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For this assignment, you will consider a text from American Literature (can be outside of our textbook and any

For this assignment, you will consider a text from American Literature (can be outside of our textbook and any type of text, such as music or a piece of art) in the context in which it was produced. This type of analysis is called New Historicism, which is a school of literary theory. Choose a text from American Literature. Any text will count as long as it is a text (poem, play, short story, novel, nonfiction, song, art) and it is American. Use the OWL at Purdue and outside research (Galileo) to write a 4-6 page analysis of your text from a New Historical perspective.
This sentence by the American poet and writer contains what art means in the modern world: experimentation. This characteristic of the modern art is deeply present in Williams’ poetic. The poet’s world is the America at the beginning of 20th century, a period in which change is everywhere. America becomes an industrialized urbanized society and starts being one of the main power in the world. The field of art in the U.S is influenced by the economical, social changes of the modern time and the artists have opposite reactions to this change. On one side they take their strength from technology, for example the invention of the typewriter will modify artists’ method of writing. On the other side, they reject the materialist stamp of the modern era by involving themselves in aesthetic experimental adventure. These artists want to substitute the old values of 19th century with a radically different attitude toward art, based on the social political changes of the that era. In the literary world, the main current of the period is Modernism, a complex movement which comprehends different artistic conceptions. The Modernism has its origin in Europe, but it develops also in America with his own timbre. The American artists of the 20th century look for their own voice, different and detached from the traditional European models. They need to emancipate themselves from the European culture. In particular, poets and writers feel the necessity of founding their own identity, they look backward to their short literal history in order to free themselves from the English and European tradition. The poets start thinking about what is poetry and what is the method to use in poetry. Their research for an identity “makes the task of the American poet one dedicated to exploring the peculiarities and strangeness of the liberal American condition.”(Clive Bloom, The American Poetry, 1995 , 3). What the poets want is to adapt the demands of Modernism to the American environment. They change the form, the language of poetry. They want to renew their poetic, their method, in order to adapt it to the modern American world. Their language will be close to the mass culture, to popular idioms and deeply different in its structure. In fact “for the Modernists, structural organization is both a way of “knowing” and acting within the world” (Clive Bloom, The American Poetry, 1995 p. 7), it becomes meaningful and changes the way the reader approaches to the poem. At the end of 1920s poets and writers’ experimentation will transform the American literature from being provincial to being cosmopolitan. All these and other aspects of the modern art are present in Williams’ poetic, which is characterized by experimentation in the modern world. Williams’ most famous poem is doubtless “The Red Wheelbarrow”, a poem which concentrates his poetic and shows his relationship with the modern world of experimentation. It was published for the first time in 1923, in the collection “Spring and All”, which mixes poetry and prose. Here the poems are just numbered, “The Red Wheelbarrow” will obtain its title only later, in “Collected Poems”, published in 1934. This poem consists of 8 lines of simple and intuitive words. It could be considered a banal poem, but from this lines it emerges Williams’ world. Many times the poet has been accused of being elementary, but this poem demonstrates the exact contrary, his poetry is complex. In fact the same Williams states in “January Morning” : “I wanted to write a poem/that you would understand ” and then he adds “But you got to try hard”. In this poem we can find the main aspects of his poetic, which leads him to experimentation: the importance of locality, the language experimentation, the objectivism, the structure experimentation and his relationship with the visual art. William’s poetic is closely connected with the experimentation of modern American and European painters. His mother was an artist, he is deeply interested in this field from his childhood. Furthermore, in 1913 in New York is held the Armory Show, an exhibition which contains the most new and fresh works of art. The Armory Show pushes the painters in New York into radical experimentations. Williams finds himself close to the New York avant-garde and from 1915 he takes part in “The others”, a group of artists and writers. He is influenced by contemporary literature, by Joyce, but it is thanks to the visual art that he finds his original style. In fact, reflecting on 1920s Williams states : “It was the French painters rather than the writers who influenced us, and their influence was very great. They created an atmosphere of release, color release, release from stereotyped forms, trite subjects.”