Offer and Acceptance

For a Simple contract to be valid one party must make an offer and the other accept it (see: Acceptance of offer). The offer will usually indicate the form the acceptance should take (e. g. , in writing, by post), and may indicate when the acceptance will be deemed to have occurred (e. g. , on delivery of the posted acceptance, see: Acceptance of offer by post). In seeking to prove that a contract was in existence, it will be necessary to show that there was a definite offer. Certain things look like offers, but aren't always what they seem. Here are some examples. Invitations to treat are not offers (see: Invitation to treat). For example, putting an item on display in a shop window with a price label is not an offer, it is merely an invitation to treat. Pre-contractual negotiations, particularly in Conveyancing, may have the appearance of offers, but it will be necessary to satisfy the courts that a real offer has been made. Tenders (see: Tender) are not offers unless they are construed as a Unilateral contract. An offer can be withdrawn (revoked) at any time up to acceptance, provided it is communicated appropriately to the offeree. There are a few of complications with this. Placing a notice of the withdrawal in the post does not constitute the withdrawal; it has to be received and understood by the offeree (see: Byrne vvan tienhov en (1880)). If the offer forms the basis for a unilateral contract, it can be difficult to revoke. Typically the offerer must take reasonable steps to revoke the offer in the same form as it was originally made. For example, if the offer was made in a newspaper, then it should probably be revoked the same way. Moreover, it is particularly problematic if a unilateral offer is revoked before full completion of the act that constitutes the acceptance. In Carlill v Carbolic, for example (see: Carlill v carbolic smoke ball co (1893)), Mrs Carlill was able to demonstrate that she had completed the acceptance, so Carbolic could not have escaped its obligations be revoking the offer. However, suppose Mrs Carlill had started using the Smoke Ball, and written to Carbolic expressing her wish to claim the compensation if it failed. If Carbolic had withdrawn the offer at that time, could the agreement be enforced? There is no clear ruling on this; the decision in Errington v Errington sees to imply that once the acceptors consideration is executory (that is, Mrs Carlill has begun using the Smoke Ball), then the offer cannot be revoked (see: Errington v errington (1951)). There are, however, some cases with the opposite conclusion. An offer may be self-terminating if the terms of the offer include, for example, a time limit for acceptance. If no time limit is given, an offer may be deemed by the courts to have expired after a ‘reasonable time'. This will be the case even if the offerers have not explicitly revoked the offer. The death of either the offerer or offeree, prior to acceptance, probably constitutes a revocation of the offer.

