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To the patients health, you mean? I think you need to be more specific with your question.Edited to reflect your comment:There are a lot of factors that make up the cost of healthcare, and certainly to an extent, the cost of patients seeing doctors unnecessarily for visits/tests certainly takes a share of that rising cost.Unfortunately I am unable to really answer this question as I have always worked at not for profit hospitals and healthcare systems and have taken a salary and not charged per patient/procedure.However, here is a great article in the New Yorker Magazine Annals of Medicine on the subject of unnecessary tests and rising healthcare costs which I think you might find interesting and useful.The cost conundrumWhat a Texas town can teach us about HealthcareWritten by Dr. Atul GawandeCostlier care is often worse care. Photograph by Phillip Toledano.It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.The explosive trend in American medical costs seems to have occurred here in an especially intense form. Our country’s health care is by far the most expensive in the world. In Washington, the aim of health-care reform is not just to extend medical coverage to everybody but also to bring costs under control. Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government. “The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”The question we’re now frantically grappling with is how this came to be, and what can be done about it. McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.From the moment I arrived, I asked almost everyone I encountered about McAllen’s health costs—a businessman I met at the five-gate McAllen-Miller International Airport, the desk clerks at the Embassy Suites Hotel, a police-academy cadet at McDonald’s. Most weren’t surprised to hear that McAllen was an outlier. “Just look around,” the cadet said. “People are not healthy here.” McAllen, with its high poverty rate, has an incidence of heavy drinking sixty per cent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight-per-cent obesity rate.One day, I went on rounds with Lester Dyke, a weather-beaten, ranch-owning fifty-three-year-old cardiac surgeon who grew up in Austin, did his surgical training with the Army all over the country, and settled into practice in Hidalgo County. He has not lacked for business: in the past twenty years, he has done some eight thousand heart operations, which exhausts me just thinking about it. I walked around with him as he checked in on ten or so of his patients who were recuperating at the three hospitals where he operates. It was easy to see what had landed them under his knife. They were nearly all obese or diabetic or both. Many had a family history of heart disease. Few were taking preventive measures, such as cholesterol-lowering drugs, which, studies indicate, would have obviated surgery for up to half of them.Yet public-health statistics show that cardiovascular-disease rates in the county are actually lower than average, probably because its smoking rates are quite low. Rates of asthma, H.I.V., infant mortality, cancer, and injury are lower, too. El Paso County, eight hundred miles up the border, has essentially the same demographics. Both counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006 Medicare expenditures (our best approximation of over-all spending patterns) in El Paso were $7,504 per enrollee—half as much as in McAllen. An unhealthy population couldn’t possibly be the reason that McAllen’s health-care costs are so high. (Or the reason that America’s are. We may be more obese than any other industrialized nation, but we have among the lowest rates of smoking and alcoholism, and we are in the middle of the range for cardiovascular disease and diabetes.)Was the explanation, then, that McAllen was providing unusually good health care? I took a walk through Doctors Hospital at Renaissance, in Edinburg, one of the towns in the McAllen metropolitan area, with Robert Alleyn, a Houston-trained general surgeon who had grown up here and returned home to practice. The hospital campus sprawled across two city blocks, with a series of three- and four-story stucco buildings separated by golfing-green lawns and black asphalt parking lots. He pointed out the sights—the cancer center is over here, the heart center is over there, now we’re coming to the imaging center. We went inside the surgery building. It was sleek and modern, with recessed lighting, classical music piped into the waiting areas, and nurses moving from patient to patient behind rolling black computer pods. We changed into scrubs and Alleyn took me through the sixteen operating rooms to show me the laparoscopy suite, with its flat-screen video monitors, the hybrid operating room with built-in imaging equipment, the surgical robot for minimally invasive robotic surgery.I was impressed. The place had virtually all the technology that you’d find at Harvard and Stanford and the Mayo Clinic, and, as I walked through that hospital on a dusty road in South Texas, this struck me as a remarkable thing. Rich towns get the new school buildings, fire trucks, and roads, not to mention the better teachers and police officers and civil engineers. Poor towns don’t. But that rule doesn’t hold for health care.At McAllen Medical Center, I saw an orthopedic surgeon work under an operating microscope to remove a tumor that had wrapped around the spinal cord of a fourteen-year-old. At a home-health agency, I spoke to a nurse who could provide intravenous-drug therapy for patients with congestive heart failure. At McAllen Heart Hospital, I watched Dyke and a team of six do a coronary-artery bypass using technologies that didn’t exist a few years ago. At Renaissance, I talked with a neonatologist who trained at my hospital, in Boston, and brought McAllen new skills and technologies for premature babies. “I’ve had nurses come up to me and say, ‘I never knew these babies could survive,’ ” he said.And yet there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.One night, I went to dinner with six McAllen doctors. All were what you would call bread-and-butter physicians: busy, full-time, private-practice doctors who work from seven in the morning to seven at night and sometimes later, their waiting rooms teeming and their desks stacked with medical charts to review.Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.“It’s malpractice,” a family physician who had practiced here for thirty-three years said.“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?“Practically to zero,” the cardiologist admitted.“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”Everyone agreed that something fundamental had changed since the days when health-care costs in McAllen were the same as those in El Paso and elsewhere. Yes, they had more technology. “But young doctors don’t think anymore,” the family physician said.The surgeon gave me an example. General surgeons are often asked to see patients with pain from gallstones. If there aren’t any complications—and there usually aren’t—the pain goes away on its own or with pain medication. With instruction on eating a lower-fat diet, most patients experience no further difficulties. But some have recurrent episodes, and need surgery to remove their gallbladder.Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.I gave the doctors around the table a scenario. A forty-year-old woman comes in with chest pain after a fight with her husband. An EKG is normal. The chest pain goes away. She has no family history of heart disease. What did McAllen doctors do fifteen years ago?Send her home, they said. Maybe get a stress test to confirm that there’s no issue, but even that might be overkill.And today? Today, the cardiologist said, she would get a stress test, an echocardiogram, a mobile Holter monitor, and maybe even a cardiac catheterization.