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ALAN BOWKETT: FAST START WILL BE CRUCIAL
Norwich City Football Club
Chairman wants Canaries to fly out of the blocks
CHAIRMAN Alan Bowkett believes the Canaries must make a fast start if they’re to achieve their ambitions in the Sky Bet Championship next season.
When speaking to the gathered media at Neil Adams’ unveiling as manager, he pointed to the example of Wigan Athletic, whose excellent form in the second part of last season was only enough to secure them a play-off spot.
“The reality is we can’t afford to have a bad start in the Championship,” said Bowkett.
“Look what happened to Wigan. They made a mistake, they changed. If they’d had the right manager at the beginning of the season they’d have probably had automatic promotion.
“My view is we’ve appointed the right manager, he will deliver, and he knows how tough it’s going to be.”
When asked to explain the 11-day gap between the last match of the campaign and the appointment, Bowkett explained a stringent process that eventually led to Adams being chosen for the job.
“If we’d have appointed Neil 10 days ago we’d have faced the criticism that it’s nepotism and that you’re not really looking at the market. So Neil can hold his head up high,” he said.
“We have looked in Germany, we have looked in Italy, looked in Spain, throughout the British Isles.
“For all the things we were looking for in terms of vision, progressive attitude, coaching skills, hunger for the job, ability to deliver professionalism and hard work – Neil came out on top.”
Bowkett also believes the current squad will be up to the task, but added that Adams will have room to manoeuvre in the transfer market too.
“We’ve managed our finances prudently so that we’re in a situation that we can hold on to all our players in the Championship,” he said.
“This squad can do an exceptional job in the Championship. However, there are opportunities to add to that squad and improve it, and we have the finances to do that.”
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‘Christian cross’ case wins in Europe
The UK courts had previously ruled that wearing a cross was not a “requirement” for adherents to the Christian faith, unlike the wearing of a turban by Sikh men or the wearing of a headscarf by Muslim women. However, the ECHR disagreed, ruling that the dress code “amounted to an interference with her right to manifest her religion”.
Three other ‘Christian discrimination’ cases were also determined in the same ECHR judgement. Shirley Chaplin, a nurse who was not allowed to wear a cross and necklace when working on a ward for health and safety reasons, lost her case. The ECHR ruled that asking her not to wear a necklace for health and safety reasons was “not excessive”.
The two other cases involved Christians who refused to carry out certain activities which they considered would condone same-sex relationships. Firstly Lillian Ladele, an Islington Registrar who refused to perform civil partnership ceremonies, and second Gary McFarlane, a Relate counsellor who refused to offer sex therapy to same-sex partners. Both of these claimants lost their cases when the ECHR ruled that their employers had been “entitled to strike a balance between the claimants’ rights to manifest their religious beliefs and the rights of others not to suffer discrimination”.
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There are people that think the notion of a Clash of Clans hack with no survey is going to be very difficult to find. That’s because most people have the wrong idea of how to get through this. If you want to learn how to hack Coc resources for free, you need to stop thinking programming.
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If you want to win, you’re going to need to cut to the chase. To win in these modern times, you’ll need to work with cheats and hacks. With that in mind, search for Clash of Clans hack download and see how far you can go.
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When it comes to the world of CoC hack downloads, you will find that some are not going to work for iOS devices. The reason why many things don’t work is because you may not have the most up to date version. The most up to date that you will want to look into is the 2017 solution.
2017 updates are important because they are in line with the game and the updates that are involved. Whether you’re looking to learn how to hack Clash of Clans for iPad and iPhone, or you are just trying to cheat the game, you will find that you need to update the latest hacks.
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INDIANAPOLIS (May 9, 2019) Conexus Indiana today announced two new members to the Conexus Indiana Board of Directors. Scott Glaze, owner, chairman and chief executive officer of Fort Wayne Metals, and Amish Shah, chief executive officer of Kem Krest, are the newest appointees to now 17-member board, which is comprised of statewide leaders who guide Conexus Indiana in its mission to accelerate, promote and grow Indiana’s advanced manufacturing and logistics economy.
“Diverse representation on our board is pivotal to ensuring the work we do benefits all Hoosiers,” said J. Mark Howell, president and CEO of Conexus Indiana. “Conexus must be industry-led and represent the full statewide ecosystem of advanced manufacturers and logistics companies in Indiana to be successful. With the addition of Scott and Amish to our board, we gain new subsector and geographical perspectives that will help us achieve our goals.”
Scott Glaze, CEO of Fort Wayne Metals
Glaze has served as CEO at Fort Wayne Metals since 1985. During his tenure, the company has grown into a global leader in the manufacture of high-quality precision wire products for the medical device industry. Today, Fort Wayne Metals employs more than 1,200 people worldwide.
Outside of his work with Fort Wayne Metals, Glaze has been involved in a number of state, regional and local organizations dedicated to economic and community development. He has worked with the Indiana Chamber of Commerce, Northeast Indiana Corporate Council and most recently, the Northeast Indiana Regional Partnership.
Amish Shah, CEO of Kem Krest
Shah started his career at Kem Krest, an Elkhart-based logistics company, in 1996 and rose to CEO in 2000. During his tenure, it has grown into a $500 million company and has won numerous awards, including: The General Motors Supplier of the Year Award; Inc. 500|5000 Fastest Growing Companies and Indiana Companies to Watch. Shah is also Ernst & Young’s 2016 Entrepreneur of the Year and a board member and co-owner of Educational Software for Guiding Instruction, a second stage education technology company focused on early literacy.
Shah currently serves on the General Motors Supplier Council, the YPO Central US Region Board, the Indiana University South Bend Chancellor’s Advisory Board, the Beacon Health System Board of Directors, and the South Bend–Elkhart Regional Development Authority Diversity & Inclusion Committee.
About Conexus Indiana
For more than a decade, Conexus Indiana, one of the Central Indiana Corporate Partnership (CICP) non-profit initiatives, has been positioning the Hoosier State as the best place for advanced manufacturing and logistics industries to invest, employ and succeed. By collaborating with industry, academic and public sector partners on a shared vision for an innovative, skilled workforce and stronger business climate, Conexus Indiana has helped to create opportunities for advanced manufacturing and logistics companies, prepare Hoosiers to succeed in the state’s largest industry sectors and maintain Indiana’s competitive advantage. For more information, go to www.ConexusIndiana.com.
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Review: “Tears In Paradise. Suffering and Struggle Of Indians In Fiji 1879-2004” by Rajendra Prasad – Britain's Indentured Indian “5 Year Slaves”
By Dr Gideon Polya
“Tears in Paradise. Suffering and struggle of Indians in Fiji 1879-2004” by Rajendra Prasad tells the story of Indian indentured labour (“5 year slaves”) taken to Fiji from British-occupied India in the period 1879-1916 and brutally exploited on British- and Australian-run sugar cane plantations. The last “5 year slaves” were finally released from bondage in 1920, 87 years after slavery was supposedly banned in the British Empire. Today effective Third World slavery is rampant through globalization.
Rajendra Prasad was the town clerk of the Fiji sugar town of Ba (1972-1987) and now lives in New Zealand. Fiji is a Pacific Island state that is an archipelago of more than 332 islands, of which 110 are permanently inhabited, and more than 500 islets, amounting to a total land area of about 18,300 square kilometres. The two major islands, Viti Levu and Vanua Levu, account for 87% of the population of about 860,000. The capital and largest city, Suva, is on Viti Levu. The population of Fiji is mostly made up of Indigenous Fijians, who are mostly Melanesians but with significant Polynesian background, especially in the eastern Lau Islands (54%), and Indo-Fijians (38%), the descendants of Indian indentured labourers (“5 year slaves” ) brought to Fiji in the period 1879-1916. The indentured labour system was called the “Girmit” system (from Indian mis-pronunciation of “agreement”) and the indentured labourers were known as “girmityas”. My wife's maternal and paternal grandparents were all girmityas and she has about 70 cousins, an indication of the expansion of the Indo-Fijian population since 1879.
Before reviewing this important book [1] in detail, it is useful to briefly outline the chronology of the history of Fiji: 3000BC, first settlement, Lapita pottery people; 1500BC, Melanesian settlement; 1643, Dutch explorer Abel Tasman reached Fiji; 1774, British explorer Cook reached the eastern Lau Islands; 1789, British Captain William Bligh reached Fiji in an open boat; 1808, Kasavu village massacre by musket-armed, ship-wrecked British sailor Charlie Savage; 1806, epidemic from shipwrecked “Argo” sailors; 1830, first Christian missionaries; 1840, US Commodore Wilkes visited but was subsequently tried and acquitted over abuses; 1871, chiefly federation based on Levuka, the island of Ovalau off Viti Levu; 1874, cession to Britain by Fijians concerned over US naval threats in response to arson of the property of an American on Nukulau Island; the 19th century Fiji and other Pacific Islands were targeted by Australian and other “blackbirders” seeking to capture slaves or trick indentured labour for sugar plantations in Fiji, Samoa and Queensland, Australia; 1875, party of important chief Ratu Cakobau returned from Sydney with measles; 40,000 Fijians died out of a 150,000 population; 1879, first Indian indentured labour (“5 year slaves”) on the ship “Leonidas”; male to female ratio about 3:1; 1916, after strong criticism of the indentured labour system, recruitment from India ceased; 1920, “Girmit” indentured labour system finally ceased with the release of the last “5 year slaves”; flu epidemic killed about 5,000; 1970, independence under Fijian-dominated Alliance Party led by Ratu Sir Kamisese Mara; 1982, Alliance rule continued; 1987, multi-racial Fijian-Indian Fiji Labor Party government under Fijian Dr Bavadra followed by 2 military coups by Colonel Sitiveni Rabuka and republic status (the US opposed Dr Bavadra's nuclear-free policy and is asserted to have been involved [2], possibly with the complicity of US lackey Australia ) – but the so-called “bloodless coup” led to a subsequent increased excess mortality of about 4,500; about 100,000 Indo-Fijians migrated (mainly to North America, New Zealand and Australia); 1998, new constitution; 1999, first Indian Prime Minister (PM) Chaudhry heading the multiracial Fiji Labor Party; 2000, Fijian anti-Indian coup led by Anglo-Fijian Australian resident George Speight with major Fijian political complicity and followed by military rule and military-installed ethnically indigenous Fijian interim government under PM Laisenia Qarase that discriminated against Indians and advanced the interests of the I'Taukei (indigenous) political elite as well as I'Taukei Chiefs; 2001, new elections won by Fijian United Party (SDL, ethnically indigenous Fijian); 2003, Supreme Court ruled exclusion of Indians from government illegal; 2005, major tourist resort expansion on track, major income from soldiers serving overseas, devastating EU sugar price decrease foreshadowed; threat of military coup if 2000 Coup participants were released from prison; 2006, military coup by the Indigenous Fijian-dominated army under Commodore Josaia Voreqe (Frank) Bainimarama to protect Indians (vital for the mainly sugar- , tourism-, sweatshop textile industry-, and repatriated money-based economy) and to stop corruption; hostility from Australia and New Zealand was countered by increasing Chinese investment in Fiji; 2014, restoration of democratic elections under a new constitution with Frank Bainimarama as elected PM [3].
In his Introduction to “Tears in Paradise”, Rajendra Prasad quotes High Tinker who in his book “A New System of Slavery” describes the British Empire indentured labour system thus: “It was their labour, along with British capital and expertise , which created the overseas wealth of Britain”. Winston Churchill, a racist, war-monger and imperialist who confessed to hating Indians ( “I hate Indians. They are a beastly people with a beastly religion”) [4] is famous for his following description of Chinese indentured labour in South Africa in the House of Commons on 22 February 1906 as Under-Secretary of the Colonial Office: “The conditions of the Transvaal ordinance ... cannot in the opinion of His Majesty's Government be classified as slavery; at least, that word in its full sense could not be applied without a risk of terminological inexactitude” [5]. Churchill through “divide and rule” was ultimately responsible for the horrors of Indian Partition (1 million deaths and 18 million refugees) and he was responsible for the 1942-1945 Bengali Holocaust in which the British with Australian complicity deliberately starved 6-7 million Indians to death for strategic reasons, with the Australia complicit by withholding food from its huge wartime grain stores [3, 4, 6-14]. Rajendra Prasad comments on the Fiji colonial period under British rule and dominated by the Australian Colonial Sugar Refining Company (CSR): “ In this period, the British colonial policy of divide and rule created a racial divide between Fijians and Indo-Fijians. Their relationship remained antagonistic right up to independence and soured subsequently, leading to the coups of 14 May 1987 and 19 May 2000. At the dawn of the new century, Fiji raged in the fire of racism and the Indo-Fijians suffered persecution, intimidation, violence and eviction. It broke their faith, hope and trust in Fiji. Despite thousands of Indo-Fijians who have emigrated, a significant number are still in Fiji, hopeful that the country may yet provide them with a safe, secure and stable future.” (pp11-12, [1]).
Part 1 of the book is entitled “Indenture period 1879-1919. Struggles of a forgotten generation”.
Chapter 1, “Pilgrimage to my ancestral roots”, outlines the author's family background. His paternal grandfather (Daadaji) and maternal grandfather (Naanaji) arrived in Fiji in 1908 as girmitiyas. The author Rajendra Prasad movingly describes how he returned to India on a management course in 1974, tracked down the location of his family's home village and was enthusiastically and lovingly welcomed home by hundreds of villagers who had always been aware of their kinsmen or fellow villagers having gone to Fiji.
Chapter 2, “Indian culture and recruitment”, describes how the British agents chose labour from impoverished Indian provinces in North, South and Eastern Indian. Rajendra Prasad comments: “Brahmins, Kshatriyas and the Punjabis were excluded” (p47, [1]) to minimize future political problems from Indian groups much less likely to tolerate enslavement and maltreatment. High caste Hindus would also have had a fear of crossing the “kaala paani” (black water). The recruiters deliberately deceived most of their targets, and by the time they were coralled in pre-embarkation sub-depots the girmityas were quite compromised, and especially so the women. Rajendra Prasad comments: “Once on the mainland [in Fiji], the girmityas were herded like animals to the plantations. They were given kennel-like living accommodation – referred to as coolie lines” (p57, [1]).
Chapter 3, “Violence in the fields”, tells shocking stories of violence by overseers and violence among girmityas. Rajendra Prasad comments: “Cases of grievous physical assaults, torture and torment by the employers against the girmityas abounded during the periods of girmit. These contributed to a general air of anxiety , anger, anguish and fear. They sometimes led to extreme retaliatory measures . These occurred when the kulambars [white overseers ] and sardars [sirdars; girmitya heads appointed by kulambars ] breached the limits of tolerance” (p59, [1]). My favourite girmitya story: a group of women girmityas, utterly fed up with the violence and sexual overtures of a sirdar, got him alone in a cane field, held him down and urinated on him. A dear elderly friend of mine recalls seeing the whip-marks on her mother's back. The sex ratio of 3 men to each woman created tensions, and contributed to violence and suicide. Thus another dear friend recounted to me how her grandfather, upset about attention being paid to his wife, chopped another man's hand off with a cane knife and avoided legal consequences by agreeing to look after the crippled man.
Chapter 4, “Plantation life and new culture”, describes the onerous circumstances of the powerless girmityas. If they failed, whether through sickness or pregnancy, to perform their back-breaking, 12-hours-per day, 6 days per week tasks, they were fined from their paltry wages and prosecuted. Rajendra Prasad notes that “In 1886, 6566 girmityas were registered in Fiji and 8835 charges were laid against them” (p83, [1]).
Chapter 5, “Tolerance of violence and violations” describes the “meekness “ of the Indian girmityas. Rajendra Prasad comments: “The Japanese, Chinese and other Pacific nations turned down subsequent requests for Labor from the Fiji [colonial] government. India being part of the British Empire, became the most reliable source of labour from the British colonies. Indian immigrants , under the indenture system, responded to the harsh and hostile conditions of indenture with meekness and submissiveness where others had rebelled” (p101, [1]). ”
Chapter 6, “Indenture – resistance, abolition and its aftermath”, recounts how international pressure, spearheaded by Mahatma Gandhi who had witnessed indentured labour abuses in South Africa, led to the end of indentured labour in the British Empire (notably in South Africa, the West Indies, Malaya, Australia and the South Pacific) and the end of the girmit system in Fiji. Rajendra Prasad comments: “Mahatma Gandhi played a key role in alleviating the suffering of the girmityas in Fiji, and ending the indenture system. In order to get first-hand information and to elucidate the truth about the social and moral conditions in Fiji, Mahatma Gandhi sent Rev. Charles Freer Andrews and Rev. William Pearson to Fiji” (p, 121 [1]).” However the end of recruitment of indentured labour in 1916 did not end the girmit system – existing indentured labourers had to serve out their full term, the last being finally released from servitude on 1 January 1920.
Part 2 of the book is entitled “Post-indenture period 1920-2004. Uncertain future”.
Chapter 7, “Cultural and political renaissance”, recounts social and political developments in post-indenture Fiji. The beginning of this period was marked by the death of 5,000 Fijians in the world-wide influenza epidemic that was spread by British commerce and the return of soldiers (including a Fijian contingent) from World War 1. A 1920 strike by municipal workers led to violence and 175 arrests. The colonial authorities called for and received assistance from the New Zealand and Australian navies and in a shooting incident at the Samabula Bridge up to 20 Indians were gunned down, up to 20 injured, and 163 (including 12 women) imprisoned. Indian leaders Manilal, Mrs Manilal, Harpal Maharaj and Fazal Ahemad Khan were banished to Nukulau Island (currently used to house the Coup criminals of 2000) and subsequently left for New Zealand. A rich Indo-Fijian culture flourished based on a complexity of religions (mainly Hindu, Muslim and Christian) , of cultures (Tamil, South and North Indian and Bengali) and languages (Tamil, Telegu and Malayalam from South India , Hindi from North India and Bengali from Bengal). Fiji Hindi became the dominant language of Indo-Fijians with many also speaking Fijian and English The close-knit Gujarati community that is very active in business came as free immigrants. Rajendra Prasad comments: “Of 65,553 who came to Fiji under indenture, 25,645 returned to India” (p147, [1]). Indian leadership came from Shiwabhai Bhailalbhai Patel (S.B. Patel) (a lawyer sent to Fiji by Mahatma Gandhi), Pundit Vishnu Deo and barrister A.D. Patel.
Chapter 8, “CSR Company and the Indo-Fijian farmers”, recounts how many Indo-Fijians leased land from the Australian CSR Company and were thence trapped economically in the post-indenture period. A farmers' strike in 1921 was defeated by the CSR company's strength and farmers' poverty and its leader Sadhu Bashist Muni was deported. Rajendra Prasad summarizes the Indo-Fijian lot: “The majority of Indo-Fijians had settled on land leased from the CSR Company for sugar can cultivation, or from Fijians, on which they cultivated sugar cane, rice, maize, leguminous crops or raised cattle. Many found employment in the sugar mills, and lived close to the mills… for two decade, following the end of girmit, the CSR Company had a free reign over the Indo-Fijian farmers and was able to manipulate, dominate, intimidate and exploit them at will” ” (pp158-159, [1]). However in 1937 Pundit Ajodhya Prasad set up the Kisan Sangh (Farmers' Association) that successfully combatted CSR Company exploitation. In 1969 Lord Denning from the UK adjudicated the sugar contracts in favour of the farmers and in 1973 the Australian CSR Company left Fiji.
Chapter 9, “Village life 1940s-1960s”, provides a loving description of the village life of Indo-Fijians. It concludes with a summary of the transition to modernity: “By the end of the1960s a massive transformation could be seen in the lives of the Indo-Fijians. Even the village landscape changed considerably. The household income increased as educated children sought employment in offices or in the commercial and industrial sectors. Fiji gained its Independence on 10 October 1970 . It was the dawn of a new era” (p194, [1]). The socio-economic transition could be quite rapid as exampled by friends mine e.g. from girmitya (generation 1), to top medical specialist (generation 2) to medical specialist and other university-educated professionals (generation 3); from girmitya (generation 1), to top lawyer (generation 2), to mostly lawyers and other university-educated professionals (generation 3), to medical specialist and other university-educated professionals (generation 4).
Chapter 10, “Post-independence era”, describes the politics of the Indigenous Fijians and the Indo-Fijians. Initially the National Federation Party (NFP) represented Indo-Fijians and the Alliance Party represented Indigenous Fijians and European interests ( my father-in-law, barrister Abdul Lateef MBE, strongly believed in a multiracial approach, was responsible for various education, community and sporting innovations, and became an Alliance Party MP for a cross-voting seat in the otherwise race-based bicameral electoral system bequeathed by the British). The 22-member Senate was composed of 8 nominees of the Great Council of Chiefs, 7 nominees of the PM, 6 nominees of the Leader of the Opposition and 1 nominee of the Council of Rotuma. An Indo-Fijian quip about the distorted electoral system: “Too many chiefs and not enough Indians”. Fundamental tensions related to the desire of Indo-Fijian farmers and others for more certainty over leased land and for untrammelled equality. Indigenous Fijian concerns were over land preservation, cultural integrity, respect for the Chiefs, the need for affirmative action for Fijians in view of the disproportionately greater wealth of the entrepreneurial Indo-Fijians, and a fundamental desire to retain Indigenous Fijian political control. Indo-Fijians had fears deriving from the expulsion of Indians from Uganda under Idi Amin and support for repatriation of Indians from Indigenous Fijian extremists such as Sakiasi Butadroka, leader of the Fijian Nationalist Party (FNP). In 1987 the Alliance Party Government of eminent and outstanding PM Ratu Sir Kamisese Mara, who had ruled Fiji for 17 years, was defeated by a Fiji Labor Party- National Federation Party Coalition under Indigenous Fijian Dr Timoci Bavadra that won 28 seats out of 52 seats.
Chapter 11, “The coup era”, describes the tragedy of the 14 May 1987 Coup by Colonel Sitiveni Rabuka that deposed the democratically-elected multi-racial Fiji Labor Party Government of Dr Timoci Bavadra and was preceded by public demonstrations by the anti-Indian Fiji nationalist Taukei Movement. Not canvassed by Rajendra Prasad, William Blum in his best-selling book “Rogue State” describes this as a US CIA-backed coup due to US opposition to Dr Bavadra anti-nuclear weapons policy [2] (indeed US lackey Australia, long America's “Deputy Sheriff ” in the South Pacific, may have been complicit). After deposing the elected government, Rabuka handed power over to the Governor-General, Ratu Sir Penaia Ganilau, a high chief. However when Ratu Ganilau attempted to reinstate the abrogated constitution, Rabuka carried out a second coup on 28 September 1987 and established a Republic . A new Constitution biased towards Fijians permitted Rabuka to rule as an elected PM. However under a racially more equitable constitution in 1999 Rabuka lost the election and was replaced by the multi-racial Fiji Labor Party's Mahendra Chaudhry, the first ever Indo-Fijian Prime Minister. However big demonstrations by the Taukei Movement were followed by the 19 May 2000 Coup by part-Fijian Australian resident George Speight. The President Ratu Sir Kamisese Mara refused to negotiate with the plotters, dismissed the kidnapped government and assumed emergency powers himself. However on 28 May Ratu Sir Kamisese Mara was kidnapped, removed on a naval vessel, allegedly approached by a group of present and former military and police officers and ordered to suspend the Constitution, which he refused, stating "If the Constitution goes, I go" . The forcible removal of Ratu Sir Kamisese Mara from the Presidency was reportedly accompanied by threats to kill him and members of his family, this strongly suggesting foreign involvement (e,g. Americans, US lackey Australians or Israeli US dirty tricks surrogates, with all of whom Rabuka had military-related connections) because it is unimaginable that Indigenous Fijians would have treated their extremely eminent and revered paramount chief in this way. A 56-day stand-off with the Fiji military under Commodore Frank Bainimarama concluded after a brief Fijian nationalist military mutiny on 2 November involving the Rabuka-created Counter Revolutionary Warfare Unit (CRWU) of the military that was promptly terminated by loyal Fijian forces and was followed by military rule, arrest of the Coup-plotters, and thence by a military-installed, ethnically Indigenous Fijian interim government under PM Laisenia Qarase that discriminated against Indians and advanced the interests of the I'Taukei (indigenous) political elite as well as I'Taukei Chiefs.