Motifs in Grendel Essay

Throughout John Gardner’s novel, Grendel, there are many literary tools and compositional risks used to support the overall meaning of the story and to show change in the main character, Grendel. One compositional risk that Gardner uses extremely effectively is motif. A motif is defined as recurring structures, contrasts, or literary devices that can help to develop and inform the piece’s major themes. The most effective motif Gardner uses over the course of the novel is the recurring references to the signs of the zodiac. Other important motifs referenced in Grendel are the seasons, machinery, and the number twelve. Starting in chapter one, Gardner effectively uses the zodiac signs to reinforce the changes in Grendel and the changes in time. Grendel is split into twelve chapters, each corresponding to a different zodiac sign. In each chapter, one of the twelve zodiac signs is referenced at least once. The zodiac references also appear in the exact order as the calendar, starting with Aries in chapter one and ending with Pisces in chapter twelve. In fact, the very first sentence of the novel is a reference to the first zodiac sign. â€Å"The old ram stands looking down over rockslides, stupidly triumphant. † (Gardner 5) This is a very simple zodiac reference and other simple references occur in chapters two and ten, when Grendel encounters a bull and goat respectively. However, some of the zodiac references are tougher to locate. Chapters five and seven are among the difficult references. Chapter five refers to Leo the Lion, but a lion is never mentioned in the text. Chapter seven refers to Libra the Balance. The reader must infer the peace offering of Wealtheow to represent a force of balance between the Scyldings and the Helmings. Another motif used extremely effectively throughout Grendel is the seasons. Grendel is not a novel written in chronological order. The book begins somewhat at the end, then enters a series of flashbacks, and ends in the present. However, even though the novel skips around chronologically, it is patterned after the passage of a one-year calendar. The novel begins in the spring of Grendel’s last year alive and ends with him dieing the following winter. This is appropriate because spring normally represents growth and new beginnings, so this is an ideal place to start a story. It is also appropriate because winter normally symbolizes death and Grendel is slain by Beowulf during the winter. Machinery is another motif used to perfection by Gardner in Grendel. Many times throughout the course of the novel, Grendel uses metaphors describing animals and humans as â€Å"machine-like† because they mindlessly adhere to set patterns of behavior. Grendel first notices this in the ram, which instinctively responds to the arrival of spring and will not leave no matter what Grendel does because the season is upon us. â€Å"I shake my two hairy fists at the sky and I let out a howl so unspeakable that the water at my feet turns sudden ice and even I myself am left uneasy. But the ram stays; the season is upon us. † (Gardner 5) Later in the book, Grendel describes himself as â€Å"mechanical as anything else† when the warm weather causes him to start his raids on the mead hall. One final motif used throughout Grendel is the significance of the number twelve. To start off, there are twelve months in a year and the narrative is broken into twelve chapters. Next, there are twelve zodiac signs and all twelve zodiac signs are referenced in the book. Finally, there are twelve years in the war between the Danes and Grendel, with Grendel being slain via Beowulf in the twelfth and final year of the war. Obviously the number twelve is a recurring theme throughout the novel making it a very significant motif. A motif is defined as recurring structures, contrasts, or literary devices that can help to develop and inform the piece’s major themes. John Gardner uses many motifs throughout Grendel to help explain the story and themes in the story. The most effective motif used is the zodiac symbolism in each chapter, but the motifs of the seasons, machinery, and the number twelve are also imperative in helping explain the overall meaning of the story. Motifs should be used whenever possible to help explain a story, plus they provide readers with an interesting topic for debate when discussing a novel.