“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.In an odd way, this news is reassuring. Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with. So the idea that there’s plenty of fat in the system is proving deeply attractive. “Nearly thirty per cent of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level in low-cost areas,” Peter Orszag, the President’s budget director, has stated.Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it. Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail.I had what I considered to be a reasonable plan for finding out what was going on in McAllen. I would call on the heads of its hospitals, in their swanky, decorator-designed, churrigueresco offices, and I’d ask them.The first hospital I visited, McAllen Heart Hospital, is owned by Universal Health Services, a for-profit hospital chain with headquarters in King of Prussia, Pennsylvania, and revenues of five billion dollars last year. I went to see the hospital’s chief operating officer, Gilda Romero. Truth be told, her office seemed less churrigueresco than Office Depot. She had straight brown hair, sympathetic eyes, and looked more like a young school teacher than like a corporate officer with nineteen years of experience. And when I inquired, “What is going on in this place?” she looked surprised.Is McAllen really that expensive? she asked.I described the data, including the numbers indicating that heart operations and catheter procedures and pacemakers were being performed in McAllen at double the usual rate.“That is interesting,” she said, by which she did not mean, “Uh-oh, you’ve caught us” but, rather, “That is actually interesting.” The problem of McAllen’s outlandish costs was new to her. She puzzled over the numbers. She was certain that her doctors performed surgery only when it was necessary. It had to be one of the other hospitals. And she had one in mind—Doctors Hospital at Renaissance, the hospital in Edinburg that I had toured.She wasn’t the only person to mention Renaissance. It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.Such an arrangement can make physician investors rich. But it can’t be the whole explanation. The hospital gets barely a sixth of the patients in the region; its margins are no bigger than the other hospitals’—whether for profit or not for profit—and it didn’t have much of a presence until 2004 at the earliest, a full decade after the cost explosion in McAllen began.“Those are good points,” Romero said. She couldn’t explain what was going on.The following afternoon, I visited the top managers of Doctors Hospital at Renaissance. We sat in their boardroom around one end of a yacht-length table. The chairman of the board offered me a soda. The chief of staff smiled at me. The chief financial officer shook my hand as if I were an old friend. The C.E.O., however, was having a hard time pretending that he was happy to see me. Lawrence Gelman was a fifty-seven-year-old anesthesiologist with a Bill Clinton shock of white hair and a weekly local radio show tag-lined “Opinions from an Unrelenting Conservative Spirit.” He had helped found the hospital. He barely greeted me, and while the others were trying for a how-can-I-help-you-today attitude, his body language was more let’s-get-this-over-with.So I asked him why McAllen’s health-care costs were so high. What he gave me was a disquisition on the theory and history of American health-care financing going back to Lyndon Johnson and the creation of Medicare, the upshot of which was: (1) Government is the problem in health care. “The people in charge of the purse strings don’t know what they’re doing.” (2) If anything, government insurance programs like Medicare don’t pay enough. “I, as an anesthesiologist, know that they pay me ten per cent of what a private insurer pays.” (3) Government programs are full of waste. “Every person in this room could easily go through the expenditures of Medicare and Medicaid and see all kinds of waste.” (4) But not in McAllen. The clinicians here, at least at Doctors Hospital at Renaissance, “are providing necessary, essential health care,” Gelman said. “We don’t invent patients.”Then why do hospitals in McAllen order so much more surgery and scans and tests than hospitals in El Paso and elsewhere?In the end, the only explanation he and his colleagues could offer was this: The other doctors and hospitals in McAllen may be overspending, but, to the extent that his hospital provides costlier treatment than other places in the country, it is making people better in ways that data on quality and outcomes do not measure.“Do we provide better health care than El Paso?” Gelman asked. “I would bet you two to one that we do.”It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.And, I realized, few people in their position do. Local executives for hospitals and clinics and home-health agencies understand their growth rate and their market share; they know whether they are losing money or making money. They know that if their doctors bring in enough business—surgery, imaging, home-nursing referrals—they make money; and if they get the doctors to bring in more, they make more. But they have only the vaguest notion of whether the doctors are making their communities as healthy as they can, or whether they are more or less efficient than their counterparts elsewhere. A doctor sees a patient in clinic, and has her check into a McAllen hospital for a CT scan, an ultrasound, three rounds of blood tests, another ultrasound, and then surgery to have her gallbladder removed. How is Lawrence Gelman or Gilda Romero to know whether all that is essential, let alone the best possible treatment for the patient? It isn’t what they are responsible or accountable for.Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.If doctors wield the pen, why do they do it so differently from one place to another? Brenda Sirovich, another Dartmouth researcher, published a study last year that provided an important clue. She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.Sirovich asked doctors how they would treat a seventy-five-year-old woman with typical heartburn symptoms and “adequate health insurance to cover tests and medications.” Physicians in high- and low-cost cities were equally likely to prescribe antacid therapy and to check for H. pylori, an ulcer-causing bacterium—steps strongly recommended by national guidelines. But when it came to measures of less certain value—and higher cost—the differences were considerable. More than seventy per cent of physicians in high-cost cities referred the patient to a gastroenterologist, ordered an upper endoscopy, or both, while half as many in low-cost cities did. Physicians from high-cost cities typically recommended that patients with well-controlled hypertension see them in the office every one to three months, while those from low-cost cities recommended visits twice yearly. In case after uncertain case, more was not necessarily better. But physicians from the most expensive cities did the most expensive things.Why? Some of it could reflect differences in training. I remember when my wife brought our infant son Walker to visit his grandparents in Virginia, and he took a terrifying fall down a set of stairs. They drove him to the local community hospital in Alexandria. A CT scan showed that he had a tiny subdural hematoma—a small area of bleeding in the brain. During ten hours of observation, though, he was fine—eating, drinking, completely alert. I was a surgery resident then and had seen many cases like his. We observed each child in intensive care for at least twenty-four hours and got a repeat CT scan. That was how I’d been trained. But the doctor in Alexandria was going to send Walker home. That was how he’d been trained. Suppose things change for the worse? I asked him. It’s extremely unlikely, he said, and if anything changed Walker could always be brought back. I bullied the doctor into admitting him anyway. The next day, the scan and the patient were fine. And, looking in the textbooks, I learned that the doctor was right. Walker could have been managed safely either way.There was no sign, however, that McAllen’s doctors as a group were trained any differently from El Paso’s. One morning, I met with a hospital administrator who had extensive experience managing for-profit hospitals along the border. He offered a different possible explanation: the culture of money.