(Wisker, William Carlos Williams, p.32). Analyzing “The Red Wheelbarrow” we can notice how Williams present three detached images with color connotation (the red wheelbarrow, the rain water, the white chickens). This implies a connection whit painters’ work, but Williams does more. He wants to transfer in his poetry the possibilities of painting. This aspect of Williams’ poetic has produced different theories, the most interesting is Bram Dijkstra’ s one. The scholar sustains in his book “Cubism, Stieglitz and the early poetry of William Carlos Williams” that Williams is attracted by the immediacy of paintings’ impact and the painter’s ability to select and isolate a moment of reality, concentrating on the aspects which increase its meaning and suspend this moment outside the progress of time. This is in fact what William is experimenting in “The Red Wheelbarrow”. He has selected an aspect of reality, in this case a common object ( the wheelbarrow) and, trying to avoid vain details, he concentrates on what for him his the real essence of the wheelbarrow, giving to it a new meaning and allowing it to be eternal, out of the flux of time. Dijkstra then demonstrates how William’s concept of imagination is close to that one of Cubism. For Williams imagination chooses the meaningful aspects of series of images which the poet remembers and intensifies them, gives them a new meaning, by putting them into its realm. In the same way, for Cubists imagination reconstructs reality. They paint moments, things, reassembling them on the page ,in order to intensify their main details and offer a new comprehensive view of reality. The effect of this feature can be seen in the rearranged structure of “The Red Wheelbarrow” and in its fragmentation, which can also corresponds to the fragmentation of the modern world. In the “Red Wheelbarrow” there are 3 images, isolated in syntactic unites, fragmented in 16 words, each of them heavily evocative and meaningful. Another interesting feature which Dijkstra points out is Williams’ ability to make tangible invisible aspects of reality, through the use of concrete words (for example in the “Red Wheelbarrow” the word “glazed”). This method could be associated to painters such as Picasso or Braque, who uses geometric forms to paint the abstract space. However, it’s important to underline that William’s poetry is influenced by European avant-garde especially in the first period of his activity, later he will concentrates on the New York avant-garde. In fact Williams is also close to American painters’ position. In 1920 the poet publishes “Kora in Hell: Improvisation”, using in the frontispiece a drawing by Stuart Davis. Choosing this picture he affirms: “It was, graphically, exactly what I was trying to do in words, put the Improvisations down as a unite on the page.”(I wanted to write a poem, 29). Williams also in “Kora in Hell” uses the fragmentation of images and sentences, with the consequent visual implication. Finally, the American poet is close to another important figure of contemporary art, Marcel Duchamp. This artist is characterized by experimentation and research. His art is not simply a material, concrete fact, it’s a mental act. Duchamp creates work of art by taking everyday objects, the famous “Ready-mades”, and placing them in an unusual context, under a new light. William does the same with poetry. In “The Red Wheelbarrow” he chooses a common object and places it in a new and uncommon situation, the page, giving to it a new meaning. This fact raises questions about the nature of a work of art, what it consists of, demonstrating the level of experimentation that Williams reaches. Williams’ contact with Duchamp shows another important feature of his poetry: the importance of locality. In fact in his works of art we find everyday situations, common objects, portraits of simple people, aspects of reality which are not usual in poetry and on the page reach a new importance, a new dignity. These objects, these people belong to the environment in which Williams lives and observes, the town of Rutherford. Williams in fact view is that the modern, the experimentation must be reached through locality. He lives all of his life in Rutherford and from here he tries to adapt Modernism to the American situation. Williams sees locality also in terms of language. In fact, through is poetry he wants to reproduce “the hum and buzz of everyday life” (American Poetry, pp 77). To achieve this for Williams is necessary to use a new language, based on the American speech, which can reproduce modern American environment. This research is common between American poets and writers at the beginning of twentieth century. In fact they feel the necessity of detaching themselves from European tradition, in order to find American models. For example for Williams a point of reference in the American literature is Poe, because he notices in his work the importance of locality. The poet’s search for a new language leads him again to experimentation. He wants to use a vernacular language, which can reproduce the American Idiom. His poetry is based on the rhythmic unit, which follows the rhythm of American speech, breaking the rules of traditional poetry. This means that the line in his poems end when the rhythmic unit ends, not the sentence. Williams the same underlines this aspect in the book “I wanted to write a poem”. However, Williams goes further. He notices how advertisements, radio and new technologies influence the way of speaking and he wants to put down it in the page. We can see this aspect in the “Poem XXV” of Spring and All. Here he uses sentences taking by advertisements and streets, for example line 7 “What the hell do you know about it?”. Moreover Williams wants to make poetry more musical and tries to reproduce in poetry the dimension of jazz. This is well explained in the essay “Rephrasing Whitman: Williams and the visual idiom” by George W. Layng. The author analyzing the poem XXV of Spring and All , shows how Williams’ variation of the pattern of the stanzas can recall the jazz music in its improvisations and returns to pattern. If we analyze the “Red Wheelbarrow” we notice the importance of locality and language experimentation. He chooses a common object, unusual for poetry, which becomes the subject of the poem. Williams could have met this rural instrument in his everyday life. In fact poetry for him and for many modern poets is a specialization. He is a doctor and lives most of the time among simple and poor people. Then , looking at the lines of the poem we can observe that they don’t end when the sentence ends. Furthermore words such as “wheelbarrow” are divided in their constituents, in an artificial way. Another poem which demonstrate Williams’ interest for locality and language experimentation is Paterson. Here he chooses a city that he knows well, Paterson, and identifies it with a man and all people in general. He describes its history, its contemporary situation, its environment with a simple and colloquial language. Besides , starting from Book Two of Paterson