Psychology Schools Paper Essay

Behaviorism Behaviorism would explain road rage by looking at the person’s environment to see why he or she would become enraged and show aggressive behavior towards other drivers. Using behaviorism, you would examine what is happening at that time, who is involved, the driver, the passengers, and other drivers. Some factors that could exhibit the driver’s frustrations are traffic jams, loud noises, a disgruntled mood before driving, and annoying passengers. To prevent road rage from happening, the driver should be in a good mood, the passengers should understand they should be well behaved, and should leave earlier so that they have a smaller risk of getting caught in traffic. Psychoanalysis Psychoanalysis can be used to determine the cause of road rage by looking at a person’s dreams and childhood. By examining the dreams, you may be able to find out if the person had an upsetting dream and could possibly put the driver in a bad mood, which could cause him to experience road rage. You could ask the person about the kind of childhood he or she had. If the person had a violent parent or a parent who experienced violent outbursts, the driver may have thought that that was an acceptable way to act. Using free association, you could give the person a word that is traffic related and ask them what comes to mind by learning about their dreams and their childhood, you may be able to gain some insight and see what caused the road rage. Humanism Within the context of humanism, you would need to get the person to examine the reality of the road rage episode and how they behaved and the ideal way they should have acted in the driving situation. You would have the person break down the problem and they could tell you that they were on their way to the market when someone suddenly veered into their lane, which upset the person and they became aggressive towards the other driver. Once they have determined what the problem is, acting aggressively while driving, you could then have the person explain how they really would have handled the situation in a perfect world. Neurobiological From a neurobiological point of view, you would want to find out if there were mental or health issues that played a part in the road rage. You could do a psychological examination to see if they had depression, bipolar, or any other mental disorder that could cause a violent reaction to a traffic incident. If it turns out that here is a chemical imbalance caused by depression or another mental disorder, then you could prescribe medications to help the person manage their behavior. Helping a fellow student who has dropped all of their books down the stairs Behaviorism Using behaviorism, you would examine what is happening at that time, who was involved, and what other factors in the surrounds are. An example of this could be a small, weak looking girl could have accidentally dropped her books down the stairs. A boy was late to class and would walk past her, but he sees a teacher and doesn’t want to leave a bad impression on the teacher by ignoring the school’s â€Å"above the line† rules, which tell students to help each other in any ways they can, so he goes and helps her pick up her books. Psychoanalysis Psychoanalysis can be used to look at a person’s dreams and childhood. They could be asked if they had any childhood memories of dropping books and having no one help the person pick them up. Using this information, you could see why the person would help another student pick up their books, because they didn’t want the other student to feel the same way they did when no one helped the person. Looking into the dreams the student may have had could also show if they had a dream where they helped another student and received thanks from the student who dropped their books. The person may have wanted to have the dream become a reality by receiving thanks by helping the other student pick up the books. Humanism Using humanism, you could get the person to examine the reality of what it would feel like if someone had dropped their books and no one helped the student, and how the student felt when no one helped pick up the books. You could have the person break down the problem into how they felt when no one helped the student, and how they might have felt if someone did help them. Once they have determined what the problem was, not helping the student pick up their books, they could have them explain how they really would have handled the situation. Neurobiological From a neurobiological point of view, there is nothing in their genetics; there are no organic problems; no chemical imbalance; and no genetic problems with empathy. The person was just trying to be nice to the student who dropped their books, so the person helped the student. A new student not wanting to join in any activities at their new school Behaviorism The environment surrounding the student may be uninviting for school activities. An example of this could be having a dance, but it is crowded, dimly lit, teachers could be watching you dance, and the other students might look like they don’t want to dance. The student would not want to join in the school activity because it does not look inviting. Another possible factor could be if the person was feeling depressed. If the person was depressed, he or she would not want to engage in the activity. Psychoanalysis Using psychoanalysis, you could determine if the person had a suppressed memory or bad childhood that dealt with a school activity. The person might not want to attend the event because it might have been a painful time for him or her. The person could also have had a possible dream in which the school activity does not turn out well. If the dream shows the school activity not turning out well, then the student might not want to go to the school event. Humanism Through humanism, the person could examine the reality of the school activity and see why they do not want to go to the activity. The person could break down the problem to see what the exact reason as to why they don’t want to go to the school activity is. Once the person sees the exact reason to why they don’t want to go to the school activity is, they can determine what it would be like if the event turned out how they want it to be. Neurobiological Through neurobiological psychology, you could determine if the person has a mental health issue such as depression, which would explain the lack of interest in going to school activities.

Budgeted Health Promotion Activity Coursework Example | Topics and Well Written Essays - 1000 words

Budgeted Health Promotion Activity - Coursework Example Community based health promotion is the most effective away out to execute such programs. This is because; it gives community members the opportunity to change their health risk habits. It is also easy to execute, as it can be done through individual counseling, focused group discussions, leaflets distribution or local support groups. It is effective when community leaders take part in achieving the set program goals and objectives. This should be focused at culture level since it is the best predictor of health habit change. Behavior change starts at an individual level but, its effectiveness will be realized at community level. Those with information should be able to disseminate the same information to those who do not have it. This can be achieved through community discussion forums need to be organized on a regular basis. Their main theme will be making people practice healthy choices. To ensure that there is overwhelming support toward the newly initiated programs; the communit y should be involved in the planning and implementation phases of the project. The community needs to be enlightened that healthy practices are the key to disease prevention, disability and death. This should involve encouraging people to adopt lifestyles that are beneficial to their well-being, while trying to abandon those lifestyles which make them vulnerable to sickness. Table of fixed, variable, controllable and unrecoverable expenses Fixed expenses Amount ($) Staff Salaries Rent Consultants costs Insurance cover for employees Variable expenses Fuel costs Car Maintenance costs Space and equipment hiring fee Materials Delivery costs Controllable expenses Program curriculum materials Program publicity materials Training of program facilitators Postages costs Unrecoverable expenses Equipment Packaging costs Material Shipping costs Travel costs Material Storage costs Cost-benefit analysis By definition, cost benefit analysis refers to as the act of comparing the cost of setting up a project or a program with the expected outcome. This technique help in making decision on whether to take up a new opportunity or make a change on an ongoing project or programmed. It simply entails summing up the benefits of an intended course and subtracting related costs (Brent, 2009). According to Brent (2009), the most accurate and best common unit of measuring cost benefit analysis is the money value. Despite the fact that at times it becomes difficult to evaluate some services in terms of money, it still remains to be the standard unit of comparison between costs and benefits in any project or program. For this case, the money aspect comes in particularly when the beneficiary access the opportunity of getting free counseling on sexually transmitted infections and even treatment before being circumcised. This would mean they will use this money in solving other day to day problems that they might encounter. The project has several benefits, this range from job creation to re duction in the rate of prevalent rates of HIV/AIDS in the intended area. The reduction in the prevalent rates of the disease might be a long term benefit, which will be realized after a substantial duration of time. For instance, the most immediate benefit is job creation, where the locals will get job opportunities as, project facilitators, monitoring and

