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Most seniors about 85 percent still enroll in original Medicare and purchase a Medicare supplement policy (Medigap policy) for additional coverage. Supplemental policies are purchased because Medicare pays only about half the medical expenses of participants. In the booklet Medicare and You, Medicare itself classifies original Medicare as having high out-ofpocket costs. The out-of-pocket expenses include Medicare s premiums, deductibles, and copayments. In addition, Medicare doesn t cover a number of procedures and expenses. For example, in 2004 the Part B Medicare premium was $66.60 per month. The hospital deductible under Part A was $876 per benefit period. The hospital copayment under Part A was $219 per day for the sixty-first through ninetieth days of each benefit period. After the Part B deductible, participants also pay 20 percent of the Medicareapproved amount on each covered expense and 20 percent of all outpatient, physical, and speech-language therapy. Medicare doesn t cover any medical care received outside the United States. There are other possible out-of-pocket costs and uncovered treatments. Details and changes are at www.medicare.gov. To help pay for uncovered expenses, participants can purchase a Medicare supplement policy. The Medigap policies used to be something of a scandal. There were numerous types of policies available, making it difficult for seniors to compare policies. In addition, unscrupulous insur-

7-1 = r - q, 7-2 = r . (1 - q)

Yield: 3 qt (3 L) Portions: 32 Portion size: 3 oz (mL)

a Mean response times, Eq. (7.43):

2. Place one-third of the apple mixture in an even layer in a well-buttered baking pan measuring 12 20 in. (30 50 cm). 3. Top with one-third of the cake crumbs. 4. Continue until all the apples and crumbs have been used. You will have 3 layers of fruit and 3 layers of crumbs. 5. Pour the melted butter evenly over the top. 6. Bake at 350 F (175 C) for about 1 hour, until fruit is tender.

Fuel flow command IGV actuator command Engine Throttle Flight conditions: altitude temperature Mach FADEC

0 7 0 3 0 4 0 7

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All wounds were redressed once or twice daily. The wound was thoroughly cleaned using cotton wool balls and forceps. The method of wiping across the wound surface varied from hospital to hospital. The Hippocratic principle of keeping wounds clean and dry became adapted to allowing wounds to dry up . Mostly gauze preparations were used but gradually all sorts of dubious practices crept in. There have been reports of Marmite, eggs and even toast used on wounds (Dobrzanski et al., 1988; Johnson, 1987). A wide variety of pharmaceutical preparations have also been applied without any recognition of the need for evidence-based care. Murray (1988) found that within her health authority, an amazing selection of pharmaceutical products were in use: 18 different cleansing agents, 53 substances left in contact with open wounds and 24 products used for packing wounds. Millward (1989) found 19 different substances being used on pressure ulcers within one hospital. Walsh and Ford (1989) have discussed the rituals in nursing, much of which can be applied to wound care. The common reasons for choosing a dressing could be listed as: We always do it that way here. Sister said so. I have used this dressing for the last 30 years, why should I change Many older nurses will have been trained to use these ritualistic methods. It is only recently that there has been a critical evaluation of these methods and changes made to a more evidence-based approach.

As you learned earlier in this chapter,one of Escof er s important achievements was the reorganization of the kitchenThis reorganization divided the kitchen into departments, or stations,based on the kinds of foods produced A station chef was placed in charge of each department In a small operation, the station chef may be the only worker in the department But in a large kitchen, each station chef might have several assistants This system,with many variations,is still used today,especially in large hotels with traditional kinds of food serviceThe major positions are as follows: 1 The chef is the person in charge of the kitchenIn large establishments,this person has the title of executive chefThe executive chef is a manager who is responsible for all aspects of food production, including menu planning, purchasing, costing, planning work schedules, hiring, and training 2.

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