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Section 1 buy renova 0.025 cream. Identifying Stress &. Trauma1.1 Sussing Out Stress by Hermann Englert 1.2 Treating a Toxin to Learning by Clancy Blair 1.3 The Trauma after the Storm by Anna Harwood buy renova 0.025 cream Section 2. Effects on the Body &. Immune System 2.1 The Danger of Stress by Melinda Wenner 2.2 Fact or Fiction?.

Stress Causes Gray Hair by buy renova 0.025 cream Coco Ballantyne 2.3 Female Stress. A Faster, Stronger Response by Debra A. Bangasser 2.4 Fight or Flight May Be in Our Bones by Diana Kwon Section 3. Effects on the buy renova 0.025 cream Mind &. Brain 3.1 This Is Your Brain in Meltdown by Amy Arnsten, Carolyn M.

Mazure & buy renova 0.025 cream. Rajita Sinha 3.2 Strain on the Brain by Brian Mossop 3.3 Why Can't Christine Blasey Ford Remember How She Got Home?. by Jim Hopper 3.4 Language Patterns Reveal Body’s Hidden Response to Stress by Jo Marchant Section 4. Burnout 4.1 Why buy renova 0.025 cream Aren’t We Talking About Burnout?. by Krystal D'Costa 4.2 Conquering Burnout by Michael P.

Leiter &. Christina Maslach 4.3 Frontline Trauma by Jillian buy renova 0.025 cream Mock Section 5. Stress Management 5.1 Fight the Frazzled Mind by Robert Epstein 5.2 How I Broke the Cycle of Stress by Ashten Duncan 5.3 The Essence of Optimism by Elaine Fox 5.4 Changing Our DNA through Mind Control?. by Bret Stetka 5.5 Mind of the Meditator by Matthieu Ricard, Antoine Lutz &. Richard J.

Davidson Section 6. Resilience. Aftermath 6.1 Ready for Anything by Steven M. Southwick &. Dennis S.

Charney 6.2 The Neuroscience of True Grit by Gary Stix 6.3 The skin care and Post-Traumatic Growth by Steve Taylor 6.4 skin care products. The Biggest Psychological Experiment by Lydia Denworth.

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Claudio Alvarado has had many memorable days as an check my site assistant nurse manager with UC Davis Health – but nothing tops what he experienced on Friday renova cream for sale. Gov renova cream for sale. Gavin Newsom and UC Davis Health Nurse Claudio Alvarado joke during renova cream for sale the Vax for the Win event that Alvarado was invited to.He got to spend an hour with California Gov. Gavin Newsom promoting skin care products vaccinations before a televised, statewide audience.Alvarado, wearing his black UC Davis Health Pediatric Emergency Medicine scrubs, was enlisted by renova cream for sale the governor’s office to appear on stage at California State Lottery headquarters in Sacramento. His role.

Stand a few feet from Newsom and place dots on a poster-sized map showing the home counties of winners in Vax for the Win, a new initiative that awards cash prizes to people who sign up for the treatment.Alvarado and Newsom interacted frequently during their time on stage, with the governor praising Alvarado for his service, and also ribbing the nurse over his geographical knowledge, or lack thereof (Alvarado is a native renova cream for sale of Texas).“He’s an expert in counties in the state of California,” Newsom quipped. €œLong story renova cream for sale short, he’s like, ‘I know most of the counties, but not all of the counties, so don’t put me on the line, don’t put too much pressure.’ “Newsom interviewed Alvarado about his work as a nurse during the renova, and his deployment as a U.S. Navy reservist to assist a community hospital in New York City during a deadly renova cream for sale surge in Spring 2020. Afterward, Newsom stood at a dispensing machine that renova cream for sale spits out random lottery balls, which he handed to Alvarado, who then reached for the sticker dots, all while conversing with each other.The experience was surreal for Alvarado, who just 15 hours earlier was the dayside charge nurse in the UC Davis Medical Center Emergency Department.“This is very exciting,” Alvarado said off-stage after the celebratory event, standing over shards of confetti. €œI’m happy to participate in any way I can to get the message out there, to get people vaccinated.”Alvarado, 34, had no idea he would ever meet the governor, let alone appear on stage with him in front of numerous cameras and news reporters.But an email invitation Thursday evening from the governor’s External Affairs division – which Alvarado initially thought was spam – changed that.Alvarado informed his supervisors and agreed to participate.Then the nerves set in.How in the world, Alvarado asked himself, will he know where each of California’s 58 counties is located?.

Alvarado brushes up on geographyAlvarado was born into a military family and graduated in nursing from the University of Texas and received a Master of Science in nursing from Western Governors University in Utah.He came to UC Davis Health about five years ago.Newsom called Alvarado an “extraordinary pediatric renova cream for sale emergency nurse.”Gov. Gavin Newsom interviews UC Davis Health Nurse Claudio Alvarado about what it’s like being an emergency department nurse during the skin care products renova.During the interview, Alvarado explained how he got called to serve in a Brooklyn hospital in his assignment as a lieutenant renova cream for sale commander in the U.S. Navy Reserves renova cream for sale. €œI still remember to this day, going through the double doors and renova cream for sale just seeing the amount of sick people and seeing the amount of death that was there, it was rampant.”After two months in New York, Alvarado told Newsom he returned to Sacramento where UC Davis Medical Center was “well prepared” for the renova. €œEspecially at UC Davis Health, we helped prepare our nurses and our staff to provide great care to our patients.”Newsom pointed out that Alvarado was one of the first people to get vaccinated when the doses arrived in December.

€œYou were renova cream for sale number two,” Newsom said. Alvarado noted that the first person in line was his colleague Eva Teniola, a nurse in the Emergency Department.Video of Alvarado getting his treatment has aired in a series of public service renova cream for sale announcements.Newsom asked Alvarado what he would say to the people who think California is over skin care products.“skin care products is real,” Alvarado replied. He reminded the public that being hospitalized with severe skin care products is a lonely and frightening experience for patients who can barely breathe, and for family members who aren’t allowed at the bedside.“I know seeing is believing, but please believe me when I say that it is true, it is devastating,” Alvarado said, “and this treatment can save your life.”State Sen. Richard Pan, a pediatrician who once worked at UC Davis Health, also participated at the machine.Newsom and Pan drew 15 lottery balls, each for a lucky Californian who would be awarded $50,000 for doing their part in being vaccinated.The randomized drawing is part of California’s new $116.5 million Vax for the Win program..

Claudio Alvarado has had many buy renova 0.025 cream memorable days as an assistant nurse manager http://guide.thetrademarkhub.com/hrf_faq/i-have-received-an-invoice-that-seems-to-be-from-one-of-the-tm-offices-what-should-i-do/ with UC Davis Health – but nothing tops what he experienced on Friday. Gov buy renova 0.025 cream. Gavin Newsom and UC Davis Health Nurse Claudio Alvarado joke during the Vax for the Win event that Alvarado buy renova 0.025 cream was invited to.He got to spend an hour with California Gov.

Gavin Newsom promoting skin care products vaccinations before a televised, statewide audience.Alvarado, wearing his black UC Davis Health Pediatric Emergency Medicine scrubs, was enlisted by the governor’s office to appear on stage at California buy renova 0.025 cream State Lottery headquarters in Sacramento. His role. Stand a few feet from Newsom and place dots on a poster-sized map showing the home counties of winners in Vax for the Win, a new initiative that awards cash prizes to people who sign up for the treatment.Alvarado and Newsom interacted frequently during their time on stage, with the governor praising Alvarado for his service, and also ribbing the nurse over his geographical knowledge, buy renova 0.025 cream or lack thereof (Alvarado is a native of Texas).“He’s an expert in counties in the state of California,” Newsom quipped.

€œLong story short, he’s like, ‘I know most of the counties, but not all of the counties, so don’t put me on the line, don’t put too much pressure.’ “Newsom interviewed Alvarado about his work as a nurse during the renova, buy renova 0.025 cream and his deployment as a U.S. Navy reservist to assist a community hospital in New York City during a deadly surge in buy renova 0.025 cream Spring 2020. Afterward, Newsom stood at a dispensing machine that spits out random lottery balls, which he buy renova 0.025 cream handed to Alvarado, who then reached for the sticker dots, all while conversing with each other.The experience was surreal for Alvarado, who just 15 hours earlier was the dayside charge nurse in the UC Davis Medical Center Emergency Department.“This is very exciting,” Alvarado said off-stage after the celebratory event, standing over shards of confetti.

€œI’m happy to participate in any way I can to get the message out there, to get people vaccinated.”Alvarado, 34, had no idea he would ever meet the governor, let alone appear on stage with him in front of numerous cameras and news reporters.But an email invitation Thursday evening from the governor’s External Affairs division – which Alvarado initially thought was spam – changed that.Alvarado informed his supervisors and agreed to participate.Then the nerves set in.How in the world, i thought about this Alvarado asked himself, will he know where each of California’s 58 counties is located?. Alvarado brushes up on geographyAlvarado buy renova 0.025 cream was born into a military family and graduated in nursing from the University of Texas and received a Master of Science in nursing from Western Governors University in Utah.He came to UC Davis Health about five years ago.Newsom called Alvarado an “extraordinary pediatric emergency nurse.”Gov. Gavin Newsom interviews UC Davis buy renova 0.025 cream Health Nurse Claudio Alvarado about what it’s like being an emergency department nurse during the skin care products renova.During the interview, Alvarado explained how he got called to serve in a Brooklyn hospital in his assignment as a lieutenant commander in the U.S.

Navy Reserves buy renova 0.025 cream. €œI still buy renova 0.025 cream remember to this day, going through the double doors and just seeing the amount of sick people and seeing the amount of death that was there, it was rampant.”After two months in New York, Alvarado told Newsom he returned to Sacramento where UC Davis Medical Center was “well prepared” for the renova. €œEspecially at UC Davis Health, we helped prepare our nurses and our staff to provide great care to our patients.”Newsom pointed out that Alvarado was one of the first people to get vaccinated when the doses arrived in December.

€œYou were buy renova 0.025 cream number two,” Newsom said. Alvarado noted that the first person in line was his colleague Eva Teniola, a nurse in the buy renova 0.025 cream Emergency Department.Video of Alvarado getting his treatment has aired in a series of public service announcements.Newsom asked Alvarado what he would say to the people who think California is over skin care products.“skin care products is real,” Alvarado replied. He reminded the public that being hospitalized with severe skin care products is a lonely and frightening experience for patients who can barely breathe, and for family members who aren’t allowed at the bedside.“I know seeing is believing, but please believe me when I say that it is true, it is devastating,” Alvarado said, “and buy renova 0.025 cream this treatment can save your life.”State Sen.