THE TACTICS OF MAYA FARMERS Essay Example | Topics and Well Written Essays - 500 words

THE TACTICS OF MAYA FARMERS - Essay Example The classic Maya civilization flourished in the southern low lands of Mexico, Guatemala, and Honduras between the last four centuries before Christ and AD 900. Despite the conditions of prolonged dry spells caused by draught, constant brushfires that devastated the earth, and erratic rain patterns that wreaked havoc on agriculture, the Maya community’s survival for such a long period of time could be attributed to their farming tactics. The hot and humid conditions of the low lands, with no possibility for irrigation, posed the primary challenge to the Mayan existence as a farming community, but they seemed to have adapted to these adverse conditions by their innovative tactics. They moved to the dense forest area that mantled the southern lowlands, cleared the primordial forest and utilized it for agriculture. In order to overcome the infertility of their homeland, they adopted the slash-and-burn cultivation by cleaning the brush and trees, and burning them. This helped them to put to use even the barren lands. However, this had a shortcoming that the fertility would last for only about two years or so. The Mayans were again imaginative here by migrating to fresher meadows where they cultivated, and returned after several years to utilize the same land they earlier abandoned. Maintaining this process as a cycle, they were able to use a wider area of land. Thus they were able to circumvent, albeit temporarily, the c hallenges of nature.

The Analysis of a Joke Essay Example | Topics and Well Written Essays - 1000 words

The Analysis of a Joke - Essay Example Although we think of the joke as a cultural constant, it is a form of humor that comes and goes with the rise and fall of civilizations.†1 The joke that was chosen was the following: A doctor walked into a bank. Preparing to endorse a check, he pulled a rectal thermometer out of his shirt pocket and tried to write with it. Realizing his mistake, he looked at the thermometer with annoyance and said, ‘Well thats great, just great... some asshole’s got my pen.’2 The category that this particular joke probably belongs in is the scatological category, because it deals with a reference to the rectum. It’s unsure why, but these types of jokes can be particularly compelling—because excrement seems to be something that humans find very funny. Of course, a simpler way to say that is to just say, â€Å"Poo is funny.† But why? What is so funny about our own feces? Fundamentally, excrement is elemental. If we didn’t have it, there would be no jokes. But why is humor about feces, farts, and, in fact—the entire range of human bodily functions, fodder for jokes? One must wonder. What makes this particular joke funny is that, through a play on words, we imagine the pen being stuck in some patient’s behind. That seems pretty funny that there would be a mix-up like that. Thus, there is a play on words and we find this joke, for the most part, funny—if not at least a bit crude. ... Now, it’s not using very polite language either. This is where the aggressive element demonstrates itself. It’s not a polite joke, and it probably wouldn’t be polite to share in mixed company, unless the mixed company were to be as foul-mouthed as the language used in the joke. Although the joke’s language is not overly offensive, it does say something about the medical profession as well. Doctors are sometimes inept, and it’s easy to make jokes about doctors and lawyers because they both have high-stress professions. Humor can be a wonderful way to deflect problems, as well as provide a platform for expressing one’s personality. This is why comedians like Jerry Seinfeld did especially well with his show Seinfeld, and why, subsequently, comedians like Larry David did so well with his show Curb Your Enthusiasm. Many times, these humorous shows have something in common—they use real-life situations as fodder for something called situatio nal comedy (or a sitcom). Situational comedies bring real-life problems to light. Who could ever forget the following bits: â€Å"Are you sponge-worthy?† â€Å"She’s got man hands!† Pig Man. The Soup Nazi. â€Å"You double-dipped the chip.† â€Å"Serenity now!† â€Å"Give me that, you old bag!† Who will ever forget these classic moments in Seinfeld history? These, and a series of other vignettes in his subsequent spin-off hit HBO comedy series--Curb Your Enthusiasm--were brought to you by none other than comedian, writer, actor, and executive producer Larry David. Larry David was the head writer and executive producer of Seinfeld, winning him a Primetime Emmy Award for Best Outstanding comedy series in the run of the show’s fourth year. Seinfeld made