Chapter 12, “The Fiji malady – causes , conflicts and casualties”, considers the complex tensions between the Indo-Fijians and the Indigenous Fijians briefly outlined above, and the serious economic and social consequences of post-1987 mass emigration of Indo-Fijians from Fiji.
In Chapter 13, “Indo-Fijian trauma and tears”, Rajendra Prasad concludes with a plea from Martin Luther King in his famous letter of April 1963 from a Birmingham, Alabama jail: “Let us hope that the dark clouds of racial prejudice will soon pass away”(p270, [1]).
Rajendra Prasad concluded his book in 2004 but the last decade saw a further Indigenous Fijian military Coup in 2006, this time by Commodore Frank Bainimarama, ostensibly to counter corruption, to protect Indians - vital for the Fijian economy and professions - and to prevent possible release of the 2000 Coup plotters from imprisonment on Nukulau Island off Suva. Fiji was expelled from the British Commonwealth and faced hostility from Australia and New Zealand. A second coup was effected in 2009 to abrogate the latest version of the Constitution and block elections then. Democracy was only restored in 2014 elections under a new Constitution that returned former military dictator of Fiji, Frank Bainimarama, as a democratically–elected Prime Minister of Fiji.
Indigenous Fijians should now be reassured that they have an Indigenous Fijian PM Frank Bainimarama and an Indigenous Fijian President, the very impressive Ratu Epeli Nailatikau (the former Commander of the Royal Fiji Military Forces who was deposed from this position in 1987 while visiting Australia by the third-ranked officer, Colonel Sitiveni Rabuka). Indo-Fijians can be somewhat reassured that they now have a government committed to protecting the equal human rights and legitimate interests of the Indo-Fijians, albeit led by a person who had abrogated basic human rights and democracy for a decade. Indeed Rajendra Prasad writing from New Zealand about the 2013 Fiji Constitution adopted a pragmatic approach in praising Frank Bainimarama: “For thirty-six years since independence (1970-2006), Fiji had the misfortune of being governed by narrow, insensitive and corrupt Governments. Their policies and practices impinge on the freedom, rights, equality and dignity of its citizens. Today, a nation that was savaged by its democratically elected leaders is being rescued by the Bainimarama Government” [15]. However, notwithstanding the failings of democratically-elected governments, what is inescapable is that democracies cannot have coups, and that we must have the rule of law, or else we have the law of the jungle (the essence of a sensible position that was put to me in conversation by a Fiji judge).
Professor Wadan Narsey (who expertly estimated that one third of Fijians lived in poverty in 2008-9 [16] and who has been critical of some expatriate Indo-Fijians, including Rajendra Prasad, for praising Frank Bainimarama) cogently commented in 2014 just prior to the Fiji elections on the current ambivalent and pragmatic political position of Indo-Fijians who through continuing emigration are now a minority in Fiji (38% of the population in 2014 versus about 50% in 2000): “For more than a century Indo-Fijian political leaders (AD Patel, Sid Koya, Jai Ram Reddy and Mahendra Chaudhry) and communities behaved with total political integrity towards the indigenous Fijians and Fijian institutions, in fighting for the legitimate rights of Indo-Fijians. They operated within the law, despite being periodic victims of violence from the military, police, and politically organized gangs of thugs, such as in the coups of 1987 and 2000, which had the undeniable support of the Great Council of Chiefs, the Methodist Church, Fijian political parties and leaders, and many Fijian people. The motivating slogans then were “the indigenous Fijian cause” or “Fiji for Fijians” or “No Indian can be Prime Minister”. The Fijian governments succeeding each coup duly implemented some discriminatory “affirmative actions” or another. But since 2006, Indo-Fijian leaders have also betrayed their history of political integrity, by supporting Bainimarama's illegal coups and government, many for totally selfish reasons… In sum, large numbers of ordinary Indo-Fijians appear willing to support an illegal government and illegal Prime Minister, as long as they themselves receive benefits, whether in education or jobs for a few boys at the top, business contracts, or enhanced emotional security as an “equal citizen”” [17].
Fiji actually provides a good example for the world of de facto inter-racial harmony – the succession of coups in 1987 and 2000 were ugly and racially-motivated but essentially “bloodless”, and the 2006 Coup by the Indigenous Fijian military under Commodore Frank Bainimarama was in part to protect the economically vital Indian minority (can you imagine the Apartheid Israeli military staging a coup to protect the human rights of Palestinians?)
The horrendous conditions of the indentured Indian labourers under the girmit system, as powerfully set out by Rajendra Prasad in “Tears in Paradise”, occurred despite the abolition of slavery in the British Empire in 1833. Today such de facto slavery is widespread in the Third World due to globalization and is backed up by neoliberal and corporatist free trade agreements. Thus in Australia (per capita nominal GDP $66,000) a shirt made in Bangladesh (per capita nominal GDP $980) sells for $8; the annual avoidable deaths from deprivation as a percentage of population are 0.0% and 0.4% for Australia and Bangladesh, respectively; and 17 million people die avoidably from deprivation each year, this including about 1 million Bengalis and zero non-Indigenous Australians [3]. Poverty kills.
[1]. Rajendra Prasad, “Tears in Paradise. Suffering and struggle of Indians in Fiji 1879-2004”(Glade, Auckland, New Zealand, 2004).
[2] William Blum, “Rogue State”.
[3]. Gideon Polya, “Body Count. Global avoidable mortality since 1950”, this including an avoidable mortality-related history of every country since Neolithic times and now available for free perusal on the web: http://globalbodycount.blogspot.com.au/2012/01/body-count-global-avoidable-mortality_05.html .
[4]. Gideon Polya, “Jane Austen and the Black Hole of British History. Colonial rapacity, holocaust denial and the crisis in biological sustainability”, now available for free perusal on the web: http://janeaustenand.blogspot.com/2008/09/jane-austen-and-black-hole-of-british.html .
[5]. “Terminological inexactitude”, Wikipedia: http://en.wikipedia.org/wiki/Terminological_inexactitude .
[6]. Gideon Polya, “Australia And Britain Killed 6-7 Million Indians In WW2 Bengal Famine”, Countercurrents, 29 September, 2011: http://www.countercurrents.org/polya290911.htm .
[7]. Madhusree Muckerjee, “Churchill's Secret War. The British Empire and the ravaging of India during World War II” (Basic Books, New York, 2010).
[8]. Colin Mason, “A Short History of Asia . Stone Age to 2000AD” (Macmillan, 2000).
[9]. Bengal Famine, BBC radio broadcast series “The things we forgot to remember”, 2008: http://www.open2.net/thingsweforgot/bengalfamine_programme.html .
[10]. Paul Greenough's “Prosperity and Misery in Modern Bengal: the Famine of 1943-1944” (Oxford University Press, 1982).
[11]. Thomas Keneally, “Three Famines” (Vintage House, Australia, 2011).
[12]. Cormac O Grada. “Famine a short history” (Princeton University Press, 2009).
[13]. J. Dreze and Amartya Sen “Hunger and Public Action” (Clarendon, Oxford, 1989).
[14]. N.G. Jog, “Churchill's Blind Spot: India ” (New Book Company, Bombay, 1944).
[15]. Rajendra Prasad, “New constitution: new era for Fiji”, Fiji Pundit, 9 January 2014: http://fijipundit.blogspot.com.au/2014/01/fijis-new-constitution-new-era-for.html .
[16]. Wadan Narsey ‘Poverty in Fiji : Changes from 2002 – 03 to 2008 - 09 and Policy Implications”.
[17]. “Australian AID launches critical report tracking poverty changes in Fiji”, PINA, 8 August 2012: http://www.pina.com.fj/?p=pacnews&m=read&o=3351767405031818bf3cb6e6ff00f9 .
[18]. Wadan Narsey, “Part II, “Leading Indo-Fijians into a political cul-de-sac” or “The Indo-Fijian Betrayal of Political Integrity”, 21 August 2014: https://narseyonfiji.wordpress.com/2014/08/24/part-ii-leading-indo-fijians-into-a-political-cul-de-sac-or-the-indo-fijian-betrayal-of-political-integrity-21-august-2014/ .
Dr Gideon Polya has been teaching science students at a major Australian university for 4 decades. He published some 130 works in a 5 decade scientific career, most recently a huge pharmacological reference text "Biochemical Targets of Plant Bioactive Compounds" (CRC Press/Taylor & Francis, New York & London , 2003). He has published “Body Count. Global avoidable mortality since 1950” (G.M. Polya, Melbourne, 2007: http://globalbodycount.blogspot.com/ ); see also his contributions “Australian complicity in Iraq mass mortality” in “Lies, Deep Fries & Statistics” (edited by Robyn Williams, ABC Books, Sydney, 2007: http://www.abc.net.au/radionational/programs/ockhamsrazor/australian-complicity-in-iraq-mass-mortality/3369002#transcript
) and “Ongoing Palestinian Genocide” in “The Plight of the Palestinians (edited by William Cook, Palgrave Macmillan, London, 2010: http://mwcnews.net/focus/analysis/4047-the-plight-of-the-palestinians.html ). He has published a revised and updated 2008 version of his 1998 book “Jane Austen and the Black Hole of British History” (see: http://janeaustenand.blogspot.com/ ) as biofuel-, globalization- and climate-driven global food price increases threaten a greater famine catastrophe than the man-made famine in British-ruled India that killed 6-7 million Indians in the “forgotten” World War 2 Bengal Famine (see recent BBC broadcast involving Dr Polya, Economics Nobel Laureate Professor Amartya Sen and others: http://www.open.edu/openlearn/history-the-arts/history/social-economic-history/listen-the-bengal-famine ). When words fail one can say it in pictures - for images of Gideon Polya's huge paintings for the Planet, Peace, Mother and Child see: http://sites.google.com/site/artforpeaceplanetmotherchild/ and http://www.flickr.com/photos/gideonpolya/ .
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Charles H. Wright Museum to preserve Afro-American Sports Hall of Fame collection
Collection created in 1982 had been in
Tyler Clifford
The Charles H. Wright Museum of African American History has taken in the Afro-American Sports Hall of Fame and Gallery, preserving the collection for share for generations to come.
The collection celebrates African-American sports icons such as Joe Louis, Turkey Stearnes and Althea Gibson along with lesser known athletes, according to a news release.
Curated by the late Elmer Anderson and Art Finney in 1982, the collection was on display in the Old Wayne County Building on Randolph Street until the county relocated in 2009. Since then, the gallery was stored by Old Wayne County Building LP and Southfield-based Farbman Group.
With Anderson's sister Sharon Hasan's approval to donate the collection, the Wayne County Council for the Arts, History and Humanities led the effort to move the collection to the 120,000-square-foot museum at Warren Avenue and Brush Street.
"The Afro-American Sports Hall of Fame helped preserve the stories of so many African-American sports legends, some of which might have been lost with time," Jocelyn Rainey, president of the council, said in the release. "When the council learned the Hall of Fame's collection was in storage, we made it our priority to find it a suitable home where these critical stories from our past would be accessible for generation after generation."
The Wright Museum will preserve, catalog and display the collection in future programming.
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Chester Cinemas
CINEMAS OF IRELAND
403 Antrim Road,
Belfast, BT15 3BG
Date opened: Saturday 9th November 1935
First film shown: ‘The Nitwits’
Date Closed: Saturday 11th January 1975
Architect: Thomas McLean
Original Seating Capacity: 1094
CAPITOL cinema, Belfast.
The Capitol cinema, which was on the Antrim Road at the corner of Alexandra Park Avenue, Belfast was the third of the new Michael Curran picture theatres to be erected in the city to the plans of architect Thomas McLean. It was opened by a Lady Turner, who congratulated the owners on the splendid building. The opening attractions on Saturday 9th November 1935 were the Wheeler and Woolsey comedy ‘The Nitwits’. The second feature was ‘By Your Leave’. Prior to the opening ceremony, a half hour’s musical programme was provided by a Mr F. Mohan and his orchestra.
Proceeds from the opening performance were donated to Belfast Newsboys’ Club. Refreshments were available from the first floor cafe, which had wide Windows overlooking the Antrim Road. The exterior was finished in a cream colour. Over the entrance there was a canopy in gold and red and the same colours were used for the entrance doors and display cases, both picked out in stainless steel. Grilles were in pale green and silver. The cinema was carpeted throughout and the press said that the tip-up arm chairs seats were extremely comfortable. The main entrance doors was on the corner. The porch had double swing doors, which prevented draughts getting into the foyer. The local press said the foyer was of ample size and had a handsome box office. Off it were cloakrooms for both sexes and a central door gave access to the auditorium.
Unlike the other Curran houses there was no dome at the Capitol. Neon lighting was supplied by the Liverpool Company Vidro Ltd, which was run by a Mr David Rowan. Furnishings, including Wilton carpet were supplied by the CO-OP Trading Company, High Street, Belfast. Glass was supplied by Campbell Brothers of Millfield, Belfast. They were also responsible for the wrought steel verandahs. Electrical installation was carried out by Curran Bros of Long Lane, Belfast. Terrazzo was employed in the foyer and staircases, and was executed by a Mr Crescenzo Fusiciardi of Belfast.
Seating was for around 1,100 and on the upper floor was a suite of offices, one of them used as a boardroom for the directors of the Curran group. The auditorium held around a thousand people and lighting was concealed behind the cornice. The local press said, Around the proscenium arch and in troughs flanking the large ventilating grilles on either side of It are other lamps, and though the auditorium can be brightly lit by these means, not a lamp is visable anywhere and glare is entirely absent.
It is said that at some point it was taken over by Rank. Through the 1950s it was still run by Curran cinemas. It was eventually demolished, making way for a supermarket. If anyone can tell us when Rank took over, we would love to hear from you.
David A Ellis©chestercinemas.co.uk
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Lido Cinema
Shore Road,
Belfast, BT15
Date opened: Saturday the 26th March 1955
First film shown: ‘Take The Stage’
Date Closed: During 1970
Architect: John McBride Neill (1905-1974)
BELFAST was home to a great number of cinemas and in 1955 another was added to the list. The Lido was the 45th cinema to be opened there on Saturday the 26th March with a Charity Gala performance. The Lido Shore Road was the first new cinema in the city to be built since the second world war. The opening was performed by a Sir James Norritt, the former Lord Mayor. The opening saw a full house, and many stood at the back and along the sides at this 1050 seat hall, which was on one level. A special feature of its design was the special acoustic treatment of the back wall and ceiling. The cinema was run by Troxy Cinema Ltd, the managing director being a Mr Harry Wilton.
Before the opening film ‘Take the Stage’, a comedy western, there was a variety programme, which was opened by the Faulat Girl Pipers, under Pipe-Major H. Galbraith. He marched in, playing from the foyer and paraded down the aisles to the front of the cinema. Other performers included James Glenn, a tenor singer and comedian Frank Carson. Proceeds from the opening performance were divided between the Ulster Schools for the deaf and blind. These were Lisburn Road, St Brigid’s School for blind girls and junior boys Whiteabbey.
From Monday the 28th March ‘The Student Prince’ was screened. This was followed by Calamity Jane, from the Thursday. The local press said that the Lido was the first cinema in Belfast specially designed to accommodate the new wide screen, and the first impression one receives on entering the auditorium is the great width of the proscenium. Some representatives of the Variety Club of Ireland were in attendance. They included a Mr R Britten, assistant chief barker, Mr F Speeds and a Mr S Durbidge, members of the Fund Raising Committee. Architect was Mr JMB Neill. The local press said, Mr Neill has used his long experience in cinema design in an attempt to obtain the maximum comfort for patrons and at the same time keep construction costs within manageable bounds.
The main contractors were Sloan Brothers. They had been responsible for the building of a large number of cinemas in Northern Ireland. The cinema housed a large cafe-shop, which opened a few weeks after the cinema’s opening. It was described as an attractive, almost Continental feature. It was said that the Lido scheme has given this rather drab stretch of road an almost Continental aspect.
The cinema, didn’t have a long life, closing in 1970. Some sources say it was the first in Belfast to install Cinemascope. This is not so, as Cinemascope was first screened in the city at the Hippodrome from the 11th January 1954. The film screened was The Robe. The Lido was bought by the local Roman Catholic Community and became a church. Eventually it was demolished to make way for a new church.
Strand Cinema
152-154 Hollywood Road,
Belfast, BT4 1NY
Date opened: Saturday 7th December 1935
First film shown: “Bright Eyes”
On December the 7th 1935 one of Belfast’s luxury cinemas opened its doors. It was the Strand, which stood on Gelston’s corner, Holywood Road. It was designed by a Mr J. McBride Neill of Belfast, who also designed the Majestic, and had seating for 1170 – 270 of those in the balcony. These were supplied by C.R Harrison and sons Ltd , Newton-Le Willows. It was Belfast’s first suburban cinema to be run by Union Cinemas and was built in six months by Sloan brothers of Pilot Street Belfast. They built three cinemas in Belfast and built the Tonic cinema in Bangor, Northern Ireland. Proceeds from the first performance went to the Lord Mayor’s Coal Fund.
The Strand’s architect-
John McBride Neill (1905-1974)
The cinema was opened by Sir Crawford McCullagh, the mayor. He said it would be a worthy acquisition to Strandtown and district. The cinema housed a cafe, which housed a soda fountain. The carpeting was similar to the auditoriums. In shape and size the cafe corrrsponded to the foyer below it. The local press said, unlike many cinemas built in years gone by there is no over decoration but the auditorium has something new to show in cinema wall decoration, at least in Ireland. The walls have a ground of waterproof plastic paint, on which is sprayed a texture of metallic paint. The colour scheme was carried out in monochromatic shades and the general effect was bright and fresh. The speckling of the sprayed metallic paint was considered most attractive.
STRAND CINEMA, Belfast. Proscenium & front stalls
The auditorium had a specially woven snake design, which was said to give a luxurious effect. The stage was equipped with a festoon curtain. The foyer was covered with terrazzo in bold bars of colour, grey, red, black and aluminium. The payback walls were were covered with white rubber and staybrite steel, which continued the modern note. The foyer was large and triangulate in shape and there was ample natural light from the long window running around the corner at the apex of the triangle. There were cloakrooms for both sexes open off the foyer. A Mr D.D.Young, president of the White Cinema Club, who presided said that from the stage the auditorium reminded him of a Transatlantic liner wending it’s way through the Ocean at night.
ABC Strand
Later, the cinema was taken over by ABC and they continued to operate it until it closed in 1983. In 1984 it became a live venue run by a Mr Ronnie Rutherford. In April 1988 it reverted back to cinema use with four screens. seating was for six hundred and forty two.
In 1999 it underwent a restoration bringing back many of its lost features and won an RIBA Architecture Award. In 2005 the cinema celebrated its seventieth birthday with a screening of A Night To Remember about the sinking of the Titanic. This was shown as part of the Belfast Film Festival. In 2013 it ceased as a commercial cinema and the Strand Arts Centre was established as a not for profit charitable venture. As well as films, it hosts many live events. The cinema is one of two remaining independent cinemas in Belfast, the other being the Queen’s Film Theatre. Seating at the Stand is now listed as seating six hundred and eight.
David A Ellis ©chestercinemas.co.uk
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Park Cinema
Oldpark Road and Torrens Avenue,
Date opened: Saturday 12th December 1936
First film shown: ‘The Three Musketeers”
Date Closed: 27th May 1972
Architect: Mr T. Eager
The Park cinema Oldpark Road and Torrens Avenue, Belfast was built on a triangular site and was one of a great number of cinemas in the city,opening its doors on Saturday 12th December 1936, with a Charity performance of ‘The Three Musketeers”. This was followed on Monday 14th December with Errol Flynn in ‘Captain Blood’. From the Thursday, ‘Follow The Fleet’ with Fred Astaire and Ginger Rogers was screened.
Proceeds of the two opening performances went to the Lord Mayor’s Coal Fund. It was reported that the fund was going to be a record and the generous support given by cinema proprietors in the city was a big factor in that success. It was Belfast’s fortieth cinema. It was owned by Supreme Cinemas Ltd, and was opened by the mayor of Belfast Sir Crawford McCullagh.
The cinema was built in record time, taking only four months to construct. It was designed by a Mr T. Eager. Sir Crawford McCullagh said: “I opened the first picture House in Belfast a good many years ago when I was Sheriff and I have been opening others ever since.” He went on to congratulate the builders McIntyre Estates Co from the Antrim Road Belfast. On the same day the Park made its debut the Curzon and Broadway cinemas opened their doors. The stalls were approached directly from the lower foyer, which was on the large side. There were two staircases leading to the balcony lounge. Seating was for 1200 and all the seats were tip up. There was ample leg room provided with a gap of three feet between rows. The lower foyer had floor of Roman Stone terrazzo. Elsewhere the theatre was carpeted luxuriously and was coloured in a shade of rust red, which went with the golden brown of the upholstery of the seating, which was supplied by Lees, Hyman and Lees Ltd, Corporation Street Belfast.
Plastic paint was used extensively. The walls in the foyer were in shades of cream, gold and pink, relieved by horizontal lines of silver. The base of the walls were in darker tones, and horizontal lines of gilt were in contrast with the lines of silver above. The ceiling and the tabs were silver. The proscenium opening was flanked by grilles, each grille in turn being flanked by a tall panel, having decorative motifs and flutes. These were in gilt. The surrounding of the proscenium was heavily silvered.
The cinema was equipped with Holophane lighting and the use of gilt and silver tones on conjunction with the Holophane gave brilliant lighting effects. Lights placed along the front of the balcony projected their rays on to the silver ceiling, which reflected the light down into the auditorium.
Up in the operating box were Kaplan projectors and Ashcraft carbon arcs, supplied by Jack Roe. The cinema suddenly closed in 1971 and re-opened on the first of May1972, but was badly damaged due to the troubles at that time and closed for good. The building remained empty and later demolished. In 2018 it was a car park.
David A Ellis@chestercinemas.co.uk
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Windsor Cinema
Donegall Road,
Date opened: Saturday 23rd March 1935.
First film shown: “Yes, Mr. Brown”, starring Jack Buchanan.
Date Closed: 1970
The Windsor cinema on the Donegal Road Belfast opened for business on Saturday 23rd March 1935. It had seating for 1,250 and would cater for people in an area that was a rapidly growing residential area, which was popularly known as the Bog meadows. Proceeds from the opening performance, which was ‘Yes, Mr Brown’ went to the Royal Victoria and Mater hospitals. It was stated that it was the widest cinema in the city, being sixty- two feet in breadth. The proscenium was constructed to give a beautiful rock garden effect. Steps led up to the screen, which had a sliding curtain of crimson silk.
The opening report states that the screen was made of perforated rubber. The cinema had its own electricity supply and much of the work was carried out by local labour. In 1970 the cinema closed and became a carpet warehouse. After a fire the building was demolished and in the late 1990s the site was occupied by a disable care centre.
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Forum Cinema
491-495 Crumlin Road,
Belfast, BT14 7GA
Date opened: 20th November 1937.
First film shown: “Walking on Air”.
Date Closed: 28th January 1967.
Architect: J McBride Neill.
The Forum cinema
On the 20th November 1937 the Forum Belfast run by Irish Theatres Ltd opened. It was their fourteenth cinema, seven of them in the city of Belfast. It was Situated on the Crumlin Road, and opened with the film ‘Walking on Air’. This was supported by news, comedy shorts and a Popeye cartoon. Films were shown for three days. The Monday after the Saturday opening, ‘Men Are Not Gods’ was screened.
It was the last cinema to open in the city before the outbreak of WW2. Proceeds from the first performance went to the Lord Mayor’s Coal Fund and other charities. It was described as a wonder cinema but had no balcony. It was another design by architect J McBride Neill. Building work was carried out by Sloan Brothers of Belfast. Seating, supplied by CD Harrison and Son was 1250.
The auditorium decoration was simple. Walls and the ceiling were sprayed in textured plastic paint. On the side walls was an abstract design in gold rose pink and russet. The proscenium was wide and had a surround of Reeded fibrous plaster treated in gold. The entrance foyer was forty feet wide and was approached through a vestibule and two lines of glass swing doors. The floor was terrazzo with sunk mat wells The foyer floor was covered in rubber. The auditorium ran parallel to the main road and the cafe was entered by an adjoining shop.