Richard Pan, a pediatrician who once worked at UC Davis Health, also participated at the machine.Newsom and Pan drew 15 lottery balls, each for a lucky Californian who would be awarded $50,000 for doing their part in being vaccinated.The randomized drawing is part of California’s new $116.5 million Vax for the Win program..

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Renova is for external use only. Do not take by mouth. Gently wash the skin with a mild, non-medicated soap before use. Pat the skin dry. Wait 20 to 30 minutes for your skin to dry before use in order to minimize the possibility of skin irritation. Apply enough medicine to cover the affected area and rub in gently. Avoid applying Renova to your eyes, ears, nostrils, angles of the nose, and mouth. Do not use more often than your doctor or health care professional has recommended. Using too much of Renova may irritate or increase the irritation of your skin, and will not give faster or better results.

Contact your pediatrician or health care professional regarding the use of this medication in children. While this drug may be prescribed for children as young as 12 years of age for selected conditions, precautions do apply.

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There are four key phases for a wound to heal successfully:[click image to enlarge] Specialized Wound Treatment Centers have better outcomes because they bring together many disciplines to not only treat wounds, but also to address the underlying barriers to healing.Hemostasis – clotting to control bleeding.Inflammation – swelling occurs as helpful materials are transported to the wound site and invasive microbes are http://www.rosaleeclark.com.au/where-can-you-get-zithromax pushed out.Proliferation – a protective layer of tissue is formed.Remodeling – rebuilding of tissue and renova zero pods amazon revascularization and reorganization of the new tissue to function like the surrounding tissue.Any factors that interfere with one or more of these phases can prevent wounds from healing. Some of the most common factors include:Poor Circulation – Oxygen and materials needed for healing can’t get to the wound site. Dead cells and harmful materials can’t be carried away.Diabetes – Diabetes interferes with healing in renova zero pods amazon many ways, including lower oxygen levels, weaker immunity and decreased ability to form new skin cells and blood vessels. Diabetic nerve damage can also make it harder to sense a wound and seek treatment. – Harmful bacteria can prolong inflammation and prevent newNutrition Deficits – Wounds need energy, protein and other vital nutrients to heal.Repeat Trauma – Wounds on feet, moving joints and any body parts that may easily get bumped, rubbed or pressured are more susceptible to reopening. Other factors that can interfere with healing include age, sex hormones, renova zero pods amazon stress, obesity, some medications, alcoholism and smoking.Specialized Wound Treatment Addresses Root Causes Specialized Wound Treatment Centers have better outcomes because they bring together many disciplines to not only treat the wound, but to also address these underlying issues that may be barriers to healing.

The Wound Treatment Centers at MidMichigan Health have a cross functional team with specialists in these and other areas:infectious disease managementcardiologydiabetes educationnutrition managementphysical therapypain managementlab and imagingdebridementhyperbaric oxygen therapyMidMichigan’s specialized Wound Treatment Centers in Alma, Alpena, Clare, Midland and West Branch have a median time to heal of 28 days and 94 percent patient satisfaction. These outcomes renova zero pods amazon places us among the top 21 percent of nearly 800 Healogics centers nationwide. Healogics is the nation’s leading wound care management company.Take Action. Seek Specialized Treatment.If you or someone you love is living with a non-healing wound, don’t wait – seek specialized treatment renova zero pods amazon. Even if you have tried other treatments, but your wound isn’t healing, a multi-disciplinary Wound Treatment Center can identify and address the underlying reasons that the wound did not heal.

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According to the American Psychiatric Association a stigma is a pervasive negative perception of people with mental health conditions. They identify three types of stigma. Public stigma – the negative attitudes others have concerning mental health disordersSelf-stigma – the negative attitude one has about their own mental health, which can show up as internalized shameInstitutional stigma – includes government or organizational policies that limit opportunities for those with mental health conditions, either intentionally or unintentionally Humans have a tendency to divide the world into ‘us’ and‘them,’ no matter renova zero pods amazon what the topic is. People will put down ‘them’ in some way,to perceive ‘them’ as not as good as ‘us.’ This is true for mental healthconditions as well as many other characteristics. Mental health issues haveadditional complexities involved renova zero pods amazon with the perception.

Often people are uncomfortable with mental illness becausethey don’t understand it. Mental health renova zero pods amazon conditions can result in behaviors thatlook bizarre or seem strange to some people. This is especially true forpsychotic disorders. But people renova zero pods amazon are often uncomfortable even with symptoms relatedto depression or anxiety, which are very common disorders. This may be becausewhen people put all mental health conditions into one category and thatcategory is associated with bizarre behavior they are likely to want to avoidit.

When people divide the world into two categories and perceive the ‘other,’ those with a mental illness, as somehow strange, they are not only perpetuating stigma and setting themselves up to treat others poorly, but they are also putting themselves at risk to feel shame when they, themselves, may struggle with a mental health condition, which they are likely renova zero pods amazon to experience at some point. According to the World Health Organization, 46 percent of people will experience a mental health condition at some point in their life. When people feel ashamed of their mental health status or repeatedly hear messages that they should feel renova zero pods amazon shame, it’s less likely they’ll seek the care they need. According to the Centers for Disease Control and Prevention, embarrassment is one of the many barriers that stop people from seeking treatment. In fact, only about 20 percent of adults with renova zero pods amazon a mental health condition actually seek treatment.

There are many things people can do to reduce stigma. It beginswith each person looking at how they think about mental health conditions.Instead of compartmentalizing the world, it is useful to recognize that everyperson is human and all humans have struggles at times. Sometimes thesestruggles interfere renova zero pods amazon with functioning. When this disruption of functioning isgreat enough it may be diagnosed and may benefit from treatment. People can also talk renova zero pods amazon about it.

Being open and honest about your own mental health can help others feel comfortable opening up about what they might be going through. People need to be careful renova zero pods amazon with words. Using real mental health conditions as negative adjectives sends a message that those diagnoses aren’t taken seriously and aren’t worthy of seeking treatment for. People renova zero pods amazon should educate themselves. Learning more about mentalhealth conditions and available treatments can help people to be betterprepared to help friends and family by recognizing symptoms of mental healthconditions, and recognizing and accepting in themselves.

There is no shame in seeking help for a mental health issue.In fact, seeking treatment is a commitment to yourself and for renova zero pods amazon everyone youlove. Recognizing that there is no shame in mental health struggles will resultin reduced stigma and increased compassion for yourself and others. All renova zero pods amazon humans have struggles. It’s part of the human condition.Recognizing this can help people to be honest and accept others, andthemselves, without shame. For those who are struggling, MidMichigan Health provides aPsychiatric Partial Hospitalization Program at MidMichigan Medical Center –Gratiot.

Those interested in more information about the PHP program may call(989) 466-3253. Those interested in more information on MidMichigan’scomprehensive behavioral health programs may visitwww.midmichigan.org/mentalhealth..

There are four key phases for a wound to heal successfully:[click image to enlarge] Specialized Wound Treatment Centers have better outcomes because they bring together many disciplines to not only treat wounds, but also to address the underlying barriers to healing.Hemostasis – clotting to control bleeding.Inflammation – swelling occurs as buy renova 0.025 cream helpful materials are transported to the wound site and invasive microbes are pushed out.Proliferation – a protective layer of tissue is formed.Remodeling – rebuilding of tissue and revascularization and reorganization of the new tissue http://www.rosaleeclark.com.au/where-can-you-get-zithromax to function like the surrounding tissue.Any factors that interfere with one or more of these phases can prevent wounds from healing. Some of the most common factors include:Poor Circulation – Oxygen and materials needed for healing can’t get to the wound site. Dead cells and harmful materials can’t be carried away.Diabetes – Diabetes interferes with buy renova 0.025 cream healing in many ways, including lower oxygen levels, weaker immunity and decreased ability to form new skin cells and blood vessels. Diabetic nerve damage can also make it harder to sense a wound and seek treatment. – Harmful bacteria can prolong inflammation and prevent newNutrition Deficits – Wounds need energy, protein and other vital nutrients to heal.Repeat Trauma – Wounds on feet, moving joints and any body parts that may easily get bumped, rubbed or pressured are more susceptible to reopening.

Other factors that can interfere with healing buy renova 0.025 cream include age, sex hormones, stress, obesity, some medications, alcoholism and smoking.Specialized Wound Treatment Addresses Root Causes Specialized Wound Treatment Centers have better outcomes because they bring together many disciplines to not only treat the wound, but to also address these underlying issues that may be barriers to healing. The Wound Treatment Centers at MidMichigan Health have a cross functional team with specialists in these and other areas:infectious disease managementcardiologydiabetes educationnutrition managementphysical therapypain managementlab and imagingdebridementhyperbaric oxygen therapyMidMichigan’s specialized Wound Treatment Centers in Alma, Alpena, Clare, Midland and West Branch have a median time to heal of 28 days and 94 percent patient satisfaction. These outcomes places us among buy renova 0.025 cream the top 21 percent of nearly 800 Healogics centers nationwide. Healogics is the nation’s leading wound care management company.Take Action.

Seek Specialized Treatment.If you or someone you love is living with a non-healing wound, buy renova 0.025 cream don’t wait – seek specialized treatment. Even if you have tried other treatments, but your wound isn’t healing, a multi-disciplinary Wound Treatment Center can identify and address the underlying reasons that the wound did not heal. Call MidMichigan’s Wound Treatment Centers toll buy renova 0.025 cream free at (877) 683-0800 or visit www.midmichigan.org/woundcenter.Source. Www.ncbi.nlm.nih.gov/pmc/articles/PMC2903966/May is Mental Health Awareness Month.

Many people in modern society seem to buy renova 0.025 cream have a perception that the world is divided into two categories when it comes to mental health conditions. Those who have them and those who don’t. This mentality leads buy renova 0.025 cream to all sorts of problems, including stigma. According to the American Psychiatric Association a stigma is a pervasive negative perception of people with mental health conditions.

They identify three types of stigma. Public stigma – the negative attitudes others have concerning mental health disordersSelf-stigma – the negative attitude one has about their own mental health, which can show up as internalized shameInstitutional stigma – includes government or organizational policies that limit opportunities for those with mental health conditions, either intentionally or unintentionally Humans have a tendency to divide the buy renova 0.025 cream world into ‘us’ and‘them,’ no matter what the topic is. People will put down ‘them’ in some way,to perceive ‘them’ as not as good as ‘us.’ This is true for mental healthconditions as well as many other characteristics. Mental health issues haveadditional complexities involved with buy renova 0.025 cream the perception.

Often people are uncomfortable with mental illness becausethey don’t understand it. Mental health conditions can result buy renova 0.025 cream in behaviors thatlook bizarre or seem strange to some people. This is especially true forpsychotic disorders. But people are often uncomfortable even with buy renova 0.025 cream symptoms relatedto depression or anxiety, which are very common disorders.