“In El Paso, if you took a random doctor and looked at his tax returns eighty-five per cent of his income would come from the usual practice of medicine,” he said. But in McAllen, the administrator thought, that percentage would be a lot less.He knew of doctors who owned strip malls, orange groves, apartment complexes—or imaging centers, surgery centers, or another part of the hospital they directed patients to. They had “entrepreneurial spirit,” he said. They were innovative and aggressive in finding ways to increase revenues from patient care. “There’s no lack of work ethic,” he said. But he had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended—and it bothered him. Several doctors who were unhappy about the direction medicine had taken in McAllen told me the same thing. “It’s a machine, my friend,” one surgeon explained.No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not. You must pay attention to insurance rejections and government-reimbursement rules. You must think about having enough money for the secretary and the nurse and the rent and the malpractice insurance.Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears and colonoscopies.Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients’ scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.In every community, you’ll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme.In a few cases, the hospital executive told me, he’d seen the behavior cross over into what seemed like outright fraud. “I’ve had doctors here come up to me and say, ‘You want me to admit patients to your hospital, you’re going to have to pay me.’ ”“How much?” I asked.“The amounts—all of them were over a hundred thousand dollars per year,” he said. The doctors were specific. The most he was asked for was five hundred thousand dollars per year.He didn’t pay any of them, he said: “I mean, I gotta sleep at night.” And he emphasized that these were just a handful of doctors. But he had never been asked for a kickback before coming to McAllen.Woody Powell is a Stanford sociologist who studies the economic culture of cities. Recently, he and his research team studied why certain regions—Boston, San Francisco, San Diego—became leaders in biotechnology while others with a similar concentration of scientific and corporate talent—Los Angeles, Philadelphia, New York—did not. The answer they found was what Powell describes as the anchor-tenant theory of economic development. Just as an anchor store will define the character of a mall, anchor tenants in biotechnology, whether it’s a company like Genentech, in South San Francisco, or a university like M.I.T., in Cambridge, define the character of an economic community. They set the norms. The anchor tenants that set norms encouraging the free flow of ideas and collaboration, even with competitors, produced enduringly successful communities, while those that mainly sought to dominate did not.Powell suspects that anchor tenants play a similarly powerful community role in other areas of economics, too, and health care may be no exception. I spoke to a marketing rep for a McAllen home-health agency who told me of a process uncannily similar to what Powell found in biotech. Her job is to persuade doctors to use her agency rather than others. The competition is fierce. I opened the phone book and found seventeen pages of listings for home-health agencies—two hundred and sixty in all. A patient typically brings in between twelve hundred and fifteen hundred dollars, and double that amount for specialized care. She described how, a decade or so ago, a few early agencies began rewarding doctors who ordered home visits with more than trinkets: they provided tickets to professional sporting events, jewelry, and other gifts. That set the tone. Other agencies jumped in. Some began paying doctors a supplemental salary, as “medical directors,” for steering business in their direction. Doctors came to expect a share of the revenue stream.Agencies that want to compete on quality struggle to remain in business, the rep said. Doctors have asked her for a medical-director salary of four or five thousand dollars a month in return for sending her business. One asked a colleague of hers for private-school tuition for his child; another wanted sex.“I explained the rules and regulations and the anti-kickback law, and told them no,” she said of her dealings with such doctors. “Does it hurt my business?” She paused. “I’m O.K. working only with ethical physicians,” she finally said.About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country. A couple of years ago, I spent several days there as a visiting surgeon. Among the things that stand out from that visit was how much time the doctors spent with patients. There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other. I accompanied a colleague while he saw patients. Most of the patients, like those in my clinic, required about twenty minutes. But one patient had colon cancer and a number of other complex issues, including heart disease. The physician spent an hour with her, sorting things out. He phoned a cardiologist with a question.“I’ll be there,” the cardiologist said.Fifteen minutes later, he was. They mulled over everything together. The cardiologist adjusted a medication, and said that no further testing was needed. He cleared the patient for surgery, and the operating room gave her a slot the next day.The whole interaction was astonishing to me. Just having the cardiologist pop down to see the patient with the surgeon would be unimaginable at my hospital. The time required wouldn’t pay. The time required just to organize the system wouldn’t pay.The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs.“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.The Mayo Clinic is not an aberration. One of the lowest-cost markets in the country is Grand Junction, Colorado, a community of a hundred and twenty thousand that nonetheless has achieved some of Medicare’s highest quality-of-care scores. Michael Pramenko is a family physician and a local medical leader there. Unlike doctors at the Mayo Clinic, he told me, those in Grand Junction get piecework fees from insurers. But years ago the doctors agreed among themselves to a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. They also agreed, at the behest of the main health plan in town, an H.M.O., to meet regularly on small peer-review committees to go over their patient charts together. They focussed on rooting out problems like poor prevention practices, unnecessary back operations, and unusual hospital-complication rates. Problems went down. Quality went up. Then, in 2004, the doctors’ group and the local H.M.O. jointly created a regional information network—a community-wide electronic-record system that shared office notes, test results, and hospital data for patients across the area. Again, problems went down. Quality went up. And costs ended up lower than just about anywhere else in the United States.Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.When you look across the spectrum from Grand Junction to McAllen—and the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.This last point is vital. Activists and policymakers spend an inordinate amount of time arguing about whether the solution to high medical costs is to have government or private insurance companies write the checks. Here’s how this whole debate goes. Advocates of a public option say government financing would save the most money by having leaner administrative costs and forcing doctors and hospitals to take lower payments than they get from private insurance. Opponents say doctors would skimp, quit, or game the system, and make us wait in line for our care; they maintain that private insurers are better at policing doctors. No, the skeptics say: all insurance companies do is reject applicants who need health care and stall on paying their bills. Then we have the economists who say that the people who should pay the doctors are the ones who use them. Have consumers pay with their own dollars, make sure that they have some “skin in the game,” and then they’ll get the care they deserve. These arguments miss the main issue. When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores.“Medicine has become a pig trough here,” he muttered.Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said.We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen.“I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.How about doing the opposite and increasing the role of big insurance companies?“What good would that do?” Dyke asked.The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”Instead, McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.Source: http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum

Hello,Everything you need to know before studying in Australia - education system, visa requirement and process, Indians living in Australia, post-study options and more.1. About the countryAustralia is the largest country, geographically, and is a continent in itself. It lies in the southern hemisphere so the weather changes are opposite than those of India. Australia has five of the 30 best cities in the world for students to live in based on student mix, affordability, quality of life, and employment opportunities. The capital of Australia is Canberra.Education systemAustralia has the third highest number of international students in the world after United Kingdom and United States. It also has seven of the top 100 universities in the world. Australia's national quality assurance system is unique in its structure and rigour. The Australian Quality Training Framework has been set up by the government to strengthen the quality assurance processes in education.College Fit: At the higher education level, students have a wide range of options when they choose a college or university. Although there are agencies that attempt to rank colleges and universities, the concept of “fit” is also important. The GPA* of admitted students are important, but majors offered, location, number of students enrolled, and campus culture are all factors influencing a prospective student’s decision. Some colleges and universities are publicly funded, while others are privately supported.*GPA means grade point average. It is the average of all grades received.Popular student destinations: The top universities in Australia are The Australian National University, The University of New South Wales, The University of Melbourne,The University of Western Sydney, and Monash University (in no particular order). The area of New South Wales on the east coast of Australia is the centre of all its renowned academic institutes. Most of the best colleges in the country are situated in cities like Sydney, Canberra, Brisbane, Melbourne, and Perth. About 12,629 Indian students were studying in Australia during the academic year 2012-13. Accounting, Master of Business Administration (MBA), Health Care, Information Technology, and Hotel Management are the popular courses Indian students pursue in Australia.Safety in Australia: Australia is a multicultural society that welcomes people from other cultures, countries and backgrounds. While majority of Indian students studying in Australia have a positive experience of living and studying in Australia, there were a number of incidents of assault as well as of robbery during 2009 and 2010, which affected not only Indian students but also members of the larger Indian community in Australia. Presently, no such incidents have been reported and active efforts have been made by the Australian government to prevent such untoward incidents from happening in future.WeatherAustralia is diverse in its geography and climate. The country is located in the southern hemisphere. This means Australia's summer starts in December and winter begins in June. Nearly a third of Australia is in the tropics where the average temperatures are in the mid 20 degrees Celsius. The southern areas are in a temperate zone.Australian Capital Territory – This region covers Canberra. It has hot, dry summers, and cold winters with occasional fog and frequent frosts. The average temperature in summers would be around 30°C to 15°C; in winters it would be around 11°C to 0°C.New South Wales – This region covers Sydney and its weather is very relaxing all round the year. The average temperature in summers would be around 22°C to 40°C; in winters it would be around 17°C to 8°C.Northern Territory – This region has a tropical climate, and has two distinct seasons, the 'Wet' and the 'Dry'. The Wet season spans from November until April and is characterised by increased humidity followed by monsoonal rains and storms. The 'Dry’ season, from May until October, is characterised by warm, dry sunny days and cool nights. This region covers Darwin. The average temperature in wet season would be around 33°C to 25°C; in dry season it would be around 35°C to 21°C.Queensland - Warm summers and mild winters are what you can expect here. This region covers Brisbane. The average temperature in summers would be around 20°C to 30°C; in winters it would be around 20°C to 10°C.South Australia – This region experiences mild weather with sunshine all the year round and covers Adelaide. The average temperature in summers would be around 17°C to 30°C; in winters it would be around 15°C to 6°C.Tasmania - Snow falls in the mountains in winter. However, most people in Tasmania live in towns and cities near the coast. The ocean moderates the temperatures there. It covers cities like Hobart and Devonport. The average temperature in summers would be around 25°C to 10°C; in winters it would be around 11°C to 4°C.Victoria – This region covers Melbourne. It enjoys warm summers, pleasant springs, mild autumns and crisp winters. The average temperature in summers would be around 26°C to 15°C; in winters it would be around 13°C to 6°C.Western Australia - This region covers Perth and is famous for its long days of sunshine, spotless blue skies and brilliant beaches. The average temperature in summers would be around 31°C to 18°C; in winters it would be around 17°C to 7°C.Lifestyle tipsAustralians are know to be friendly and helpful people, with a great sense of humour. Australia is considered one of the most competitive nations on Earth. This covers all areas of life including the workplace. While English is Australia’s national language, there are certain words and expressions that have come to be regarded as uniquely Australian through common usage. Some of them might seem strange to non-Australians.Australians love their sport, both playing it and watching it. The most loved sports in Australia include Australian football, rugby, and cricket. This relatively benign climate has resulted in a country where people spend a good deal of time outdoors at beaches, in the countryside or on sporting fields as either spectators or participants.Indians living in AustraliaThere were nearly 308,542 Indian immigrants living in Australia in 2011. They represent the second-largest immigrant group by country of origin, after China. Almost one-third of all Indian immigrants resided in Victoria.Download this guide to read it offlineGet it Now!2407 People downloaded this guide2. Student lifeAccommodationFirstly, you need to decide whether you want to live in university managed accommodation, or with a private landlord. Choosing university managed accommodation can also give you a catered or self-catered