Power for everything in the building was provided by a generator on the premises. There were two oil engines each of fifty horse power. The electrical installation was carried out by Belfast firm Lewers, Carroll and company. They specialised in wiring cinemas.
When the cinema was twenty one years old, the chief projectionist Michael Bunting was guest of honour at the party. He was introduced on stage by the manager Mr N McLorinan, having completed twenty one years with them. Another one introduced was Mrs Margaret Maguire, who was present at the cinema’s first birthday and guessed the correct weight of a cake. The Forum closed on the 28th January 1967 and was used as a social club. In the 1990s the social club shared the property with the ABC credit union.
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Tuesday, Jan 15, 2019 11:55 AM
Three Chiefs Make the PFWA’s All-NFL Team
The Kansas City Chiefs have been well represented in the annual postseason all-pro teams that make the rounds this time of year, from those published by the Associated Press to Pro Football Focus, and the latest “All-NFL” team delivered more of the same.
The Pro Football Writers of America (PFWA), which is made up of accredited writers who cover the NFL, released their “All-NFL” team on Tuesday morning with quarterback Patrick Mahomes, tight end Travis Kelce and right tackle Mitchell Schwartz all earning a spot on the roster.
Steve Sanders
Mahomes is considered by many to be the MVP of the NFL this season after becoming just the second player in league history to throw for 5,000 yards and 50 touchdowns during a single campaign. Kelce, meanwhile, put together the second-most productive season by a tight end in NFL history with 1,336 yards through the air while Schwartz authored yet another impressive year up front.
Kansas City’s three selections were second to only the Chicago Bears, who tallied four roster spots.
Additionally, wide receiver Tyreek Hill and defensive tackle Chris Jones joined Mahomes, Kelce and Schwartz on the “All-AFC” team for a conference-high five selections.
Click here to check out the complete All-NFL, All-AFC and All-NFC teams as voted on by the PFWA.
All five of the Chiefs’ All-AFC selections will return to action this Sunday as the Chiefs take on the New England Patriots in the AFC Championship Game.
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Maharajas & Mughal Magnificence collection makes history in New York
Spanning over 500 years of history, the collection of Indian jewels and jewelled objects sells for $109.3 million
After a global tour that saw thousands of people flocking to Christie’s salerooms, a specially designed New York exhibition, and a 12-hour auction presided over by five auctioneers, the Maharajas & Mughal Magnificence collection totalled $109,271,875 / £87,138,656 in New York — the highest for any auction of Indian art and Mughal objects, and the second highest for a private jewellery collection.
Almost 400 lots were offered, ranging from legendary Golconda diamonds to dazzling coloured stones, jewelled objects used in the royal courts to swords and daggers once owned by Indian rulers. Bidders came from 45 countries, and included a significant number of institutions; full results are listed below.
‘Beginning with the sale announcement in April, there has been an overwhelming response to this exceptional collection,’ said Rahul Kadakia, International Head of Jewellery at Christie’s, after the auction. ‘Momentum has been building from the international tour to the New York exhibition culminating with the excitement witnessed in the saleroom.’
'The Arcot II’ diamond, 17.21 carats, D colour, internally flawless clarity. Sold for $3,375,000 on 19 June 2019 at Christie’s in New York
That excitement was evident from the very start as lots breezed past their high estimates: an antique diamond Rivière necklace made $2,145,000; an antique emerald bead and pearl necklace sold for $855,000; a diamond and emerald bead brooch by Bhagat achieved $399,000; a five-strand natural pearl and diamond necklace, also by Bhagat, fetched $1,695,000; a carved emerald with two interchangeable emerald and diamond mountings by Cartier realised $735,000; and a natural pearl and diamond necklace was acquired for $1,095,000.
After 150 lots, 10 had sold for in excess of $1 million. A world auction record was set for an Indian / Mughal huqqa, or water pipe at $759,000, and a folio from The Late Shah Jahan Album narrowly missed out on another when it made $615,000.
An enamelled and gem-set model of a parrot, Hyderabad, Deccan, circa 1775-1825. Sold for $1,035,000 on 19 June 2019 at Christie’s in New York
The collection featured a number of outstanding Golconda diamonds, including the Mirror of Paradise and the Arcot II. The latter, which has a storied past that includes the Nawab of Arcot and Queen Elizabeth II, sold for £3,375,000. The former, a rectangular-cut diamond of 52.58 carats, achieved $6,517,500. Later, an extremely rare, large portrait-cut diamond of 20.22 carats fetched $1,095,000.
As afternoon gave way to evening in New York, the bidding continued apace. An enamelled and gem-set model of a parrot, one of the main attractions on the international tour stops, soared past its high estimate to achieve $1,035,000; an elephant brooch by JAR made more than five times its low estimate at $555,000; a Belle Époque diamond jigha sold for $1,815,000; a stunning gem-set mace realised $747,000, more than 10 times its low estimate; and an antique emerald sarpech by Cartier went for $915,000.
A Belle Époque diamond jigha, 1907 and remodelled circa 1935. Sold for $1,815,000 on 19 June 2019 at Christie’s in New York
One of many star lots, an Art Deco emerald belt buckle by Cartier drew applause from the room when it sold for $1,545,000 — more than three times the low estimate. The buckle was designed for Sybil Sassoon, Marchioness of Cholmondeley, who wore it to the coronations of King George VI in 1937 and Queen Elizabeth II in 1953.
Not long afterwards, ‘The Patiala Ruby Choker’, one of the most impressive jewels from the collaboration between the Maharaja of Patiala and Cartier, fetched $975,000.
As symbols of military prowess and political authority, Indian arms and armour used in royal processions produced fierce bidding. A ceremonial sword of the Nizam of Hyderabad made $1,935,000, a new world auction record for an Indian sword, followed immediately by the Nizam of Hyderabad Necklace, which sold for the same price.
A gem-set mace, India, 17th century. Sold for $747,000 on 19 June 2019 at Christie’s in New York
Lot 277 produced the highest price of the sale — a Belle Époque devant-de-corsage by Cartier, bought for $10,603,500. Made-to-order in 1912 for Solomon Barnato Joel, who made his fortune in the South African diamond mines, it is a stunning example of the delicate ‘Lily-of-the-Valley’ setting used by Cartier at the time.
Composed of approximately 950,000 ‘Basra pearls’, emeralds, sapphires, rubies and coloured glass beads, ‘The Baroda Pearl Canopy’ almost trebled its low estimate to make $2,235,000. Moments later, an antique imperial spinel necklace did likewise, selling for $3,015,000.
As the auction moved into its final stages, an exquisite ibex-headed carved jade cup from circa 1660-1680 realised $1,095,000; an antique imperial spinel and pearl necklace sold for $1,035,000; and a pair of emerald, natural pearl, ruby and diamond clips by Cartier achieved $1,695,000.
The penultimate lot of the sale, The Shah Jahan Dagger, sold for $3,375,000, establishing the record price for an Indian jade object and the record for a piece with Shah Jahan provenance.
When the final lot — The ‘Taj Mahal Emerald’ brooch by Cartier — sold for $1,815,000, the marathon auction was 93 per cent sold by lot and 92 per cent sold by value.
The Shah Jahan Dagger (kard), North India, hilt 1620-1630. 11⅝ ins (29.7 cm) long; hilt 4⅜ ins (11.1 cm) long. Sold for $3,375,000 on 19 June 2019 at Christie’s in New York
‘This incredible collection traced the history of Mughal jewels and objects to present day,’ said William Robinson, International Head of World Art at Christie’s. ‘From exceptional daggers worn by the elite nobles and royal families of India to important jewels inspired by Indian tradition and architecture, the auction represented a significant cultural moment for Indian and Islamic art. We are delighted with the strong results witnessed across the category.’
Christie's Online Magazine delivers our best features, videos, and auction news to your inbox every week
These objects were offered from The Al Thani Collection. From next year, works of art from this encyclopedic collection will be shown at a new museum space in Paris. In addition to new acquisitions, sale proceeds will support ongoing initiatives of The Al Thani Collection Foundation which extend from exhibitions, publications and lectures to sponsorships of projects at museums around the world.
Jewellery | Auction Results
Highlighted sale
Maharajas & Mughal Magnificence
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Jewels from the royal courts of India
Related auctions
A special multi-media presentation of treasures from Maharajas & Mughal Magnificence, and the stories of the Indian royals who owned or commissioned them
Cartier and the ‘Indian style’
Stunning jewels offered from the Maharajas & Mughal Magnificence sale: a glorious fusion of aesthetic ideas from two continents
Jewelled daggers and ceremonial swords
Decorative and dangerous, the most impressive group of courtly quality weapons to come to auction in well over a generation
The diamonds of Golconda
Diamonds from Golconda in India are prized above all others, and the Mughal & Maharaja Magnificence auction presents a once-in-a-lifetime selection
Related department
Arms, armour & sporting guns
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Houston is beating Dallas at something else now
https://www.chron.com/news/houston-texas/article/Houstonians-mourn-loss-of-rock-radio-s-KLOL-1972969.php
Houstonians mourn loss of rock radio's KLOL
The day a music icon died
Houstonians mourn the loss of KLOL and its 34 years on-air
By Carol Christian, Chron.com / Houston Chronicle
Published 6:30 am CST, Monday, November 15, 2004
Neil Young once sang, "Rock 'n' roll will never die." On Houston radio airwaves, it appears to be all but gone.
Clear Channel Radio's format switch Friday at KLOL-FM (101.1) from rock 'n' roll to Spanish hip-hop and other pop styles aimed at a young Latino audience leaves Houston with just two rock stations, both also owned by Clear Channel.
KKRW at 93.7 FM, known as the Arrow, carries classic rock. KTBZ at 94.5 FM, the Buzz, plays moderate rock and bills itself as "Houston's new music alternative."
Some rock 'n' roll artists don't fit either format, said Doug Harris, former promotions director at KLOL and a listener since the station made its debut in August 1970.
Harris, 50, said he found the loss so sad that he's hosting a wake for the former KLOL on Saturday at his Houston home.
"A lot of people want to come in from out of town," said Harris, who's expecting about 100 to show up.
Now a broadcast marketing consultant for radio stations in the United States and Canada, Harris was listening to the new KLOL Saturday afternoon in his car when the Chronicle reached him on his cell phone.
"Out of disbelief, I punch (the radio button) ... every once in a while to see if it was a bad dream," he said.
Tim Reynolds of Houston's Clear Lake area, who also listened to KLOL throughout its 34-year history, said he had done the same thing.
Reynolds, a NASA contractor who works in crew training, said he didn't know which station would take KLOL's place on his dial. "I'll have to look into the alternative stations around, but they all have different formats from what 101 was," he said. "What do you do? There's just not another station out there like 101."
'No warning'
The Chronicle has received several e-mail messages and phone calls from KLOL listeners expressing various degrees of anger at the change.
"No explanation, no warning and no one in Houston, that I know, is happy about it," wrote one reader, an account representative at an area business.
Andrew Fuselier of La Porte, who works in an east Houston shop assembling heat exchangers, said by phone that the format change was upsetting to his 20 to 30 co-workers.
"It was not the same Friday without 101," said Fuselier, 37.
Longtime KLOL listener Steve Evans said he was online this weekend seeking the comfort of other classic rock fans when he learned of an Internet petition at www.rock101.info, which implores Clear Channel to "Bring Back Houston's Rock 101."
"KLOL is a radio legend — this is crazy," he said of the new Spanish music format.
Fewer than 100 KLOL fans had signed the petition Sunday evening.
Change is common
Former disc jockey Dayna Steele Justiz , who was on the air for about 13 years, beginning in the 1980s, said many former listeners had called her to find out what happened.
"The station has incredible loyalty," she said. "I haven't been on the air in 8 1/2 years, yet my phone's been ringing for 24 hours."
Although Justiz said she didn't know exactly why the change occurred, she noted that change is common in the radio business.
"There are not many stations anywhere that can say they were the same format for 34 years," she said. "Radio years are similar to dog years, but even shorter."
Among the oldies
Unlike with many stations, Justiz said, KLOL personalities were well-known around town and stayed a long time. Among them were the morning duo Stevens and Pruett ( Mark Stevens and Jim Pruett , 1991-2000) and "Outlaw" Dave Andrews , from 1993 to the close.
"With radio today, you can pick up any station and plop it down in any city and no one would notice," said Justiz, a 45-year-old mother of three and president of an online business she started. "They're all playing the same thing, giving away the same thing."
What happened at KLOL was probably an inevitable result of music trends, said Joseph A. Kotarba, professor of sociology at the University of Houston.
Kotarba, who has taught about rock music for 20 years, said the traditional audience for hard rock and heavy metal has decreased since the 1980s. That audience is not as lucrative for radio stations and their advertisers as the quickly growing, young Latino audience, he said.
"Traditional hard rock is falling into the category of oldies," he said.
That means the music will be heard from time to time but with less and less talk about who the performer is, where the band is touring and so forth, Kotarba said.
"Hip-hop dance music, techno and various other styles of pop music are taking over in popularity," he said. "So that is what radio stations like the ones owned by Clear Channel go for. Everyone wants a more lucrative segment of the population."
Being part of the change can be painful, Kotarba said.
"There's a real sadness when one sees the style of music one grew up with fall into that neverland of the oldies bin," he said. "It's no longer fashionable. That hurts and contributes to a sense of aging."
What's a heavy-metal fan to do?
Some will turn to satellite radio and cable TV stations that play music, Kotarba said. Another increasingly popular source is legal downloading from the Internet, he said.
Perhaps most important, Kotarba said, rock devotees will continue doing what they've done for years — go to concerts.
carol.christian@chron.com
Texas town cracks list of 50 worst-run cities in America
Texas inmate who gouged his eye out with a plastic spoon suing over understaffing
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Subsidence is a serious problem
Subsidence in peat and clay soils specifically in the western part of the Netherlands is developing faster than had previously been assumed.
This is illustrated in the new Subsidence Map of the Netherlands, presented this week by the Netherlands Centre for Geodesy and Geo-Informatics (NCG).
Especially 'shallow' subsidence turns out to be far greater than had been anticipated until now, and occurs particularly in peat and clay soils. The drought this past summer only accelerated this process, causing cracks to appear in some homes.
The shallow subsidence has been determined for the first time using satellite and gravitational measurements, states the press release from Delft University of Technology, where the map was compiled.
The ground is subsiding at the points marked in red (0.5 cm) and yellow (0.1 cm). In the province of Limburg, the ground is rising (blue), thanks to the discontinuation of mining operations many years ago.
Until now, the soil map has been drawn up using manual gauging: Rijkswaterstaat sent out surveyors to carry out roadside measurements with their instruments. The new, interactive map, drawn up under the direction of professor in Geodesy and Satellite Earth Observation Ramon Hanssen (NCG / Delft University of Technology), uses satellite radars, GPS and gravitational measurements. The new map is thus not based on a ‘paltry’ 35 thousand data points, but on no less than 31 million. Another major difference is that surveyors only carry out new measurements once every ten years, while the satellites do this every single day.
Anyone may consult the map on the website bodemdalingskaart.nl, and it is kept up-to-date on a daily basis with new satellite measurements.
The map also shows where oil and gas is being extracted. This should also clarify whether or not reduced natural gas extraction in Groningen will bring a halt to the subsidence there.
According to the map's compilers, climate change is a major cause of the increased subsidence. This is especially true for the low-lying peat soils in Holland and the northern provinces. The combination of dewatering by agriculture and the dry summer has resulted in extremely low groundwater levels. Drained peat soils 'burn' with oxygen. This peat oxidation process not only accelerates subsidence, but also releases more CO2. At some spots in the west of the Netherlands, the ground is subsiding faster than in the natural-gas extraction areas in Groningen, say the researchers. Moreover, the subsidence is going faster than the sea-level rise, at up to half a centimetre per year in some locations. If no measures are taken, then by 2050 the soil will be as much as half a metre lower than today.
The extremely low groundwater levels also have consequences for older buildings and dwellings built on wooden piles: when they dry out, they rot. But nature reserves are also affected: they are drying out as the water is flowing to lower-lying and desiccating areas of peat soils.
According to Hanssen, we are talking about a serious problem. ‘If subsidence continues at this pace, it could mean the end of the characteristic Dutch landscape with meadows, cows and windmills, or enormous damage to historic town centres,’ he says in a press release from Delft University of Technology. The damage could amount to as much as 22 billion euros.
Peat oxidation is an irreversible process. Water authorities can only prevent the subsidence continuing at the current rate by maintaining water levels more consistently and anticipating periods of drought, suggests Hanssen.
Two years ago, the Netherlands Environmental Assessment Agency had already warned about the high costs of subsidence in peaty areas (read: 'Subsidence means high costs').
Nearly 10% of the territory of the Netherlands is peaty soil. Earlier this year, a group of experts launched an initiative to prevent the Frisian peaty soils from disappearing completely over the coming decades (read: 'The impending demise of the Frisian fens'). They argue for flooding a portion of the fens.
Opening photo: Platform Slappe Bodem/Vincent Basler
IJmuiden sees CO2-efficient steel process depart to India
Robot harness helps patients to walk again
New needle reaches deep into the body
Plastic catcher facing problems at sea
Lobby for circular education
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Pecinovsky, Greene lead B-W
Caitlyn Pecinovsky of Hartley and Jenny Greene of Thomas Worthington will lead the Baldwin-Wallace nto the NCAA Division III women's tennis tournament this weekend.
It it the third time in the last four years B-W will be in the tournament.
Pecinovsky, a junior, won the OAC No. 1 singles and No. 1 doubles championships. Pecinovsky is 15-9 in singles, including 10-1 in the Ohio Athletic Conference.
"Caitlyn is one of the best singles players in the OAC," B-W coach Jack Bethlenfalvy said. "She is a talented young lady, both in the classroom and on the tennis court. Caitlyn is our team leader."
Greene won the OAC No. 2 singles championship and the No. 2 doubles championship.
"Jenny has just improved throughout the season and gives a strong No.2 player," Bethlenfalvy said. "She also is a strong student in the classroom and is a very consistent player on the court."
Pecinovsky has a 3.8 average in psychology. Greene has a 3.1 in education and mathematics.
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City System (1e)
It is called the City of Splendors: Waterdeep, most populous of the cities of North. It is a city of wealth, adventure, and danger. More men have died in its taprooms and bars than in all the sieges of Dragonspear Castle. Success and death lurk in its shadowed entranceways and dimly -lit streets. Come explore the greatest city of the Realms in this incredible product dealing with urban fantasy adventures.... [click here for more] Wizards of the Coast $4.99
Forgotten Realms Campaign Set (1e)
The Forgotten Realms Campaign Set ESD contains two books and four maps. Two of the maps are drawn to provide a general overview of the Realms, running from the Moonshae Isles in the west to the land of Thay in the east, and from the Spine of the World Mountains in the north to the Jungles of Chult in the south. The other two maps are detailed blow-ups of sections of the former maps, covering that... [click here for more] Wizards of the Coast $9.99
I9 Day of Al'Akbar (1e)
"The land of Arir - a once peaceful desert country, dotted with oases, teeming with caravans - fell into the hand of infidels. The ruler, the dearly loved Sultan Amhara, was killed in the battle for the capital city of Khaibar. He left behind one of the greatest treasure stores ever amassed - jewels and coins, more than anyone had ever seen before or since - and in addition, the Cup and Talisman... [click here for more] Wizards of the Coast $4.99
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Spring 2010 ›
Tales of a Film Festival Hustler: On the Road with 'Beyond the Call'
By Adrian Belic
Traveling the film festival circuit for the past three years with my documentary Beyond the Call took some adjustment, but not much. After 18 months of living in my studio editing the film, I was ready to live anywhere else. I committed myself to a life on the road and allowed myself to go where my film would take me.
I gave away my favorite ivy plant that covered my entire bedroom, a homage to a Where the Wild Things Are book illustration. I simplified the rest of my life and focused my creative attention on the potential journey ahead. When Beyond the Call was invited to premiere at the Tribeca Film Festival, I had a good feeling. "Here we go again--maybe," I thought.
It was at the 1999 Sundance Film Festival, with our first documentary feature Genghis Blues, where my brother Roko and I were introduced to the film festival circuit, and we loved it! We were newbie 20-somethings, we had never gone to film school, we shot on our Hi-8 camera from college and we made Genghis Blues because it sounded more interesting then going to film school.
Surrounded by a small group of talented, experienced and passionate mentors to guide us, we found ourselves riding the first waves of digital filmmaking and the early renaissance of independent distribution. With an exponentially fast crash course in promotion and figuring out who was our audience moment by moment, we positioned ourselves between Buena Vista Social Club and The Blair Witch Project. It was an amazing rocket ride full of adventures, experiences and lessons.
By 2006, it was clear that those heady days of big payday distribution deals were quickly fading, and I was coming back on the festival circuit with Beyond the Call, just as the market was flooding with war documentaries from Iraq and more from Afghanistan. I knew it would take a lot of creative hustle and effort to make it, but I believed in the film and the film believed in me.
It is not just that I believed in the film; it was more that I saw its powerful, broad potential: An Indiana Jones-meets-Mother Teresa adventure in which three middle-aged men--former soldiers and modern-day knights--travel the world delivering life-saving humanitarian aid directly into the hands of civilians and doctors. Ed Artis, James Laws and Walt Ratterman inspire through deeds, not words, in some of the most dangerous yet beautiful places on Earth: the frontlines of war.
From the moment I began learning about these men and their story, I could clearly see the very large potential audiences. I also quickly developed different angles and themes within the film's story that I could present to different segments of the audiences in different ways. I began to do this even before the shooting started.
I saw that the stories I told about the film resonated with numerous audiences, and I began to refine and broaden the potential audiences. It was also during this early time that I began to build the fans and facilitators that have championed the film on the festival circuit and throughout distribution.
I survived financially like most artists throughout history. I freelanced when I was not touring with the film, and even sometimes when I was. To a lesser degree, there were screening fees, speaking honoraria and a few cash awards. I focused my creative abilities as much on spending as I did on earning. I lived a financially humble life at home and never traveled to a film festival without my travel expenses being covered by someone else.
As we all know, few film festivals offer hotel accommodations and even fewer extend plane tickets, especially to documentary filmmakers. For the festivals that I really wanted to attend and who did not initially offer to cover my expenses, I would work with them. I would explain to them how having me there would be worth more then the cost of getting me there. I would show the festival how it could use me and the film to reach out to broader audiences in their community. Where most festivals drew a middle-age to young progressive audience, with Beyond the Call we could reach out to seniors, conservatives, military veterans and active personnel and their families, to name a few. At a time of hyper-polarization, I would present my film and its stars as a way to bring different groups together around a common human desire to help people. I would offer to work with the festivals to help them reach out to these demographics.
About half the time, the film festivals were not open-minded enough to see the benefit of having me there, or were too busy to bother trying, so I would directly contact organizations and people in the city where the festivals were to find other sponsors to help get me there and put me up during the festival.
I would present a similar pitch to the organizations, institutions and groups as I did to the festivals. I would highlight the benefits of helping the arts in their community. I would also offer to meet with their members and give talks, visit schools and speak with young people, and do interviews with the media about how I was working with this group or that organization to bring art and artists to the community. I would find travel support from universities, local businesses, veterans groups, service organizations like Rotary Club International and even wealthy individuals who offered funds or airline or hotel points to cover my expenses.
I have met many filmmakers who would hear how I do what I do, and in exasperation, would say they could never do this. I would reply, enthusiastically, "Wow, so when you were making your film, everything simply came to you with a bow on it? Wow, you're so lucky! I want to work with you!" They would look at me in a strange way, and then I would look at them seriously and say, "I am not doing anything more than any of us have done to make our films, and I am not about to stop now. I have spent too much of myself, and too many people have given me too much to make the film to drop the ball now. Plus, I'm having a lot of fun!"