This may be becausewhen people put all mental health conditions into one category and thatcategory is associated with bizarre behavior they are likely to want to avoidit. When people divide the world into two categories and perceive the ‘other,’ those with a mental illness, as somehow strange, they are not only perpetuating stigma and setting themselves up buy renova 0.025 cream to treat others poorly, but they are also putting themselves at risk to feel shame when they, themselves, may struggle with a mental health condition, which they are likely to experience at some point. According to the World Health Organization, 46 percent of people will experience a mental health condition at some point in their life. When people feel ashamed of their mental health status or repeatedly hear messages that they should feel shame, buy renova 0.025 cream it’s less likely they’ll seek the care they need.

According to the Centers for Disease Control and Prevention, embarrassment is one of the many barriers that stop people from seeking treatment. In fact, only buy renova 0.025 cream about 20 percent of adults with a mental health condition actually seek treatment. There are many things people can do to reduce stigma. It beginswith each person looking at how they think about mental health conditions.Instead of compartmentalizing the world, it is useful to recognize that everyperson is human and all humans have struggles at times.

Sometimes thesestruggles interfere with functioning buy renova 0.025 cream. When this disruption of functioning isgreat enough it may be diagnosed and may benefit from treatment. People can also talk about it buy renova 0.025 cream. Being open and honest about your own mental health can help others feel comfortable opening up about what they might be going through.

People need to be careful with buy renova 0.025 cream words. Using real mental health conditions as negative adjectives sends a message that those diagnoses aren’t taken seriously and aren’t worthy of seeking treatment for. People should educate buy renova 0.025 cream themselves. Learning more about mentalhealth conditions and available treatments can help people to be betterprepared to help friends and family by recognizing symptoms of mental healthconditions, and recognizing and accepting in themselves.

There is no shame in seeking help for a mental health issue.In fact, seeking treatment is a commitment to yourself and for buy renova 0.025 cream everyone youlove. Recognizing that there is no shame in mental health struggles will resultin reduced stigma and increased compassion for yourself and others. All humans have struggles buy renova 0.025 cream. It’s part of the human condition.Recognizing this can help people to be honest and accept others, andthemselves, without shame.

For those buy renova 0.025 cream who are struggling, MidMichigan Health provides aPsychiatric Partial Hospitalization Program at MidMichigan Medical Center –Gratiot. Those interested in more information about the PHP program may call(989) 466-3253. Those interested in more information on MidMichigan’scomprehensive behavioral health programs may visitwww.midmichigan.org/mentalhealth..

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Over the last decade, Medicare Advantage, the renova massage private plan alternative to traditional Medicare, has taken on a larger role in the Medicare program. In 2020, more than 24 million Medicare beneficiaries are enrolled in a Medicare Advantage plan. This brief provides an overview of the Medicare Advantage plans that are available for 2021 and key trends over renova massage time.Plan Offerings in 2021Number of PlansNumber of Plans Available to Beneficiaries. For 2021, the average Medicare beneficiary has access to 33 Medicare Advantage plans, the largest number of options available in the last decade (Figure 1).Figure 1.

The average Medicare beneficiary has access to 33 Medicare renova massage Advantage plans in 2021, an increase from prior yearsAmong the 33 Medicare Advantage plans generally available for individual enrollment to the average Medicare beneficiary, 27 of the plans include prescription drug coverage (MA-PDs). These numbers exclude employer or union-sponsored group plans, Special Needs Plans (SNPs) and PACE plans, which are only available to select populations.Total Number of Plans. In total, 3,550 Medicare Advantage plans are available nationwide for individual enrollment in 2021 – a 13 percent increase (402 more plans) from 2020 and the largest number of plans ever available (Figure 2. Appendix Table renova massage 1).

The vast majority (89 percent) of all Medicare Advantage plans offered include prescription drug coverage in 2021. .As in renova massage prior years, HMOs continue to account for about two-thirds (62%) of all plans offered in 2021. The availability of local PPOs has increased rapidly over recent years. In 2021, one-third renova massage of plans offered are local PPOs, compared to a quarter in 2018.

Between 2020 and 2021, the number of regional PPOs has remained constant, while the number of private fee-for-service plans has continued to decline.The growth in number of plans varies across states and counties, with the preponderance of the growth occurring in Florida and California (41 more and 30 more plans, respectively. Data not shown). Virginia has 6 fewer plans available for 2021 than in 2020, while South Carolina has 3 fewer plans, and Maryland and Nebraska each have one fewer plan available in 2021 than in 2020.While many employers and unions also offer Medicare Advantage plans to their retirees, no information about these 2021 plan offerings is made available by CMS renova massage to the public during the Medicare open enrollment period because these plans are not available to the general Medicare population.One notable change for 2021 is that people with end-stage renal disease (ESRD) are eligible to enroll in Medicare Advantage plans. Prior to this change, people with ESRD were not able to enroll in most Medicare Advantage plans, subject to limited exceptions, such as C-SNPS for people with ESRD.Special Needs Plans (SNPs).

More SNPs are available for 2021 renova massage than in any year since they were authorized, increasing from 855 plans in 2020 to 975 plans in 2021, a 14 percent increase (Figure 3). .The rise in SNPs for people who require an institutional-level of care (I-SNPs) has been particularly notable, more than doubling from 83 plans in 2017 to 174 plans in 2021. I-SNPs may be attractive to insurers because they tend to have much lower marketing costs than other plan types since they are often the only renova massage available option for people to receive their Medicare benefits in certain retirement communities and nursing homes. The number of SNPs for people dually eligible for Medicare and Medicaid (D-SNPs) has also increased sharply over the past five years, rising from 373 dual SNPs in 2017 to 598 dual SNPs in 2021, a 60% increase, suggesting insurers’ continue to be interested in managing the care of this high-need population.The number of SNPs offered for people with chronic conditions (C-SNPs) is also increasing in 2021, most of which focus on people with diabetes, heart disease, or lung conditions, as has been the case since the inception of C-SNPs.

For 2021, three firms are offering C-SNPs for people with dementia (the same as 2020), two firms are offering a C-SNP for people with mental health conditions (up one from 2020), three firms are offering C-SNPs for people with end-stage renal disease (one fewer than 2020) and two firms are offering C-SNPs for people with HIV/AIDS (similar to 2020).Variation in the Number of Plans, by Geographic Area. On average, beneficiaries in metropolitan areas can choose from about twice as many Medicare Advantage plans as beneficiaries in non-metropolitan areas (36 plans versus 20 plans, respectively).In 11 percent of counties (accounting for 41% of beneficiaries), beneficiaries can choose from more than 35 plans in 2021, including eleven counties in Ohio renova massage and five counties in Pennsylvania where more than 60 Medicare Advantage plans are available (Figure 4). In contrast, in 4 percent of counties (accounting for 1% of beneficiaries), beneficiaries can choose from two or fewer Medicare Advantage plans. The number of counties with no Medicare Advantage plans for 2021 is 82, similar renova massage to 2020.

As in prior years, there are no Medicare Advantage plans offered in Alaska. Additionally, no Medicare Advantage plans are available in territories renova massage other than Puerto Rico. .Access to Medicare Advantage Plans, by Plan TypeAs in recent years, virtually all Medicare beneficiaries (99%) have access to a Medicare Advantage plan as an alternative to traditional Medicare, including almost all beneficiaries in metropolitan areas (99.9%) and the vast majority of beneficiaries in non-metropolitan areas (97.7%). In non-metropolitan counties, a smaller share of beneficiaries have access to HMOs (87% in non-metropolitan versus 99% in metropolitan counties) or local PPOs (89% in non-metropolitan versus 96% in metropolitan counties), and a slightly larger share of beneficiaries have access to regional PPOs (77% in non-metropolitan counties versus 72% in metropolitan counties).

Number of FirmsThe average Medicare beneficiary is able renova massage to choose from plans offered by 8 firms in 2021, one more than in 2020 (Figure 5). Despite most beneficiaries having access to plans operated by several different firms, enrollment is concentrated in plans operated by UnitedHealthcare, Humana, and Blue Cross Blue Shield affiliates.Figure 5. More than one-quarter of beneficiaries can choose among Medicare Advantage renova massage plans offered by 10 or more firmsMore than one-quarter of beneficiaries (27%) are able to choose from plans offered by 10 or more firms. Fifteen or more firms are offering Medicare Advantage plans in three counties.

Orange County, California and Summit and Medina Counties in Ohio. In contrast, in 109 counties, most of which are rural counties with relatively few Medicare beneficiaries (1% of total), only one firm will offer Medicare Advantage plans in renova massage 2021. Over the past several years, the number of counties with a single firm offering Medicare Advantage plans has fallen substantially. As recently as 2019, there was a single firm offering plans in nearly 200 counties.UnitedHealthcare and Humana, the two firms with the most Medicare Advantage enrollees in 2020, have large footprints renova massage across the country, offering plans in most counties.

Humana is offering plans in 84 percent of counties and UnitedHealthcare is offering plans in 66 percent of counties in 2021 (Figure 6). More than 8 in 10 (87%) Medicare beneficiaries have access to at least renova massage one Humana plan and 86 percent have access to at least one UnitedHealthcare plans. .Most major Medicare Advantage firms have also expanded the number of counties where they are offering plans. UnitedHealthcare is offering plans in 2,117 counties in 2021, an increase of 245 from 2021, while Humana is offering plans in 2,703 counties in 2021, an increase of 33 from 2020.

Centene is offering renova massage plans in 1,129 counties in 2021, an increase of 261 plans from 2020. Blue Cross Blue Shield Affiliates are offering plans in 1,181 counties, an increase of 152 plans. CVS Health is offering plans in 1,759 counties, renova massage an increase of 119 plans. And Cigna is offering plans in 369 counties, an increase of 67 plans.

Kaiser Permanente had the smallest growth and is offering plans in 109 counties, an increase of renova massage 4 plans.New Market Entrants and ExitsMedicare Advantage continues to be an attractive market for insurers, with 14 firms entering the market for the first time in 2021, collectively accounting for about 6 percent of the growth in the number of plans available for general enrollment and about 10 percent of the growth in SNPs (Appendix Table 2). Nine new entrants are offering HMOs available for individual enrollment. Five of the new entrants are offering SNPs. Three firms are offering D-SNPs for people dually eligible for Medicaid, three firms are offering C-SNPs for people with select chronic conditions, and one firm is offering an I-SNPs Four of the new firm entrants are offering plans in California, two are offering plans in Indiana, and the remainder are offering plans in at least one of ten other states (Colorado, renova massage Georgia, Illinois, Mississippi, Missouri, Ohio, Texas, Utah, and Wisconsin).Six firms that previously participated in the Medicare Advantage market are not offering plans in 2021.