he achieves the theorization of the variable foot. He was looking for a way not to use neither the free verse, nor the fixed foot. With the variable foot he reaches an half way between them. In I Wanted to Write a Poem he says that in this way “the verse becomes not free at all but just simply variable, as all things in life properly are.” This demonstrates how Williams in this poem experiments and how also talking about the local Paterson he can be modern and cosmopolitan. Another important feature of Williams’ poetic and experimentation is objectivism. In fact, he moves from the position of the Imagists poets to reach a more radical style. Williams shares Imagists’ idea of direct treatment of the thing, of the theme of the poem, using new rhythms and patterns. Then he becomes more radical. In his poetry he wants to shift from the concept, the abstract thought present in Imagists’ poetry, to the poem, the thing itself. In fact in Williams’ style the poem becomes a thing among other things in the world and independent of them. In order to achieve this result, he does not use metaphors or symbolic meanings, because the subject of the poem must be the image, the thing, which represents itself and nothing else. This idea can be summed up in the poet’s dictum “No ideas but in things”. Therefore, for Williams the poem is an object, made by poetry itself and nothing else. Moreover the poem is constituted by words, which have their intrinsic meaning and are independent of each other. This feature of Williams’ poetic demonstrated in J. Hillis Miller’ s essay “William Carlos Williams”. Here the author demonstrates how William can observe directly an object, without fear, because the object and the poem about that object are independent things, they don’t need each other. Besides, Miller sustains that each word in Williams’ poems has its intrinsic meaning and is separated from other words, as in the real world things have their own existence and are independent of other things. To demonstrate this, Miller takes the example of one version of the poem “The Locust Tree in Flower”. Here Williams separate each word to make it stand alone in the page. Every line is constituted by one word, forcing us to reflect upon their own evocative meaning. In the “Red Wheelbarrow” this aspect of Williams’ poetic is clear. Here we can observes the direct treatment of the object, the wheelbarrow. There are no metaphors, no comparisons. The image of the wheelbarrow is built through simple and descriptive words, which make the wheelbarrow tangible and visible (for example “glazed”, “red”, “rain”). Then, we can see how the structure of the poem( tree words in the first line of each stanza, one word in the second line of each stanza) stresses the important presence of each word and leads us to reflect on them. There are few words, only sixteen, sometime divided between the lines in an artificial way (wheel/barrow). Each of them is meaningful and independent, but at the same time they build a single, whole image. Again, this aspect of Williams’ poetry, objectivism, demonstrates how his poetic is led by experimentation in the modern world. His need to treat the object of poems in a more direct way, brings him to modify deeply the structure, in order to represent a new modern idea of world and of poetry. The search for a new structure is common between the poets of twentieth century. This poets don’t want to use the traditional methods of poetry. They don’t want to create poems copying reality, they want to create a poetry which is reality itself. This aspect of Williams and other poets’ experimentation raises a new relationship between the reader and the poem. The reader now must reflect not only on the content of a poem, but also on the structure. He must analyze each part, each word of the poem, trying to understand why the poet has chosen that particular word or structure, what he wants to communicate through what “”he makes “. In this way the relationship between reader and poem becomes more complex and modern. If we take again the poem “The Red Wheelbarrow” we can demonstrate now how behind this eight lines, which could be considered simple and elementary, it’s hidden the proof of Williams’ complex and experimental poetry. It’s a complete piece of art. It shows Williams’ contact with the visual art, in his use of images with color connotation, of lines fragmentation, of tangible concrete words. He chooses a common object (as Duchamp does), the wheelbarrow, intensifies its meaning and makes it eternal, a concept used by Cubism and other experimental movement. Then, writing about a local, rural wheelbarrow, with a simple language he reaches experimentation again. Williams wants to use the American idiom and for doing this he breaks the rules of traditional poetry about rhythm and versification. The words of the poem are simple and descriptive, the lines do not follow the logical sentences and breaks words in an artificial way. Williams uses here free verses, no traditional rhyme scheme and no metaphors. Each part of this poem, from the way words are placed in its structure, to the choice of words that William has done, tells us something new compared to the previous methods used in poetry. There are different theories about the meaning of the sixteen words of “The Red Wheelbarrow”. In fact the poems doesn’t say what depends upon the wheelbarrow, leaving to us the answer. The scholar Barry Ahearn believes that is the human civilization that depends upon this rural machine. Williams maybe wants to tell us that the poetry itself depends upon this common object and a wheelbarrow can contains all the new , radical experimentations of the modern poetry. Most probably there is no answer. What is sure is that “The Red Wheelbarrow” is a symbol of Williams’ experimental poetic and it demonstrates that the American poets aims at “a new form of poetic composition, a form for the future”.( American Poetry, William Carlos Williams, pp77)
4 short response questions and 2 short essay questions Short response questions must be answered in 1 paragraph and short essay questions must be answered in 3 to 4 paragraphs. You must cite any sources used in your answers.. I need an explanation for this Art & Design question to help me study.

