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In Medical Park Hospital in Winston-Salem, N.C., Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer gently jokes with her. When Koons says she's itchy under her cast, Cammer warns, "Do not stick anything down there to scratch it!" Koons smiles and says, "I know."

Koons tells me Cammer's kind attention and enthusiasm for nursing has helped make the hospital stay more comfortable.

"They've been really nice, very efficient, gave me plenty of blankets because it's really cold in this place," Koons says. Koons and her stepfather, Raymond Zwack agree they'd give Medical Park a perfect 10 on the satisfaction scale.

My poll of the family is informal, but Medicare's been taking actual surveys of patient satisfaction, and hospitals are paying strict attention. The Affordable Care Act ties a portion of the payments Medicare makes to hospitals to how patients rate the facilities.

Medical Park, for example, recently received a $22,000 bonus from Medicare in part because of its sterling results on patient satisfaction surveys.

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Medical Park Hospital's patients tend to be pretty happy customers, leading to thousands of dollars in rewards from Medicare. Novant Health hide caption

itoggle caption Novant Health

Medical Park Hospital's patients tend to be pretty happy customers, leading to thousands of dollars in rewards from Medicare.

Novant Health

Novant Health is Medical Park's parent company, and none of its dozen or so other hospitals even come close to rating that high on patient satisfaction. Figuring out why Medical Park does so well is complicated.

First, says Scott Berger, a staff surgeon, this isn't your typical hospital.

"It kind of feels, almost like a mom-and-pop shop," he says.

Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and most of their patients have insurance.

Another key is that no one at Medical Park was rushed to the hospital in an ambulance, or waited a long time in the emergency room. In fact, the hospital doesn't even have an emergency room.

The hospital doesn't tend to do emergency surgeries, says Chief Operating Officer Chad Setliff. These procedures are all elective, scheduled in advance. "So they're choosing to come here," he says. "They're choosing their physician."

These are the built-in advantages that small, specialty hospitals have in terms of patient satisfaction, says Chas Roades, chief research officer with Advisory Board Company, a global health care consulting firm.

"A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals]," Roades says.

Shots - Health News

Medicare Starts To Reward Quality, Not Quantity, Of Care

This is the third year hospitals can get bonuses or pay cuts from Medicare (partly determined by those scores) that can add up to hundreds of thousands of dollars.

More typical hospitals that handle many more patients – often massive, noisy, hectic places – are more likely to get penalized, Roades says.

"In particular, the big teaching hospitals, urban trauma centers — those kind of facilities don't tend to do as well in patient satisfaction," he says. Not only are they busy and crowded, but they have many more caregivers interacting with each patient.

Still, Roades says, although patient surveys aren't perfect, they are fair.

"In any other part of the economy," he points out, "if you and I were getting bad service somewhere – if we weren't happy with our auto mechanic or we weren't happy with where we went to get our haircut – we'd go somewhere else." In health care, though, patients rarely have that choice. So Roades thinks the evaluation of any hospital's quality should include a measurement of what patients think.

Shots - Health News

Hospitals' Medicare Quality Bonuses Get Wiped Out By Penalties

Medical Park executives say there are ways big hospitals can seem smaller — and raise their scores. Sometimes it starts with communication – long before the patient shows up for treatment.

On my recent visit, Gennie Tedde, a nurse at Medical Park, is giving Jeremy Silkstone an idea of what to expect after his scheduled surgery – which is still a week or two away. The hospital sees these conversations as a chance to connect with patients, allay fears, and prepare them for what can be a painful process.

"It's very important that you have realistic expectations about pain after surgery," Tedde explains to Silkstone. "It's realistic to expect some versus none."

Medical Park now handles this part of surgery prep for some of the bigger hospitals in its network. Silkstone, for example, will have surgery at the huge hospital right across the street — Forsyth Medical Center.

Carol Smith, the director of Medical Park's nursing staff, says that after she and her colleagues took over these pre-surgical briefings, "Forsyth's outpatient surgical scores increased by 10 percent."

But some doctors and patients who have been to both hospitals agree that the smaller one is destined to have higher scores. It is just warmer and fuzzier, one patient says.

This story is part of NPR's reporting partnership WFAE and Kaiser Health News.

health care quality

Affordable Care Act

North Carolina

Hospitals

New Zealand-born photographer Amos Chapple was a long, long way from home. Out in the middle of Russia's vast Sakha Republic, an area that spans over 1 million square miles, he was heading towards the world's coldest city.

And he was alone.

In these far reaches of northeast Russia, Chapple says, "If people don't need to be outside, they won't be outside. So in the smaller towns, they all look abandoned. And if you see somebody, they're racing between doors with mitts clasped over faces hurrying to get inside again."

