare/pdf/pending_changes_reimbursements Fuchs, Victor (2010) â€Å"Health Care Reform,† Retrieved from http://siepr.stanford.edu/system/files/shared/Health_care_document.pdf