Short Response (10 pts. each)
1) Do you think that class divisions still exist in modern theatre audiences? To support your response, compare the strict divisions of theatre audiences in Shakespeare’s time to audiences of today and how such divisions might still be in force to some degree, albeit however subtle.
2) Explain why protest songs become dated. Then, identify a contemporary protest song (2010-2019) and discuss why it will eventually become dated. Be specific (provide artist’s name, song title, and date song was created and/or first performed).
3) In the lecture on Theatre and Gender, we saw mainly how the role of women in theatre has gone from non-existent to something approaching parity with male actors. Give your opinions and takeaways on this topic. You can write from a standpoint of what your comfort level was in seeing women in traditionally men’s roles and vice versa if you have seen such a production, or what you anticipate your reaction might be if you have not.
4) Create a hypothetical scenario centered on a music therapy session. Using your notes from our lecture on music therapy, in addition to any outside research, provide a setting/institution, a brief description of the patient and their disability, a musical approach the therapist might use, and an explanation of how the musical approach might help the patient accomplish their goal(s).
Short Essay (30 pts. each)
1) We saw through the course of the semester how theatre has mirrored and influenced the advancement of racial and gender equality. Theatre has often led the arts in championing these racial and gender struggles, perhaps in part because theatre, along with film, can confront these issues more directly, with or without symbolism and metaphor.
Do you think that theatre has a current-day influence on American society, in particular on social issues such as racial and gender equality? Or, do you believe that because we are now so divided into our “tribes”—each with different sets of belief systems dictating what we view regarding news, entertainment, and the arts—that theatre ends up merely “preaching to the choir” and not changing or enlightening minds outside of its established audience? Drawing upon racial and/or gender struggles in regards to theatre, explain your position.
2) Throughout the semester we touched on the idea of art commenting on a social issue, responding to a significant event, or defending a cultural group. Not all art is conceived for these purposes, nor should it be. However, we understand that when artists approach their craft in this manner they leave us with works that are particularly reflective of their environment and deeper in substance. For this short essay, think about your favorite artist and their work. The artist does not have to work in music, and they might even work in multiple fields (ex. music and painting, sculpting and dancing, etc.). Consider the following questions and use your answers to formulate your essay.
Has your favorite artist used their work to reflect culture or society? If so, do they regularly approach their art in this manner or only do so infrequently?
If your favorite artist uses their art only for entertainment, do fans—or you—wish the artist would use their work for one of the purposes mentioned in the first paragraph? This last question is most relevant, but not limited, to artists who are viewed more like celebrities.
Providing specific names, titles of works, and any cited quotes and/or referenced sources, respond to these questions in a manner that shows thoughtful consideration and a genuine stance.
4 short response questions and 2 short essay questions Short response questions must be answered in 1 paragraph and short essay questions must be answered in 3 to 4 paragraphs. You must cite any sources used in your answers.