Two of the firms (ApexHealth, Inc. And Clarion Health) offered plans for the first time in 2020, but did not appear to renova massage enroll any participants. The other four firms had very low enrollment in 2020. Three of the six exiting firms offered plans in New York.PremiumsThe vast majority of Medicare Advantage plans for individual enrollment (89%) will include prescription drug coverage (MA-PDs), and 54 percent of these plans will charge no premium, other than the Part B premium, renova massage similar to 2020.

More than nine out of ten beneficiaries (96%) have access to a MA-PD with no monthly premium in 2021. However, in Wyoming, beneficiaries do not have access to a zero-premium MA-PD, and in Idaho, less than half of beneficiaries have access to a zero-premium MA-PD.In 2020, 60 percent of enrollees in MA-PD plans pay no premium other than the Medicare Part B premium of $144.60 per month. Based on enrollment in March 2020, nearly one in five enrollees (18%) pay at least $50 a month, and 6 percent pay $100 or more renova massage. CMS announced that the average monthly plan premium among all Medicare Advantage enrollees in 2021, including those who pay no premium for their Medicare Advantage plan, is expected to decrease 11 percent from 2020 to $21 a month.

CMS does not disclose the methods or assumptions used in deriving their calculations, but since most Medicare Advantage enrollees pay no additional premium, the average they report is heavily influenced by zero-premium plans, and does not reflect the average premium paid renova massage by those who are in plans with an additional premium.Extra BenefitsMedicare Advantage plans may provide extra benefits that are not available in traditional Medicare, are considered “primarily health related,” and can use rebate dollars (including bonus payments) to help cover the cost of these extra benefits. Beginning in 2019, CMS expanded the definition of “primarily health related” to allow Medicare Advantage plans to offer additional supplemental benefits. Medicare Advantage plans may also restrict the availability of these extra benefits to certain subgroups of beneficiaries, such as those with diabetes or congestive heart failure, making different benefits available to different enrollees.Beginning in 2020, Medicare Advantage plans have also been able to offer extra benefits that are not primarily health related for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill (SSBCI). Information on the availability of SSBCI for 2021 has not yet been published by CMS, but may include services such as pest control, food and produce (beyond a limited basis), and renova massage non-medical transportation.

Since plans are permitted to offer these benefits non-uniformly to enrollees, it will be important to examine how these benefits are distributed across subgroups of enrollees.Availability of Extra Benefits in Plans for General Enrollment. Historically, the most offered extra benefits were fitness, dental, vision, and renova massage hearing. Nearly two-thirds of plans (68%) provide all four of these benefits for 2021. Though these benefits are widely available, the scope renova massage of specific services varies.

For example, a dental benefit may include cleanings only or more comprehensive coverage. As of 2020, Medicare Advantage plans have also been allowed to offer more telehealth benefits than traditional Medicare (though Medicare has temporarily expanded these benefits during the renova). The vast majority (98%) of Medicare Advantage renova massage plans are offering telehealth in 2021 (up from 91% in 2020) (Figure 7).Figure 7. Most Medicare Advantage plans provide fitness and dental benefits but much fewer provide in-home or caregiver supportOther extra benefits that are frequently offered for 2021 include over the counter items (75%), meal benefits, such as a cooking class, nutrition education, or meal delivery (55%), and transportation benefits (36%).Less than 10 percent of plans provide bathroom safety devices (6%) or in-home support (6%).Availability of Extra Benefits in Special Needs Plans.

SNPs are designed to serve a disproportionately high-need population, and a somewhat larger percentage of SNPs than plans for other Medicare beneficiaries provide their enrollees with over the counter items (91%), transportation benefits renova massage (85%) and meal benefits (63%). Similar to plans available for general enrollment, a relatively small share of SNPs provide bathroom safety devices (11%) or in-home support (18%).Access to Extra Benefits. Virtually all renova massage Medicare beneficiaries live in a county where at least one Medicare Advantage plan available for general enrollment has some extra benefits not covered by traditional Medicare, with 98% having access to some dental, fitness, vision, and hearing benefits for 2021. The vast majority of beneficiaries also have access to telehealth benefits (99%), over the counter items (99%), transportation assistance (95%) and a meal benefit (98%), but far fewer have access to bathroom safety (55%) or in-home support (62%).DiscussionMore Medicare Advantage plans are being offered for 2021 than in any other year.

Fourteen insurers are entering the Medicare Advantage market for the first time, and six insurers are exiting the market, suggesting thatMedicare Advantage remains an attractive, profitable market for insurers. As in prior years, some (mostly non-metropolitan) counties are less attractive to renova massage insurers, with fewer firms and plans available, though the number of areas where this is the case has declined over time. Overall, more than 99 percent of beneficiaries will have access to one or more Medicare Advantage plans in 2021, similar to prior years. With more firms offering SNPs and the number of SNPs rapidly growing, there may be greater focus on how well high-need, vulnerable beneficiaries are being served by Medicare Advantage plans, including SNPs as well as plans for renova massage general enrollment.

As Medicare Advantage enrollment continues to grow, insurers seem to be responding by offering more plans and choices to the people on Medicare. This analysis focuses on the Medicare Advantage marketplace renova massage in 2021 and trends over time. The analysis includes more than 24 million enrollees in Medicare Advantage plans in 2020.Data on Medicare Advantage plan availability, enrollment, and premiums were collected from a set of data files released by the Centers for Medicare &. Medicaid Services (CMS):Medicare Advantage plan landscape files, released each fall prior to the annual enrollment periodMedicare Advantage plan and premium files, released each fallMedicare Advantage plan crosswalk files, released each fallMedicare Advantage contract/plan/state/county level enrollment files, released on a monthly basisMedicare Advantage plan benefit package files, released each fallMedicare Enrollment Dashboard files, released on a monthly basisIn previous years, KFF has used the Medicare Advantage Penetration Files to calculate the number of Medicare beneficiaries eligible for Medicare.

The Medicare Advantage Penetration Files includes people who were previously, but no longer covered by renova massage Medicare (e.g., people who obtained employer-sponsored health insurance coverage after initially enrolling in Medicare). It also includes people within 5 months of their 65th birthday, but not yet age 65. In addition, CMS has identified an issue where beneficiaries with renova massage multiple addresses were double counted in the Penetration File. KFF has refined its approach this year and is using the Medicare Enrollment Dashboard to calculate the number of Medicare beneficiaries because it only includes Medicare beneficiaries with either Part A or Part B coverage, which is a more accurate estimate of the Medicare population.

The numbers published here supersede all prior estimates by KFF of the number of Medicare beneficiaries.Jeannie Fuglesten Biniek, Meredith Freed, and Tricia Neuman are with KFF.Anthony Damico is an independent consultant..

Over the last decade, Medicare Advantage, the private see this website plan alternative to traditional Medicare, has taken buy renova 0.025 cream on a larger role in the Medicare program. In 2020, more than 24 million Medicare beneficiaries are enrolled in a Medicare Advantage plan. This brief provides an overview of the Medicare buy renova 0.025 cream Advantage plans that are available for 2021 and key trends over time.Plan Offerings in 2021Number of PlansNumber of Plans Available to Beneficiaries. For 2021, the average Medicare beneficiary has access to 33 Medicare Advantage plans, the largest number of options available in the last decade (Figure 1).Figure 1. The average Medicare beneficiary has access to 33 Medicare Advantage plans in 2021, an increase from prior yearsAmong the buy renova 0.025 cream 33 Medicare Advantage plans generally available for individual enrollment to the average Medicare beneficiary, 27 of the plans include prescription drug coverage (MA-PDs).

These numbers exclude employer or union-sponsored group plans, Special Needs Plans (SNPs) and PACE plans, which are only available to select populations.Total Number of Plans. In total, 3,550 Medicare Advantage plans are available nationwide for individual enrollment in 2021 – a 13 percent increase (402 more plans) from 2020 and the largest number of plans ever available (Figure 2. Appendix Table 1) buy renova 0.025 cream. The vast majority (89 percent) of all Medicare Advantage plans offered include prescription drug coverage in 2021. .As in prior years, HMOs continue to account for about two-thirds (62%) of all buy renova 0.025 cream plans offered in 2021.

The availability of local PPOs has increased rapidly over recent years. In 2021, one-third of plans offered are local PPOs, compared to a buy renova 0.025 cream quarter in 2018. Between 2020 and 2021, the number of regional PPOs has remained constant, while the number of private fee-for-service plans has continued to decline.The growth in number of plans varies across states and counties, with the preponderance of the growth occurring in Florida and California (41 more and 30 more plans, respectively. Data not shown). Virginia has 6 fewer plans available for 2021 than in 2020, while South Carolina has 3 fewer plans, and Maryland and Nebraska each have one fewer plan available in 2021 than in 2020.While many employers and unions also buy renova 0.025 cream offer Medicare Advantage plans to their retirees, no information about these 2021 plan offerings is made available by CMS to the public during the Medicare open enrollment period because these plans are not available to the general Medicare population.One notable change for 2021 is that people with end-stage renal disease (ESRD) are eligible to enroll in Medicare Advantage plans.

Prior to this change, people with ESRD were not able to enroll in most Medicare Advantage plans, subject to limited exceptions, such as C-SNPS for people with ESRD.Special Needs Plans (SNPs). More SNPs are available for 2021 than in any year since they buy renova 0.025 cream were authorized, increasing from 855 plans in 2020 to 975 plans in 2021, a 14 percent increase (Figure 3). .The rise in SNPs for people who require an institutional-level of care (I-SNPs) has been particularly notable, more than doubling from 83 plans in 2017 to 174 plans in 2021. I-SNPs may be attractive to insurers because they tend to have much lower marketing costs than other plan types since they are often the only available option for people to receive their Medicare benefits in certain retirement communities and buy renova 0.025 cream nursing homes. The number of SNPs for people dually eligible for Medicare and Medicaid (D-SNPs) has also increased sharply over the past five years, rising from 373 dual SNPs in 2017 to 598 dual SNPs in 2021, a 60% increase, suggesting insurers’ continue to be interested in managing the care of this high-need population.The number of SNPs offered for people with chronic conditions (C-SNPs) is also increasing in 2021, most of which focus on people with diabetes, heart disease, or lung conditions, as has been the case since the inception of C-SNPs.

For 2021, three firms are offering C-SNPs for people with dementia (the same as 2020), two firms are offering a C-SNP for people with mental health conditions (up one from 2020), three firms are offering C-SNPs for people with end-stage renal disease (one fewer than 2020) and two firms are offering C-SNPs for people with HIV/AIDS (similar to 2020).Variation in the Number of Plans, by Geographic Area. On average, beneficiaries in metropolitan areas can choose from about twice as many Medicare Advantage plans as beneficiaries in non-metropolitan areas (36 plans versus 20 plans, respectively).In 11 percent of counties (accounting for 41% of beneficiaries), beneficiaries can choose from more than 35 plans in 2021, including eleven counties in Ohio and five counties in Pennsylvania where more than 60 buy renova 0.025 cream Medicare Advantage plans are available (Figure 4). In contrast, in 4 percent of counties (accounting for 1% of beneficiaries), beneficiaries can choose from two or fewer Medicare Advantage plans. The number of counties with no Medicare Advantage plans for buy renova 0.025 cream 2021 is 82, similar to 2020. As in prior years, there are no Medicare Advantage plans offered in Alaska.