BUS 101 Essay Example | Topics and Well Written Essays - 500 words

BUS 101 - Essay Example When the central bank is "tightening", it slows the process of private bank issue by selling securities on the open market and pulling money (that could be loaned) out of the private banking sector. It reduces or increases the supply of short term government debt, and inversely increases or reduces the supply of lending funds and thereby the ability of private banks to issue new money through debt. The operative notion of easy money is that the central bank creates new bank reserves (in the US known as "federal funds"), which let the banks lend out more money. These loans get spent, and the proceeds get deposited at other banks. Whatever is not required to be held as reserves is then lent out again, and through the magic of the "money multiplier", loans and bank deposits go up by many times the initial injection of reserves. (Wilkepedia.org.) Accounts Payable: This is the most important source of short-term financing for many firms. Beware that increased use of Accounts payables (such as by not paying off when you should) can be expensive as most firms offer favorable terms for prompt payment and delaying payments can also upset your suppliers. Commercial Paper-IOUs.

Project management (coca-cola) Essay Example | Topics and Well Written Essays - 2500 words

Project management (coca-cola) - Essay Example We have considerable experience in the area and we have organized for international organizations in the coast. In this proposal, we outline our capability and how we will offer the best service if we get the chance to work with you. We intend to bring all the experience we have accumulated for years in areas such as risk management and project management to make sure that he event will be successful and will run smoothly. We have outlined the lineup of mangers who will be mandated with each areas of the project as a way to deter any mishap. This proposal provides the budget for the event and the various costs that will have to be incurred. As a tradition in PrudentEvent, we always ask the client to provide with at least one in-house employees to act as the project collaborate in order to give our staff an eye into the operations of the fir, we understand that there are numerous things which can go wrong with an international event. ... Our catering experts will make sure that the delegates in the conference will get the food they need, regardless of their culture or religious constraints it diet. We also have a well established travel and transport managers who will be able to manage the arrival of the delegates and their transport fro reach of the day they will stay in London. This team will not rest until the delegates have been sent back to their flights on their way back home. Being an events planner, we understand the importance of entertainment and understand that such an event can never go well without some form of entertainment. In this regard, we have specified a number of ways in which the guests will be entertained. More importantly, we understand the need for communication equipment especially with regard to the fact that an international event like this will need communication equipment which will take care of language translation. We have an already existing team to manage any transport needs with reg ard to the event. PrudentEvent is a world renowned event organizer that has achieved a number of world-class vents. Our main clients are international NGOs, and we have successfully organized meetings for their officials in a number of cities. Our greatest strength is that we have offices across the global and that makes global coordination easier. We have organized for meetings for large organizations around the world and we intend to use the experience we have achieved to make sure that the event is the success. We deliver success and quality for all our clients. 2 Conditions of the contract 1 Description of the nature of contract Planning the event with regard to the coordination of how the attendees will arrive and leave at the scene of the conference. †¢ This