Seneca Provincial and Territorial Resources Canadian and USA Estate Law Discussion

Seneca Provincial and Territorial Resources Canadian and USA Estate Law Discussion.

Make a comparison between Canadian and USA estate Law, Estate Taxation or some other aspect such as family law or powers of attorney. 2-3 paragraphs are sufficient. Include your references.Maybe challenges due to demogrpahics, culture or COVID 19 as an example.Professor example. Estate Tax (none in Canada, but USA has Estate tax…see link below)https://www.taxtips.ca/personaltax/usestatetax.htmCanadians are protected by Article XXIX B (8) of the Canada – U.S. Tax Treaty which provides that:If, at the time of death, the entire worldwide estate of a Canadian resident (other than a U.S. citizen) does not exceed $1.2 million US, the U.S. will only impose estate tax on property for which, on disposal by the owner, any gain would have been subject to income taxation by the U.S. This includes American situated assets such as real estate, stock portfolio and taxable personal property (car, boat & furniture).A tax credit (this is deducted from any taxes owing) called “The unified credit amount” for U.S. residents is $4,417,800 for 2018 ($2,141,800 for 2017), which is equal to the tax on a $11.18 million ($5.49 million for 2017) estate. The unified credit available to Canadians is prorated based on the ratio of U.S. assets to the total worldwide estate.In Canada many types of registered and non-registered assets may be deemed disposed of at death and thus taxable (unless a spousal roll-over is possible re tax delayed to death of second spouse). For example, a stock portfolio may be deemed sold and this Capital Gains tax can be charged (FV – ACB = CG X 50% tax :formula).
Seneca Provincial and Territorial Resources Canadian and USA Estate Law Discussion

write project in Secure Data Aggregation in Wireless Sensor Networks in IEEE-style papers

best essay writers write project in Secure Data Aggregation in Wireless Sensor Networks in IEEE-style papers.