Additionally, no Medicare Advantage plans are available buy renova 0.025 cream in territories other than Puerto Rico. .Access to Medicare Advantage Plans, by Plan TypeAs in recent years, virtually all Medicare beneficiaries (99%) have access to a Medicare Advantage plan as an alternative to traditional Medicare, including almost all beneficiaries in metropolitan areas (99.9%) and the vast majority of beneficiaries in non-metropolitan areas (97.7%). In non-metropolitan counties, a smaller share of beneficiaries have access to HMOs (87% in non-metropolitan versus 99% in metropolitan counties) or local PPOs (89% in non-metropolitan versus 96% in metropolitan counties), and a slightly larger share of beneficiaries have access to regional PPOs (77% in non-metropolitan counties versus 72% in metropolitan counties). Number of FirmsThe average Medicare beneficiary is able to choose from plans buy renova 0.025 cream offered by 8 firms in 2021, one more than in 2020 (Figure 5). Despite most beneficiaries having access to plans operated by several different firms, enrollment is concentrated in plans operated by UnitedHealthcare, Humana, and Blue Cross Blue Shield affiliates.Figure 5.

More than one-quarter of beneficiaries can choose among Medicare Advantage plans offered by 10 or more firmsMore than one-quarter of beneficiaries (27%) are able to choose from plans offered by 10 buy renova 0.025 cream or more firms. Fifteen or more firms are offering Medicare Advantage plans in three counties. Orange County, California and Summit and Medina Counties in Ohio. In contrast, in 109 counties, most of which are rural counties with relatively few Medicare beneficiaries (1% buy renova 0.025 cream of total), only one firm will offer Medicare Advantage plans in 2021. Over the past several years, the number of counties with a single firm offering Medicare Advantage plans has fallen substantially.

As recently as 2019, there was a buy renova 0.025 cream single firm offering plans in nearly 200 counties.UnitedHealthcare and Humana, the two firms with the most Medicare Advantage enrollees in 2020, have large footprints across the country, offering plans in most counties. Humana is offering plans in 84 percent of counties and UnitedHealthcare is offering plans in 66 percent of counties in 2021 (Figure 6). More than 8 in 10 (87%) Medicare beneficiaries have access to at least buy renova 0.025 cream one Humana plan and 86 percent have access to at least one UnitedHealthcare plans. .Most major Medicare Advantage firms have also expanded the number of counties where they are offering plans. UnitedHealthcare is offering plans in 2,117 counties in 2021, an increase of 245 from 2021, while Humana is offering plans in 2,703 counties in 2021, an increase of 33 from 2020.

Centene is buy renova 0.025 cream offering plans in 1,129 counties in 2021, an increase of 261 plans from 2020. Blue Cross Blue Shield Affiliates are offering plans in 1,181 counties, an increase of 152 plans. CVS Health is offering plans in buy renova 0.025 cream 1,759 counties, an increase of 119 plans. And Cigna is offering plans in 369 counties, an increase of 67 plans. Kaiser Permanente had the smallest growth and is offering plans in 109 counties, an increase of 4 plans.New Market Entrants and ExitsMedicare Advantage continues to be an attractive market for buy renova 0.025 cream insurers, with 14 firms entering the market for the first time in 2021, collectively accounting for about 6 percent of the growth in the number of plans available for general enrollment and about 10 percent of the growth in SNPs (Appendix Table 2).

Nine new entrants are offering HMOs available for individual enrollment. Five of the new entrants are offering SNPs. Three firms are offering D-SNPs for people dually eligible for Medicaid, three firms are offering C-SNPs for people with select chronic conditions, and one firm is offering an I-SNPs Four of the buy renova 0.025 cream new firm entrants are offering plans in California, two are offering plans in Indiana, and the remainder are offering plans in at least one of ten other states (Colorado, Georgia, Illinois, Mississippi, Missouri, Ohio, Texas, Utah, and Wisconsin).Six firms that previously participated in the Medicare Advantage market are not offering plans in 2021. Two of the firms (ApexHealth, Inc. And Clarion Health) offered plans for the first time in 2020, but did not appear to enroll buy renova 0.025 cream any participants.

The other four firms had very low enrollment in 2020. Three of the six exiting firms offered plans in New York.PremiumsThe vast majority of Medicare Advantage plans for individual enrollment (89%) will include prescription drug coverage (MA-PDs), and buy renova 0.025 cream 54 percent of these plans will charge no premium, other than the Part B premium, similar to 2020. More than nine out of ten beneficiaries (96%) have access to a MA-PD with no monthly premium in 2021. However, in Wyoming, beneficiaries do not have access to a zero-premium MA-PD, and in Idaho, less than half of beneficiaries have access to a zero-premium MA-PD.In 2020, 60 percent of enrollees in MA-PD plans pay no premium other than the Medicare Part B premium of $144.60 per month. Based on enrollment in March 2020, nearly one in five enrollees (18%) pay at least $50 a month, and buy renova 0.025 cream 6 percent pay $100 or more.

CMS announced that the average monthly plan premium among all Medicare Advantage enrollees in 2021, including those who pay no premium for their Medicare Advantage plan, is expected to decrease 11 percent from 2020 to $21 a month. CMS does not disclose the methods or assumptions used in deriving their calculations, but since most Medicare Advantage enrollees pay no additional premium, the average they report is heavily influenced by zero-premium plans, and does not reflect the average premium paid by those who are in plans with an additional premium.Extra BenefitsMedicare Advantage plans may provide extra benefits that are not available in traditional buy renova 0.025 cream Medicare, are considered “primarily health related,” and can use rebate dollars (including bonus payments) to help cover the cost of these extra benefits. Beginning in 2019, CMS expanded the definition of “primarily health related” to allow Medicare Advantage plans to offer additional supplemental benefits. Medicare Advantage plans may also restrict the availability of these extra benefits to certain subgroups of beneficiaries, such as those with diabetes or congestive heart failure, making different benefits available to different enrollees.Beginning in 2020, Medicare Advantage plans have also been able to offer extra benefits that are not primarily health related for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill (SSBCI). Information on the availability of SSBCI for 2021 has not yet buy renova 0.025 cream been published by CMS, but may include services such as pest control, food and produce (beyond a limited basis), and non-medical transportation.

Since plans are permitted to offer these benefits non-uniformly to enrollees, it will be important to examine how these benefits are distributed across subgroups of enrollees.Availability of Extra Benefits in Plans for General Enrollment. Historically, the most offered extra benefits were fitness, dental, buy renova 0.025 cream vision, and hearing. Nearly two-thirds of plans (68%) provide all four of these benefits for 2021. Though these benefits are widely available, the buy renova 0.025 cream scope of specific services varies. For example, a dental benefit may include cleanings only or more comprehensive coverage.

As of 2020, Medicare Advantage plans have also been allowed to offer more telehealth benefits than traditional Medicare (though Medicare has temporarily expanded these benefits during the renova). The vast buy renova 0.025 cream majority (98%) of Medicare Advantage plans are offering telehealth in 2021 (up from 91% in 2020) (Figure 7).Figure 7. Most Medicare Advantage plans provide fitness and dental benefits but much fewer provide in-home or caregiver supportOther extra benefits that are frequently offered for 2021 include over the counter items (75%), meal benefits, such as a cooking class, nutrition education, or meal delivery (55%), and transportation benefits (36%).Less than 10 percent of plans provide bathroom safety devices (6%) or in-home support (6%).Availability of Extra Benefits in Special Needs Plans. SNPs are designed to serve a disproportionately high-need population, and a somewhat larger percentage of SNPs than plans for other Medicare beneficiaries provide their enrollees with over the counter buy renova 0.025 cream items (91%), transportation benefits (85%) and meal benefits (63%). Similar to plans available for general enrollment, a relatively small share of SNPs provide bathroom safety devices (11%) or in-home support (18%).Access to Extra Benefits.

Virtually all Medicare beneficiaries live in a county where at least one Medicare Advantage plan available for general enrollment has some extra benefits not covered by traditional Medicare, with 98% buy renova 0.025 cream having access to some dental, fitness, vision, and hearing benefits for 2021. The vast majority of beneficiaries also have access to telehealth benefits (99%), over the counter items (99%), transportation assistance (95%) and a meal benefit (98%), but far fewer have access to bathroom safety (55%) or in-home support (62%).DiscussionMore Medicare Advantage plans are being offered for 2021 than in any other year. Fourteen insurers are entering the Medicare Advantage market for the first time, and six insurers are exiting the market, suggesting thatMedicare Advantage remains an attractive, profitable market for insurers. As in prior years, some (mostly non-metropolitan) counties are less attractive to insurers, with fewer firms buy renova 0.025 cream and plans available, though the number of areas where this is the case has declined over time. Overall, more than 99 percent of beneficiaries will have access to one or more Medicare Advantage plans in 2021, similar to prior years.

With more firms offering SNPs and buy renova 0.025 cream the number of SNPs rapidly growing, there may be greater focus on how well high-need, vulnerable beneficiaries are being served by Medicare Advantage plans, including SNPs as well as plans for general enrollment. As Medicare Advantage enrollment continues to grow, insurers seem to be responding by offering more plans and choices to the people on Medicare. This analysis focuses on the Medicare Advantage marketplace in 2021 and trends buy renova 0.025 cream over time. The analysis includes more than 24 million enrollees in Medicare Advantage plans in 2020.Data on Medicare Advantage plan availability, enrollment, and premiums were collected from a set of data files released by the Centers for Medicare &. Medicaid Services (CMS):Medicare Advantage plan landscape files, released each fall prior to the annual enrollment periodMedicare Advantage plan and premium files, released each fallMedicare Advantage plan crosswalk files, released each fallMedicare Advantage contract/plan/state/county level enrollment files, released on a monthly basisMedicare Advantage plan benefit package files, released each fallMedicare Enrollment Dashboard files, released on a monthly basisIn previous years, KFF has used the Medicare Advantage Penetration Files to calculate the number of Medicare beneficiaries eligible for Medicare.