Everywhere I traveled, I carried Beyond the Call DVDs, and I would creatively mention at some point in every appearance that I had only a few of them with me. I would say something like, "My Hollywood friends have told me not to sell the DVDs until they are officially released, but I am having such a great time in your town/country that I'm not going to listen to them today. If anyone wants to take home a few to share with friends or see it again, I've got some here in my bag. It would be great if I could receive $20." Then I would quietly add, "It's a sliding scale, if you really want one and don't have $20." And then I'd conclude, with a smile, "If you can contribute more, I would greatly appreciate it. It goes to funding my and my brother's next film."
I would usually sell to about 20 percent of the audience. Very few would give me less then $20, and on occasion I would receive more. I would give the generous donors a second DVD and suggest they give it as a gift. One never knows where a DVD can travel, in the hands of a passionate fan. My brother and I learned that in a big way with Genghis Blues. Often my profit would be around what I would earn with a screening fee.
And all along, as I traveled the world with Beyond the Call, I was looking for other opportunities to screen the film. I was connecting with audiences, meeting community leaders, learning from people, learning more about Beyond the Call and the many ways it touches people. I was also learning about the world, hearing stories and meeting people, including fellow filmmakers, for potential future films. I was making connections that could assist not only in getting Beyond the Call out into the world, but in helping me travel with the film as well.
Beyond the Call has now screened at over 150 film festivals on five continents, winning more then 50 awards. We have screened at the Landmark, Laemmle and other independent theaters across the US, and aired nationwide on PBS' Independent Lens. I have traveled to many of the festivals, hopping four continents--collecting not only frequent flyer miles, but stories to last a lifetime.
When people ask if I knew that this was going to happen with Beyond the Call, I respond, "No more then I did with Genghis Blues." But I add, "What I was sure of was that I believed both films could do great things. I simply had to work hard and creatively assemble things so that my dreams became my reality."
When people comment that I have a great job or career, I clarify, with a smile, and say, "I have a great life."
Adrian Belic is a filmmaker based in Los Angeles
Doc Funding and Climate Change Highlight TIFF Conference
This Is England: Sheffield Doc/Fest Holds Forth as Northern UK Destination
Hot Springs Eternal--Well, for Ten Years, at Least
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Environment / Politics
Conservation Colorado grades state lawmakers on environmental issues
Posted By Faith Miller on Tue, Jul 9, 2019 at 5:22 PM
Tony Webster via Flickr
Back in May, we reported on nonprofit Mental Health Colorado's release of its 2019 legislative scorecard, which assigned scores to state lawmakers based on how they voted on mental health-related bills.
If voting records on environment-related legislation (such as the notorious "oil and gas bill," Senate Bill 181) play a role in whom you choose to help elect, you also might appreciate this scorecard from Conservation Colorado.
The Denver-based nonprofit gave state lawmakers "scores" based on how they voted on "priority bills that affect Colorado’s land, water, climate, and communities." (Conservation Colorado isn't affiliated with a political party.)
The rankings are based on five bills related to "climate and clean energy," the oil and gas bill, two transportation bills, and five bills related to "land, water and wildlife." Most were approved by lawmakers and signed into law by Gov. Jared Polis, a Democrat.
Environmental issues appear to be more polarizing then mental health, based on a comparison of the two scorecards. While Mental Health Colorado assigned scores across the spectrum, most lawmakers got either an A+ or an F when it came to conservation.
Spoiler alert: Three El Paso County Republicans (Tim Geitner, Dave Williams and Shane Sandridge) got big, fat zeroes from Conservation Colorado. For voters who don't like environmental regulations, that could, of course, be a good thing.
Here's a handful of included bills you maybe haven't heard of (and you can view the rest at Conservation Colorado's website):
• House Bill 1026: "Parks and Wildlife Violations of Law" increases fines for violations of laws enforced by Colorado Parks and Wildlife — such as possessing live wildlife without a license, fishing without a license, or hunting without a hunter education certificate. It also changes the way fine revenue is distributed.
• House Bill 1050: "Encourage Use of Xeriscape in Common Areas" prevents homeowners associations from prohibiting drought-tolerant landscaping in common areas. (There's already a law protecting individual property owners in HOAs who want to xeriscape.) It also requires special districts to allow such landscaping in open space and park land.
• House Bill 1113: "Protect Water Quality Adverse Mining Impacts" essentially tells hardrock mines they can’t say that water quality can be maintained only through treating water for an indefinite period; they must show that their reclamation plan will lead to an end date for such measures. They must also provide financial assurances "in an amount sufficient to protect water resources, including costs for any necessary water quality protection, treatment, and monitoring,” according to the bill's fiscal note.
• House Bill 1231: "New Appliance Energy And Water Efficiency Standards," according to Conservation Colorado, "sets new energy and water efficiency standards for many household appliances sold in our state, benefitting Colorado consumers, businesses and our environment."
• House Bill 1264: Under a conservation easement agreement, a property owner agrees to limit the use of their land to serve a conservation purpose, in exchange for a state income tax credit. This bill, "Conservation Easement Improvements," extends the state's Conservation Easement Oversight Commission and the conservation easement certification program, and makes various changes to the process.
• House Bill 1314: "Just Transition From Coal-based Electrical Energy Economy" creates the "Just Transition Office" to provide benefits for former employees of retired coal plants, award grants, and receive utility reports related to coal plant retirement.
• Senate Bill 181: "Protect Public Welfare Oil & Gas Operations" makes major changes to the way the oil and gas industry is regulated in Colorado. It grants local governments broad powers to regulate oil and gas operations, including to “zone land use for mineral resource development, to site, monitor, and inspect oil and gas facilities, and to impose fees and fines,” according the bill’s fiscal note.
• Senate Bill 236: This bill, "Sunset Public Utilities Commission," will "help Colorado’s Public Utilities Commission — the regulatory body responsible for determining which resources to use to power Colorado’s grid — drastically reduce these emissions by directing utilities in the state to generate more carbon-free electricity and consider the 'social cost' of carbon when planning future energy projects," according to the nonprofit. The bill requires a $1.1 million appropriation to multiple state agencies.
Here's how El Paso County legislators scored, on a 100-point scale.
• Rep. Terri Carver (R): 15
Carver opposed all of the bills except HB 1026 and HB 1113.
• Rep. Tony Exum (D): 100
Exum was excused for HB 1231, HB 1314, SB 236 and HB 1264, but voted for all of other the bills.
• Rep. Tim Geitner (R): 0
Geitner opposed all of the bills.
• Rep. Lois Landgraf (R): 8
Landgraf opposed all of the bills except HB 1050. She was excused for HB 1026.
• Rep. Larry Liston (R): 15
Liston opposed all of the bills except HB 1264 and HB 1050.
• Rep. Shane Sandridge (R): 0
Sandridge opposed all of the bills.
• Rep. Marc Snyder (D): 100
Snyder voted for all of the bills.
• Rep. Dave Williams (R): 0
Williams opposed all of the bills.
• Sen. Bob Gardner (R): 8
Gardner opposed all of the bills except HB 1264.
• Sen. Owen Hill (R): 8
Hill opposed all of the bills except HB 1264.
• Sen. Dennis Hisey (R): 17
Hisey opposed all of the bills except HB 1264 and HB 1050.
• Sen. Pete Lee (D): 100
Lee voted for all of the bills.
• Rep. Paul Lundeen (R): 8
Lundeen opposed all of the bills except HB 1264.
Tags: Conservation Colorado, Mental Health Colorado, environment, oil and gas, Jared Polis, legislative scorecard, Tony Exum, Tim Geitner, Shane Sandridge, Marc Snyder, Dave Williams, Pete Lee, Image
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Environment / Health / Outdoors
Bike to Work Day is June 26
Posted By J. Adrian Stanley on Mon, Jun 24, 2019 at 5:30 PM
Allen Beauchamp
Mayor John Suthers and police officers were among those to participate in the 2018 Bike to Work Day.
Colorado Springs' Bike to Work Day is June 26, and there are plenty of reason to press your feet the pedals — starting with your stomach. The event, for which the Independent is a sponsor, features over 30 locations for cyclists to get a free breakfast including local businesses with yummy offerings. (Find yours on the map!)
You don't have to register to get breakfast, but you are encouraged to: It's a way for the city to judge how many people are getting out on their bikes and that factors into a lot of decision-making on how best to accommodate cyclists. You can register as late as the morning of Bike to Work Day!
Feeling nervous about your route? Check the city's bike map to figure out the safest way from home to work.
By the way, Bike to Work Day is just one of many events for Bike Month. So be sure to check out the other happenings.
Here are some tips to keep you safe on the road:
Under state law bicyclists are considered vehicles, however, they are much more vulnerable on the road. Please consider the following safety suggestions to help make for a pleasant ride to work that morning.
• People get around our city on foot, in car, by bus, on bikes and wheelchairs. Let’s be mindful so that we all arrive safely.
• Always wear a helmet.
• Always signal when riding on the road and obey all Colorado traffic laws.
• Be visible and alert to surroundings.
• Respect and be considerate of others on the roads and trails.
Want to hit a Happy Hour on the ride home and get a special deal? Here's the list:
Stop at any one of the local breweries listed below for a special deal as you bike home from work:
• Brass Brewing Co. (318 E. Colorado Ave), $1 off beer all day, $2 off beer during Happiest Hour (4-7 p.m.)
• Brewer’s Republic (112 N. Nevada Ave), $1 off beer all day, $2 off beer during Happiest Hour (4-7 p.m.)
• Cerberus Brewing Co. (702 W. Colorado Ave), $1 off beer all day, $2 off beer during Happiest Hour (4-7 p.m.)
• FH Beer Works Downtown (521 S. Tejon St), $1 off pints for riders
• FH Beer Works East (2490 Victor Pl/ Rock Island Trail & Powers), $1 off pints for riders
• Goat Patch Brewing Co. (2727 N Cascade Ave, #123/ Lincoln Center), BOGO for riders
• Local Relic (320 S. Weber St), ½ off first flight or full pour, plus BOGO select bottles
• Peaks N Pines Brewery (4005 Tutt Boulevard 80922), BOGO for riders
• Phantom Canyon Brewing Co. (2 East Pikes Peak Avenue 80903), free pint with purchase of an appetizer ($10 minimum)
• Storybook Brewing Co. (3121A, N El Paso St), BOGO for riders on BTWD, 10% off for riders all year
• Tap Traders (3104 N Nevada Ave #100), BOGO for riders on BTWD
• Trails End Taproom (3103 W. Colorado Ave), 15% off beer pours for riders
Tags: Bike to Work Day, bicycle, breakfast, happy hour, food and drink, outdoors, Bike Month, Image
Environment / Local Government
City tries "gutter bins" to keep cigarette butts out of creek
Posted By Faith Miller on Wed, Jun 19, 2019 at 3:38 PM
"Gutter bins" are shaped like giant socks.
To keep pollution out of waterways, city staff are thinking outside the box — and have their minds in the gutter.
In May, the city installed "gutter bins" in three downtown locations. The sock-like devices catch cigarette butts, pieces of Styrofoam coffee cups or whatever else people happen to discard that would otherwise flow down the gutter and, eventually, into the creek.
"The other day we pulled about 15 pounds out of one of them," says city stormwater specialist Jerry Cordova. "...We actually found a brand-new softball."
Cordova's team plans to try out the three bins for a while and possibly add them later in other parts of the city. The devices, manufactured by environmental technology company Frog Creek Partners, come with a price tag, but the bin lids are customizable — so companies who want to "sponsor" a gutter bin could have their names etched on the top, Cordova adds.
"This is one opportunity to [improve the water quality] without making a huge investment up front: Try it, see how it works and we can always scale this larger," he says.
Cordova also runs the Adopt-A-Waterway Program, which allows businesses and organizations to "adopt" a stretch of creek by keeping it clean in exchange for getting their name on a sign. And the city's Creek Week event draws hundreds of volunteers to clean up trash along Fountain Creek each fall.
While volunteers in those two programs can see the immediate difference that picking up trash for a day or two makes, Cordova points out that small pieces of litter accumulated over time can also harm the creek ecosystem.
The "gutter bin" lids are customizable.
When someone walking downtown sees a cigarette butt discarded on the sidewalk, they may think, "Oh it's just a cigarette butt," Cordova says.
"But think about all the health warnings that you see about cigarettes and the dangers of smoking. ... Well, all those toxins get stuck in that little filter, that cigarette butt — so when that gets into our water, it's been leaching those chemicals into the water."
What's more, he says, fish will often eat cigarette butts floating on the water, and water fowl nibble them up while pecking at the ground for food.
"It seems like something small, but little things can make big differences, positive or negative, and so that's why we wanted these filters to capture those little pieces that many people overlook," Cordova says.
Tags: Jerry Cordova, Adopt-A-Waterway, Creek Week, gutter bins, stormwater, Image
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Environment / Health / Military
Air Force diverted $66 million from other projects for PFAS cleanup
Posted By Faith Miller on Mon, Jun 17, 2019 at 6:06 PM
U.S. Air Force/Eddie Green
Military firefighting foam once used at Peterson Air Force Base contaminated the drinking water in Fountain and Security-Widefield.
In March, the top Democrat on the Senate Environment and Public Works Committee asked the Department of Defense for details about funding diverted from other projects to pay for cleanup and testing for PFAS, a toxic group of man-made chemicals used in military firefighting foam.
On June 5, the DoD responded to Sen. Tom Carper of Delaware by acknowledging that the Air Force had diverted $66.6 million from other projects to pay for PFAS-related efforts. The Army and Navy did not have to divert any funding, according to the DoD's letter.
Many of the projects put on hold involved cleaning up other pollution at former Air Force sites.
They included a $37 million landfill cap repair and soil remediation project at Galena Air Force Station in Alaska, a $8.6 million radiological cleanup at McClellan Air Force Base in California, and $4.5 million groundwater bioremediation and landfill cap repair at Wurtsmith Air Force Base in Michigan.
The funding diverted from those and other projects paid for PFAS testing at 16 former Air Force installations, along with groundwater and drinking water treatment for communities around Wurtsmith, Pease Air National Guard Base in New Hampshire and March Air Reserve Base in California.
“Congress needs to ensure that the Department of Defense has the resources needed to fully address its millions of dollars—perhaps billions of dollars—in liabilities related to the DOD-related PFAS contamination in our communities," Sen. Carper said in a statement following the announcement. "Otherwise, the DOD will just keep robbing Peter to pay Paul by putting important projects on standby and stretching budgets to clean up PFAS contamination."
"Otherwise, the DOD will just keep robbing Peter to pay Paul by putting important projects on standby and stretching budgets to clean up PFAS contamination." click to tweet
Lawmakers are looking to the National Defense Authorization Act of 2020, which funds the Department of Defense, to procure more funding for PFAS testing and cleanup.
The bill already requires the DoD to phase out all firefighting foam that contains PFAS by 2023. While military installations including Peterson Air Force Base have switched to a version thought to be safer, and have stopped using the foam for training purposes, the military continues to use foam with "short-chain" PFAS chemicals, thought to be safer for public health and the environment.
On June 13, Sen. Michael Bennet, D-Colorado, introduced an amendment to the Defense Authorization Act that would reimburse water districts (including those in Security-Widefield and Fountain) for treating and mitigating PFAS in drinking water.
“In the wake of contamination, local water districts around Peterson Air Force Base took the initiative and covered the cleanup costs to ensure the safety of drinking water for residents,” Bennet said in a statement. “This amendment will ensure these districts receive the full reimbursement they deserve.”
A separate amendment filed by a bipartisan group of senators would expand monitoring and testing of PFAS, and set a deadline for the Environmental Protection Agency to develop a drinking water standard for PFOA and PFAS, two types of PFAS chemicals once found in firefighting foam.
Tags: PFAS, Air Force, Michael Bennet, Tom Carper, Environmental Protection Agency, Department of Defense, Image
Environment / Health
PFAS chemicals found in food illustrate scale of toxic problem
Posted By Faith Miller on Fri, Jun 7, 2019 at 12:35 PM
The PFAS problem just got a little scarier.
According to a leaked sampling results presented at an international conference in May, Food and Drug Administration researchers detected toxic, man-made PFAS chemicals in produce, meat, dairy, grain and seafood products across the U.S.
"This really is another blow to those who live in contaminated areas who are already experiencing negative economic impacts and fears of elevated health risks from PFAS contamination," says Jamie C. DeWitt, a pharmacology and toxicology professor at North Carolina State University.
A few days after the results were leaked, The Food and Drug Administration acknowledged it's investigating public exposure to the toxic, man-made chemicals through the food supply.
"The widespread use of PFAS and their ability to remain intact in the environment means that over time PFAS levels from past and current uses can result in increasing levels of contamination of ground water and soil," reads a recently added page on the FDA's website. "...PFAS can occur in food primarily through environmental contamination, including contaminated water and soil used to grow the food."
Advocates note that PFAS-contaminated sewage sludge, which contains waste from residential and industrial sources, could spread PFAS to soil when used as fertilizer. Currently, there are no federal regulations requiring testing of sludge for PFAS.
There are more than 5,000 chemicals in the PFAS group. Their use in household cooking products, food packaging, paints, fabrics and firefighting foam was once more widespread, but studies linking two of the chemicals, PFOA and PFOS, to serious health conditions has led to some efforts by government agencies to limit them.
Colorado recently banned the use of firefighting foam containing PFAS (except when required by the military).
And several years ago, the FDA got manufacturers of certain “long-chain” PFAS chemicals, thought to be more harmful to health and the environment, to agree to stop using them in items such as nonstick pans and packaging.
However, little is known about the health and environmental effects of newer, "short-chain" chemicals still in use by manufacturers. Some environmental advocates dispute that they are much safer.
Leaked results obtained by the Environmental Defense Fund, an advocacy organization, show that FDA researchers found PFOS — one of the more widely studied, long-chain PFAS chemicals — in approximately half of the meat and seafood products they tested from across the U.S. But the FDA determined the levels of PFOS in those products probably weren't a health concern.
However, chocolate cake with chocolate icing contained high levels of a little-studied short-chain chemical, PFPeA. That chemical was never approved by the FDA for use in products that contact food, says Tom Neltner, chemicals policy director for the Environmental Defense Fund. Neltner hypothesized that the contamination came through greaseproof paper.
"That may happen because of a loophole in the law that says the company can determine something is safe without ever telling FDA," Neltner says.
The researchers also found PFBA (a short-chain chemical once used to make photographic film) in pineapple samples, and PFHxS in sweet potatoes.
PFHxS, like PFOS, is a long-chain chemical previously used by the military in firefighting foam. Notably, residents who lived near the Peterson Air Force Base while the foam was in use recently tested for blood levels of this chemical 10 times higher than that of the general population.
The leaked results describe how PFAS in firefighting foam contaminated milk samples at a dairy farm in New Mexico near an Air Force base. Those products were determined to be unfit for consumption and discarded.
Finally, according to the leaked presentation, the researchers detected the PFAS chemical GenX and numerous other PFAS in samples of leafy greens grown within 10 miles of a PFAS production facility in the eastern United States — though they determined those levels probably did not constitute a health concern.
Tags: PFAS, food, Environmental Working Group, Environmental Defense Fund, Peterson Air Force Base, firefighting foam, Jamie DeWitt, Tom Neltner, FDA, Image
Education / Environment / Health / Media / Politics
Gov. Polis signs final bills into law, announces five vetoes
Posted By Faith Miller on Wed, Jun 5, 2019 at 3:02 PM
Faith Miller
Polis spoke about his legislative accomplishments at Pikes Peak Community College on June 5.
At a June 3 appearance in Colorado Springs, Colorado Gov. Jared Polis, a Democrat, said this year's legislative session delivered victories for health care and education.
He emphasized that 95 percent of the 454 bills he signed "were bipartisan: Republicans and Democrats working together to make Colorado better."
Polis vetoed five bills on May 31, three of which concerned state occupational licensing requirements. The vetoes drew consternation from lawmakers in Polis' own party, including Rep. Monica Duran of Wheat Ridge. Duran sponsored House Bill 1212, which would have extended a program requiring managers of homeowners associations, or HOAs, to have state licenses.
“We are greatly disappointed that the work we have done to protect homeowners’ biggest investments in their lifetime — their homes — has been undone," Duran said via a statement from the Community Associations Institute (CAI) Colorado Legislative Action Committee. CAI is an international membership organization for homeowners, HOA managers and businesses that provide services for HOAs.
“We are greatly disappointed that the work we have done to protect homeowners’ biggest investments in their lifetime - their homes - has been undone." click to tweet
"Managers of HOAs will no longer have to be licensed, which means they are not required to have background checks, demonstrate any knowledge of core competencies, show they understand Colorado HOA law or get continuing education," Duran continued.
On the other hand, Polis' vetoes drew rare approval from some conservatives.
“Governor Polis is right to veto legislation that makes it harder for Coloradans to find work," said Jesse Mallory, the state director of libertarian and conservative group Americans for Prosperity. Mallory was quoted in a statement from the group.
"Too often occupational licenses—government permission slips to work—are misused to protect entrenched interests, slamming the door on the dreams of would-be entrepreneurs," he added.
“Governor Polis is right to veto legislation that makes it harder for Coloradans to find work." click to tweet
With his veto statement, Polis issued an executive order directing the Department of Regulatory Agencies to review existing and potential laws around HOAs and their managers, and recommend strategies for "efficient and effective" regulation.
"Before any unregulated occupation is to be regulated, or any regulated occupation is to be continued, the state should complete its due diligence to ensure that regulation will, in fact, ensure consumer safety in a cost-efficient manner," Polis wrote in his veto letter. "This bill does not meet that threshold."
Similarly, Polis vetoed Senate Bills 99 and 133, which would have required licenses for sports agents and genetic counselors. Both bills were sponsored by Democrats.
"Licensing in the United States over the years has at times prevented minorities and the economically disadvantaged from having the ability to access occupations," Polis wrote.
He also vetoed Senate Bill 169, which would have made changes to the budget submission process for information technology projects, saying that it limited the governor's ability to manage state contracts.
House Bill 1305 would have given tribal governments access to state databases for conducting background checks in child welfare cases. In his veto letter, Polis said the bill contained errors that would have forced tribes to comply with state child protection requirements. So in place of the bill, he issued an executive order allowing tribal governments access to the state databases while leaving out those mandates.
"In Colorado, we respect our government-to-government relationship with the Tribes," Polis wrote. "We also are committed to making resources available to assist the Tribes in conducting their governmental responsibilities."
In other news, here's some highlights from the list of bills Polis recently signed.
House Bill 1032: "Comprehensive Human Sexuality Education" appropriates money ($1 million annually) for the state’s grant program for schools that want to add comprehensive sexual education, closes a loophole that allowed private contractors to collect government money for teaching abstinence-only classes in public schools and ends an exemption for charter schools to the requirements. It also prohibits schools that have sex ed courses from teaching religious ideology, using shame-based or stigmatizing language, employing gender stereotypes, or excluding the experiences of LGBT individuals.
Sponsors: Reps. Susan Lontine, D-Denver, and Yadira Caraveo, D-Thornton, and Sens. Nancy Todd, D-Aurora, and Don Coram, R-Montrose
House Bill 1110: "Media Literacy" creates an advisory committee to make recommendations for ways to teach K-12 students how to read news critically, and discern fake news from the real thing. It allocates $19,800 from the state's general fund to the Department of Education for this purpose.
Sponsors: Rep. Lisa Cutter, D-Evergreen, and Sen. Brittany Pettersen, D-Lakewood
Senate Bill 007: “Prevent Sexual Misconduct At Higher Ed Campuses” requires higher education campuses to adopt policies on sexual misconduct based on minimum requirements set out in the bill. It provides for oversight and requires training on the policies.
Sponsors: Sens. Pettersen and Faith Winter, D-Westminster, and Reps. Barbara McLachlan, D-Durango, and Janet Buckner, D-Aurora
House Bill 1039: "Identity Documents For Transgender Persons" makes it easier for transgender and nonbinary people to change the gender on their birth certificates (without court order, surgery or doctor recommendation).
Sponsors: Rep. Daneya Esgar, D-Pueblo, and Sen. Dominick Moreno, D-Commerce City
House Bill 1129: "Prohibit Conversion Therapy for A Minor" prevents licensed mental health and medical professionals from attempting to change a minor’s gender identity or sexual orientation through therapy. Democrats, who won control of the Senate last fall, were finally able to pass this bill on the fifth annual attempt.