option. Catered accommodation offers the benefits of your meals being cooked for you and a degree of certainty with meal costs.If you have an idea about what you prefer, the accommodation office at your university will be able to tell you what accommodation they have available - so that’s the place to start. If you are thinking of renting from a private landlord or if your chosen university can’t offer you anything in its own residential facility, the accommodation office should be able to provide you with a list of private properties and landlords in the area.Wherever you choose to live, you should make sure that you know your contractual rights and responsibilities. In most cases you will be asked to enter into a tenancy agreement, which you should read thoroughly before you sign.OrientationOrientation week is mandatory for international students so ensure that you arrive before it starts. This is the time where you will be introduced to the university and its services, as well as enroll in your classes. It is essential that you read your guidebook, which is provided by the college. The guide explains each part of the admission process.ActivitiesAlong with sport, colleges offer extra-curricular activities that provide students a wide range of experiences. Music, drama, science and literary societies in colleges offer opportunities for outdoor education and other leisure activities. Visits to theatres, concerts, and places relevant to the courses of study such as art galleries and museums, religious centres or historical sites, scientific companies and projects are all part of college life.3. Admission processRequirementsThese vary between study programs and levels. For each course, Indian students will need to meet a minimum English language requirement. Along with that a minimum academic record of 65% and above in class XII will be required. Foundations and Diploma programs are available for students who have secured below 60%. The student should have completed 18 years of age before joining a degree program.It is important to note that these numbers are just for reference purpose, the actual numbers may differ from university to university.The following documents also need to be submitted:Attested copies of mark sheets of class X, XII, and the Bachelors degree (if applicable)At least, two academic reference letters from professors who have taught you most recentlyIf you have work experience then two letters of recommendation from the employer/manager who knows you well and can comment on your professional abilitiesStatement of Purpose (SOP)ResumePhotocopied score reports of GMAT / IELTS / TOEFLPortfolio (in case of Students applying for art and design courses & architecture programs)Others (certificates / achievements at the state and national level and extracurricular activities)Proof of fundsTimelineMost of the colleges in Australia accept online applications. You will have to visit each college's website to apply. In most cases, you will have to make an account on the college website to provide your basic information, submit the scanned version of your documents, and pay application fees. You will be informed about the application process and its stages through this account. Please refer to the website of the colleges of your choice to know the process of applying.Application fee: All colleges require that you pay an application fee while applying. The fee amount will differ depending upon the college and course being applied to, so check with individual colleges about their application fee.Steps: The common steps to applying for admission are as follows:Search for colleges and coursesContact schools and visit websites for informationNarrow down your list of schoolsTake the entrance exams like SAT, GMAT, GRE, TOEFL, IELTSWrite SOPs and ask for LORsApply to the colleges which fit your interestsAppear for video interviews to the colleges who shortlisted youIf accepted, apply for student visaSOP: A Statement of Purpose (SOP) is your introduction to the college and admission officers. It is always written in first person and describes the reason for applying to a particular college. It needs to highlight why you are a perfect fit for the college and why the college should accept you. The style of writing could differ from formal to casual, but it is important to remember that it should reflect your personality as well.Essay: Essays are also required to be submitted by a prospective student. Essays are an important part of the university admissions process. Students may be required to write one or two essays, along with a few optional essays too. Common topics include career aspirations, strengths and weaknesses, skills, experiences, and reasons for considering a particular school.LOR: A letter of recommendation (LOR) is a reference letter written by a third party describing the qualities, characteristics, and capabilities of the prospective student to recommend him to the college in terms of that individual’s ability to perform a particular task or function. The third party could be a professor, direct manager etc.Intake seasonsAustralia generally has two intakes i.e. February and July, with few universities offering multiple intakes in September & November. You should start your admission process around six months before the application deadline. Typically most universities have three deadlines, during one intake. It is up to the convenience of the students, which deadline to aim for. You should be done with your language and aptitude tests by three months before the deadline. The last three months should be dedicated to filling out the application form properly.It is essential to ensure that the ‘complete application process’ along with appearing for interviews and visa application procedure should be complete by Nov-Dec for the February intake.If you are looking to get admission into vocational courses, then some courses may have admissions open in January and perhaps even May or July.4. ExamsLanguage examsInternational English Language Testing System (IELTS), Test Of English as a Foreign Language (TOEFL) and Pearson Test of English (PTE) are all standardised language tests, which are required to be taken for the purpose of getting admission into colleges. These follow different formats, structure and result bands. These tests are different in various ways but many colleges ask for any one of the results. So it's up to the student to decide which exam to appear for.Repetition of exams: IELTS can be taken unlimited number of times. TOEFL can be retaken as many times as wished, but cannot be taken more than once in a 12-day period. Same with PTE, it can be taken as many times as desired. You must wait to receive your scores before you can book your next test.Fee: The fee for these exams is Rs 9,300 for IELTS, Rs 10,000 for TOEFL and Rs 9,350 for PTE.Time to apply: Ideally, if you are aiming at the September intake you should appear for these exams by November, so that you can apply before the first deadline. The universities you will be applying to will mention which exam results they will accept. But if they give a choice to go for either of these, then the choice depends on you. The time required to prepare for IELTS/TOEFL/PTE would depend on the existing English language proficiency. You may require 2 to 4 months of preparation before the exam date.General examsGMAT - The Graduate Management Aptitude Test is used to measure the abilities of the potential MBA aspirant to undertake higher education in the field of business or management. It measures mathematical, english, and reasoning skills of the student.GRE - The Graduate Record Examination is another test required to be taken by students applying to graduate schools to pursue MA or MS. Increasingly many business schools are also accepting GRE scores for the purpose to granting admission for MBA.Repetition and Fee: You can give GMAT unlimited number of times, subject to five times