Rites of Passage Research Paper Example | Topics and Well Written Essays - 750 words

Rites of Passage - Research Paper Example This gives him the energy and spirit to enter the next stage with valor and delight. The theme behind is that such rites help us stay connected to our natural events of life or life cycle. A person is able to go through a happy flashback of his life when he thinks in old age how cheerfully he entered each stage and coped with the hardships that come with every phase. This paper intends to compare and contrast the rites of passage in modern American and Indian cultures. Modern American society celebrates many rites of passage, like baby showers, bar mitzvahs, quinceaneras, and school graduations. There are very few definite events that mark a person’s shift from adolescence into adulthood. We see an absence of clearly defined rites of passage in the contemporary culture, which have prevailed in olden times in America. Indian culture also does not have very clearly defined rites of passage except some important ones like birth, marriage and funeral. However, there are some simil arities that both cultures share, for example grief is symbolized with color. American society relates black with grief and Indians link white with sadness. For example, on funerals, Americans wear black and Indians wear white. There are more differences in the carrying out of the rites of passage than similarities, in the two cultures. ... The expectant mother is dressed in a heavy dress with a lot of garlands. Elderly ladies shower blessings on her, and women share tips and tricks of mothering a child. The home deity is worshipped. The mother is given the gifts which are meant for her and not the baby. American culture celebrates adolescence ceremonies both for boys and girls, to honor their stepping into puberty. The most prominent adolescent rite of passage celebrated in America is the quincearena. Quinceanera celebrates a girl’s fifteenth birthday thus commemorating her past fifteen years into a get-together where people related to her make merry and congratulate her for her coming adulthood (Alvarez). Her journey from childhood to adulthood is recollected and she transforms from a naughty little kid into a delicate, pretty lady. The invited families are encouraged to select the customs that have special meaning to them and to add to the customs as they wish. That is what makes the celebration unique and ver y special. In contrast, in Indian culture, there is no such ceremony that celebrates the passing of fifteen years or steeping of a girl or boy into the sixteenth year of life. American practices have more or less become dependent on the economical and psychological aspects of life. For example, funeral practices in America depict true picture of capitalism and materialism. Corpse is displayed in the public for last viewing. This is a general acceptance of the fact that death is expected of all human beings and none of us resist to it. Corpses, nowadays, are prepared with makeup and expensive clothes before burial. Memorial services and cremations are also in practice. Hence, American funeral is an organized and