Sponsors: Reps. Dafna Michaelson Jenet, D-Commerce City, and Esgar, and Sen. Stephen Fenberg, D-Boulder
House Bill 1176: The "Health Care Cost Savings Act of 2019" creates a task force to analyze the costs of alternative health care financing systems, such as single-payer, and make a report to state legislators. Polis signed the bill, but noted his concern that the bill's appropriation (around $100,000) wouldn't be enough to hire an analyst. He directed the Department of Health Care Policy and Financing to let him know in October whether legislators should request more money next session.
Sponsors: Reps. Emily Sirota, D-Denver, and Sonya Jaquez Lewis, D-Longmont, and Sen. Mike Foote, D-Lafayette
House Bill 1279: "Protect Public Health Firefighter Safety Regulation PFAS Polyfluoroalkyl Substances" bans firefighting foam that contains certain toxic, man-made chemicals: those classified as per- and polyfluoroalkyl substances, better known as PFAS. (An amendment to the bill makes an exception for when PFAS-containing foam is "required for a military purpose.") The bill also requires manufacturers to disclose when personal protective equipment contains PFAS.
Sponsors: Reps. Tony Exum, D-Colorado Springs, and Lois Landgraf, R-Colorado Springs, and Sens. Pete Lee, D-Colorado Springs, and Dennis Hisey, R-Colorado Springs
Senate Bill 077: "Electric Motor Vehicles Public Utility Services" requires public utilities to facilitate charging stations and to support the adoption of electric vehicles.
Sponsors: Sens. Kevin Priola, R-Henderson, and Angela Williams, D-Denver, and Rep. Chris Hansen, D-Denver
COURTS AND PUBLIC SAFETY
House Bill 1324: "Strategic Lawsuits Against Public Participation" adds protections against lawsuits viewed by First Amendment advocates, media organizations and others at infringing upon free speech. Specifically, it allows defendants accused of libel or slander to ask a judge to dismiss a civil case on the grounds that they were simply exercising their constitutional right to free speech or to petition the government.
Sponsors: Reps. Cutter and Shannon Bird, D-Westminster, and Sen. Foote
Senate Bill 179: "Enhance School Safety Incident Response Grant Program" adds funding to an existing state program, which funds nonprofit-led school safety training for law enforcement and school districts. The bill appropriates $1.16 million to the Department of Public Safety for the program.
Sponsors: Sen. Lee and Rep. James Wilson, R-Salida
Tags: Jared Polis, vetoes, Assembly, Legislature, Dominick Moreno, Daneya Esgar, Monica Duran, Jesse Mallory, Americans for Prosperity, Brittany Pettersen, Pete Lee, Lisa Cutter, Mike Foote, Image
City Council approves Maverik gas station next to Cheyenne Creek
Posted By Faith Miller on Fri, May 31, 2019 at 4:53 PM
Maverik’s Fillmore Street location opened in 2018.
City Council voted unanimously May 28 to approve a gas station and convenience store in a streamside overlay zone, despite protests from Ivywild residents over traffic and environmental concerns.
Related Maverik pushes for (prohibited) fuel sales in streamside overlay
Maverik pushes for (prohibited) fuel sales in streamside overlay
By Faith Miller
The project, which will be Maverik's third location in Colorado Springs, was approved by the Planning Commission in April at the recommendation of staff. City Council's approval was also required because the company had to apply for a variance to vacate an existing alleyway on the project site at Tejon Street and Motor Way.
But the more contentious issue to residents was another variance allowing a gas station next to Cheyenne Creek, in a streamside overlay zone where city code explicitly prohibits convenience stores with fuel sales.
At the City Council meeting, city planner Matt Fitzsimmons defended the project, explaining that none of the gas station components would be inside the streamside buffer zone 70 feet from the creek.
As part of the site itself falls within that buffer, the entire property is also designated as streamside overlay. That designation will require Maverik to make improvements along the creek by adding a trail and vegetation.
Maverik representatives argued that their state-of-the-art system for trapping runoff and fuel spills, including detention basins and triple-walled pipes, would keep contaminants out of the water. They also cited a traffic study that found most customers would come from adjacent streets, and wouldn't go out of their way to visit the store — meaning traffic wasn't likely to increase by much.
But for Valerie Fix and her son, Alexander Fix, both of whom testified at the meeting, those statements were dubious.
"Though they assure us they have the best of facilities and detention basins, even the best of detention basins could not stand up to a flood," Alexander Fix said, pointing out that the property is downhill from the rest of the neighborhood. He added that the city should wait until a different traffic study for the area is finished before approving new development.
"I support infill and smart development in our communities. This is just the wrong thing in the wrong location," Valerie Fix said. She recounted a recent episode in which one of Maverik's underground fuel tanks at its store in Lander, Wyoming, leaked into the Popo Agie River. The company was ordered to make repairs and pay $1 million on top of the $1 million provided by a financial assurance account, K2 Radio reported in April.
Landscape architect Chis Lieber countered that the improvements Maverik has made to its system since then would prevent such a situation from occurring in Colorado Springs.
While the Fixes were the only two people who testified against the project at the meeting, Fitzsimmons said he received 30 letters from residents opposing the project, and just three letters from people supporting it.
Eric Wyatt, who said he had lived in the area for 50 years and owned 13 local properties, argued in defense of the Maverik store.
"Going inside of the Kum 'n' Go convenience store and the Maverik convenience stores, I really notice the Maverik stores are a lot nicer," Wyatt said. "... I am for Maverik and what they’re doing there. I think they’re doing a first-class job, and I say a win-win."
In the end, city councilors also sided with the developers.
"I’m not crazy about the notion of a national chain, another national chain store in an area that’s kind of a strip for that," Council President Richard Skorman said. "That whole South Nevada corridor is almost all national chains, and I’m not crazy about the notion of another one, but that’s not my criteria to be able to weigh in on this."
Councilor Bill Murray said he was more worried about fuel leaks with gas stations that use older equipment than Maverik stores, which use newer fuel infrastructure.
"Make a mistake, you’re going to pay big time," he added. "And we all know that. So I’m going to support it."
Editor's note: The original version of this web story didn't include the proposed Maverik gas station's location at Tejon Street and Motor Way.
Tags: Maverik, City Council, gas station, Cheyenne Creek, Ivywild, Valerie Fix, Chris Lieber, Richard Skorman, Bill Murray, Image
Colorado Springs locals advocate for clean cars
Posted By Faith Miller on Tue, Apr 30, 2019 at 3:17 PM
From left: Retired Lt. Col. Hal Bidlack, energy consultant John Duprey, medical and public health student Jake Fox, and City Councilor Tom Strand speak in support of clean car standards.
City Councilor Tom Strand was among a group of locals who spoke out against the Donald Trump administration's rollback of clean car standards at a press conference April 24.
Strand, along with retired Lt. Col. Hal Bidlack, energy consultant John Duprey, and medical and public health student Jake Fox, urged action to oppose the move.
"I'm just asking everyone, in particular our two United States senators, Sen. Bennet and Sen. Gardner, to do what they can to ensure that these rollbacks are reconsidered," Strand said. "I think that if we continue on with the clean-car standards into the second phase that we'll in fact have more jobs in our state, we'll in fact create a much healthier environment."
The clean car standards Strand referred to were implemented under the Barack Obama administration in 2012. They were aimed at cutting down on harmful pollution from vehicle emissions, and came in two phases: 2012-2016 and 2017-2025.
But the Environmental Protection Agency and the National Highway Traffic Safety Administration have moved to roll back the initiative, freezing emission standards at 2020 levels.
Fox emphasized the public health risks of the rollback.
"In El Paso County it's estimated we have about 13,000 children, and 60,000 adults with asthma and chronic lung disease," Fox said. "When they breathe polluted air, they are much more likely to land in our emergency departments and intensive care units. It's imperative that we keep our air clean to protect these vulnerable populations in our communities."
In response to the proposed rollback last year, Colorado — along with 13 other states and the District of Columbia — will adopt its own Low Emission Vehicle Program standards for cars and trucks, modeled after California's. Gov. John Hickenlooper began that state rule-making process with a June executive order, which was finalized by a unanimous vote of approval from the state Air Quality Control Commission in November.
The Colorado Automobile Dealers Association sued the state government over the new standards in February, alleging that they would hurt working families by increasing automobile prices. Colorado Senate Republicans released a statement supporting the lawsuit.
Duprey, a local energy consultant and the owner of The e-bike Company, called such state and local environmental policies "the last line of defense for the health and the economies of our communities."
"Having clean air to breathe is a basic human right. It does not belong only to those who are wealthy enough to live in environments where they're not affected by that." click to tweet
"Colorado, D.C. and 13 other states have exercised their rights under the Clean Air Act to establishing strong pollution standards to protect our citizens and our environment," Duprey added. "Having clean air to breathe is a basic human right. It does not belong only to those who are wealthy enough to live in environments where they're not affected by that."
Retired Lt. Col. Bidlack emphasized that rolling back emission standards could increase the harmful effects of global warming.
"Back in 1998, I was asked to write the first draft of the Department of Defense's statement on the effect of climate change on the U.S. national security, and then I had two major conclusions," he said. "The first is that it will cause new conflict and the second is it will act as a force multiplier and will make other situations worse in traditional combat."
On Jan. 17, Gov. Jared Polis ordered the Department of Public Health and Environment to also develop a proposal for a Zero Emission Vehicle (ZEV) program, which would require manufacturers to supply dealers with a certain number of electric vehicles. The state's Air Quality Control Commission will decide in May whether to approve CDPHE's proposed ZEV program.
After the event, Strand expressed more caution when asked about his support for a ZEV program.
"I think that technology needs to be worked on very carefully," Strand said. "In terms of zero emissions, that's a great goal, but I don't think we ought to jump into that too quick."
Strand called himself "kind of a moderate," saying that was why he didn't mention climate change in his remarks, "because I know that there are different sides to that argument."
"But I do think that the clean car standards just make eminent good sense, that we continue along that path," he said. "And I think since we're, as a city and a state, we're kind of a right-to-rule kind of a community ... to have these things pushed down on us by either the federal EPA or the National Transportation Agency is something that I think we ought to take a hard look at."
A video of the event was live-streamed on the Facebook page of Defend Our Future Colorado, a project of the nonprofit Environmental Defense Fund. However, Ashley Lynch, a senior account executive with Resolute Consulting who publicized the event, said it was not organized by Defend Our Future or any one organization but was the product of concerned citizens coming together.
Defend Our Future, which has team members on college campuses in Colorado, Arizona and Pennsylvania, is focused on "building a diverse coalition of partners that share the goal of finding actionable and common sense solutions to solving climate change," according to its Facebook page.
Tags: clean car standards, clean cars, Tom Strand, Jake Fox, John Duprey, Hal Bidlack, Defend Our Future, Environmental Defense Fund, Image
Gov. Polis signs major oil and gas bill
Gov. Jared Polis signed Senate Bill 181 into law on April 16, setting into motion major changes to the way the oil and gas industry is regulated in Colorado.
The new law grants local governments broad powers to regulate oil and gas operations, including to “zone land use for mineral resource development, to site, monitor, and inspect oil and gas facilities, and to impose fees and fines,” according the bill’s fiscal note.
The Colorado Oil and Gas Conservation Commission will move from “fostering” the oil and gas industry to “regulating” it, and will add new rules aimed at protecting health and the environment. The law makes that a full-time, seven-member board appointed by the governor with the Senate’s approval. Only one board member can hail from the oil and gas industry.
The bill first passed the Senate on March 13 with a vote of 19-15, and passed the House on March 29 with several amendments, one of which requires that local regulations are “reasonable” in scope. The Senate approved House amendments on April 3, sending the bill to the governor's desk.
The law's opponents — who argue that it could hurt state and local economies supported by the oil and gas industry — are already seeking to recall certain elected officials that supported the bill and to overturn the new law.
Weld County Commission Chair Barbara Kirkmeyer, along with John Brackney, a former Arapahoe County commissioner, have filed ballot initiative language with the Colorado Secretary of State. Once that's approved, they'll need to gather nearly 125,000 petition signatures to refer an initiative to voters.
Their ballot initiative would remake the Oil and Gas Conservation Commission into a board selected by retired judges from a list of nominees. (Senate Bill 181 lets the governor appoint the board with the Senate's approval.)
Under the ballot initiative, the Commission would also have to adopt the rules that were in place on Dec. 31, 2018. SB181 changed those rules to protect public health and the environment.
Tags: oil and gas, Jared Polis, Oil and Gas Conservation Commission, Barbara Kirkmeyer, John Brackney, Image
Colorado Springs Utilities to add solar panels to power 30,000 homes
Posted By Pam Zubeck on Wed, Mar 20, 2019 at 3:59 PM
Courtesy Colorado Springs Utilities
Here's an aerial view of Springs Utilities newest source of renewable energy at Clear Spring Ranch south of the city. This project features 42,000 solar panels that will produce enough energy to power 3,000 homes annually. It also moves the city closer to its Energy Vision, which requires 20 percent of total electric energy be produced through renewable sources by 2020.
In the last few years, the buzz about energy locally has focused on when the downtown Drake Power Plant, powered by coal or natural gas, will be shut down for good.
We still don't have a definitive answer, beyond the official Utilities Board action to shutter the plant by 2035, but Colorado Springs Utilities is taking a significant step toward renewables in seeking to finalize a contract for 150 more megawatts of solar power.
This is in addition to an existing solar array at Clear Springs Ranch about 10 miles south of the city.
Here's Utilities' news release about the coming addition of solar panels:
Colorado Springs Utilities (Springs Utilities) is finalizing negotiations and in the coming months will award a contract for 150 megawatts of new solar generation plus a 25-megawatt battery storage system by the end of 2023. At this time, it is the largest energy storage facility announced in Colorado.
“Energy storage is an integral part of our ability to transition from fossil fuels to incorporating more renewables into our system,” says Springs Utilities Chief Executive Officer Aram Benyamin.
“We are changing the way we power the Pikes Peak region and are on a path to reduce our carbon emissions by 40 percent or more from 2005 to 2035.”
The battery project will provide the utility with valuable information about improving solar power integration and reducing the need for natural gas to maintain reliability. For this reason, the utility will negotiate an option to add more storage capacity to the battery system in the future.
“This project will familiarize us with utility-scale battery technology and give us the flexibility to seek better pricing as the technology improves and our load growth materializes,” Benyamin explains.
The battery will be used to store less expensive solar energy during the day so that it can be used during more expensive peak demand periods. With the ability to run for up to four hours at maximum capacity, upwards of 30,000 homes will be powered when the battery is dispatched.
The reduction of carbon emissions will be realized by decommissioning one of the utility’s coal-fired power plants and the addition of more solar power. Beyond the 150-megawatt project, the utility is planning to add another 95 megawatts of solar power by the end of the year.
Once all of these renewable energy projects are online, more than 95,000 homes annually will be powered by this carbon-free energy.
Watch a video of the solar array south of the city here.
Tags: Colorado Springs Utilities, energy, sustainability, Image
Environment / Health / Military / Politics
Former Fountain resident testifies on PFASs in D.C.
Posted By Faith Miller on Wed, Mar 6, 2019 at 5:43 PM
Courtesy of Mark Favors
Mark Favors, second from left, submitted written testimony to the House Oversight and Reform Subcommittee on Environment. He spoke with Rep. Alexandria Ocasio Cortez, D-New York, center, about the effects of PFAS contamination on his family. Also pictured, from left: Chet Whye, Hope Grosse and Loreen Hackett.
An Army veteran who grew up near Peterson Air Force Base was among those in attendance at a House subcommittee hearing March 6 on Capitol Hill. The subject: PFASs, a toxic group of chemicals found in household products and military firefighting foam, and their effects on health and the environment.
Lawmakers questioned representatives from the Environmental Protection Agency and Department of Defense while holding up the stories of those — including former Fountain resident Mark Favors — who have been personally affected by the military's decades-long use of the chemicals. PFASs, which researchers have linked to low birth weights, liver and kidney cancer, and thyroid problems, leached into the drinking water supply in areas surrounding hundreds of military installations around the world.
"Mark Favors is a U.S. Army veteran who had 16 family members ... diagnosed with cancer, all of whom lived next to the Peterson Air Force Base in Fountain, Colorado." click to tweet
"Mark Favors is a U.S. Army veteran who had 16 family members, 16 family members, diagnosed with cancer, all of whom lived next to the Peterson Air Force Base in Fountain, Colorado," Rep. Harley Rouda, D-California, chair of the Oversight and Reform Subcommittee on Environment, said in his opening remarks. "Several of those family members are also veterans."
The Department of Defense has taken some actions to address PFASs, including implementing a new type of firefighting foam that it says is safer for public health and the environment. And on Feb. 14, the Environmental Protection Agency revealed its long-awaited PFAS action plan, announcing it would start the process for setting a maximum contaminant level (MCL) under the Safe Drinking Water Act for two chemicals in the PFAS group, PFOA and PFOS.
Related Local family suffers heavy losses — and blames chemicals the EPA reportedly won’t limit: Bad blood
Local family suffers heavy losses — and blames chemicals the EPA reportedly won’t limit
But for many lawmakers and advocates, the steps outlined in the plan weren't enough to address the problem, and to hold the Department of Defense accountable for contamination of communities. (Read more on the plan here.)
And Congress is bringing on the pressure.
The same day as the subcommittee hearing, a group of senators signed a letter demanding copies of communications between the EPA, Department of Defense, Office of Management and Budget, and Department of Health and Human Services regarding the PFAS Action Plan and groundwater cleanup guidelines.
And Colorado Sens. Cory Gardner (R) and Michael Bennet (D) were among a bipartisan group of Senators to introduce a bill on March 1 that would require the EPA to designate PFASs as hazardous substances, making polluters responsible for funding cleanup. (An identical bill was introduced in the House in January.)
At the subcommittee hearing, Rep. Katie Hill, D-California, began her question for Dave Ross, the EPA's assistant administrator for the Office of Water, by saying she had been born on an Air Force base where high concentrations of PFAS chemicals had been detected. She asked Ross whether he, like embattled former EPA Administrator Scott Pruitt, would call PFAS contamination a "national emergency."
"We do believe it is a major national issue for EPA and our federal partners to address," Ross said, citing the agency's successful effort to get manufacturers to voluntarily pull products containing PFOA and PFOS off the market.
Rep. Alexandria Ocasio-Cortez, D-New York, told the story of a woman who grew up in Warminster, Pennsylvania near the Naval Air Warfare Center.
"[Hope] Grosse was diagnosed with Stage 4 cancer at the age of 25 years old," Ocasio-Cortez said. "Ms. Grosse's father died of cancer at 52 years of age, and her sister suffered from ovarian cysts, lupus, fibromyalgia and abdominal aneurysms. She worries that she has unwittingly exposed her own children to [PFAS] chemicals as well... Mr. Ross, do you believe that the EPA should further regulate these chemicals?"
"Yes, and that’s what we’ve stated in our action plan," Ross replied. "We have a robust plan to regulate these chemicals across a wide variety of our programs."
Rep. Ro Khanna, D-California, asked whether the Department of Defense knew how many active service members, veterans and their families had had been exposed to the chemicals.
"Our health affairs staff is going to be conducting a health study and creating an inventory of those service members that have been exposed through drinking water or occupational exposure and work in coordination with the Veterans Administration to share that information," replied Maureen Sullivan, deputy assistant secretary of defense for environment.
The hearing was held the same day that Environmental Working Group, a nonprofit advocacy organization, released an updated map with information on 106 military sites where drinking water or groundwater is contaminated with PFASs. (The Department of the Defense has said that there are 401 sites in the U.S. alone with known or suspected contamination.)
The group also released a report with several recommendations for Congress and President Donald Trump's administration.
While the problem of PFAS contamination has persisted for decades without major enforcement actions by the federal government, Congress's renewed interest could move the needle on the issue, says Melanie Benesh, Environmental Working Group's legislative attorney.
"I think Congress will continue to push the [EPA] and do everything that they’re doing now —introducing bills, holding oversight hearings — and I think the states have an important role to play," Benesh says. "State policy tends to move federal policy and tends to move marketplace actions... And then there’s a whole grassroots network of people who have been affected by these chemicals, particularly veterans and military families, and those voices really matter."
Peterson Air Force Base replaced the old firefighting foam in all of its emergency response vehicles in 2016, a spokesperson said. The new, supposedly safer formula is only used in emergencies, and not during training.
Water districts surrounding the base have changed water sources or filtration systems since evidence of contamination began to emerge in 2015.
But the spread of PFASs in drinking water left lasting effects that should have been addressed by the state, Favors argues.
"Despite having a budget surplus in 2018 of over $1.1 billion, the state of Colorado still has not
conducted a formal investigation on the scope of the PFAS contamination, conducted PFAS
blood level tests of our affected children, nor passed legally enforceable MCLs of PFAS in
drinking water," Favors, now a New York resident, wrote in his testimony to Congress.
Favors goes on to list the 10 blood relatives and in-laws he has lost to cancer, all of whom lived for years near Peterson Air Force Base.
Tags: PFAS, water, health, politics, Melanie Benesh, Alexandria Ocasio-Cortez, Mark Favors, Image
Environment / Outdoors
Fisher's Peak in Trinidad will open to the public, thanks to land purchase
Posted By Faith Miller on Tue, Mar 5, 2019 at 5:52 PM
Courtesy of The Nature Conservancy/Lauryn Wachs
Crazy French Ranch, which contains Fisher's Peak, is a 30-square-mile area south of Trinidad.
Just east of Interstate 25, a few miles north of the New Mexico border, 9,600-foot-tall Fisher's Peak is a hidden gem in plain sight.
The Trinidad landmark has long been closed to the public. But thanks to a land purchase completed Feb. 28, the peak and the ranch it sits on will open for as-yet-undefined public use within a few years.
The Nature Conservancy and the Trust for Public Land, two nonprofit organizations focused on conservation and land access, bought Crazy French Ranch and will spend the next two years or so working with the city of Trinidad, Colorado Parks and Wildlife, Great Outdoors Colorado, and Trinidad State Junior College to develop a management plan for the peak-containing property. That could include opportunities for hiking, mountain biking, horseback riding and education, says Matthew Moorhead, director of business development and strategic partnerships for The Nature Conservancy.
"We can make sure that this is a well-managed, a properly-managed natural area that protects everything living there that makes it special," Moorhead says. "At the very same time ... we’re able to provide for the kind of public recreational access that’s going to bring a cultural and economic and educational value to the citizens of Trinidad, Las Animas County and Colorado."
Great Outdoors Colorado — which invests a portion of state lottery proceeds into state parks, trails, wildlife, rivers and open spaces — has awarded a $7.5 million grant for the Fisher's Peak Project, and Colorado Parks and Wildlife has pledged an additional $7 million.
After the management plan and financing is in place, the two nonprofits will turn over the property to a local or state entity, such as Colorado Parks and Wildlife or the city of Trinidad, Moorhead says.
The project could have widespread appeal to Coloradans who might not otherwise visit Trinidad. Colorado College's 2019 State of the Rockies poll showed 90 percent of Coloradans believe the outdoor recreation economy is important to the future of their state and the Western U.S. And the town doesn't have other recreation opportunities nearby that compare with what Fisher's Peak offers, Moorhead says.
In fact, he adds, the only way the public can currently access the state land adjacent to Fisher's Peak is by first crossing into New Mexico and undertaking a difficult hike.
“The ranch embodies the amazing history of this area, we look forward to conserving that for future generations,” Trinidad Mayor Phil Rico was quoted in a statement from The Nature Conservancy. “We are also excited about the economic opportunities that public lands and recreation can bring to our community.”
Tags: Fisher's Peak, Trinidad, The Nature Conservancy, Trust for Public Land, State of the Rockies, Matthew Moorhead, public land, Image
EPA will look at regulating PFAS chemicals
Posted By Alissa Smith on Thu, Feb 14, 2019 at 12:36 PM
Doug Benevento, left, and Peter Wright, right, discuss EPA's plans to address PFAS problem.