a year and a gap of 30 days between two tests. You can take these tests with a gap of 30 days from the first time. The cost of GMAT is Rs 16,000, and GRE is Rs 12,000.Ideally, if you are aiming at the September intake you should appear for these exams by November, so that you can apply before the first deadline. The preparatory duration generally ranges from 4 to 6 months.Average Scores: The average GMAT accepted across universities is 520. Average GRE score is 145 for Verbal, 160 for Quantitative and 4.0 for Writing.It is important to note that these numbers are just for reference purpose, the actual scores may differ from university to university.5. Cost of livingThe cost of living depends heavily on what part of Australia will you be living in along with how much you will socialie. Some of the basic elements for living as an international student in Australia are:Accommodation rent ( on campus or off campus )Groceries and foodUtilities like electricity, water, gas, internetPhone billsText and reference booksAirfare for traveling back to IndiaOther elements which may differ from person to person would be:Dining outTravel and VacationCar rent and Car insuranceCable TV connectionSchool expensesThe tuition fee varies according to different universities, courses and the city. The tuition expenses in Australia might be up to $15,000 to $33,000 per year for an undergraduate course. And if you are thinking of applying to a postgraduate course, the cost would be $20,000 to $37,000 per year approximately.Living expensesThe Department of Immigration and Border Protection has financial requirements you must meet in order to receive a student visa. You must have $18,610 to study in Australia.Health insuranceOverseas Student Health Cover (OSHC) is compulsory and you will not be able to apply for your student visa until you have purchased a policy recommended by your host university. It includes cover for visits to the doctor, some hospital treatment, ambulance cover and limited pharmaceuticals (medicines). The Department of Immigration and Citizenship requires overseas students to maintain OSHC for the duration of time they are in Australia.ScholarshipsFee waivers are awarded to international students on the criteria of merit and need of it. Candidate with strong academics, good performance in standardised exams and extracurricular achievements would be eligible for scholarship awards and financial assistance. To benefit from these opportunities, one has to make sure to send all the required documents by particular deadlines. In addition to this, the presentation of the application is also important because one is judged by the image one projects.Documents required: The documents usually needed for a scholarship application are as follow, although the requirements may differ:Academic records and photocopiesA recent CVA letter of intent, which acts as a cover pageCertificate of Language Proficiency (TOEFL or IELTS scores)Letters of ReferenceLoansStudent Eligibility criteria: The first thing is to be aware whether you are eligible to apply for the loan or not. The general eligibility criteria that are followed by all the banks are –You should be an Indian nationalYou must have a strong academic recordYou must be seeking admission to a professional, technical or other course of studies. Most banks maintain that the selected course should be job oriented.You must have secured admission to foreign university institutions.You must be above the age of 18 years or else your parents can avail the loan.Eligibility for course: You may not get a loan on every course. Here are the kinds of courses that qualify for the education loan.For Graduation: Job oriented professional or technical courses offered by reputed universitiesFor Post Graduation: MCA, MBA, MS and also diplomasThese courses could be from foreign universities or institutes approved by the state and central government.Loan amount: If your total fee is Rs 10 lakh, the bank may offer to give a loan of 80% of the amount and you will have to put in the balance 20%. This is called the margin amount. The maximum loan amount offered by banks for studies abroad is generally around Rs 20 lakh.If your tuition fees amount is Rs 30 lakh, you’ll have to manage the rest of the funds by yourself. Some banks charge a processing fee, while others don’t. it may be a fixed amount or a percentage of the total loan amount. So if the bank charges you 1% as processing fee, that will be an additional cost you’ll have to cover.Documentation required: You will have to provide the acceptance letter sent by the University reflecting that you have been selected for the course and the schedule of fees. You will also need to show the mark sheet of the last qualifying examination to show your academic record.All banks have different requirement for documentation, so you need to confirm with the bank first.Repayment: Repayment starts only after the course period. If the student got employed within one year after completion of the course, the repayment should start immediately after the expiry of one month from the date of employment.If you do not secure a job within a year of completing the course, then repayment starts irrespective of whether or not you are employed. The loan is generally to be repaid in 5-7 years after commencement of repayment. If the student is not able to complete the course within the scheduled time, extension of time for completion of course may be permitted for a maximum period of two years. Generally, you will get up to a maximum number of 10 years to repay the loan.6. VisaConditionsIf you want to attend a University or college in Australia you will need a student visa. Following documents will be required for the application purposes –Valid Passport - Your passport must be valid for at least six months beyond your period of stay in the Australia.Nonimmigrant Visa ApplicationApplication fee payment receipt, as you are required to pay before your interviewConfirmation of Enrolment Form (COE) To obtain a visa to study in Australia you must be fully enrolled in an Australian institution and receive a “Confirmation of Enrollment (COE)”. These forms are issued by the Australian institution you will be attending. The forms are usually issued after the tuition fees have been received.Acceptance letter from your host university, this will include the proposed study planLetter from your current institution confirming status as a Study Abroad StudentOverseas health insurance receipt2 or 4 passport sized photographsNote: Additional Documentation May Be Required. During the personal interview additional documents may be requested by the interviewer. These may be documents to prove evidence of academic or financial status -Transcripts, diplomas, degrees, or certificates from schools you attendedScores from tests that your college required, such as the TOEFL, SAT, GRE, or GMATYour intent to depart Australia upon completion of the course of studyHow you will pay all educational, living and travel costsProcessThe average time taken by the Australian High Commission for the visa procedure is anywhere between 8 to 12 weeks depending on the individual’s background, so the students need to apply for their visas at least three months prior to their course commencement.As an international student, you must complete your course within the minimum course duration listed on your CoE. You must leave Australia after completion of your studies. If you wish to stay in Australia for your graduation ceremony, you may need to apply for a visitor class visa.Work permitStudent visa holders are allowed to work up to 40 hours per fortnight during their study in Australia. The spouses of Masters and PhD students can work unlimited hours. If you are doing voluntary, unpaid work, it is not included in the limit of 40 hours per fortnight.Visa for spouseThe partner of the student gets a Dependent Visa and a valid work permit for the same duration