Out in the freezing cold, he finally crossed paths with the only other creature audacious enough to face this kind of weather.

"I saw some cows out in the streets," he says. "So I figured, OK, they're on their way somewhere, they're going to take me back to a person, who hopefully I can speak to, who will be doing something outdoors. So I decided to follow these cows."

They led him off the road through a forest.

"Finally, I come to this sort of secondary settlement — a couple of houses and there's this stable. And then sure enough this old man kind of stumbles outside into the cold," Chapple says. "He looks around, he does a double take when he sees me, like, 'Where did you come from?' There was this beautiful moment when I was able to say, 'Oh, I'm from New Zealand! Hello!' "

In that remote region six time zones from Moscow, Chapple was making his way into Yakutsk, Russia.

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A woman sells an arctic hare along with her usual fare of frozen fish in the central market of Yakutsk. Amos Chapple hide caption

itoggle caption Amos Chapple

A woman sells an arctic hare along with her usual fare of frozen fish in the central market of Yakutsk.

Amos Chapple

Life In The Heart Of Siberia

Maybe you've heard of Yakutsk from the board game Risk, which you might have played in the comfort of your warm home. Out here, the average winter temperature dips down to -30 degrees Fahrenheit.

"The first impression I had was being physically gripped by [the cold]," Chapple says. "It was literally like something had wrapped around my legs."

Chapple says he's never experienced a cold like that. He describes the streets of Yakutsk, a city of about 270,000, as dark and foggy.

"The mist from people's breath, from car exhaust and from factory emissions, it never goes away, it never dissipates," he says. "It just hangs there. So very, very misty, all through the day and night."

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While the majority of the city's population are indigenous Yakutian, many ethnic Russians and Ukrainians moved to Yakutsk in Soviet times, lured by high wages for working in the harsh climate. Amos Chapple hide caption

itoggle caption Amos Chapple

While the majority of the city's population are indigenous Yakutian, many ethnic Russians and Ukrainians moved to Yakutsk in Soviet times, lured by high wages for working in the harsh climate.

Amos Chapple

He says Yakutsk was one of his most difficult assignments. Being outside for hours on end took a toll on his body and his camera would seize up in the cold.

"It took me a while to figure out why I was getting all of these kind of hazy, very un-contrasty images. And that was because when I would breathe, when I would exhale, the mist from my breath would just kind of waft around in front of the lens and ruin the shot," Chapple says. "So you would have to hold your breath before you took a picture."

Indoor Entertainment, Outdoor Adventure

Yakutsk is the largest city in the world built on permafrost. Most buildings are constructed on stilts that go deep underground. And while the weather may be hostile, this giant region in Russia is rich with natural resources — especially gold and diamonds.

The people braving the cold here have lived in this region for generations, like freelance journalist, Bolot Bochkarev. He was born and raised in Yakutsk.

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A woman enters Preobrazhensky Cathedral in Yakutsk. "You get this blast of freezing mist coming through the door," photographer Amos Chapple says. "It was just spectacular." Amos Chapple hide caption

itoggle caption Amos Chapple

A woman enters Preobrazhensky Cathedral in Yakutsk. "You get this blast of freezing mist coming through the door," photographer Amos Chapple says. "It was just spectacular."

Amos Chapple

"We've got many facilities like stadium, restaurants, many nightclubs, concert halls," Bochkarev says. "We've got enough entertainment. But everything is done indoors because it's cold outside."

Bochkarev says he plays tour guide to visitors who travel across the world.

"When tourists, international visitors come to Yakutsk, we go on the ice to catch fish," he says. "Also snowmobiling, dog sledding. You know, frozen 'eye brushes,' frozen noses. People like it."

Bochkarev says in the world's coldest city, there's always adventure.

cold

Russia

Last year, frozen fruit sales in this country surpassed a billion dollars, shattering all previous records. Sales have more than doubled since 2011.

So what's behind this explosion of frozen fruit?

Sarah Nassauer, who reports on the food business for the Wall Street Journal, points to a pair of studies from the world's biggest seller of fresh fruit.

"Dole [Packaged Foods] got into this business, started selling frozen fruit in 2005," she says. "So in 2006, they did a big sort of frozen fruit usage study, and then they did another one last year in 2014."

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One of Dole Packaged Food's frozen fruit options. Over the years, frozen fruit companies have adjusted packaging to make it flashier and more colorful, and also put their products in stand-up bags, says Wall Street Journal reporter, Sarah Nassauer. Dole.com hide caption

itoggle caption Dole.com

One of Dole Packaged Food's frozen fruit options. Over the years, frozen fruit companies have adjusted packaging to make it flashier and more colorful, and also put their products in stand-up bags, says Wall Street Journal reporter, Sarah Nassauer.