Expected Project outcomesThe ability to design/analyze a research problem and express your ideas/thoughts on what you have learnedfrom it is a skill that you want to enhance from this course project. The primary goals of this course projectare: Conduct original research on a problem of interest in computer security Develop project development and documentation writing expertise employing scientic style and vo-cabulary Demonstrate your work to other teams via presentationsI did the Project Proposal and the Initial Draft and you have to do the Final Report and the Project Presentationthere are some mistake in my Draft and I have the correct for my teacher you can fix it .Please read the requirement and do what the teacher ask
write project in Secure Data Aggregation in Wireless Sensor Networks in IEEE-style papers

Subspecialties in Forensic Psychology and Psychological Features Discussion

Subspecialties in Forensic Psychology and Psychological Features Discussion.

As you learned from last week’s readings, forensic psychology can apply to many areas of the legal system. Narrowly defined forensic psychology professionals conduct evaluations of defendants and appear in court to testify based on their findings. However, in reality, the activities of forensic psychology professionals, because of their knowledge of human behavior, might include working in prisons as mental health professionals; working with law enforcement agencies screening applicants; engaging in criminal profiling; or assisting in hostage negotiations, crisis intervention, or in the selection of a suitable jury.
As you have seen in the Learning Resources this week, there are forensic psychology subspecialties that include criminal forensic psychology, juvenile forensic psychology, civil forensic psychology, investigative psychology, correctional psychology, police psychology, and military psychology. Additionally, there are a variety of roles and responsibilities within each subspecialty. Studying and understanding the various roles and responsibilities of a forensic psychology professional within specific subspecialties, will help you to understand the field and identify a subspecialty of forensic psychology you may find most interesting.
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To prepare for this assignment:

Review Chapter 1 of the course text, Introduction to Forensic Psychology. Pay particular attention to the subspecialties and roles that fall under the umbrella of forensic psychology.
Review this week’s DVD program, “Practice Areas, Roles, and Responsibilities.” Consider all of the roles, responsibilities, and opportunities pertaining to forensic psychology professional.
Review the article “An Interesting Career in Psychology: Forensic Psychologist” (Pinizzotto) on the APA Online: Law and Psychology Web site and consider the roles of a forensic psychology professional within this specific subspecialty.
Think about the subspecialties of forensic psychology and the various roles within them.
Choose two roles that are of interest to you in one or more of the subspecialties.
Consider how each of the roles you selected contributes to a subspecialty and why.
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The assignment (1.5 pages):

Describe the two roles you selected.
Describe the two subspecialties to which the roles belong and contribute.
Explain how each role contributes to the subspecialty you selected and why.
Explain how roles of forensic psychology professionals in general contribute to forensic psychology subspecialties.

Readings

Course Text: Bartol, C. R.,& Bartol, A. M. (2019). Introduction to forensic psychology: Research and application (5th ed.). Sage.

“Cases Cited” (page CC-1)
Chapter 1, “Introduction to Forensic Psychology”

Article: Pinizzotto, A. J. (2003, Convention). An interesting career in psychology: Forensic psychologist. Psychological Science Agenda 16(4).
Retrieved from http://www.apa.org/careers/resources/profiles/pinizzotto.aspx

Media

Video: Laureate Education, Inc. (Executive Producer). (2009). Introduction to forensic psychology: Practice areas, roles, and responsibilities. Baltimore: Author.

https://studyhall.laureate.net/forensic-psych/prof…

Web Site

APA Online: Law and Psychology
http://www.apa.org/research/action/law.aspx

Optional Resources

Note: Because of the ever-changing nature of Web sites such as the one listed below, there is no guarantee that clips or Web sites will always be available. Hence, the following link is listed as a Optional Resource only. However, it is highly recommended that you view it as it will assist you in completing one or more of your assignments.
Article: MacKain, S. J., Tedeschi, R. G., Durham, T. W., & Goldman, V. J. (2002). So what are master’s-level psychology practitioners doing? Surveys of employers and recent graduates in North Carolina. Professional Psychology: Research and Practice, 33, 408–412.
Use the PsycINFO database and search using the article’s Accession Number: 2002-15385-009.