Gregor Mendel Biography Essay Example for Free

Gregor Mendel Biography Essay His first conclusion was his Law of Segregation, which said that dominant and recessive traits are passed down randomly from parents to offspring. He also provided and alternate way of heredity through his Law of Independent Assortment, which established the idea that traits were passed down independently from traits from parent to offspring. Although his work was overlooked for some period of time, his work later became appreciated by biologists and botanists who were also doing work on heredity. Mendel’s work became the basis and formed the foundation of genetics, in the study of heredity. Although all his work was done through experimentation with pea plants, his laws can be applied on all living organisms that exist today. With his work, people have been able to create anything as crops resistant to harsh weathers reducing the risk of famine, and been able to modify certain traits not just in agricultural life to our benefit. In medicine, doctors have been able to practice preventative medicine now that they know that certain people are at risk for certain diseases. There’s a lot more things, just think how much Mendel’s help at understanding heredity has benefited the human race. Gregor Mendel was born Johann Mendel on July 22, 1822, to Anton and Rosine Mendel, on his family’s farm in Austria. He was given the name Gregor later on in life when he joined the St. Thomas Monastery in Brno. Once his brilliance was noticed by his local school teacher, he was sent to a secondary school in Troppau to continue his education. The Mendels were somewhat poor, but they were able to find enough money for his tuition. It was a hard strain on the family, and also a hard experience for the young Gregor Mendel who suffered of depression, but that didn’t keep his from excelling in his studies, and he graduated in 1840 with honors. He wanted to continue his education, and so he enrolled at the Philosophy Institute of Olomouc. After two years, he was recommended by one of his teachers to go to the St. Thomas Monastery, where he was seen to be of worth to become a monk by the head of the monastery. Here was where he adopted the name of Gregor, to follow tradition. Even after joining the monastery at the age of 21, Gregor further pursued his education and went to the University of Vienna to continue his studies in science, at the monastery’s expense. Here he studied physics and mathematics under Christian Doppler, the same man that the Doppler effect wave frequency was named after. After finishing his studies in 1853 he came back to the monastery, and began teaching secondary school for about a decade, which is where he began most of his experiment which he is best known for. Mendel did not begin his work on heredity using pea plants, but rather with mice. It was on mice on who he began his first experiments, due to his interest in the inheritance of the color of mice coats. He kept doing so until the head of the monastery, Abbot Nap, suggested that looking at mice mate wasn’t the best task for a religious Catholic monk, and so he switched to plants. Mendel chose to use pea plants for his experiment because offspring could be quickly produced, and so he didn’t have to wait too long for them to grow. He cross fertilized pea plants that had opposite characteristics, such as tall with short, smooth to wrinkled, and those containing green seeds with those containing yellow seeds. It is here where he reached to his two most famous conclusions: The Law of Segregation, and the Law of Independent Assortment. Even though Mendel himself believed that this only applied to certain species and certain traits, it became the theory that this applies to all existing organisms. When he was older Mendel became having problems with his eye sight, which kept him away from continuing his experiments. He died on January 6, 1884 at the age of 62. His funeral was well attended, but his work still remained very unknown. He too did not seem to promote much of his work, but not until about a decades later this his work become appreciated and his studies began to be called Mendel’s Laws. It is these laws that are the foundational principles in biology today.