On Feb. 14, the United States Environmental Protection Agency (EPA) held a conference in the city of Fountain to announce plans to address toxic chemicals that have been found in the area’s drinking water, and in the water of communities across the nation.
The chemicals at issue: PFASs, man-made contaminants found to have originated primarily, in the Fountain area, from firefighting foam used by the Air Force Academy for training purposes.
The EPA’s plan outlines steps to develop new analytical tools for four key areas: human health and ecological effects, significant sources of these chemicals, cost and effectiveness of treatment methods, and how best to support stakeholders. However, this plan does not include a maximum contaminant level (MCL) for drinking water, though citizens have been calling for an MCL since the EPA first toured affected areas in 2018.
Representatives from the EPA, regional administrator Doug Benevento and senior counsel to the administrator Peter Wright, said they were bound by the processes put in place by the Safe Drinking Water Act, and had to undergo certain legal steps to declare an MCL and recommend treatment, such as gathering data and undergoing a period of public comment.
The EPA has started this process to set an MCL for two types of PFASs (PFOA and PFOS). By the end of 2019, they hope to propose a regulatory determination for establishing an MCL for both — it may take longer to actually establish that MCL, but they do not have a solid timeframe.
They also announced that the EPA has already issued direct enforcement orders in eight instances of contamination, and have begun steps toward regulating PFASs as dangerous chemicals. They plan to issue groundwater cleanup recommendations soon, but offered no solid timeline.
(You can watch the full presentation on the EPA for Region 8’s Facebook page. Dough Benevento takes the podium for opening remarks at 39 minutes in.)
If all of this strikes you as less than a firm plan, you're not alone. The Environmental Working Group released a statement that read in part:
The Environmental Protection Agency’s so-called PFAS management plan would only make the nationwide crisis of pervasive pollution from fluorinated compounds worse, EWG said.
The plan from the Trump EPA, released today, would not stop the introduction of new PFAS chemicals, end the use of PFAS chemicals in everyday products, alert Americans to the risk of PFAS pollution or clean up contaminated drinking water supplies for an estimated 110 million Americans.
Instead, it perpetuates the agency’s record of foot-dragging on establishing meaningful protections against a class of chemicals linked to cancer, thyroid disease and weakened childhood immunity, among other serious health harms.
The release goes on to lay out what the EWG believes the EPA ought to do to address PFASs and protect the public. Read the full release here.
Tags: EPA, PFAS, Air Force Academy, health, environment, government, Image
Environment / Outdoors / Politics
Senate votes to reauthorize Land and Water Conservation Fund
Posted By Faith Miller on Wed, Feb 13, 2019 at 10:22 AM
National Park Service Photo/ Walker Hall
The Land and Water Conservation Fund paid for more than $8 million in projects in Rocky Mountain National Park, according to the Land and Water Conservation Fund Coalition.
The U.S. Senate has passed a massive public lands package that includes legislation to permanently reauthorize the Land and Water Conservation Fund.
The package, Senate Bill 47 — which encompasses more than 100 bills addressing land exchanges, national parks, wildlife conservation, recreation and more nationwide — soared through on a vote of 92 to 8. It now goes to the House for consideration.
Colorado Republican Sen. Cory Gardner issued a statement championing the legislation's passage. Gardner, like his counterpart, Democratic Sen. Michael Bennet, has been a vocal supporter of reauthorizing the Land and Water Conservation Fund. The fund, which expired in September after legislators failed to reauthorize it, had been used since 1965 to buy and preserve land, water and recreation areas with royalty payments from offshore oil and gas money.
"The [Land and Water Conservation Fund] has a direct impact on public lands in Colorado and will be used to protect our state’s natural beauty for future generations," Gardner said in the statement. "I’m thrilled we were able to finally permanently reauthorize this commonsense program supported by Coloradans across the political spectrum."
Gardner sponsored or cosponsored several Colorado-related bills that were included in the package.
Bennet also issued a statement praising the public lands package. He led or co-led several of the bills, including some that were collaborations with Gardner.
“It’s rare that a bipartisan lands package moves in Congress, so this bill is a significant accomplishment for communities across Colorado,” Bennet said.
Bennet tried to get his Colorado Outdoor Recreation and Economy Act, which combined four previously introduced bills to protect 400,000 acres of public land in Colorado, included in the package, but that amendment did not pass.
Conservation groups in Colorado and beyond applauded the public lands package, especially the fund's reauthorization.
“Today’s vote is a big step toward ending the cycle of uncertainty that has plagued this amazing and incredibly important conservation program," Carlos Fernandez, state director for the Nature Conservancy, said in a statement. “Thank you, Senators Bennet and Gardner, for championing this effort. Your leadership and stalwart support has helped get this legislation to where it is today."
Since 1965, Colorado has received more than $268 million from the fund, according to the Land and Water Conservation Fund Coalition, a group advocating for its reauthorization. The money has paid for projects in Mesa Verde National Park, Canyons of the Ancients National Monument, Arapaho National Forest, Two Ponds National Wildlife Refuge, Rocky Mountain National Park, Cross Mountain Canyon Ranch and more.
Tags: outdoors, politics, Land and Water Conservation Fund, Cory Gardner, Michael Bennet, Image
Green New Deal proposes sweeping environmental change
Posted By Regan Foster on Thu, Feb 7, 2019 at 3:52 PM
Alexandria Ocasio-Cortez, co-author of the Green New Deal, and target for anti-socialist rhetoric.
A bill rolled out in the U.S. House Thursday, Feb. 7, aims to make the U.S. net-zero, emissions wise, by 2050.
Dubbed the “Green New Deal,” the legislation backed by New York freshman Rep. Alexandria Ocasio-Cortez and Massachusetts Sen. Edward J. Markey proposes an overhaul of the nation’s infrastructure, energy and transportation sectors. Both lawmakers are Democrats.
The bill echoes some of Colorado Gov. Jared Polis’ priorities laid out in his January State of the State address, and was released the same date that Democratic Senate hopeful Mike Johnston of Denver announced his own green energy proposal.
Polis in January reiterated a campaign pledge to make the state’s energy supply totally renewable by 2040: “That means modernizing both our grid infrastructure and our regulatory processes to ensure all Coloradans are reaping the full suite of benefits associated with swift adoption of renewable energy,” the governor said. “It means working to electrify our cars and busses and trucks ... And it means taking advantage of modern technology to use energy more efficiently — cleaning our air and saving consumers money in the process.”
The federal legislation taps similar goals, although it offers more concepts than details. Among the Green New Deal’s goals:
• To achieve net-zero greenhouse gas emissions “through a fair and just transition for all communities and workers.”
• To create “millions of good, high-paying jobs and ensure prosperity and economic security” for all Americans.
• To invest in infrastructure and industry
• To promote justice and equity “by stopping current, preventing future and repairing historic oppression of indigenous communities, communities of color, migrant communities, deindustralized communities, depopulated rural communities, the poor, low-income workers, women, the elderly, the unhoused, people with disabilities and youth” — all so-called “frontline and vulnerable communities.”
It proposes doing so through a massive infrastructure reconstruction effort reminiscent, the bill’s authors said, of President Franklin D. Roosevelt’s iconic “The New Deal,” which stabilized a Great Depression economy through jobs and infrastructure construction.
Included in the Green New Deal’s vision:
• Meeting 100 percent of the nation’s power demands through renewable, green energy.
• Building efficient power grids.
• Upgrading the nation’s existing buildings to maximize efficiency.
• Embracing ecologically sound manufacturing processes.
• Encouraging reinvestment and support for family and sustainable farming.
• Overhauling the transportation network to include zero-emission cars and boost high-speed rail.
“Today is a really big day for our economy, the labor movement, the social justice movement, indigenous peoples and people all over the United States of America,” Ocasio-Cortez said during a Thursday press conference. “Today is the day we truly embark on a comprehensive agenda of economic, social and racial justice in the United State of America.”
The proposal offers more breadth than details, and the price tag for the massive overhaul was not immediately known.
Adding to its uphill battle, the response from leaders on both sides of the aisle has been tepid. House Speaker Nancy Pelosi, during her Thursday press conference, said “We welcome the enthusiasm that is out there ... The Green New Deal points out the fact that the public is much more aware of the challenge that we face, and that is a good thing.”
But John Barrasso, a Wyoming Republican and chair of the Senate Republican Conference, derided the plan: “It’s a socialist manifesto that lays out a laundry list of government giveaways, including guaranteed food, housing, college and economic security even for those who refuse to work,” he said in a statement. “As Democrats take a hard left turn, this radical proposal would take our growing economy off the cliff and our nation into bankruptcy. It’s the first step down a dark path to socialism.”
Read the proposal's full text below:
PDF Resolution_on_a_Green_New_Deal.pdf
Tags: politics, Alexandria Ocasio-Cortez, Nancy Pelosi, Green New Deal, environment, Jared Polis, Image
Re: Locals protest inhumane immigration detention centers, raids
Not one of them has directly visited the centers. Moreover, the people of Mexico are…
Posted by Terry
Re: City plans pedestrian-friendly rainbow crosswalk for Pride
Whereas "Silky Johnson" is so medieval.
Posted by Mr. K--
Re: Airbnbs are commercial properties, assessor says. The fallout could be huge.
I am curious what legal ramifications this might have for the potential to develop the…
Posted by Donatello Fodness
Gay promotion is soooooo 1990's!
Posted by Silky Johnson
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2 die after car rear ends DDOT bus on west side
The crash took place at 7:25 a.m. Sunday at Meyers and Curtis, south of West Seven Mile and east of West Outer Drive
2 die after car rear ends DDOT bus on west side The crash took place at 7:25 a.m. Sunday at Meyers and Curtis, south of West Seven Mile and east of West Outer Drive Check out this story on detroitnews.com: https://www.detroitnews.com/story/news/local/detroit-city/2019/01/13/two-die-after-rear-ending-bus-west-side/2563798002/
James David Dickson, The Detroit News Published 9:04 a.m. ET Jan. 13, 2019 | Updated 11:48 a.m. ET Jan. 13, 2019
Detroit — Two people who were passengers in a car that police say rear-ended a Detroit Department of Transportation bus on the city’s west side died at the scene Sunday morning, police said.
Officer Dan Donakowski, a spokesman for the Detroit Police Department, said the crash took place at 7:25 a.m. at Meyers and Curtis, south of West Seven Mile and east of West Outer Drive.
Police say a silver 1989 Acura was traveling eastbound on Curtis when it hit DDOT bus No. 1030 that was traveling southbound on Meyers.
The crash threw the rear seat passenger, an unidentified woman believed to be 20 to 25 years old, through the Acura's windshield. She died on the hood of the car.
The front seat passenger, an unidentified man believed to be 20 to 25 years old, was found unresponsive and died at the scene.
The driver, identified only as a male, was taken to an area hospital.
One passenger on the bus claimed a minor injury, police said.
Read or Share this story: https://www.detroitnews.com/story/news/local/detroit-city/2019/01/13/two-die-after-rear-ending-bus-west-side/2563798002/
City Council rejects plan for permanent Woodward plaza
Farmington Hills police ID drivers killed in Saturday crash
Poop splashes cold water on Macomb Twp. subdivision's summer pool access
Boy, 3, dies after falling into restaurant grease trap
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JERUSALEM: More Bible proof: Temple relics unearthed
Archaeologists discover official seals from Kingdom of Judah
FROM WND'S JERUSALEM BUREAU
Click HERE for the article (text below).
Israeli archaeologists yesterday announced the discovery of a large building dating to the time of the First and Second Temples associated with Hezekiah, the King of Judah.
The Israeli government's Antiquities Authority oversaw the excavation in the southern Jerusalem village of Umm Tuba. The agency said its archaeologists unearthed the remains of an ancient building consisting of several rooms arranged around a courtyard, containing pottery and other artifacts from the First and Second Temple Periods.
The finds include official government seals bearing the names of Ahimelekh ben Amadyahu and Yehokhil ben Shahar, who were high-ranking officials in Hezekiah's government. The life of Hezekiah, the son of King Ahaz is detailed in the biblical books of Kings, Isaiah and Chronicles. Hezekiah was the 13th king of independent Judah.
Archaeologists also found a Hebrew inscription - dating 600 years after the Kingdom of Judah seals - on a fragment of a jar neck, characteristic of the beginning of the Hasmonean period. The ancient building was partially destroyed during the Babylonian conquest of Jerusalem.
The finds are the latest in a mountain of unearthed remains giving a clearer picture of the Jewish presence in Jerusalem during the First and Second Temple periods. Still, the Palestinian Authority, which seeks control of the Temple Mount and eastern Jerusalem, steadfastly denies the Jewish temples ever existed.
In November, Ahmed Qurei, the PA's chief negotiator, who oversees all peace talks with the Jewish state, told reporters the Jewish Temples never existed and contended Israel has been working to "invent" a Jewish historical connection to Jerusalem. PA websites make similar claims.
Holiest site
The Temple Mount is the holiest site in Judaism. The First Temple was
built there by King Solomon in the 10th century B.C. when the Kingdom of Israel was united. After the kingdom split into two entities, Israel and Judah, the temple was destroyed by the Babylonians in 586 B.C. The Second Temple was rebuilt in 515 B.C. after Jerusalem was freed from Babylonian captivity. That temple was destroyed by the Roman Empire in A.D. 70. Each temple stood for a period of over four centuries.
The Jewish Temple was the center of religious Jewish worship. It housed the Holy of Holies, which contained the Ark of the Covenant and was said to be the area upon which God's shechina, or "presence," dwelled. All Jewish holidays centered on worship at the Temple. The Jewish Temple served as the primary location for the offering of sacrifices and was the main gathering place for the Jewish people.
According to the Talmud, the world was created from the foundation stone of the Temple Mount. The site is believed to be the biblical Mount Moriah, the location where Abraham fulfilled God's test to see if he would be willing to sacrifice his son Isaac.
Jewish tradition holds Mashiach, or the Jewish Messiah, will return and rebuild the third and final Temple on the Mount in Jerusalem. The Kotel, or Western Wall, is the one part of the Temple Mount that survived the destruction of the Second Temple by the Romans and stands today in Jerusalem.
Throughout all notorious Jewish exiles, thorough documentation shows the Jews never gave up hope of returning to Jerusalem and reestablishing their Temple. To this day, Jews worldwide pray facing the Western Wall, while Muslims turn their backs away from the Temple Mount and pray toward Mecca. The Al Aqsa Mosque was constructed around A.D. 709 to serve as a shrine near another shrine, the Dome of the Rock, which was built by an Islamic caliph. About 100 years ago, the Dome of the Rock in Jerusalem became associated with the place Muslims came to believe Muhammad ascended to heaven. Jerusalem, however, is not mentioned in the Quran.
Islamic tradition states Muhammad took a journey in a single night from "a sacred mosque" - believed to be in Mecca in southern Saudi Arabia - to "the farthest mosque," and from a rock there ascended to heaven to receive revelations from Allah that became part of the Quran. Palestinians today claim exclusivity over the Temple Mount, and Palestinian leaders routinely deny Jewish historic connection to the site, but historically, Muslims did not claim the Al Aqsa Mosque as their third holiest site and admitted the Jewish Temples existed.
According to research by Israeli author Shmuel Berkovits, Islam previously disregarded Jerusalem. He points out in his book "How Dreadful Is this Place." that Muhammad was said to loathe Jerusalem and what it stood for. Berkovits wrote that Muhammad made a point of eliminating pagan sites of worship and sanctifying only one place - the Kaaba in Mecca - to signify the unity of God. As late as the 14th century, Islamic scholar Taqi al-Din Ibn Taymiyya, whose writings influenced the Wahhabi movement in Arabia, ruled that sacred Islamic sites are to be found only in the Arabian Peninsula and that "in Jerusalem, there is not a place one calls sacred, and the same holds true for the tombs of Hebron."
It wasn't until the late 19th century - incidentally when Jews started immigrating to Palestine - that some Muslim scholars began claiming Muhammad tied his horse to the Western Wall and associated Muhammad's purported night journey with the Temple Mount.
A guide to the Temple Mount by the Supreme Muslim Council in Jerusalem published in 1925 listed the Mount as the site of Solomon's Temple. The Temple Institute acquired a copy of the official 1925 "Guide Book to Al-Haram Al-Sharif," which states on page four, "Its identity with the site of Solomon's Temple is beyond dispute. This, too, is the spot, according to universal belief, on which 'David built there an altar unto the Lord.'"
Categories: Articles, General Study
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Daily Breeze Football Preview: Serra’s…
SportsHigh School SportsHigh School Football
Daily Breeze Football Preview: Serra’s Malik Roberson ready for comeback
Serra High School running back Malik Roberson for pre season feature. Photo by Brad Graverson/The Daily Breeze/ 08/25/14
By Evan Barnes | ebarnes@scng.com | Daily News
PUBLISHED: August 27, 2014 at 1:50 am | UPDATED: September 6, 2017 at 6:14 am
December 15, 2012. That was the last time Malik Roberson played on a football field as he celebrated Serra winning the CIF Division 2 state championship.
Twenty months later, Roberson will take the field for the first time since tearing his ACL in May 2013, and the words of his mother will ring in his head
“Never second guess yourself.”
As Serra prepares to open its season against Lakewood on Friday, Roberson could only wait anxiously as the countdown for his comeback neared its conclusion.
“Every Friday, there’s jitters, but this time, I can’t wait for the clock to wind down,” he said, “That first play is going to be nerve-wracking, but right after that, I’ll be back in game mode.”
Confidence is a key part of what makes Roberson’s return one of the most anticipated in the South Bay. It’s not just about playing again, he said, it’s about exceeding what he did two years ago as an All-CIF running back.
After replacing injured starter Anterio Bateman, he rushed for over 100 yards in five of the team’s last 11 games in 2012. In the playoffs he had a career-high 237 yards against Santa Monica and followed it with 197 yards against Lompoc.
Against Chaminade in the CIF-SS Western Division final, he ran for 104 yards and two touchdowns in the win, which bookended his 156-yard performance against the Eagles earlier that season.
He finished the season with 1,506 yards and 13 touchdowns. When track and field started in the spring, his profile grew as he set a divisional record of 10.46 seconds in the CIF-SS Division 4 100-meter final.
But at the Masters Meet the following week, everything changed when Roberson took off in the long jump competition and landed awkwardly on his right leg.
“I just had a feeling that I’m not OK. I knew there was something really wrong and I had to respect that,” he said.
He ended up tearing the anterior cruciate ligament in his right knee, and suddenly his promising career was on hold as his junior season was over before it started.
“I wanted to come back that year, but I knew after my surgery, I realized that I needed to make my knee stronger for my senior year,” Roberson said.
The rehabilitation process involved water therapy as well as teaching his mind to trust his knee again. During the time off, he became a greater student of the game by watching more film and offering tips to Adoree Jackson and Darrion Naylor as they took over tailback duties.
“He’s a selfless kid who knew that those guys needed help, so that’s what he did,” Serra coach Scott Altenberg said.
Roberson also soaked up encouragement from his mother Dishawn, whom he calls his No. 1 fan, and drew inspiration from Marcus Lattimore, who suffered two similar knee injuries in 2011 and 2012 at South Carolina and yet was still drafted by the San Francisco 49ers.
“If he could fight through it and still get drafted, then I have no reason to not still get the offers that I worked hard for,” Roberson said.
During his junior year, he also became Coach Red Bull, a constant presence on the sidelines who picked up his teammates or encouraged them after a big play.
“Injuries are never good, but as far as revealing character, it has for him,” Altenberg said. “He’s one of our leaders and the kids love him.”
There have already been hints that Roberson is regaining his form. He competed in the 4×100 at the Penn Relays in April and called it a sign of gratitude for those who supported him.
In the summer, a photo of him dunking a basketball made the rounds on social media. Despite being only 5-foot-7, he leaped high and slammed the ball off a pass from teammate Caleb Wilson.
“I had been dunking before I got hurt, so it was another sign that I was back to where I was,” he said.
The only thing left is to complete the final step, which is taking his first handoff against Lakewood and beginning the journey back to where he was two years ago and beyond.
“I want to have the senior season that everyone dreams of,” he said. “Hurt or not, I still have that dream, and I don’t think an injury should stop me from being the best.”
Evan Barnes
Evan Barnes is the Daily News' prep sports coordinator and has covered high school sports since 2006 for various publications, including the Los Angeles Sentinel, Daily Breeze and Long Beach Press-Telegram. He also has covered college and pro sports ranging from UCLA, USC, the Dodgers and CSUN. Before covering sports full-time, Evan also covered news and won a National Newspaper Publishers Association award for his story on President Barack Obama's campaign in Los Angeles in 2008. A Los Angeles native and a graduate from the University of San Diego, he also has written for online publications such as Bleacher Report.
Follow Evan Barnes @evan_b
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Baxter – End Of The World EP (Malloty Up Records)
Charlie Ashcroft | Wednesday, 19 August 2009
After spending a couple of years touring the capital's extensive range of intimate venues, the latest stage of London band Baxter's development comes in the form of this new four-track offering, 'End Of The World'.
All the press surrounding the quintet has seen them described as being 'epic songcrafters', but save for the occasional lighters-in-the-air moment, this EP does little to suggest such songwriting grandeur.
The title track has an intro reminiscent of 3 Colours Red at their most poignant, but proves to be fairly predictable in terms of melody and structure. In spite of Jamie Tinkler's decent vocals and a fairly rousing middle eight, it fails to live up to its early promise.
Although the powerpop pace of 'Standing On The Edge Of The Tide' has the band treading an altogether different territory, perhaps somewhere along the lines of a British incarnation of The Gaslight Anthem, it seems that nothing can prevent the song from tailing off somewhat.
The frustrating thing about Baxter is that it's perfectly clear that they've got a decent tune or two in them somewhere. Songs such as 'Avenue' lead you to believe that they're a just a couple of hooks away from having the kind of mass-market-friendly hit that Radio 2 or Heart would lap up in no time at all.
It's a real shame then that the memorable moments tend to be drowned out by the rest of the standard MOR indie fare served up on the EP. As bands such as Royworld and Headway found out last year, this area of the market is a particularly crowded one, so unless Baxter can hone their 'epic songcraft' further, the chances of them opening the floodgates in the near future appear slim.
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Flathead Beacon: Bipartisan Collaboration Preserves the North Fork
BLANKENSHIP BRIDGE – It didn’t matter that a noxious veil of smoke blotted out the peak-studded horizon on Aug. 24 because everyone who converged here was focused on the crystal-clear, coruscating waters of the North Fork Flathead River, which forms the western boundary of Glacier National Park.
A coalition of unlikely bedfellows gathered on the banks of the North Fork, just north of Columbia Falls, to commemorate a historic measure to protect the sparkling river that rolled beside them. Energy executives mingled among fish biologists, while land managers, business champions, community boosters, tree huggers, and tree cutters all milled about the rock-strewn shore for a single unifying reason – the North Fork Watershed Protect Act.
The measure to ban new energy development on 430,000 acres of wild and scenic river corridor has stood out for its singular brand of bipartisan support.
The Montana-made bill gained near universal esteem, even at the height of partisanship, and was hailed by conservationists, oil tycoons and politicians alike as a commonsense piece of legislation – 80 percent of energy leases in the area have been voluntarily released, and it dovetails with an effort by British Columbia’s parliament to place similar protections north of the border, on the headwaters of the Flathead River.
At the center of the scrum along the river stood Montana’s U.S. Senators – Democrat Jon Tester, a dirt farmer from Big Sandy, and Republican Steve Daines, a successful businessman from Bozeman.
Despite their weekly coffee clutches and open dialogue, the senators share more bones of contention than instances of accord, and fall on different sides of most political issues. It’s rare that they share the same stage during public appearances, and even rarer that they stand under the same spotlight to celebrate a conservation measure that they hammered out together.
As such, the symbolism of their perch this smoky morning at the confluence of two forks of the Flathead River was lost on none of the stakeholders who cheered and applauded as the senators took turns extolling the importance of protecting the North Fork.
“Today’s partisan politics is not known for its spirit of cooperation, but these two agreed on at least one thing, and that’s the North Fork,” said Michael Jamison of the National Parks Conservation Association, which organized the event to hail passage of the North Fork Watershed Protection Act last December.