The Medicare Advantage Penetration Files includes people who were previously, but no longer covered by Medicare (e.g., people who obtained employer-sponsored health insurance coverage after initially enrolling in Medicare) buy renova 0.025 cream. It also includes people within 5 months of their 65th birthday, but not yet age 65. In addition, buy renova 0.025 cream CMS has identified an issue where beneficiaries with multiple addresses were double counted in the Penetration File. KFF has refined its approach this year and is using the Medicare Enrollment Dashboard to calculate the number of Medicare beneficiaries because it only includes Medicare beneficiaries with either Part A or Part B coverage, which is a more accurate estimate of the Medicare population. The numbers published here supersede all prior estimates by KFF of the number of Medicare beneficiaries.Jeannie Fuglesten Biniek, Meredith Freed, and Tricia Neuman are with KFF.Anthony Damico is an independent consultant..

Renova solar reviews

Lord Scarman’s judgment about when someone under the Where to buy generic lasix age renova solar reviews of 16 years should have the right to make their own medical decisions emphasised the decision-making abilities of the particular child. He said:…the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed (p188–189).1That created a duty on healthcare practitioners to assess whether a particular minor has decision-making abilities at a degree that would enable them to understand the decision to a high extent, sufficient hopefully that they would ‘own’ the renova solar reviews decision. In December of 2020, the High Court considered whether young people with gender dysphoria (GD) and seeking access to puberty blocking (PB) therapy, were likely to pass Scarman’s mature minor test and cast doubt on their ability to fully understand that decision, thereby making it less likely that a healthcare practitioner would decide they are a mature minor for that therapy. The High Court said:It is highly unlikely that a child aged renova solar reviews 13 or under would be competent to give consent to the administration of puberty blockers.

It is doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences of the administration of puberty blockers (p151).2Since then, the Journal of Medical Ethics has published papers about the ethical issues raised by that judgment. Beattie, writing at renova solar reviews the time the judgment was made, disagreed with the High Court and claimed that the decision to take puberty blockers is no more complex than many of the other medical decisions that minors are assessed as being competent to make.3 Central to the High Court’s decision was the claim that the decision to start PB therapy (the first stage of therapy for GD) is inextricably linked to the more permanent and significant, cross-sex hormone (CSH) therapy. That meant the abilities required to fully understand what was proposed became very demanding because they would require someone who had not yet gone through puberty to know what a second round of treatment, that would result in permanent and complex changes, would mean for them. Beattie objects to that claim for several reasons including that ‘…high progression rates to CSH may merely represent successful identification of persistent GD, rather than PBs promoting persistence’ (p4).Giordano et al consider the possibility that consenting to PB might be more complex than other treatments a minor might consent to.4 They point out that many other medical decisions are similarly complex and emotionally involving, so PB should not be viewed differently from other decisions a minor might take.The High Court’s judgment was recently overturned by the Court of Appeal who criticised the judgment on a number of grounds, including the implications that it would have for those seeking therapy for renova solar reviews GD.Moreover, the effect of the guidance was to require applications to the court in circumstances where the Divisional Court itself had recognised that there was no legal obligation to do so.

It placed patients, parents and clinicians in a very difficult position. In practice the guidance would have the effect of denying treatment in many circumstances for want of resources to make such an application coupled with inevitable delay through court involvement (p86).5While some might read that as an ethical point about access to therapy, the Court of Appeal is making a legal point about when it is appropriate for the court to become involved and the costs of them doing so renova solar reviews. That kind of concern continues where they object to the court making age-based recommendations about the likely ability of young people to consent.We conclude that it was inappropriate for the Divisional Court to give the guidance concerning when a court application will be appropriate and to reach general age-related conclusions about the likelihood or probability of different cohorts of children being capable of giving consent (p89).5Predictably, the Court of Appeal judgment has been hailed as ‘a positive step forwards for trans rights in the UK and around the world’.6 It is important to be clear, though, about exactly what was and what was not an issue here. The court was renova solar reviews careful not to take a position on the debate about PBs.

It recognised renova solar reviews that this is an ongoing controversy. €˜The present proceedings do not require the courts to determine whether the treatment for GD is a wise or unwise course’.5Furthermore, there is nothing in the judgment about how often minors seeking access to PBs will be assessed as competent to make that decision, nor about what they will need to demonstrate in order to show that competence.As we have already said, the principle enunciated in Gillick was that it was for clinicians rather than the court to decide on competence (p87).5The point is precisely that it is not appropriate for courts to involve themselves in such matters. It will renova solar reviews be for clinicians to make that determination. There is nothing inherent to the nature of PBs that set them apart from other healthcare decisions, nothing that justifies the court intruding on what is a well-recognised area of clinical expertise.Certainly, it is not for the court to require that young people accept as matters of fact propositions that are currently factually contested or complex, such as the claim that PBs almost always serve as precursors to ‘much greater medical interventions’.

And it is not for the court to issue guidance, in general terms, about when renova solar reviews capacity assessments should require judicial intervention.There was a recognition here that this is a ‘difficult and controversial area’, where facts are contested and deep-seated values set in conflict. But as the court acknowledged, the concept of ‘Gillick competence’ arose in a context where that could also have been said of the provision of contraceptives to minors. Generalisations about capacity assessment were no more appropriate here than they were back in that earlier context.Ethics statementsPatient consent for publicationNot required.IntroductionIn the last decade there has been a marked increase in patients labelled with pre-diabetes in the UK.1 The ‘diagnosis’ renova solar reviews of pre-diabetes is made on the basis of a patient having one or more markers of abnormal blood glucose. Levels are higher than normal but have not reached the threshold where the patient gets diagnosed as diabetic.

Patients with blood sugar levels in a pre-diabetic range renova solar reviews are asymptomatic and disease free. The rationale behind labelling patients as pre-diabetic is that patients with pre-diabetes are at higher risk of going on to develop type 2 diabetes.2 Type 2 diabetes can cause significant mortality and morbidity.3 There is evidence that lifestyle change (altered diet and increased physical activity) in patients with pre-diabetes can prevent progression to diabetes.4 Although patients may be labelled as ‘pre-diabetic’, and this might look like a diagnosis of a pathological condition, pre-diabetes is a risk factor for the development of diabetes, not a disease in its own right.5Pre-diabetes is highly prevalent in Western countries. Its prevalence rises with age, and by age 75 years nearly 50% of the population in the USA is classified as renova solar reviews pre-diabetic or diabetic.6 7 However, not all patients with pre-diabetes will develop diabetes. The risk of a person with pre-diabetes progressing to diabetes within 12 months renova solar reviews is between 1 in 10 and 1 in 20.8 This annual conversion rate drops even lower as patients age.9 A 12-year follow-up of older adults with pre-diabetes, showed most remained stable or reverted to normal blood sugar levels, whereas only one‐third developed diabetes or died.10If a person develops diabetes, they do not automatically develop symptoms or complications.

Complications, such as retinopathy and renal disease, develop over time and are more likely to occur the longer a patient has suffered with diabetes.11 Therefore, if a patient is approaching the end of their life, developing type 2 diabetes may have no direct impact on their health or quality of life.In order for a patient to eventually benefit from the label of pre-diabetes they must fulfil three criteria. They must:Be in the group of patients that are going to convert from pre-diabetes to diabetes.Be in the group of patients that are going to develop symptoms or complications of diabetes.Be in the group of patients for whom lifestyle changes or medication can prevent the conversion from pre-diabetes to diabetes.If a patient does not belong to all three renova solar reviews of these groups then labelling them as pre-diabetic will not confer any benefit to them. As conversion rates from pre-diabetes to diabetes reduce as a person ages and shortening life expectancy (which inevitably comes with ageing) reduces the risk of developing complications from diabetes, there is going to be a point in any patient’s life, even assuming that lifestyle changes could prevent progression to diabetes, where a patient will not benefit from knowing they have pre-diabetes. Calculating the exact age at which that will occur for an individual patient is problematic but certain renova solar reviews general principles can be established to help clinicians decide on the benefit of labelling.This paper explores the pros and cons of a pre-diabetes label and a pragmatic ethical approach that could be taken by clinicians when faced with a new unanticipated pre-diabetic blood result that has been discovered through ‘routine’ blood tests.What are the harms of a pre-diabetes label?.

The treatment for pre-diabetes is, in essence, adopting a healthier diet and taking more exercise. If adopted and maintained, these lifestyle changes are likely to renova solar reviews benefit most patients in multiple aspects of health, not just their risk of developing diabetes. However, although they may slightly delay the point at which a patient develops diabetes, studies of lifestyle-based diabetes prevention programmes show that most patients do not or cannot maintain long-term lifestyle changes.5 12 Weight loss is generally short term or minimal and patients usually slip back into old habits and routines. While there renova solar reviews is undoubtedly an argument for informing younger patients who may receive a benefit from knowing they have pre-diabetes, the harms of informing increase with age.Many elderly patients with comorbidities may struggle to increase physical activity.

Dietary change and attempts to lose weight after a certain age can have detrimental health effects13 Labelling somebody as having a medical condition carries a psychological burden in itself, and being unable to engage in the behaviour change recommended may also have negative consequences, that is, engendering a feeling of being ‘a failure’.14–16 If the label leads to further follow-up this may also place a burden on patients. There are also considerable implications for the use of health resources if the labelling of individuals as renova solar reviews pre-diabetic requires further follow-up and intervention. Annual blood renova solar reviews tests are standard (£6.42), subsequent general practitioner (GP) or nurse (£30) appointments to discuss results frequently take place as do referrals on to the national Diabetes Prevention Programme (£270).17 There are roughly 3 million people in the UK aged 80 years or over.18 If one-third of them have pre-diabetes and, of those, half have an annual blood test, a quarter have a GP appointment and one in eight get referred to the National Health Service (NHS) Diabetes Prevention Programme that is an annual cost of around £37 million.What is ideal practice and what is the reality?. While some patients may have been tested following screening for being at risk of diabetes, in the UK most patients in whom pre-diabetes is diagnosed have blood sugar level tests carried out as part of a battery of other blood tests that are performed as part of annual chronic disease monitoring for conditions such as hypertension.19 The contents of the battery are determined by individual practices and usually based on guidance and payment targets issued by the NHS.20 In theory, a patient should give informed consent before any test, including blood sugar and HbA1c testing.

In reality many patients who are given a diagnosis of pre-diabetes are unaware that they had blood tests for diabetes/pre-diabetes.19 When checking blood glucose or HbA1c in an elderly patient, especially one without symptoms of diabetes, the clinician should talk through with them the potential outcomes of renova solar reviews the test and the implications this may have to them. The patient can then make an informed decision as to whether they want to go ahead with testing or not. In routine renova solar reviews clinical practice in the UK this happens rarely, if at all. This is likely due to the volume of blood testing, the automated nature of the process, the limited time a clinician has to devote to each individual patient and the priority that individual clinicians assign to such conversations.As we discussed in a recent paper a more individualised approach to ‘routine’ blood tests needs to be taken.19 The utility of each test should be gauged for each patient as an individual, not as the average patient that has a particular disease.