as the primary applicant. This is applicable only for Master's degree application.Please note that the Student Visas for Australia have changes effective July 1, 2016. Please read about the New Student Visa Guide for Australia to understand the various rules.7. Checklist before departureYour checklist before you leave for AustraliaBook airline ticketsArrange accommodation in AustraliaArrange transportation to/from the airport to home in AustraliaArrange your banking – consider buying traveler’s chequesCheck baggage and customs limitationsClear all paperwork with your home educational institutionGet your documents in order and make photocopies to store in your baggage and keep at home, including:PassportAirline ticketsTravel insurance certificateLetter of Acceptance by the educational institutionKey addresses and phone numbersA bank statement showing proof of fundsPrescriptions for any medication you are carryingTraveler’s cheques—if applicableMedical and immunization recordsAcademic history and university transcripts8. Once you landHomesicknessHomesickness is a predictable problem faced by most students at one point or another. It may occur at the beginning or even well into your year. Homesickness will pass. Be patient. Give it at least two weeks. If you are feeling sad, explain what is happening to your friends. Do not hide in your room; if you do, the homesickness will only worsen. Find your counselor on staff with whom you can talk about homesickness or other problems.Homesickness might be made worse by frequent, long telephone calls home. Most homesick students feel more homesick after a call home than they did before they picked up the phone. Try to limit yourself to one call home every week. The sooner you integrate into the university experience, the sooner your homesickness will pass.Shopping in AustraliaLarge shopping malls and supermarkets like Wal-Mart, Target in the Australia are one-stop shops for all of your daily needs. Be vigilant to ensure that all of your shopping is properly billed and that you keep the bills with you at all times.Learning basic cookingCooking for yourself will save you money. Indian food is expensive in Australia. It will also satisfy your urge to eat ‘your food’ during moments of cultural shock. Indian spices are not commonly available in smaller cities, but there are often shops on campus where you can get ingredients used in most Indian food.TravelEach large city has and provides different methods of public transportation, such as buses, taxis or trains. You might wish to rely on a private car for transportation. Even with the rising cost of petrol, private cars are the most economical and convenient mode of transportation because you get a lot of flexibility and freedom with your car. You can travel wherever and whenever you want, and don't have to depend on the schedule of public transport. However, before you buy your own car, you will have to use public transportation or ask friends for rides.Stay on Student VisaWhen you enter Australia, you may remain there as long as you are enrolled in the school to complete your academic program. After the program ends you may apply for the temporary graduate visa through either the new post-study work stream or the graduate work stream provided you meet the specific eligibility requirements. The duration of the subclass 485 visa you are granted will depend on the qualification that you have used to qualify for the arrangements.9. Post studies optionsPlacementsIndian students are used to the concept of campus placements and on-campus recruitment for getting jobs. There is no concept of placements in Australia, like most other countries. Most Australian Universities have a cell called a Career Services Center, which helps you get jobs and help you prepare for interviews. The on-campus recruitment is always driven by student interest. Companies that recruit through the university do not offer a job directly. What they offer is an internship or co-op. Companies like to see your work for few months before they hire you full time.Work visaGraduates who have completed a Bachelor’s degree, Master’s degree may be eligible to apply for a two year post-study work visa. Graduates who have completed a Master’s by research degree or a Doctorate may be eligible to apply for a three or four year post-study work visa respectively. Other graduates may be eligible to apply for an 18 month subclass 485 visa through the graduate work stream.

I grew up on a small homestead type farm. We grew a 1/2 acre garden, a small orchard with cherries, peaches and apples, A milk goat named Salley, 200+ chickens, and a whole bunch of rabbits, 3 beef cows, strawberry patch etc… You get the idea. All us kids were active in Scouts and 4H. Pretty typical rural US childhood. And this little homestead was right square in the middle of a huge commercial farmer’s corn field. Across the road was another slightly smaller commercial farmer, who also grew corn etc… But just enough to feed his pastured pig and beef cow operation. As soon as I could work I was working on those neighbors’ farms.So I literally grew up seeing first hand and understanding all scales of farming here in US, from the tiny small family farm to the large commercial operations and everything in between. I even took a job at the seed company next town over for summer work and learned corporate farming and seed research, building and documenting test plots with controls, running and training an agricultural labor crew etc… too. I have even collected those nasty eggs from battery caged hens.But then Dad lost our home to the evil lying bank even though he was not even behind a payment. (That’s a whole other subject that we won’t get into now, but believe me, if the bank wants your property, they will get it. Never trust a bank on their word only.)The home we built to last forever with our bare hands gone, I went first to engineering school, dropped out sophomore year, and then traveled the country and later the world. But every place I went, I always grew at least a small potted herb garden, and sometimes very big gardens. I ended up as a marine engineer, so that wasn’t always easy, but it was always in my blood. It was my connection to “home” and a stolen family dream.Later and semi retired from the oceans, I found my way to Oklahoma. Naturally I just had to have a great big garden here.Turns out Oklahoma gardening is hard! My mind always drifts to the movie when Forest says, “shrimping is hard!” It was like that!It could frost any time as late as it did in Indiana even though much further south, and it also could literally be 100 degrees Fahrenheit just 1 week after last frost! (as happened a few years ago) Did I remember to say Oklahoma gardening was hard?We were in a record breaking drought, and I knew nothing about Oklahoma gardening or farming even from the best of years. But I am not one to cry about it. I just grabbed a shovel and got to work…..Oops this ground is hard! Here is me, a rather large man, jumping up and down on a shovel with full force like a pogo stick and the shovel is not going into the sod it is literally bouncing like a pogo stick back up!!!! Is the grass growing around a rock? Is it sprouted over a cement slab? What gives? Up and down I jumped until I literally tore up the soles of my shoes and had to throw them away and after several days back breaking work I have a tiny dug garden about 10 feet x 10 feet. (Did I remember to say Oklahoma gardening is hard?) Turns out it is just Oklahoma red sandy clay that on good rainy years is pretty fertile, but that year had been through a multi year drought that baked it almost as hard as kiln dried bricks!So I threw away my shoes. They were ruined anyway. And I got out a rake and raked up all the grass clippings from my yard and the neighbors yard. Then I got some old newspapers and unfolded them 6 layers thick right over the sod cut short, and covered the newspapers with