The bill has been decades in the making, but emerged late last year as a rider to the National Defense Authorization Act, a piece of must-pass legislation that included a package of 70 national public land bills, the largest collection since the Omnibus Public Land Management Act of 2009.
Both senators said the bill is an example of bipartisan support for a commonsense legislation that will ensure future generations can enjoy the landscape.
“It turns out that protecting a landscape on the borders of a national park isn’t as controversial as you might think,” Tester said.
Both senators gave credit to the collaborative efforts of those in attendance, as well as to former U.S. Sen. Max Baucus for his early and lasting involvement in working to protect the North Fork.
Baucus, whose retirement to become ambassador to China cast doubt on the bill’s future, did not attend, but said in a statement the bill’s passage was the culmination of decades of work he and the conservation community began more than 40 years ago.
“This has been a long journey, and we really stand on the shoulders of a lot of the work that you all began. You took this and carried a lot of that water for many, many years,” Daines told the crowd Aug. 24.
Bij Agarwal, of ConocoPhillips, the first company to relinquish its energy leases, said he was honored to see the scenic river corridor for himself.
“In 2010 we were the first company to release its leases on the North Fork and establish this preservation status,” he said. “We hope that generations to come will be able to enjoy this beautiful area.”
By: Tristan Scott
Source: The Flathead Beacon
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Jon Ronson: How to ruin your life in 140 characters
Filed under Commentary at Mar 2015
Jon Ronson
Connect with Jon Ronson
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As she made the journey from New York to South Africa, to visit family during the holidays in 2013, Justine Sacco, 30 and the senior director of corporate communications at IAC, began tweeting acerbic little jokes about the indignities of travel. There was one about a fellow passenger on the flight from John F. Kennedy International Airport:
“‘Weird German Dude: You’re in First Class. It’s 2014. Get some deodorant.’ — Inner monologue as I inhale BO. Thank God for pharmaceuticals.”
Then, during her layover:
“Chilly — cucumber sandwiches — bad teeth. Back in London!”
And on Dec. 20, before the final leg of her trip to Cape Town:
“Going to Africa. Hope I don’t get AIDS. Just kidding. I’m white!”
She chuckled to herself, then wandered around Heathrow Airport for half an hour, sporadically checking her phone. No one replied, which didn’t surprise her. She had only 170 Twitter followers.
Sacco boarded the plane. It was an 11-hour flight, so she slept. When the plane landed and was taxiing on the runway, she turned on her phone. Right away, she got a text from someone she hadn’t spoken to since high school: “I’m so sorry to see what’s happening.” Sacco looked at it, baffled.
Then another text: “You need to call me immediately.” It was from her best friend, Hannah. Then her phone exploded with more texts and alerts. And then it rang. It was Hannah. “You’re the No. 1 worldwide trend on Twitter right now,” she said.
Sacco’s Twitter feed had become a horror show. “How did @JustineSacco get a PR job?! Her level of racist ignorance belongs on Fox News. #AIDS can affect anyone!” and “I’m an IAC employee and I don’t want @JustineSacco doing any communications on our behalf ever again. Ever.” And then one from her employer, IAC, the corporate owner of The Daily Beast, OKCupid and Vimeo: “This is an outrageous, offensive comment. Employee in question currently unreachable on an intl flight.”
The anger soon turned to excitement: “All I want for Christmas is to see @JustineSacco’s face when her plane lands and she checks her inbox/voicemail” and “Oh man, @JustineSacco is going to have the most painful phone-turning-on moment ever when her plane lands” and “We are about to watch this @JustineSacco bitch get fired. In REAL time. Before she even KNOWS she’s getting fired.”
The furor over Sacco’s tweet had become not just an ideological crusade against her perceived bigotry but also a form of idle entertainment. Her complete ignorance of her predicament for those 11 hours lent the episode both dramatic irony and a pleasing narrative arc. As Sacco’s flight traversed the length of Africa, a hashtag began to trend worldwide: #HasJustineLandedYet. “Seriously. I just want to go home to go to bed, but everyone at the bar is SO into #HasJustineLandedYet. Can’t look away. Can’t leave” and “Right, is there no one in Cape Town going to the airport to tweet her arrival? Come on, Twitter! I’d like pictures #HasJustineLandedYet.”
A Twitter user did go to the airport to tweet her arrival. He took her photograph and posted it online. “Yup,” he wrote, “@JustineSacco HAS in fact landed at Cape Town International. She’s decided to wear sunnies as a disguise.”
By the time Sacco had touched down, tens of thousands of angry tweets had been sent in response to her joke. Hannah, meanwhile, frantically deleted her friend’s tweet and her account — Sacco didn’t want to look — but it was far too late. “Sorry @JustineSacco,” wrote one Twitter user, “your tweet lives on forever.”
In the early days of Twitter, I was a keen shamer. When newspaper columnists made racist or homophobic statements, I joined the pile-on. Sometimes I led it. Journalist A. A. Gill once wrote a column about shooting a baboon on safari in Tanzania: “I’m told they can be tricky to shoot. They run up trees, hang on for grim life. They die hard, baboons. But not this one. A soft-nosed .357 blew his lungs out.” Gill did the deed because he “wanted to get a sense of what it might be like to kill someone, a stranger.”
I was among the first people to alert social media. (This was because Gill always gave my television documentaries bad reviews, so I tended to keep a vigilant eye on things he could be got for.) Within minutes, it was everywhere. Amid the hundreds of congratulatory messages I received, one stuck out: “Were you a bully at school?”
Still, in those early days, the collective fury felt righteous, powerful and effective. It felt as if hierarchies were being dismantled, as if justice were being democratized. As time passed, though, I watched these shame campaigns multiply, to the point that they targeted not just powerful institutions and public figures but really anyone perceived to have done something offensive. I also began to marvel at the disconnect between the severity of the crime and the gleeful savagery of the punishment. It almost felt as if shamings were happening for their own sake, as if they were following a script.
Eventually I started to wonder about the recipients of our shamings, the real humans who were the virtual targets of these campaigns. So for the past two years, I’ve been interviewing individuals like Justine Sacco: everyday people pilloried brutally, most often for posting some poorly considered joke on social media. Whenever possible, I have met them in person, to truly grasp the emotional toll at the other end of our screens. The people I met were mostly unemployed, fired for their transgressions, and they seemed broken somehow — deeply confused and traumatized.
Late one afternoon last year, I met Sacco at a New York restaurant. Dressed in chic business attire, Sacco ordered a glass of white wine. Just three weeks had passed since her trip to Africa, and she was still a person of interest to the media. Websites had ransacked her Twitter feed for more horrors. (For example, “I had a sex dream about an autistic kid last night,” from 2012, was unearthed by BuzzFeed in the article “16 Tweets Justine Sacco Regrets.”) A New York Post photographer had been following her to the gym.
“Only an insane person would think that white people don’t get AIDS,” she told me. It was about the first thing she said to me.
Sacco had been three hours or so into her flight when retweets of her joke began to overwhelm my Twitter feed. I could understand why some people found it offensive. Read literally, she said that white people don’t get AIDS, but it seems doubtful many interpreted it that way. More likely it was her apparently gleeful flaunting of her privilege that angered people. But after thinking about her tweet for a few seconds more, I began to suspect that it wasn’t racist but a reflexive critique of white privilege — on our tendency to naively imagine ourselves immune from life’s horrors. Sacco had been yanked violently out of the context of her small social circle. Right?
“To me it was so insane of a comment for anyone to make,” she said. “I thought there was no way that anyone could possibly think it was literal.” (She would later write me an email to elaborate on this point. “Unfortunately, I am not a character on South Park or a comedian, so I had no business commenting on the epidemic in such a politically incorrect manner on a public platform,” she wrote. “To put it simply, I wasn’t trying to raise awareness of AIDS or piss off the world or ruin my life. Living in America puts us in a bit of a bubble when it comes to what is going on in the third world. I was making fun of that bubble.”
I would be the only person she spoke to on the record about what happened to her, she said. It was just too harrowing — and “as a publicist,” inadvisable — but she felt it was necessary, to show how “crazy” her situation was, how her punishment simply didn’t fit the crime.
“I cried out my body weight in the first 24 hours,” she told me. “It was incredibly traumatic.” She released an apology statement and cut short her vacation. Workers were threatening to strike at the hotels she had booked if she showed up. She was told no one could guarantee her safety.
Her extended family in South Africa were African National Congress supporters — the party of Nelson Mandela. They were longtime activists for racial equality. When Justine arrived at the family home, one of the first things her aunt said to her was: “This is not what our family stands for. And now, by association, you’ve almost tarnished the family.”
As she told me this, Sacco started to cry. I sat looking at her for a moment. Then I tried to improve the mood. I told her that “sometimes, things need to reach a brutal nadir before people see sense.”
“Wow,” she said. She dried her eyes. “Of all the things I could have been in society’s collective consciousness, it never struck me that I’d end up a brutal nadir.”
She glanced at her watch. It was nearly 6 p.m. The reason she wanted to meet at this restaurant, and that she was wearing work clothes, was that it was only a few blocks from her office. At 6, she was due there to clean out her desk.
“All of a sudden you don’t know what you’re supposed to do,” she said. “If I don’t start making steps to reclaim my identity and remind myself of who I am on a daily basis, then I might lose myself.”
The restaurant’s manager approached our table. She sat down next to Sacco, fixed her with a look and said something in such a low volume I couldn’t hear it, only Sacco’s reply: “Oh, you think I’m going to be grateful for this?”
We agreed to meet again, but not for several months. She was determined to prove that she could turn her life around. “I can’t just sit at home and watch movies every day and cry and feel sorry for myself,” she said. “I’m going to come back.”
After she left, Sacco later told me, she got only as far as the lobby of her office building before she broke down crying.
It’s possible that Sacco’s fate would have been different had an anonymous tip not led writer Sam Biddle to the offending tweet. Biddle was then the editor of Valleywag, Gawker Media’s tech-industry blog. He retweeted it to his 15,000 followers and eventually posted it on Valleywag, accompanied by the headline, “And Now, a Funny Holiday Joke From IAC’s P.R. Boss.”
In January 2014, I received an email from Biddle, explaining his reasoning. “The fact that she was a P.R. chief made it delicious,” he wrote. “It’s satisfying to be able to say, ‘O.K., let’s make a racist tweet by a senior IAC employee count this time.’ And it did. I’d do it again.” Biddle said he was surprised to see how quickly her life was upended, however. “I never wake up and hope I [get someone fired] that day — and certainly never hope to ruin anyone’s life.” Still, he ended his email by saying that he had a feeling she’d be “fine eventually, if not already.”
He added: “Everyone’s attention span is so short. They’ll be mad about something new today.”
Four months after we first met, Sacco made good on her promise. We met for lunch. I told her what Biddle had said — about how she was probably fine now. I was sure he wasn’t being deliberately glib, but like everyone who participates in mass online destruction, uninterested in learning that it comes with a cost.
“Well, I’m not fine yet,” Sacco said. “I had a great career, and I loved my job, and it was taken away from me, and there was a lot of glory in that. Everybody else was very happy about that.”
Sacco let me in on one of the hidden costs of her experience. “I’m single; so it’s not like I can date, because we Google everyone we might date,” she said. “That’s been taken away from me too.”
Biddle was almost right about one thing: Sacco did get a job offer right away. But it was an odd one, from the owner of a Florida yachting company. “He said: ‘I saw what happened to you. I’m fully on your side,’ ” she told me. Sacco knew nothing about yachts, and she questioned his motives. (“Was he a crazy person who thinks white people can’t get AIDS?”) She turned him down.
After that, she left New York, going as far away as she could, to Addis Ababa, Ethiopia. She flew there alone and got a volunteer job doing PR for an NGO working to reduce maternal-mortality rates. “It was fantastic,” she said. She was on her own, and she was working. If she was going to be made to suffer for a joke, she figured she should get something out of it. “I never would have lived in Addis Ababa for a month otherwise,” she told me. She was struck by how different life was there. Rural areas had only intermittent power and no running water or Internet. Even the capital, she said, had few street names or house addresses.
Addis Ababa was great for a month, but she knew going in that she would not be there long. She was a New York City person. Sacco is nervy and sassy and sort of debonair. And so she returned to work at Hot or Not, which had been a popular site for rating strangers’ looks on the pre-social Internet and was reinventing itself as a dating app.
But despite her near invisibility on social media, she was still ridiculed and demonized across the Internet. Biddle wrote a Valleywag post after she returned to the work force: “Sacco, who apparently spent the last month hiding in Ethiopia after infuriating our species with an idiotic AIDS joke, is now a ‘marketing and promotion’ director at Hot or Not.”
“How perfect!” he wrote. “Two lousy has-beens, gunning for a comeback together.”
Sacco felt this couldn’t go on, so six weeks after our lunch, she invited Biddle out for a dinner and drinks. Afterward, she sent me an email. “I think he has some real guilt about the issue,” she wrote. “Not that he’s retracted anything.” (Months later, Biddle would find himself at the wrong end of the Internet shame machine for tweeting a joke of his own: “Bring Back Bullying.” On the first anniversary of the Sacco episode, he published a public apology to her on Gawker.)
Recently, I wrote to Sacco and asked her to meet me one final time to update me on her life. Her response was speedy. “No way.” She explained that she had a new job in communications, though she wouldn’t say where. She said, “Anything that puts the spotlight on me is a negative.”
It was a profound reversal for Sacco. When I first met her, she was desperate to tell the tens of thousands of people who tore her apart how they had wronged her and to repair what remained of her public persona. But perhaps she had come to understand that her shaming wasn’t really about her at all.
Social media is so perfectly designed to manipulate our desire for approval, and that is what led to her undoing. Her tormentors were instantly congratulated as they took Sacco down, bit by bit, and so they continued to do so. Their motivation was much the same as Sacco’s own — a bid for the attention of strangers — as she milled about Heathrow, hoping to amuse people she couldn’t see.
This article is adapted from Jon Ronson’s new book, “So You've Been Publicly Shamed.” Follow him on Twitter at @jonronson.
Public trust won’t be restored at DeSoto City Hall until authorities fully investigate fraud
Say what you will, former City Council member Carolyn Davis loved South Dallas
Letters: Presidential tweets, Democratic congresswomen, Grand Prairie ISD superintendent, Derrill Osborn, Ross Perot
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Before Erykah Badu Plays Sound Select, She Explains Her Dallas Love: "It's the Birds"
Vanessa Quilantan
Vanessa Quilantan | July 26, 2013 | 7:00am
This week, Red Bull launches its Sound Select series in five new cities, including Dallas. And it's starting strong: Tonight at Prophet Bar, the energy drink/lifestyle brand has curated a local lineup that includes Erykah Badu with the Cannabanoids, Larry Gee and Dustin Cavazos.
Admission to the now at-capacity show was free, facilitated by a social networking strategy in which fans gained tickets by posting and sharing moments they've contributed to the local music scene. (Disclosure: I'll be painting really elaborate things on people's nails there.)
The queen of that scene, Erykah Badu, sat down with us before her headlining set to discuss the city's place in her heart, attending Booker T. and the creative inspiration she draws from Texas songbirds.
Are you a fan of your fellow Red Bull Sound Select artists, Larry Gee and Dustin Cavazos? I can't say that I am. I've only heard little pieces so far. I can tell you what I am looking forward to is watching them perform. Recording is perfecting a moment, you can feel that and actually say what you want to say. Performance is creating a moment. In that creative space is where I connect with other artists.
You've done a few Red Bull events in the past. How would you describe your relationship with the brand? Red Bull -- I mean, what we have tried to accomplish for the last five years is to create a neutral platform for artists to interact, hone their gifts, communicate together, signed and unsigned. I'm just pleased to be a part of that kind of organization that actually takes the time to know the people, and the necessity for those kind of things. Iron sharpens iron. Artists who commune together generally grow together in some kind of way, which in turn strengthens the community. Through our art, words and frequency of the music, we begin to change things. And when we begin to organize as artists, we begin to change politics. This is probably the beginning of some really incredible friendships, some really great activism, and some great work.
What was your introductory experience into the Dallas arts and culture scene as a child? I grew up in South Dallas, the part of Dallas that is now dilapidated. Our green grass was on its way to brown when I was a kid and we didn't really have a lot of choices, so we were blessed to have a community center called Martin Luther King Recreation Center, where they had summer programs.
Because of these summer camps and programs, as kids, we were able to travel all over the world without ever leaving the gymnasium. People would volunteer their time, talk to us, read to us, teach us songs in different languages, African dance, ballet, Mozerka -- Russian tap dance. These are things we probably would have never seen had it not been for this summer camp. That's where I first had a chance to express my art and work it out, and become comfortable about it. I'm grateful for that.
How did growing up here shape and inspire your artistic vision? Growing up with one of my best friends, Roy Hargrove, who is a jazz musician -- a trumpet player -- we went to the same school. We were best friends in high school. Artists who have mastered their skill at an early age are also very profound minds. There's something about their minds that work a little differently from being morally correct, so it's amazing to grow up in a high school with all of these different minds.
When I was maybe a freshman in high school, one of the students, Edie Brickell of The New Bohemians, who is actually married to Paul Simon right now, returned to the school to perform on the stage. I actually saw the concert, and she gave me the idea that it doesn't have to be something that you're afraid to do. It made me focus on not being afraid.
Where do you hope to see the Dallas music scene evolve to in the next decade? I like the Dallas music scene. I can't really predict, I don't like to do that. But where we are right now is who we are, you know? Hip-hop and music is the people, and what we're feeling and what we think. As long as we're being honest in our expression, we are doing our part for the evolution of the social world.
To be honest, it's what will create new ideas and new thoughts. I think new ideas and new thoughts are inevitable. These platforms make it even better, even easier for us to share with one another the things that we've learned and experienced.
You are often referred to as "the queen of Dallas." Is that a surreal experience for you? Hmm, not yet. Not yet. It's all real. I feel each person's gratitude, or criticism, or comforting and I take all of those things in.
Our mothers are here, our grandmothers are here in some parts of Texas. I don't know, it's the birds for me. I stay here because of the birds. Their song has influenced my song, my rhythm. The amount of oxygen they breathe gives them the amount of breath for song. It has been embedded in my DNA since I was born. I feel good here, I feel like I'm an improvement on a design, generationally. And my mother was an improvement on her mom's design. This is where we have grown, and ate, and lived, and birthed babies. This part of the world gives me energy. So I live just right where I want to be.
Any big plans for your set on Friday night? Sure! I don't know what it is yet. We usually just take cues from the audience's energy. We can have a set list or songs prepared, but where that set goes is totally up to everyone in the room. I'm always anxious to see what happens. I mean, I'm home. I feel the most the most comfortable and the most love here. I feel good about it, no complaints about that. I just want to be able get on that stage and perform because that's my therapy, and I'm happy it is for anyone else as well.
DFW Music News
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April 4, 2013 / by emptywheel
VirginLeak
A number of journalistic outlets are cooperating in a project to describe the contents of 200 gigabytes of financial information from private incorporation agencies in the British Virgin Islands. The International Consortium of Investigative Journalists has links to all the stories using the data. The CBC has some of the most interesting graphics.
But I have yet to see a really good explanation of where this data came from–or why it was leaked in this form. The Guardian has one of the best explanations of what’s out there.
The leak of 2m emails and other documents, mainly from the offshore haven of the British Virgin Islands (BVI), has the potential to cause a seismic shock worldwide to the booming offshore trade, with a former chief economist at McKinsey estimating that wealthy individuals may have as much as $32tn (£21tn) stashed in overseas havens.
The whistleblowing group WikiLeaks caused a storm of controversy in 2010 when it was able to download almost two gigabytes of leaked US military and diplomatic files.
The new BVI data, by contrast, contains more than 200 gigabytes, covering more than a decade of financial information about the global transactions of BVI private incorporation agencies. It also includes data on their offshoots in Singapore, Hong Kong and the Cook Islands in the Pacific.
And CBC offered this explanation of why they are shielding the identity of 450 Canadians who are stashing their money offshore.
The documentation provided to CBC News includes the names of some 450 Canadians who have set up these offshore accounts or holdings. We have already reported details concerning one such account-holder and expect to produce more such reports in the weeks and months to come.
At the same time, we are mindful of the reality that holding an offshore account is not evidence of wrongdoing and may not be controversial. So we are not simply reproducing the raw information we have received through the consortium. Our journalists are working through that information in a careful and methodical way to confirm the information received, identify appropriate stories, and complete them with appropriate context.
We shall see — both whether the elite of the world respond to this leak with the outrage they responded to Bradley Manning’s leaks, and whether the thus far selective nature of the stories on this betray whose agenda the leaks are serving.
While this data may just come from an insider releasing the information publicly (but then why not leak it all?), it is not inconceivable that BVI’s competitors in the secrecy business might want to cut into their market.
Originally Posted @ https://www.emptywheel.net/2013/04/04/virginleak/
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July 17, 2019 / by
A Gas Tax Instead of CAFE
I’m working on a post describing what I think the Big Two and a Half ought to propose on December 2 when they drive their hybrids to DC (in lieu of flying) to beg for money again. As part of that, I will suggest that they ask Congress to levy a stiff gas tax. But since I am getting into more and more discussions with environmentalists who want any bailout to be tied to increased CAFE standards, I’m going to lay out why I think a tax is much better than increased CAFE standards for everyone.
Why CAFE Standards Suck at Achieving their Goal
I’m going to start with the assumption that the goal of CAFE standards is to force auto manufacturers to build more environmentally efficient cars (arguably that’s not what it was originally intended to do). It does so with brute force regulation that does not, at the same time, change the actual market-wide interest (or not) in environmental efficiency.
Until gas reached $4 plus this summer (and things are returning–though haven’t entirely returned–to where they were now that gas has gotten cheaper again), people calculated "energy efficiency" into their considerations when buying a car in terms of cost of ownership–that is, as one factor among others: how much the car cost, how much monthly loan payments would be, how much maintenance cost, how much insurance cost, and how much gas to run the car cost (this is reflected by the stickers dealers use to sell their cars, which usually describe efficiency both in terms of MPG but also in terms of year gas costs). For most people, efficiency is still a cost issue, and not a benefit per se.
Now consider how that will factor into the choice of a vehicle. For a lot of people, all those cost calculations will be less important than perceived safety or utility arguments. So if having something that feels like a tank is really important to you, you’re going to buy something that feels like a tank and only then consider how much it’ll cost you to run your psuedo-tank. The cost calculations will weigh, overall, much less in your consideration.
But if cost of ownership is your primary consideration, then you’re going to look at the cheapest cars that meet your basic needs, and pick which one is actually cheapest to run. And so long as energy efficiency remains one cost calculation among others, when people choose to buy based on cost of ownership, you can bet they’re going to be choosing to forgo a bunch of other bells and whistles–things like upgraded radios or fancy interiors or navigation devices or things like that–precisely the kinds of bells and whistles that contribute to higher profit margins on cars. In other words, for consumers who are looking at cost of ownership, chances are very good that they’re looking for cheap (which, for the auto industry, means low profit margins).
What you don’t have, in this calculation, are very many consumers who are interested in environmental efficiency and are willing to pay more for it the way a pseudo-tank driver will pay more to feel powerful on the road. As of May–at a time when rising gas prices were already affecting consumer choices–hybrids made up 2.2 percent of the US market. (I realize this grossly undercounts the people who value energy efficiency, but it’s a fair measure of the people who will pay 10% to 25% more solely for efficiency and environmental cache.) That was when gas averaged $3.76 a gallon; it’s down to $2.02 a gallon. And manufacturers are still selling those hybrids at a loss or with slim profits, so while those 2.2 percent of consumers will certainly spend more to have an energy efficient car, manufacturers aren’t necessarily making more.
All things being equal, the market suggests that manufacturers make their energy efficient cars cheaply and their gas guzzlers more expensively, because consumers buy energy efficient cars because they’re cheap to own, whereas consumers buy trucks or SUVs or sports car because some other feature: speed or pseudo-tank or utility. And so long as gas is cheap, that will remain true.