The reality, however, is that this change will, at renova solar reviews best, be adopted slowly or, at worst, not at all. What then, should clinicians who are presented with a pre-diabetic blood result in an elderly patient do?. The see-saw model of paternalismWhen faced with a series of test results for a patient, clinicians exercise judgement about renova solar reviews what they consider ‘normal’ or ‘satisfactory’. They also exercise judgement in what they communicate to the patient about the results.

In certain renova solar reviews circumstances a patient may, for instance, have a mildly raised bilirubin or mildly decreased albumin and the clinician may file the result as ‘satisfactory’ and not inform the patient. Is this an act of paternalism or is it the act of a clinician filtering out the ‘noise’ that is generated from carrying out tests and using an individual patient’s renova solar reviews circumstances to contextualise what is ‘normal’?. Should clinicians, therefore, assume that all new pre-diabetic blood results above a certain age should not be disclosed to patients?. This is obviously an indefensible renova solar reviews position as a general policy since patients have a right to information that concerns their health.

However, while the blood result may be a factual piece of data, the labelling of a result as ‘satisfactory’, ‘acceptable’ or ‘abnormal’ is a clinical judgement. There is, renova solar reviews in most circumstances, a moral obligation on the clinician to disclose to a patient that they are suffering with a disease. Pre-diabetes is not a disease and unless a patient fulfils the three criteria set out in the introduction to this paper the information is not likely to benefit the patient.In younger patients, where the criteria related to a significant likelihood of progressing to diabetes with negative health effects are likely to be fulfilled, there is an onus on the clinician to inform patients they have pre-diabetes. In many younger patients it will be difficult to judge whether they fulfil the third criterion and can successfully change renova solar reviews their lifestyle.

In these cases the likely benefits of ‘diagnosis’ outweigh any potential drawback. However, as a patient ages and develops certain other comorbidities, a tipping point is reached where the criteria are very renova solar reviews unlikely to be fulfilled and the harms of a ‘diagnosis’ will outweigh any potential benefits. At that point informing the patient becomes harmful and should arguably only be done if the patient explicitly requests the information.Rather than having a full discussion of the pros and cons of a pre-diabetes label with each patient we would advocate a ‘see-saw’ model of paternalist considerations. Younger fitter patients are automatically informed of their pre-diabetes whether or not they have requested the information explicitly while those who are very elderly renova solar reviews and have comorbidities and a limited life expectancy are not informed.

In the middle is the group of patients for whom paternalism either way is not appropriate because renova solar reviews the benefits and harms of a ‘diagnosis’ are uncertain. These patients in the middle of the see-saw are those for whom an in-depth discussion about the relevance and meaning of ‘pre-diabetes’ to them as an individual needs to take place, and also those patients where the blood test most strongly ought to have been discussed before it was performed.It could be argued that a drawback to this approach is the effect that it may have on patient–physician trust. In modern medicine patients are frequently renova solar reviews seen by multiple clinicians. Clinician one may choose, quite ethically, not to reveal to a patient that they are pre-diabetic.

The patient may then see clinician two renova solar reviews who tells them. This could then create a situation where the patient loses trust in clinician one and, indeed, the whole medical profession. However, pre-diabetes is renova solar reviews not a disease state. The non-disclosure of pre-diabetes is markedly different to the non-disclosure of a disease.

If the patient understands that clinician one did not disclose to them because pre-diabetes is a risk factor that is not relevant to them, and not a disease, then, renova solar reviews hopefully, there would be no loss of trust. In primary care in the UK, there is frequently non-disclosure of other ‘pre’ conditions, such as chronic kidney disease.21 This non-disclosure takes place where the condition is of relevance to the patient and full disclosure would, generally, be in the best interest of the patient. This is ethically renova solar reviews and professionally problematic. However, the renova solar reviews response of patients who find out about non-disclosure in these cases is of interest.

When interviewed, the response of patients to finding out about these non-disclosures is nuanced and varied.21 It does need lead to automatic loss of trust in the medical profession.Wider use of this approach?. The purpose of the paper is to outline principles that could be applied, in an ethical manner to an unexpected blood renova solar reviews test result of pre-diabetes. In theory, the principles outlined could be more widely applicable in other pre-conditions and other risk factors. To be applicable, a condition must have a fairly predictable trajectory, have a point renova solar reviews where ‘pre-disease’ becomes ‘actual disease’ and be potentially reversible (or delayable).

The principles could possibly be applied to early chronic kidney disease or early hypertension but may not be appropriate for other conditions or risk factors. The difficulty in other conditions is predicting whether a patient is going to convert from a renova solar reviews pre-condition to a disease state, predicting when they are going to convert and predicting whether this is going to cause harm. In these cases, where there is doubt, this should always be discussed fully with the patient.ConclusionWe have outlined a pragmatic ethical approach that can be used to guide a clinician when deciding how to manage an unexpected pre-diabetic blood result in an elderly patient. We argue that, while patients should have full access to all information and test results, pre-diabetes is a renova solar reviews risk state, not a disease, and is only of relevance to patients that fulfil certain criteria.

While the individual characteristics of each patient should always be considered, in general, those patients that do not fulfil these criteria should not be burdened or potentially harmed by being labelled. Where there is any renova solar reviews doubt about the harms and benefits of a pre-diabetes label, full disclosure and open discussion should take place with the patient. This will help avoid a situation where trust in the medical profession is eroded when a patient finds out at a later date that they ‘had pre-diabetes’ and were not informed.Data availability statementThere are no data in this work.Ethics statementsPatient consent for publicationNot required..

Lord Scarman’s judgment about when someone under the age of 16 years should have the right to make company website their own medical decisions emphasised the decision-making abilities of buy renova 0.025 cream the particular child. He said:…the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed (p188–189).1That created a duty on healthcare practitioners to assess buy renova 0.025 cream whether a particular minor has decision-making abilities at a degree that would enable them to understand the decision to a high extent, sufficient hopefully that they would ‘own’ the decision. In December of 2020, the High Court considered whether young people with gender dysphoria (GD) and seeking access to puberty blocking (PB) therapy, were likely to pass Scarman’s mature minor test and cast doubt on their ability to fully understand that decision, thereby making it less likely that a healthcare practitioner would decide they are a mature minor for that therapy. The High Court said:It is highly unlikely that a child buy renova 0.025 cream aged 13 or under would be competent to give consent to the administration of puberty blockers. It is doubtful that a child aged 14 or 15 could understand and weigh the long-term risks and consequences of the administration of puberty blockers (p151).2Since then, the Journal of Medical Ethics has published papers about the ethical issues raised by that judgment.

Beattie, writing at the time the judgment was made, disagreed with the High Court and claimed that the decision to take puberty buy renova 0.025 cream blockers is no more complex than many of the other medical decisions that minors are assessed as being competent to make.3 Central to the High Court’s decision was the claim that the decision to start PB therapy (the first stage of therapy for GD) is inextricably linked to the more permanent and significant, cross-sex hormone (CSH) therapy. That meant the abilities required to fully understand what was proposed became very demanding because they would require someone who had not yet gone through puberty to know what a second round of treatment, that would result in permanent and complex changes, would mean for them. Beattie objects to that claim for several buy renova 0.025 cream reasons including that ‘…high progression rates to CSH may merely represent successful identification of persistent GD, rather than PBs promoting persistence’ (p4).Giordano et al consider the possibility that consenting to PB might be more complex than other treatments a minor might consent to.4 They point out that many other medical decisions are similarly complex and emotionally involving, so PB should not be viewed differently from other decisions a minor might take.The High Court’s judgment was recently overturned by the Court of Appeal who criticised the judgment on a number of grounds, including the implications that it would have for those seeking therapy for GD.Moreover, the effect of the guidance was to require applications to the court in circumstances where the Divisional Court itself had recognised that there was no legal obligation to do so. It placed patients, parents and clinicians in a very difficult position. In practice the guidance would have the effect of denying treatment in many circumstances for want of resources to make such an application coupled with inevitable delay through court involvement (p86).5While buy renova 0.025 cream some might read that as an ethical point about access to therapy, the Court of Appeal is making a legal point about when it is appropriate for the court to become involved and the costs of them doing so.

That kind of concern continues where they object to the court making age-based recommendations about the likely ability of young people to consent.We conclude that it was inappropriate for the Divisional Court to give the guidance concerning when a court application will be appropriate and to reach general age-related conclusions about the likelihood or probability of different cohorts of children being capable of giving consent (p89).5Predictably, the Court of Appeal judgment has been hailed as ‘a positive step forwards for trans rights in the UK and around the world’.6 It is important to be clear, though, about exactly what was and what was not an issue here. The court was careful not to take a position on buy renova 0.025 cream the debate about PBs. It recognised that this is buy renova 0.025 cream an ongoing controversy. €˜The present proceedings do not require the courts to determine whether the treatment for GD is a wise or unwise course’.5Furthermore, there is nothing in the judgment about how often minors seeking access to PBs will be assessed as competent to make that decision, nor about what they will need to demonstrate in order to show that competence.As we have already said, the principle enunciated in Gillick was that it was for clinicians rather than the court to decide on competence (p87).5The point is precisely that it is not appropriate for courts to involve themselves in such matters. It will be buy renova 0.025 cream for clinicians to make that determination.

There is nothing inherent to the nature of PBs that set them apart from other healthcare decisions, nothing that justifies the court intruding on what is a well-recognised area of clinical expertise.Certainly, it is not for the court to require that young people accept as matters of fact propositions that are currently factually contested or complex, such as the claim that PBs almost always serve as precursors to ‘much greater medical interventions’. And it is not for the court to issue guidance, in general terms, about buy renova 0.025 cream when capacity assessments should require judicial intervention.There was a recognition here that this is a ‘difficult and controversial area’, where facts are contested and deep-seated values set in conflict. But as the court acknowledged, the concept of ‘Gillick competence’ arose in a context where that could also have been said of the provision of contraceptives to minors. Generalisations about capacity assessment were no more appropriate here than they were back in buy renova 0.025 cream that earlier context.Ethics statementsPatient consent for publicationNot required.IntroductionIn the last decade there has been a marked increase in patients labelled with pre-diabetes in the UK.1 The ‘diagnosis’ of pre-diabetes is made on the basis of a patient having one or more markers of abnormal blood glucose. Levels are higher than normal but have not reached the threshold where the patient gets diagnosed as diabetic.