Subspecialties in Forensic Psychology and Psychological Features Discussion

Impact of the PhilHealth Z Benefit Package Implementation

Share this: Facebook Twitter Reddit LinkedIn WhatsApp Financial Impact of the PhilHealth Z Benefit Package Implementation in Two DOH-Retained Hospitals Author Alvin S. Concha, MD Co-author Jaryll Gerard L. Ampog INTRODUCTION Topic background One of the strategic thrusts of the Department of Health is “financial risk protection through expansion in National Health Insurance Program enrollment and benefit delivery (DOH, 2010). Philippine Health Insurance Corporation (PhilHealth) is the duly mandated government-owned corporation to administer the National Health Insurance Act, which is aimed to provide universal financial access to health services among Filipinos (RA 7875). In September 2011, PhilHealth started to implement new case-based payment (CBP) schemes for 12 surgical and 11 medical cases. A no-balance-billing policy was also imposed on all government hospitals for implementation among PhilHealth members from sponsored programs, mainly comprised of indigent people (PhilHealth, 2011). In June 2012, PhilHealth created another set of benefit packages with CBP schemes called the PhilHealth Z Benefit Packages (PZBP). Four conditions that are considered medically and financially catastrophic were initially included in the list of conditions with Z benefit packages (PhilHealth, 2012b). Another five conditions were added in 2013 (PhilHealth, 2013a; PhilHealth, 2013b) and two more conditions were added in 2014 (PhilHealth 2014a; PhilHealth, 2014b) to the list. A fixed reimbursement rate was set by PhilHealth for each of the conditions included in the PZBP list. PhilHealth also set a fixed co-pay amount for each condition. The implementing health facility can collect the allowed fixed co-pay amount from non-sponsored members and their qualified dependents. The no-balance-billing (NBB) policy is applied to all sponsored members and their dependents. Table 1 shows the list of conditions with Z benefit packages and corresponding specifications as of September 2014. Table 1. List of conditions with Z benefit packages and corresponding specifications as of September 2014. Abbreviations: ALL– acute lyphocytic (lymphoblastic) leukemia; CABG– Coronary artery bypass graft surgery, standard risk; Cervical cancer A– Chemoradiation with cobalt and low-dose brachytherapy or primary surgery for Stage IA1, IA2-IIA1; Cervical cancer B– Chemoradiation with linear accelerator and high-dose brachytherapy; PD First– Peritoneal Dialysis First; PHC– PhilHealth Circular; TOF– Total correction of Tetralogy of Fallot (for children); VSD– Closure of ventricular septal defect (for children); Z MORPH– Mobility, Orthosis, Rehabilitation and Prosthesis Help. Review of related literature Provider payment schemes A provider payment mechanism is the scheme of transferring funds from the health care service purchaser to the health care provider (Cashin et al, 2005). When an individual who has paid premiums for health insurance needs to access health care services covered by the insurance, the insurance company funds the health care services and pays the health care provider according to a pre-defined provider payment mechanism (GIZ, 2011a). Fee-for-service (FFS), case-based payment (CBP), line item budget ant capitation are all examples of a provider payment mechanism (GIZ, 2011b).Aside from the transfer of funds, provider payment mechanisms also facilitate the attainment of health policy objectives by creating incentives, supporting information systems and purchaser provider accountability mechanisms that affect health care resource allocation service delivery (Cashinet al, 2005; Econex, 2010). Fee-for-service scheme Prior to September 2011, to fund almost all treatments and procedures, PhilHealth paid health care providers of its members using a fee-for-service scheme. Under this scheme, the health service providers are paid for each reported service input, activity or use of items towards treatment of diseases or performance of procedures (Sutherland, 2011). The fees for health care in this scheme are not fixed (Langenbrunner et al, 2009). The greater the volume of activities or use of items, the higher the healthcare providers’ revenues are (ACHE, n.d.). Case-based payment scheme In a case-based payment mechanism, such as the PhilHealth Z Benefit Package, health service providers are paid a pre-determined fixed amount (case rate) per case or episode of care (GIZ, 2011b; Langenbrunner et al, 2009). The payment is intended to cover all inputs and activities within the entire episode of care (Reinke, 2007). Because the payment is fixed, limited and prospectively set, health care providers face greater financial risk in CBP than in FFS (GIZ, 2011b; Langenbrunner et al, 2009; Maciera, 1998). Trade-offs between FFS and CBP Financial risk for providers and health care purchasers, as well as stakeholder incentives, paperwork and system efficiency all vary among different provider payment mechanisms (Cashin et al, 2005; Mihalik et al, 1998). Implementing or shifting from one provider payment mechanism to another can also involve various difficulties (Mathauer et al, 2013). While an FFS scheme involves low financial risk to health care providers, health funders such as insurance companies may face high financial risk in this payment mechanism (GIZ, 2011b). This scheme encourages great volumes of services, sometimes beyond what is called for (Cashin et al, 2005). This involves high costs for health funders and yield high revenues for providers, but it does not promote high quality and efficient health services (Langenbrunner et al, 2009; Reinke, 2007; Sutherland, 2011). On the other hand, a CBP mechanism creates incentives for health care providers to be efficient (i.e., minimize service input) and to increase the number of cases (Langenbrunner et al, 2009; Maciera, 1998). Efficient providers profit from the difference between the case rate and the actual cost of care (Sutherland, 2011). CBP is also associated with a decrease in the average length of stay of patients in the health care facility (Langenbrunner et al, 2009; Sutherland, 2011), but has not been shown to decrease the quality of care. Yet, there has been mixed evidence for a lower cost of health care per episode within a CBP scheme (Sutherland, 2011). In a CBP scheme, the adequacy of the prospectively set payment, which is usually determined through statistical modeling and stakeholder consultations, may also be prone to arguments. Because of the fixed nature of the payments, inaccurate estimation of case rates may put health care providers to a serious disadvantage (Mihalik, 1998). Greater goals of health policy There is no single provider payment mechanism that will work for any kind of health system (GIZ, 2011b). It is every health system’s challenge to work out payment mechanisms that contribute towards the greater goals of health policy, most importantly, those that pertain to access to high quality health care services, reduction of financial risks and efficient use of health care resources (Cashin et al, 2005; PhilHealth, 2012a). Research question/s The study aims to assess the financial impact of PhilHealth Z Package implementation in two DOH-retained hospitals namely; Southern Philippines Medical Center and Davao Regional Hospital. Significance of the study The PZBP is a CBP mechanism for conditions that are medically and financially catastrophic. Under the CBP scheme, a fixed provider payment is set for a particular case or diagnosis. The fixed provider fee is the amount reimbursed by PhilHealth to the health facility for treating an active PhilHealth member. The reimbursement amount is fixed, regardless of the actual costs that accrue during the course of treatment. In instances wherein the actual treatment cost is less than the fixed reimbursement fee, the health facility gains income. When the actual treatment cost is higher than the reimbursement fee, the health facility loses income. This provider payment scheme is supposed to encourage health facilities to employ cost-efficient approaches to treatment. The complex nature of the medical conditions included in the Z benefit package list, however, makes it difficult for insurance agencies and health care providers to predict the actual cost of care that each treatment entails. To date, we do not know whether the Z benefit package scheme efficiently reimburses the health care provider with the actual cost