grass clippings.Now this is pretty standard on a garden that has already been a garden and plowed or tilled before. But I had always turned under the soil in the past and then mulched. This was new. I would mulch right over the virgin sod because I simply couldn’t defeat that hard as a rock clay!I really didn’t know if my experiment would work, but I figured I had nothing to lose and worst case scenario is that the soil would at least loosen up enough to let me build a bigger garden the next year.Oh but boy did it work. Amazingly in less than 1 week the soil was so loose I could dig seedlings in with a hand trowel. And wow did those seedlings grow! Twice as big and twice as fast as the dug ground right beside it!So for a couple years I expanded that garden just by mulching over the new area I wanted to grow in. Each year it worked perfectly. And, this is what surprised me…..the worst part of the garden even years later was the part I dug up!Now that really got me thinking. Why am I digging up my garden? Because Dad taught me that? Why did Dad dig up his garden? Because Grandpa taught him that? But why is anyone really digging up their garden? Because of this?Image courtesy wikimedia commonsIs it really so simple as each generation’s ancestors following the previous ones all the way back to the origins of agriculture? So why did these ancient Egyptians plow? Turns out they plowed to speed up the drying of the land after the spring floods in preparation for planting seed.D’oh! I had my epiphany right then and there! We were blindly following each generations example, even when the last thing we needed to be doing was drying out the land for planting!So about 5 years ago I decided to turn my hobby into my second career and I started the Red Baron Project, to turn my little gardening experiment into something scale-able for farmers of any size to use.For my project I am using various principles:Principle 1: No till and/or minimal till with mulches used for weed controlPrinciple 2: Minimal external inputsPrinciple 3: Living mulches to maintain biodiversityPrinciple 4: Companion plantingPrinciple 5: The ability to integrate carefully controlled modern animal husbandry (optional)Principle 6: Capability to be mechanized for large scale or low labor for smaller scalePrinciple 7: As organic as possible, while maintaining flexibility to allow non-organic growers to use the methodsPrinciple 8: Portable and flexible enough to be used on a wide variety of crops in many areas of the worldPrinciple 9: Sustainable ie. beneficial to the ecology and wildlifePrinciple 10: Profitable ie. Must yield higher net profits than industrial high input Ag with all its synthetic fertilizers and pesticides to compete successfully.Then I made this my goal in life! I took online soil science courses, an online climate science course, an online holistic management course. I wrote the Wikipedia page on holistic management just so I wouldn’t lose all my research! I found read studied and compiled countless research papers. The little experiment that is turning into an all consuming monster!Imagine a field like this instead of a plowed field:Oh did I mention Oklahoma Gardening is hard?Believe it or not even after this massive Oklahoma storm and flood with hail setting records going back to recorded history for the area. These plants recover and lived just fine. That would have been a muddy mess in a plowed field.It’s been 5 years now and I can say confidently it works fantastic at the gardening size scale. Many is the year I am the only one in the whole area with a decent crop. (Did I mention Oklahoma gardening is hard?) I have lots of help though, see if you can spot this helpful insect eating tree frog in my tomato patch:When you don’t plow up and poison the land, all sorts of interesting beneficial things start happening. Did you know that Oklahoma has this certain native species of earthworms not found up north? They began coming back in larger numbers to “till” in the mulch.The Earthworms (Oligochaeta: Acanthodrilidae, Lumbricidae, Megascolecidae, and Sparganophilidae) of Oklahoma, USA.So the ecosystem that evolved to survive these harsh Oklahoma conditions begin to help you! It’s a good thing too. I needed all the help I could get. Here is the same rows as above only 4 weeks after the storm.And how do we scale this up? Turns out we can re-purpose equipment already in common use made by many manufacturers. Here is one to give you an idea. I unroll the 1000 pound bales by hand now.Did I mention gardening in Oklahoma is hard? Here is the mechanized way a farmer full scale might do it.I also need to be able to do seeded crops as well as transplants to fit principle 8. For that I will need something like this, a no til planter capable of planting right into sod but narrow enough to just plant the mulched strips. It could grow sweet corn and beans this way. I do it now by hand using this:New Garden Seeder Improves Planting Experience - Organic Gardening - MOTHER EARTH NEWS**I just learned this brilliant tool is no longer in production.Turns out that no til drills are already designed like this for wildlife forage planting.Features of the Dew Drop DrillBut of course I can’t really prove that this will scale up until I actually test the equipment re-purposed and partly modified for my purposes…and prove it is actually profitable and really does rebuild carbon in the soils large scale too. And all at a profit. That’s the next step and I need funding to purchase the equipment and get the before and after soils testing etc… The land has been generously offered for lease basically free as long as I improve it rather than degrade it.So if you want to see if my crazy gardening experiment can really work at full scale for farmers, I have a gofundme for the proof of concept trial.Click here to support Sustainable Ag Research organized by Scott StroughAll it takes is enough people donating $10 dollars to change the world …. maybe. We won’t know for sure til we try. But if it works, it actually could revolutionize the way we do certain kinds of agriculture. No-Til agriculture without herbicides or much of any inputs at all since at scale the grass from the field can make the hay that mulches the field! I tested that one year too, but instead of hay equipment I just used my hand mower.In my opinion it is the only significant gap remaining in a comprehensive holistic strategy to both save agriculture from collapse due to soil degradation[1], and mitigate Anthropogenic Global Warming[2], and repopulate our rural areas with a new generation of profitable young farmers[3], and restore ecosystem function over vast acreage of the planet[4], and feed a growing population with vastly healthier food[5][6][7][8][9][10], and strengthen our economy due to reducing agricultural subsidies[11], etc… all at the same time!More information on the rest of the strategy can be found here:Scott Strough's answer to How can we combat climate change?Footnotes[1] Only 60 Years of Farming Left If Soil Degradation Continues[2] Soil as Carbon Storehouse: New Weapon in Climate Fight?[3] Youth in Agriculture: The Coming Demographic Challenges[4] Ecosystem services and agriculture: tradeoffs and synergies[5] Can Organic Farming Feed Us All?[6] A review of fatty acid profiles and antioxidant content in grass-fed and grain-fed beef[7] Meet Real Free-Range Eggs - Real Food - MOTHER EARTH NEWS[8] http://go.galegroup.com/ps/anonymous?authCount=1&id=GALE%7CA225739685&isAnonymousEntry=true&issn=10895159&it=r&linkaccess=fulltext&p=AONE&sid=googleScholar&sw=w&v=2.1[9] Monsanto’s Roundup Triggers Over 40 Plant Diseases and Endangers Human and Animal Health - The Permaculture Research Institute[10] Higher antioxidant and lower cadmium concentrations and lower incidence of pesticide residues in organically grown crops: a systematic literature r... - PubMed - NCBI[11] A reflection on the lasting legacy of 1970s USDA Secretary Earl Butz