Healthcare Affordability in the US

Healthcare Affordability in the US Advanced Nurse Practitioner Scope of Practice Issues Marina Bukhrashvili New York State needed an additional 1,200 physicians to address the shortage by 2012, according to a 2012 Haney’s survey by the Healthcare Association of New York State (Verdon, Ritchie, Marbury Mazzolini, 2014). The scope of Certified Nurse Practitioner (CNP) practice is currently debated in some states. In New York State, the Nurse Practitioners Modernization Act will allow those nurses who have more than 3,600 hours of experience to treat patients without the supervising physician’s signed practice agreement (Farmer, 2014).This act will become law on January 1, 2015. This act may fill that void; however, various New York physician advocate groups continue to argue that patient safety will be compromised because of the gap in training of CNPs (Verdon et al., 2014). The United States (U.S.) health care system faces many challenges due to demographical, economic and political shifts. There are existing gaps in quality and accessibility of care and patient safety. U.S. population is aging rapidly and it is estimated that about 18 percent of the U.S. population will be 65 years old or older by 2025 (U.S. Census Bureau, 2012). With growing number of Medicare beneficiaries, there will be more demand for primary care providers. It is estimated that by 2020, the U.S. nation will require 40 percent more primary care providers (Hauer et al., 2008). U.S people 65 and older will have more than one chronic disease and physicians’ shortages will not meet the demands that are expected (Centers for Disease Control and Prevention, 2012). The National Governors Association (NGA) reviewed of the literature and summarized that CNPs can reduce disparities in access to care, promote cost effectiveness through policy advancement, patient advocacy and the development of innovative models of care to improve patient care (NGA, 2013). The push for giving CNPs more autonomy continues with the shortage of primary care physicians on the rise. The American Academy of Family Physicians (AAFP) is not supporting the idea of allowing CNPs the full scope of practice without working under the physician’s supervision. One of the reasons cited is that family physicians have extensive training and education, which would ensure patients’ safety and provide the best quality of care (American Academy of Family Physicians, 2012). The scope of CNPs’ practice is currently debated in some states. Researchers studied care provided by both nurse practitioners and physicians and showed that while quality of care was similar for both providers, patients’ results were same or better for NPs as compared to physicians (Bauer, J. 2010). In addition, it was found that nurse practitioners provide care at a lower cost as well as more disease prevention counseling, health education, and health promotion activities than physicians (Mehrota et al., 2009). Another study which used data from the Association of American Medical Colleges’ Consumer Survey showed that consumers are open to the idea of obtaining medical care from NPs (Dill, Pankow, Erikson Shippman, 2013). Compared to physicians, CNPs traditionally are reimbursed at a lower Medicare rate for delivery of the same services. Yet, while our healthcare desperately needs to reduce cost, it is estimated that a cost savings would remain, even if CNPs were to receive equivalent reimbursement, because they utilize fewer resources than physicians (Health Policy Brief, 2012). In 2009, on average, it cost 20% less to visit a nurse practitioner than to visit a physician (Eibner, Hussey, Ridgely Glynn, 2009). In Massachusetts, after the insurance reform was implemented, it was shown that the state could save from $4.2 to $8.4 billion over a 10-year period when nurse practitioners use was increased (Eibner et al., 2009). Accountable care organizations (ACA), community and nurse-managed health centers, patient-centered medical homes success will require that CNPs have full scope of practice to have the ability to practice independently without restrictions (Fairman, Rowe, Hassmiller, Shalala, 2011). Organizational barriers exist for reimbursements of care provided by CNPs. Notwithstanding that the quality and standards of preventing care established in the ACA are met by these providers, their current rate of reimbursement for Medicare services to residents in long term care (LTC) facilities is only 85 percent of the rate that physicians charge for the same services (American Association of Nurse Practitioners, 2013). The unlimited contribution of CPNs will be even more important considering that with the implementation of the ACA, millions of newly insured Americans will seek the access to healthcare. Expanding the scope of practice of advanced practice nurses can possibly translate to an increased access to healthcare for many current and future patients, especially in underserved areas (National Governors Association, 2012). There is a need for the uniform standards for practice and to eliminate the difference in the level of practice among CNPs from one state to another (NGA, 2012). The scope of practice will establish which activities are reimbursed by third party payers and will have direct impact on the independent practice of CNPs (NGA, 2012). When CNPs are required to collaborate or to be supervised by the physician, they are less likely to be selected by insurers and are unable to directly bill for the services they render (NGA, 2012). Instead, the bill for their services is coded under the physician’s provider number. If the requirement for physician involvement is dropped, CNPs would be allowed to be credentialed as providers and directly reimbursed for their services. This is also important if a physician moves or does not want to collaborate with a CNP. Another issue related to scope of practice is the lack of universal, federal recommendations for mobility across states for practitioners involved in telemedicine. The significant discrepancy in CNP scopes of practice across states limits the ability of expert CNPs to work as consultants in a different state, which may limit the access of individuals to specialty consultations that may not be available locally. In their study of nurse migration, it was reported that nurses, including CNPs, move to states with less restrictive scopes of practice. Migration of CNPs may contribute to the shortage of primary care providers, especially in disadvantaged areas (Kalist, Spurr, Wada, 2010). Nurses are restricted to certify in some state to do health care visits or stay in skilled nursing facilities, admit patients to hospitals or prescribe medications without physician’s supervision and because of that nurses move to less restrictive states, and from primary to specialist care, a resu lting loss of access to care a lot of patients (Eibner et al., 2009). With millions of people signing up for health care under the Affordable Care Act, the aging population and number of chronic illnesses growing, the demand for primary care services is projected to grow. NPs will play a significant part in expansion and shaping of health care delivery. The looming shortage of primary care practitioners can be alleviating by integrating into health care delivery primary care nurse practitioners and physicians assistants. Medical profession should have an active interest in advancing the role of NPs and making sure that the high standards of the profession are intact. While NPs should not be a replacement for doctors they should be allowed to practice to the full extent of their training. Relaxing the scope of practice laws that prevent nurse practitioners from playing the important role in providing basic primary health care services is the first step that should be undertaken. References American Association of Nurse Practitioners (2013). 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