Patients with blood sugar levels in a pre-diabetic range are asymptomatic buy renova 0.025 cream and disease free. The rationale behind labelling patients as pre-diabetic is that patients with pre-diabetes are at higher risk of going on to develop type 2 diabetes.2 Type 2 diabetes can cause significant mortality and morbidity.3 There is evidence that lifestyle change (altered diet and increased physical activity) in patients with pre-diabetes can prevent progression to diabetes.4 Although patients may be labelled as ‘pre-diabetic’, and this might look like a diagnosis of a pathological condition, pre-diabetes is a risk factor for the development of diabetes, not a disease in its own right.5Pre-diabetes is highly prevalent in Western countries. Its prevalence buy renova 0.025 cream rises with age, and by age 75 years nearly 50% of the population in the USA is classified as pre-diabetic or diabetic.6 7 However, not all patients with pre-diabetes will develop diabetes. The risk of a person with pre-diabetes progressing to diabetes within 12 months is between 1 in 10 and 1 in 20.8 This annual conversion rate drops even lower as patients age.9 A 12-year follow-up of older adults with pre-diabetes, showed most remained stable or reverted to normal blood sugar levels, whereas only one‐third developed diabetes or died.10If a person develops diabetes, they do not automatically develop symptoms or buy renova 0.025 cream complications. Complications, such as retinopathy and renal disease, develop over time and are more likely to occur the longer a patient has suffered with diabetes.11 Therefore, if a patient is approaching the end of their life, developing type 2 diabetes may have no direct impact on their health or quality of life.In order for a patient to eventually benefit from the label of pre-diabetes they must fulfil three criteria.

They must:Be in the group of patients that are going to convert from pre-diabetes to diabetes.Be in the group of patients that are going to develop symptoms buy renova 0.025 cream or complications of diabetes.Be in the group of patients for whom lifestyle changes or medication can prevent the conversion from pre-diabetes to diabetes.If a patient does not belong to all three of these groups then labelling them as pre-diabetic will not confer any benefit to them. As conversion rates from pre-diabetes to diabetes reduce as a person ages and shortening life expectancy (which inevitably comes with ageing) reduces the risk of developing complications from diabetes, there is going to be a point in any patient’s life, even assuming that lifestyle changes could prevent progression to diabetes, where a patient will not benefit from knowing they have pre-diabetes. Calculating the exact age at which that will occur for an individual patient is problematic but certain general principles can be established to help clinicians decide on the benefit of labelling.This paper explores the pros and cons of a pre-diabetes label and a pragmatic ethical approach that could be taken by clinicians when faced with a new unanticipated pre-diabetic blood buy renova 0.025 cream result that has been discovered through ‘routine’ blood tests.What are the harms of a pre-diabetes label?. The treatment for pre-diabetes is, in essence, adopting a healthier diet and taking more exercise. If adopted and buy renova 0.025 cream maintained, these lifestyle changes are likely to benefit most patients in multiple aspects of health, not just their risk of developing diabetes.

However, although they may slightly delay the point at which a patient develops diabetes, studies of lifestyle-based diabetes prevention programmes show that most patients do not or cannot maintain long-term lifestyle changes.5 12 Weight loss is generally short term or minimal and patients usually slip back into old habits and routines. While there is undoubtedly an argument for informing younger patients who may receive a benefit from knowing they have pre-diabetes, the harms of informing increase buy renova 0.025 cream with age.Many elderly patients with comorbidities may struggle to increase physical activity. Dietary change and attempts to lose weight after a certain age can have detrimental health effects13 Labelling somebody as having a medical condition carries a psychological burden in itself, and being unable to engage in the behaviour change recommended may also have negative consequences, that is, engendering a feeling of being ‘a failure’.14–16 If the label leads to further follow-up this may also place a burden on patients. There are also considerable buy renova 0.025 cream implications for the use of health resources if the labelling of individuals as pre-diabetic requires further follow-up and intervention. Annual blood tests are standard (£6.42), subsequent general practitioner (GP) or nurse (£30) appointments to discuss results frequently take place as do referrals on to the national Diabetes Prevention Programme (£270).17 There are roughly 3 million people in the UK aged 80 years or over.18 If one-third of them have pre-diabetes and, of those, half have an annual blood test, a quarter have a GP appointment and one in eight get referred to the National Health Service (NHS) Diabetes Prevention Programme that is buy renova 0.025 cream an annual cost of around £37 million.What is ideal practice and what is the reality?.

While some patients may have been tested following screening for being at risk of diabetes, in the UK most patients in whom pre-diabetes is diagnosed have blood sugar level tests carried out as part of a battery of other blood tests that are performed as part of annual chronic disease monitoring for conditions such as hypertension.19 The contents of the battery are determined by individual practices and usually based on guidance and payment targets issued by the NHS.20 In theory, a patient should give informed consent before any test, including blood sugar and HbA1c testing. In reality many patients who buy renova 0.025 cream are given a diagnosis of pre-diabetes are unaware that they had blood tests for diabetes/pre-diabetes.19 When checking blood glucose or HbA1c in an elderly patient, especially one without symptoms of diabetes, the clinician should talk through with them the potential outcomes of the test and the implications this may have to them. The patient can then make an informed decision as to whether they want to go ahead with testing or not. In routine buy renova 0.025 cream clinical practice in the UK this happens rarely, if at all. This is likely due to the volume of blood testing, the automated nature of the process, the limited time a clinician has to devote to each individual patient and the priority that individual clinicians assign to such conversations.As we discussed in a recent paper a more individualised approach to ‘routine’ blood tests needs to be taken.19 The utility of each test should be gauged for each patient as an individual, not as the average patient that has a particular disease.

The reality, however, buy renova 0.025 cream is that this change will, at best, be adopted slowly or, at worst, not at all. What then, should clinicians who are presented with a pre-diabetic blood result in an elderly patient do?. The see-saw buy renova 0.025 cream model of paternalismWhen faced with a series of test results for a patient, clinicians exercise judgement about what they consider ‘normal’ or ‘satisfactory’. They also exercise judgement in what they communicate to the patient about the results. In certain circumstances a patient may, for instance, have a mildly raised bilirubin or mildly decreased albumin and the clinician may file buy renova 0.025 cream the result as ‘satisfactory’ and not inform the patient.

Is this an act of paternalism or is it the act of a clinician filtering out the ‘noise’ that is buy renova 0.025 cream generated from carrying out tests and using an individual patient’s circumstances to contextualise what is ‘normal’?. Should clinicians, therefore, assume that all new pre-diabetic blood results above a certain age should not be disclosed to patients?. This is obviously an indefensible position as a general policy buy renova 0.025 cream since patients have a right to information that concerns their health. However, while the blood result may be a factual piece of data, the labelling of a result as ‘satisfactory’, ‘acceptable’ or ‘abnormal’ is a clinical judgement. There is, in most circumstances, a moral obligation on the clinician to disclose buy renova 0.025 cream to a patient that they are suffering with a disease.

Pre-diabetes is not a disease and unless a patient fulfils the three criteria set out in the introduction to this paper the information is not likely to benefit the patient.In younger patients, where the criteria related to a significant likelihood of progressing to diabetes with negative health effects are likely to be fulfilled, there is an onus on the clinician to inform patients they have pre-diabetes. In many younger patients it will be difficult to judge whether they fulfil the third criterion and can buy renova 0.025 cream successfully change their lifestyle. In these cases the likely benefits of ‘diagnosis’ outweigh any potential drawback. However, as a patient ages and develops certain other comorbidities, a tipping point is reached where the criteria are buy renova 0.025 cream very unlikely to be fulfilled and the harms of a ‘diagnosis’ will outweigh any potential benefits. At that point informing the patient becomes harmful and should arguably only be done if the patient explicitly requests the information.Rather than having a full discussion of the pros and cons of a pre-diabetes label with each patient we would advocate a ‘see-saw’ model of paternalist considerations.

Younger fitter patients are automatically informed of their pre-diabetes whether or buy renova 0.025 cream not they have requested the information explicitly while those who are very elderly and have comorbidities and a limited life expectancy are not informed. In the middle is the group of patients for whom paternalism either way is not appropriate buy renova 0.025 cream because the benefits and harms of a ‘diagnosis’ are uncertain. These patients in the middle of the see-saw are those for whom an in-depth discussion about the relevance and meaning of ‘pre-diabetes’ to them as an individual needs to take place, and also those patients where the blood test most strongly ought to have been discussed before it was performed.It could be argued that a drawback to this approach is the effect that it may have on patient–physician trust. In modern medicine patients are frequently seen by multiple clinicians buy renova 0.025 cream. Clinician one may choose, quite ethically, not to reveal to a patient that they are pre-diabetic.

The patient buy renova 0.025 cream may then see clinician two who tells them. This could then create a situation where the patient loses trust in clinician one and, indeed, the whole medical profession. However, pre-diabetes is not a disease state buy renova 0.025 cream. The non-disclosure of pre-diabetes is markedly different to the non-disclosure of a disease. If the patient understands that clinician one did not disclose to them because pre-diabetes is a risk factor that is not relevant to them, buy renova 0.025 cream and not a disease, then, hopefully, there would be no loss of trust.

In primary care in the UK, there is frequently non-disclosure of other ‘pre’ conditions, such as chronic kidney disease.21 This non-disclosure takes place where the condition is of relevance to the patient and full disclosure would, generally, be in the best interest of the patient. This is ethically and professionally problematic buy renova 0.025 cream. However, the response of patients who buy renova 0.025 cream find out about non-disclosure in these cases is of interest. When interviewed, the response of patients to finding out about these non-disclosures is nuanced and varied.21 It does need lead to automatic loss of trust in the medical profession.Wider use of this approach?. The purpose of the paper buy renova 0.025 cream is to outline principles that could be applied, in an ethical manner to an unexpected blood test result of pre-diabetes.

In theory, the principles outlined could be more widely applicable in other pre-conditions and other risk factors. To be applicable, a condition must buy renova 0.025 cream have a fairly predictable trajectory, have a point where ‘pre-disease’ becomes ‘actual disease’ and be potentially reversible (or delayable). The principles could possibly be applied to early chronic kidney disease or early hypertension but may not be appropriate for other conditions or risk factors. The difficulty in other conditions is predicting whether a patient is going to convert from a pre-condition to a disease state, predicting when they buy renova 0.025 cream are going to convert and predicting whether this is going to cause harm. In these cases, where there is doubt, this should always be discussed fully with the patient.ConclusionWe have outlined a pragmatic ethical approach that can be used to guide a clinician when deciding how to manage an unexpected pre-diabetic blood result in an elderly patient.

We argue that, while patients should have full access to all information and test buy renova 0.025 cream results, pre-diabetes is a risk state, not a disease, and is only of relevance to patients that fulfil certain criteria. While the individual characteristics of each patient should always be considered, in general, those patients that do not fulfil these criteria should not be burdened or potentially harmed by being labelled. Where there is any doubt about the harms and benefits of a pre-diabetes label, full disclosure and open discussion should take place with the patient buy renova 0.025 cream. This will help avoid a situation where trust in the medical profession is eroded when a patient finds out at a later date that they ‘had pre-diabetes’ and were not informed.Data availability statementThere are no data in this work.Ethics statementsPatient consent for publicationNot required..