Dole.com

In the studies, Dole asked things like: What kind of frozen fruit do you buy? How much? And, most importantly, what do you use it for?

Back in 2006, Nassauer says, "People saw it more as a dessert topping. It was near whipped toppings in the frozen food aisle. And it was in these sort of hard-to-find lie-flat bags that were what frozen fruit was in for decades."

But Dole thought, here's this inherently healthy food — there has to be a bigger market out there.

"So they very intentionally said, 'Let's put it in these stand-up bags, put shiny graphics on it, suggest healthy recipes like smoothies on the back of the bag,' " Nassauer says. "And that was definitely their approach."

"At the same time," she adds, "I do think they probably got pretty lucky in terms of the health trends that has happened those years as well."

One health trend in particular is leading the charge: Smoothies. Busy, health-conscious Americans are sucking them down like mad.

"In 2014, they estimate that 60 percent of frozen fruit purchased went into smoothies," Nassauer says. "And that number was 21 percent in 2006."

NPR host Arun Rath went to Whole Foods, where you don't have to take the trouble of sliding glass. Unlike bags of veggies, frozen fruit containers are ready-to-grab in an open, reach-in freezer.

Tart cherries, sweet cherries, organic blueberries, cranberries, wild blueberries, mango chunks: the selections was extensive.

The Salt

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The Salt

Blending Vs. Juicing? How To Get The Most Nutrition From Your Fruit

He also noticed the fruits were more nicely presented than they used to be, some in stand-up bags: "Some of these bags, the organic ones, look nice and wholesome ... beautiful pictures all over them."

When he was a kid, he remembers, they were packaged in plainer, white bags.

Nassauer says that with the smoothie craze spreading, it's no surprise that blender sales also hit the billion-dollar mark for the first time last year.

And to make things even easier, Dole and other companies are now selling combo bags, ready to blend.

You can even get kale in the mix, if you're so inclined. Or you could stick to the classic frozen berries — even if they come in new-fangled packaging.

smoothies

fruit

Parallels

Libya Today: 2 Governments, Many Militias, Infinite Chaos

The headquarters of the National Oil Corporation in Tripoli are gleaming, the floors marble, the offices decked out with black leather chairs and fake flowers. It seems far from the fighting going on over oil terminals around the country.

But the man in charge looks at production and knows the future is bleak.

"We cannot produce. We are losing 80 percent of our production," says Mustapha Sanallah, the chairman of Libya's National Oil Corporation.

He looks like a typical executive, decked out in a suit and glasses. But beneath his calm veneer, he's worried.

"Now we have two problems: low production and low price," he says.

At the current rate, he expects that the country won't even earn 10 percent of the budget money Libya had in 2012, before militias started taking oil infrastructure hostage.

"If there is security in Libya, we can resume production within a few days," Sanallah says.

If there's one thing that has a chance of keeping Libya from totally falling apart, it's oil. It provides nearly all the country's revenue. It's what militias are fighting over. And it's the prize coveted by the two rival governments — one in Tripoli, the other in Libya's east — that claim to be running the country.

The Tripoli faction is seen as Islamist, the eastern government as anti-Islamist — but the fighting is mainly over turf and resources like oil, rather than ideology.

The international community has recognized the eastern government, but it opposes what it sees as the east's divisive attempt to set up a rival national oil company and take control of the industry, something Sanallah says is impossible anyway.

"We are still the NOC [National Oil Company]; the legal NOC is here. I am the chairman of NOC," he says. "[The east] nominated a new chairman of NOC, but there's no staff, there's no people, there's no hardware, there's no software."

International mediators are trying to keep the oil company independent of either side, but oil fields are under attack. One tanker was bombed, and another one was threatened.

Sanallah says he wants to keep oil out of the fight.

"I hope so. I hope so," he says — but he doesn't sound convinced.

His employees are fighting fires at major oil terminals, and with no real security forces, it only takes a few gunmen to shut things down or hold them hostage.

"I think the message was clear to the oil company: There is no security, good security. Otherwise a few people cannot control the vein of the blood of Libya," he says.

And with the terminals closing, Libya's battered economy is taking even more blows because foreign oil companies are pulling out. Libya is only producing about 330,000 barrels a day, increasing the economic burden.

"When you are closing the terminals, it means you cannot produce oil, and if you cannot produce oil, then you cannot produce gas. So we are making up the gas by importing diesel. This is another burden on the shoulders of NOC," he says.

Again, oil is basically what pays for any central Libyan government. How much? "All — 90 to 95 percent. There is no revenue but oil," he says.

If negotiations don't end the fighting, Sanallah says, the country will collapse. A functioning oil industry could be all that stands between Libya as a nation, and Libya as a failed state.

Libya

oil