of care. There is a need to determine the financial impact of the PhilHealth Z benefit package in institutions that have implemented it. Financial gain through the scheme affirms the provision not only of financial risk protection to PhilHealth members, but also of efficient therapeutic approaches taken by the health care provider. A positive net income also leaves the health care provider with adequate funds to improve its services. On the other hand, an experience of income loss from the implementation of the scheme can eventually affect the finances and operations of the health care provider. A good assessment of the financial impact of the scheme will facilitate the planning and implementation of measures within the health facility that will make its therapeutic approaches more efficient. The assessment will also inform PhilHealth of the adequacy of the initially set reimbursement rate of each of the conditions in the Z benefit package list. Most importantly, the assessment will enable us to gauge whether or not the PZBP affords financial risk protection to PhilHealth members who avail of it. Objective/s The main objective of this study is to determine the financial impact of the implementation of the PhilHealth Z Benefit Package in Davao Regional Hospital and Southern Philippines Medical Center. METHODOLOGY Research design This study will utilize a descriptive design. Setting This study will be conducted in two DOH-retained hospitals. Davao Regional Hospital is a 200-bed tertiary care training hospital in Tagum City. Southern Philippines Medical Center is a 1200-bed tertiary care training hospital in Davao City. The two institutions are 60 km apart. Participants All PhilHealth patients from DRH and SPMC who have availed of the PZBP since the start of each package implementation will be included in this study, and will constitute the first half of the study sample. An equal number of PhilHealth patients admitted right before the implementation of the PZBP with the same diagnoses as those in the first half, but who were billed on a fee-for-service basis, will be chosen from among the patients in the same hospitals. This latter group of patients will serve as the second half of the study sample and comparison group. Inclusion criteria Patients who have partially availed of case-based PhilHealth reimbursement (i.e., any of the 23 medical and surgical conditions covered in the initial PhilHealth case rates of 2011) (PhilHealth 2011) for a diagnosis similar to the conditions in the PBZB list, but at a time when PBZP was not yet implemented, will be considered to have availed of a fee-for-service PhilHealth reimbursement. An example for this is a patient who was diagnosed to have breast cancer in 2011 (prior to PBZP implementation), who availed of the case rate provider payment mechanism for modified radical mastectomy, but who paid for or availed of PhilHealth benefits for the subsequent chemotherapy on a fee-for-service basis. For purposes of this study, such patient would be classified into the fee-for service group. Exclusion criteria Patients with incomplete billing data will be excluded from this study. Sampling procedures* Not applicable on this study Interventions and comparisons* Not applicable on this study Randomization* Not applicable on this study Data gathering Secondary data from patients’ hospital records will be the main source of data for this study. No direct patient interviews or interaction will happen. The list of patients who received Z package benefits (PZBP group) will come from the PhilHealth Office of each hospital, which keeps a log of PhilHealth members who have availed of the Z benefits since start of PZBP implementation. The list of PhilHealth patients who were admitted right before the PBZP implementation with the same diagnoses as those who have availed of the Z benefits, but who were billed on a fee-for-service basis (FFS group) will come from the Medical Records Section of each hospital. All the hospital bills will come from the Billing Section of each hospital, and all the official receipts, guarantee letters, notes and PhilHealth reimbursement records will come from the Accounting Section of each hospital. Table 2 shows the list of hospital records needed for this study and the corresponding offices in the hospital where the records will be obtained. Table 2. Hospital records needed for this study and the corresponding offices in the hospital where the records will be obtained. Hospital Records Office where records will be obtained List of PhilHealth patients under PZBP PhilHealth Section List of PhilHealth patiennts under FFS Medical Records Section Individual patients Billing Section Official receipts, guarantee letters, notes Accounting Section Individual PhilHealth reimbursement records Accounting Section Independent variables The hospital records will be reviewed to obtain the data reflected in the case report form (Appendix A).For each institution (DRH, SPMC), the following outcomes, as operationally defined, will be computed per condition per provider payment mechanism (fee-for-service scheme prior to PZBP implementation; case-based scheme during PBZP implementation) for reporting: Mean actual total bill – this is the average amount of actual total bill reflected in the summary of charges in individual patient bills. The actual total bill represents the total cost of health care for a patient with a particular condition. Mean out-of-pocket payments – this is the average amount of health care cost that is paid by the patient and/or other sources and is not reimbursed by PhilHealth. The individual patient’s out-of-pocket payment is inclusive of the actual amount paid by patient as reflected in the official receipts and the actual amount paid by other sources like PCSO, PDAF, MHCAP, etc. Under the PZBP scheme, the out-of-pocket fee is termed “fixed co-pay”, because PhilHealth has set a ceiling amount, beyond which health care providers are not allowed to charge patients. Mean PhilHealth reimbursement – this is the average amount of reimbursement received by the hospital from PhilHealth for treating a patient with a particular condition. The individual patient reimbursements are expected to vary in a fee-for-service scheme. In a case-based scheme such as PZBP, the PhilHealth reimbursement amount is fixed and predetermined. Main outcome measures and other dependent variables Mean hospital subsidy – this is the average amount of the portion in the actual total bill that is not paid back to the hospital. The amount is positive if the actual total bill is greater than the PhilHealth reimbursement amount plus the out-of-pocket fee. The hospital subsidy for individual patients is inclusive of discounts, the unpaid balance and the amount slashed by PhilHealth (if applicable). The hospital subsidy may also be called “negative income”. Mean net gain – this is the average amount of positive income. This amount is positive if the actual total bill is lesser than the PhilHealth reimbursement amount. In such instance, no out-of-pocket payment is charged, the hospital does not subsidize any amount to cover part of the health care cost and the hospital actually gains income. Sample size computation* Not applicable on this study Data handling and analysis Data for this study will be encoded in a spreadsheet and analyzed using Epi Info 7. Continuous variables will be summarized using means ± standard deviation. Categorical variables will be summarized using frequencies and percentages. Ethical considerations Ethics review The protocol of this research will be submitted for approval to the Department of Health XI Cluster Ethics Review Committee (DOH XI CERC). Confidentiality Patient data will be retrieved using hospital case numbers and name initials provided by the respective PhilHealth Sections and Medical Sections of Davao Regional Hospital and Southern Philippines Medical Center. Anonymized patient data, devoid of personally-identifiable information like addresses, phone numbers, or e-mails, will be requested from the Billing Sections and Accounting Sections of the two hospitals. The data will be in both hardcopies and softcopies. Only the investigators and study staff will have access to the raw data. Hardcopies will be destroyed upon study closure. Softcopies will be kept by the principal investigator in a computer in a password-protected file. The full study report will not contain patient names or any personally-identifiable information. Share this: Facebook Twitter Reddit LinkedIn WhatsApp