And CAFE standards don’t change this equation at all. They force manufacturers to make more of those cheap energy efficient cars to get their fleet-wide averages down (which cuts into their profitability). And, to some extent, make those cars more palatable to less price-sensitive consumers by adding in things like air bags. But because CAFE standards don’t change the market calculations of consumers, CAFE standards don’t make energy efficiency more valuable to consumers. CAFE standards basically force manufacturers to put costs into their cars that–unlike, say, safety, for which there has been a dramatic increase of value over the years–consumers don’t value. Even while the costs of energy efficiency went down over time, those were still costs with little market value, and therefore costs that cut into the profitability of cars in the short term.
Of course, the increase of gas prices this year dramatically changed that. Fairly quickly (measured, at least, in terms of an industry that things in terms of 3-year cycles), people decided the utility-based reasons they invented for needing a full-sized pickup were less important reasons than getting a car they could afford to drive. All of a sudden, the percentage of people who valued energy efficiency spiked way, way higher than just the people who could buy a hybrid.
This meant that a lot more people who would pay for the bells and whistles that contribute to a profitable car sale also wanted a car that got very good gas mileage.
A Good Gas Tax
One good way to get auto makers to make super-efficient cars and allow them to remain profitable is to ensure that market conditions continue to value energy efficiency as a benefit unto itself, above any consideration of cost of ownership. And one way to do that is to ensure that gas prices remain high enough–with the kind of stability and predictability that would drive 3-year product cycle calculations–such that consumers continue to place energy efficiency at the forefront of their decision-making about new cars.
You could do this by imposing a gas tax that would keep gas prices up at levels that make energy efficiency a leading factor in choosing cars. Make it a big gas tax, maybe a dollar a gallon, so that the value of energy efficiency remains where it was in August. (Obviously, phase it in, but even at a dollar a gallon gas would still be cheaper than where it was in August.) And use it as a revenue source to accomplish a number of things you need to do to enhance energy efficiency all around.
Retire US auto pension debt
Continually invest to help all US manufactuers (incl Toyota and Honda and Tesla) retool to meet higher standards (ha! Richard SHelby, got you some cash, I did!!)
Invest in public transportation
Invest in infrastructure
Give credits to middle and working class people to pay their gas bills
Give credits to middle and working class people to get out of their gas guzzler and into something efficient
As part of 6, implement a recycling program designed to meet European requirements on recycling, which will simultaneously get gas guzzlers off the road while also creating a new green economy
Retiring auto pension debt
Use some gas tax proceeds to help the American car companies become more competitive by eliminating the biggest remaining budget item that they pay that their Japanese competitors don’t pay. The more you free up the pension debt with a dedicated tax, the more the American car companies can invest in new technology and–just as importantly–the less chance there is that the Pension Benefit Guarantee Corporation has to pick up that pension obligation.
Continual investment to help all US manufactuers (incl Toyota and Honda and Tesla) retool to meet higher standards
Rather than offer one-time $25 billion packages, a gas tax could fund an ongoing investment fund, both for manufacturers of all kinds (including transplants and smaller manufacturers like Tesla) invest in production. It might also fund a general fund for technology, that would result in technologies that any manufacturer could implement.
Goes without saying.
Also goes without saying–but also addresses an ongoing problem in that decreased driving has cut into the tax-based road fund as it is. Some of this could go to pay for plug-in and/or hydrogen infrastructure.
Credits for middle class and working class people
These credits would serve to do two things. In the very short term, it would help people pay for the higher gas prices, so there were some offset of the tax for those who genuinely couldn’t afford it (but obviously not a total offset, since you still need to change the valuation of efficiency). At the same time, part of the revenues from the tax could pay for a program that got people out of old clunkers and into new, efficient cars. (Obviously, this would stimulate the kind of good production we want manufacturers to focus on). This way, you’d increase efficiency in the short term, and keep the customer base at dealers up.
Credits for recycling
But you don’t junk those clunkers. Instead, you have the manufacturers dispose of them, with the expectation that they salvage everything possible as materials (that is, no sales of big engines, but you can sell the steel). You spend some of the funds to offset the costs of a recycling program aiming to match the European standard, with the expectation that new cars would begin to have to meet these standards. Thus, in addition to the credits for new efficient cars, the tax would also lead to a support of a vehicle recycling program.
T. Boone or not T. Boone
h/t www.thewindturbines.com/
We have had quite the go lately here at the FDL Borg Hive over the automaker bailout and, more specifically, the most pressing of which is GM. For the moment though, I want to touch on a corollary to the future of the American auto industry, and that is the transition to clean and green that needs to occur for long term sustainability of Deetroit wheels.
If we could flip the switch on a perpetual motion device, heck even the Chevy Volt, tomorrow, that would be wonderful. But we cannot. The path back to health and profit prosperity for American auto will be a process that takes time, and it is going to take intermediate steps while the new technology comes on line, gets refined and evolves into maturity.
The guy, for better or worse, that has been out front making noise about the transition from oil to clean and green is none other than the infamous, and legendary, Texas oil man T. Boone Pickens. Transition is the key word regarding the Pickens Plan as it relates to our topic de jour, automobiles. Because the Volt is not scheduled for release until 2010, and even assuming GM and its Volt makes it that far (which is no given), it will take a while for plug in technology to become deeply rooted. And, of course, a massive shift all at once to electric autos would crash our strapped and deteriorating power grid.
Pickens’ main point on internal combustion transition is that natural gas should be a, it not the, transition fuel for cars, and, more significantly, fleet vehicles.
Pickens’ Plan proposes that the natural gas that is currently used to fuel power plants could be used instead as a fuel for thousands of vehicles. Ken Medlock says that the US will continue to use natural gas for electric power generation. Natural gas burns cleaner than coal, making it an increasingly popular fuel for power plants. Gas plants also produce fewer greenhouse gas emissions.
The technology needed for Compressed Natural Gas (CNG) vehicles such as City buses, fork lifts and passenger cars with CNG drivetrains is available now. Honda sells the Civic GX, with a 170-mile range. In addition, it is possible to convert vehicles to run on CNG in addition to leaving the conventional fuel injection intact, allowing the driver to switch back and forth at will. Kits are available for the do-it-yourselfer. One can buy a CNG compressor called Phill that hooks up to the city natural gas line making it possible to refuel a CNG car at home.
There are a lot of issues to be taken with T. Boone Pickens however, there is some merit to the compressed natural gas (CNG) idea as an interim fuel to power the transition to the clean and green engine/power modalities of the future. Especially for municipal and other fleet vehicles; however, the Honda Civic GX and conversion kits are viable ideas for daily driving by individuals as well.
Now, as to whether T. Boone or not T. Boone, well that is a much more difficult proposition. It is pretty hard to listen to the Boonester preach about all this after being one of the leading right wing asshole oil men of all time. Very hard. Is he genuine? Probably not entirely, no; he stands to profit from the build out, production and sale of facilities and the product, and, make no mistake, at some point there is a domestic and global natural gas peak limit just like that of oil.
As a short term, interim part of the transition, however, there are some real merits to consideration of CNG, especially on fleets. And as to T. Boone, well I am not buying in very far to his schticht, but his relentless hawking of his plan on TV, radio, and every other forum he can get his mug in front of has some incredible side benefits of getting the public inured to alt fuels and new ways of thinking on energy. That is a very good thing. We don’t want to throw in with the man and his plan, but the publicity for wind and solar, and alt fuels is priceless.
Putin Invades Alaska
Apparently, while Alaska’s eagle-eyed governor has been traipsing about the lower 48 inciting lynch mobs, the Russians have invaded Alaska.
OAO Gazprom offered to help Alaska develop its natural resources, as Russia’s largest energy producer seeks to expand into the U.S. amid the worst chill in relations since the Cold War.
State-run Gazprom sent eight senior executives to Anchorage for talks yesterday with Alaska’s Department of Natural Resources and ConocoPhillips Chief Executive Officer Jim Mulva, state and company officials said.
Gazprom, which already supplies a quarter of Europe’s natural gas, is seeking to increase its reach with projects around the world, including in North America. The courtship of Alaska comes three weeks before the U.S. presidential election, in which Russia’s resurgence has become a campaign issue.
"The timing is as interesting as the visit itself,” said Chris Weafer, chief strategist at UralSib Financial Corp. in Moscow.
Sarah Palin, governor of Alaska and Republican candidate for vice president, has criticized Prime Minister Vladimir Putin for "rearing his head” over Russia’s sea border with her home state. Relations between the countries hit a low after Russia routed U.S. ally Georgia in a five-day war in August.
"Gazprom’s entire senior management goes into Sarah Palin’s backyard during a contentious election,” Weafer said. "There’s a message there.”[my emphasis]
Actually, I think one of two things is going on. Vote for which you think it is–or give your own explanation in the comments.
It’s possible that Vladimir Putin took one look into Sarah Palin’s eyes (between winks, of course) and saw they were soulmates: authoritarian, vindictive, and power hungry. So he decided Alaska was a place he wanted to be. (Plus, Putin’s been known to be impulsive when it comes to beautiful women.)
More likely, he saw Sarah Palin as an easy mark, and thought it’d be fun to fuck with Palin’s bid to be Vice President.
Update: Looks like the answer’s B! Putin snuck into Alaska and negotiated with Palin’s direct appointees without Palin knowing about it.
Palin has argued that her state’s proximity to Russia, as well as trade missions between the between Alaska and Russia, have helped give her the foreign policy experience necessary to be Vice President. But the campaign said the governor did not know that the Gazprom delegation was meeting with the commissioner of the Alaska Department of Natural Resources, who is a Palin appointee. [my emphasis]
Ut oh. I guess Putin found the weak point in our defenses…
From Pollan to the President
I’ve been arguing for a while that Michigan–the state with the second greatest agricultural diversity after California–ought to use innovations in sustainable agriculture as part of its plan to drive economic recovery. Agriculture is going to have to be more sustainably produced in the future, and MI is uniquely suited to lead in developing the policies and technology to accomplish this goal.
But then, we should be talking about how to pursue this sustainable future more widely.
Which is what Michael Pollan does in this long letter to the next President, recommending a number of changes to our food policies. Here are Pollan’s comments on the ties between our food and the petroleum that goes into it.
After cars, the food system uses more fossil fuel than any other sector of the economy — 19 percent. And while the experts disagree about the exact amount, the way we feed ourselves contributes more greenhouse gases to the atmosphere than anything else we do — as much as 37 percent, according to one study. Whenever farmers clear land for crops and till the soil, large quantities of carbon are released into the air. But the 20th-century industrialization of agriculture has increased the amount of greenhouse gases emitted by the food system by an order of magnitude; chemical fertilizers (made from natural gas), pesticides (made from petroleum), farm machinery, modern food processing and packaging and transportation have together transformed a system that in 1940 produced 2.3 calories of food energy for every calorie of fossil-fuel energy it used into one that now takes 10 calories of fossil-fuel energy to produce a single calorie of modern supermarket food. Put another way, when we eat from the industrial-food system, we are eating oil and spewing greenhouse gases. This state of affairs appears all the more absurd when you recall that every calorie we eat is ultimately the product of photosynthesis — a process based on making food energy from sunshine.
The F.D.A. should require that every packaged-food product include a second calorie count, indicating how many calories of fossil fuel went into its production. Oil is one of the most important ingredients in our food, and people ought to know just how much of it they’re eating.
And you should also let it be known that the White House observes one meatless day a week — a step that, if all Americans followed suit, would be the equivalent, in carbon saved, of taking 20 million midsize sedans off the road for a year. Let the White House chef post daily menus on the Web, listing the farmers who supplied the food, as well as recipes.
There a many other great suggestions in the letter. The only problem is that Pollan uses arugula as an example–one I’m sure the lizard brains will use to discredit these ideas.
John McCain and Sarah Palin Wallowing in Oil
I noted the other day that John McCain had falsely claimed that Sarah Palin was governor of the state that provided 20% of the nation’s energy.
Now aside from the fact that McCain is wrong about his claim that Alaska provides 20% of our energy supply (it provides 20% of our oil, relatively little–at least thus far–of our natural gas, and insignificant amounts of coal, nuclear, wind, or solar power), he’s basically arguing that a guy like George Bush has the national security qualifications to be President.
And we saw how well that worked out.
All in all, I’d say, McCain’s making a great case for voting against Sarah Palin.
Apparently, the woman McCain says more about energy than anyone else in the country–Sarah Palin–believes the same erroneous thing.
GIBSON: But this is not just reforming a government. This is also running a government on the huge international stage in a very dangerous world. When I asked John McCain about your national security credentials, he cited the fact that you have commanded the Alaskan National Guard and that Alaska is close to Russia. Are those sufficient credentials?
PALIN: But it is about reform of government and it’s about putting government back on the side of the people, and that has much to do with foreign policy and national security issues Let me speak specifically about a credential that I do bring to this table, Charlie, and that’s with the energy independence that I’ve been working on for these years as the governor of this state that produces nearly 20 percent of the U.S. domestic supply of energy, that I worked on as chairman of the Alaska Oil and Gas Conservation Commission, overseeing the oil and gas development in our state to produce more for the United States.
GIBSON: I know. I’m just saying that national security is a whole lot more than energy.
PALIN: It is, but I want you to not lose sight of the fact that energy is a foundation of national security. It’s that important. It’s that significant.[my emphasis]
Here’s FactCheck.org correcting McCain and Palin (and me–turns out I was too generous to Alaska in my earlier post):
Palin claims Alaska "produces nearly 20 percent of the U.S. domestic supply of energy." That’s not true.
Alaska did produce 14 percent of all the oil from U.S. wells last year, but that’s a far cry from all the "energy" produced in the U.S.
Alaska’s share of domestic energy production was 3.5 percent, according to the official figures kept by the U.S. Energy Information Administration.
And if by "supply" Palin meant all the energy consumed in the U.S., and not just produced here, then Alaska’s production accounted for only 2.4 percent.
Now, I’m not so interested that McCain and Palin have been caught in a lie, again. After all, that’s getting to be old hat. Rather, I’m interested in what it says that a team claiming to support all sorts of alternative energy sources simply forget about those sources when they’re making up talking points?
Is this the proof that McCain, who used to support alternative energy has ditched that support in favor of an exclusive love affair with big oil?
Or is Sarah Palin just using this opportunity to shamelessly booster for Alaska’s oil industry, in case this Veep thing doesn’t work out?
I don’t know the answer–but the consistency of this erroneous talking point sure suggests that when they were screaming "Drill! Baby! Drill!" they meant "Drill and Do Nothing But Drill!"
McCain Makes the Case that Energy State Governors Are Great on National Security
Joe Sudbay is right—this interview, in which McCain is challenged to explain why Governor Palin is qualified to be a 72-year old heartbeat away from the presidency, is terrible.
But I’m most interested–disturbed, really–by his latest explanation of how Sarah Palin is qualified on the matter that McCain says matters most: national security.
Reporter: You say you’re sure she has the experience, but I’m just asking for an example. What experience does she have in the field of national security?
McCain: Energy. She knows more about energy than uh probably anyone else in the United States of America. She represe–is a governor of the state that 20% of America’s energy supply comes from there. And you all know that energy is a critical and vital national security issue.
McCain is basically arguing that serving as governor of a state that supplies a lot of America’s energy gives a person great national security credentials.
Hmmm. Governors of states that supply lots of energy … states that supply lots of energy … lets see, those would include Alaska, Louisiana, …
Ut oh.
And Texas.
What ELSE Mukasey Declines to Prosecute: Sexual Assault of a Subordinate
I’ve just gotten through the first Department of Interior IG report, and wanted to pull out these few discrete details as an example of what Attorney General Mukasey has declined to prosecute.
The first report describes the corrupt acts of Gregory Smith, who managed the Royalty in Kind program. In that program, companies drilling on Federal land, give the government oil or gas, which the government then contracts to sell in lieu of payment for the drilling; one of the scandals underlying this program is that the companies contracted to sell the oil were getting contracts because they were cozy with someone in DOI, not because they could get us the best price.
Among other things this report reveals is that Smith repeatedly offered himself as a consultant to companies doing business with RIK, promising to alert those companies of opportunities with other companies doing business with RIK.
But what really fries my ass is this bit.
We interviewed yet another RIK employee who stated that in approximately 2005, Smith "insisted" that she ride in his car from one business establishment to another, and she agreed.
The employee stated that Smith took "the long way" between the two businesses, and during the drive, he asked to go to her nearby home, but she refused. "He wanted to have sex; I said no," she recalled. Smith then asked if she would have oral sex with him, but she told him she did not want to. She said then Smith "basically forced [her] head into his lap," and she performed oral sex on him while he drove the car slowly. She said she resisted Smith when he pulled her head into his lap, but Smith did not relent and continued to pull her head down. She said Smith was "real persistent" but not violent, and she did not feel as though she had been sexually assaulted by Smith. She stated that it was difficult for her to have sex with Smith because he superivised her and RIK, but she "felt like [she] could get fired," so she did what Smith wanted. SHe said she was "scared" that if she did not do what Smith wanted her to do, it could possibly affect her employment.
The report goes on to describe Smith telling this employee, when the OIG investigations began, that he was going to deny it if asked about it by investigators.
And the outcome?
The results of this investigation, to include a substantial amount of information obtained through federal grand jury process that is not included here, were provided to the Public Integrity Section of the U.S. Department of Justice (DOJ) in March 2008 for prosecutorial consideration. In May 2008, DOJ advised that it was declining to prosecute Smith on various charges.
Now, perhaps this woman just refused to serve as a witness to her own sexual assault. Perhaps DOJ has a good reason not to prosecute this guy that they’re not telling us.
But Smith did this while you and I were paying his salary. And Michael Mukasey’s DOJ seems to think a government manager sexually assaulting a woman on our dime is okay.
Update: Link to report added.
What Republicans REALLY Mean When They Say Drill! Baby! Drill!
They mean sex, corruption, and political scandal.
I first covered the scandal that is breaking big today at about the same time as Governor Palin took the oath of office in Alaska.
This appears to have been the scam: Some time ago, the Interior Department introduced a "royalties in kind" program, which allowed oil companies to pay for the privilege of drilling for oil on our land in kind–in oil and gas–rather than in cold hard cash. The gimmick is that it was supposed to facilitate accounting. Up until recently (don’t worry–I’m going to figure out these dates), the oil went into the Strategic Petroleum Reserve (SPR).* But the SPR apparently is all filled up now, so recently the US government started contracting with companies to sell the oil on the "open market." But, as these things are bound to happen in the BushCo world, we didn’t take open bids for the contracts to sell the oil. We apparently just gave companies with ties to a bunch of Interior Department employees in Denver the contracts, which of course meant we got less money than we otherwise would have.
I even predicted,
How appropriate–this Administration will begin with an oil scandal. And it looks like it will end with one, too.
That looks to be prescient, as the Department of Interior Inspectors General’s Report describing the scandal has thrown a whole lot of sex and drugs and improper gifts into the mix.
Government officials handling billions of dollars in oil royalties engaged in illicit sex with employees of energy companies they were dealing with and received numerous gifts from them, federal investigators said Wednesday.
The alleged transgressions involve 13 Interior Department employees in Denver and Washington. Their alleged improprieties include rigging contracts, working part-time as private oil consultants, and having sexual relationships with — and accepting golf and ski trips and dinners from — oil company employees, according to three reports released Wednesday by the Interior Department’s inspector general.
The investigations reveal a "culture of substance abuse and promiscuity" by a small group of individuals "wholly lacking in acceptance of or adherence to government ethical standards," wrote Inspector General Earl E. Devaney.
The reports describe a fraternity house atmosphere inside the Denver Minerals Management Service office responsible for marketing the oil and gas that energy companies barter to the government instead of making cash royalty payments for drilling on federal lands. The government received $4.3 billion in such Royalty-in-Kind payments last year. The oil is then resold to energy companies or put in the nation’s emergency stockpile.
Between 2002 and 2006, nearly a third of the 55-person staff in the Denver office received gifts and gratuities from oil and gas companies, the investigators found.
And don’t forget–those "improper gifts" even included a scam on a house for Sue Ellen Wooldridge and Stephen Griles. Sounds like … Ted Stevens, doesn’t it? Or, for that matter, Duke Cunningham, but that wasn’t oil and sex and drugs, just defense contracts and sex and drugs.
See, this is why those Republicans get so worked up when they scream for drilling. It’s not a solution to an energy crisis for them. It’s a shortcut to a gravy train that might just get them laid.
Update: the reports (there are three of them) are here.
Oil Wars
The Hill reports that, rather than forcing John McCain and a lot of endangered Republican incumbents to vote againt children’s healthcare again, Democrats in Congress are going to work on an energy bill that will include some allowance for drilling.
House Democrats are ready to propose an expansion of offshore drilling as part of a broader energy bill they plan to introduce this month, according to a top Democrat.
Democratic Caucus Vice Chairman John Larson (Conn.) said the majority is prepared to back “responsible” offshore drilling through a bill that could be brought to the floor as early as next week.
“We will consider responsibly opening portions of the Outer Continental Shelf for drilling while demanding that Big Oil companies use the leases they have already been issued or return them to the public,” Larson said Saturday in the Democratic response to the President’s radio address.
Larson said the legislation will also seek to curb excessive oil market speculation and call for a reinvestment of government royalties into alternative energy technology.
This is not actually news. When Obama said he would reluctantly accept more drilling as part of a package that included a lot of other, smarter energy policies, it became clear the party would follow his lead.
And, if it is done well, it might actually be brilliant jujitsu. If the bill were to define "responsible" by requiring that states agree to the drilling and by demanding that the drilling actually look like it would do some good, it would result in very little new drilling at all–because drilling is, from a policy standpoint, not "responsible." And a package could take the Republicans’ most successful (arguably, their only) policy recommendation, drilling, off the table for the election.
Of course, that all assumes this would be done well…
Meanwhile, in Alaska, the Caribou Barbie is trying to pull of her own energy jujitsu, though it’s not yet clear what that jujitsu might entail. Andrew Halcro reports that Governor Palin is trying to get the oil companies onto a conference call this week, but it’s not yet clear why she wants to talk.
Governor Sarah Palin has requested a conference call this week with the CEO’s of the major oil companies playing a role in the potential development of Alaska’s natural gas pipeline.
The requested participants include Tony Hayward from BP, James Mulva from ConocoPhillips, Rex Tillerson from Exxon along with others. According to my source, no one knows exactly what the purpose of the call is, but some have never the less speculated.
Last week in her address to the nation, Palin stepped far over the line of truthiness (thanks Steven Colbert) when she told the country, "I fought to bring about the largest private-sector infrastructure project in North American history. And when that deal was struck, we began a nearly forty billion dollar natural gas pipeline to help lead America to energy independence."
Halcro lists the following possible reasons she’s requesting the call:
She has realized she actually has to deliver on the promise she made in her acceptance speech–so she has finally decided to make nice with the oil companies and start negotiating terms for the natural gas project that will be economically viable for the oil companies.
She wants to persuade the oil companies to stop referring to the massive new taxes she levied against them as a "windfall profits tax" (which of course Democrats support but McCain and the Republicans oppose strongly).
She has realized she has to at least be speaking to oil company executives if she wants to claim to be an energy expert–so she has decided to play nice to achieve, at least, some dialogue.
She wants to publicly browbeat the oil companies again, to bolster the McCain campaign’s claim to being assholes mavericks.
Mind you, that is all speculation from Halcro, not verified facts.
Now, Sarah Palin may be utterly inexperienced in most things that pertain to being a Vice President; she may be a more interesting subject for stories about her false maverickyness, her love of pork, and her lying. But she is definitely in a position to offer Republicans a story to tell about energy plans. We would do well to consider both these developments–Congress’ negotiation of an energy package and Palin’s attempts to do who knows what with the oil companies in AK–as two skirmishes in the battle over who gets to claim their party has a real plan to solve the current energy pinch.
This may be one of the policy issues that could decide this election–whether one or both of these sides successfully pulls of their jujitsu. I say "may," because who knows whether it will remain the one policy issue on which Republicans outpoll Democrats, what with the price of a barrel of oil down to $107 but with OPEC threatening to cut production. But both sides are treating it as the one policy issue that one or another side might be able to show real progress on between now and the election.
Photo by kristen.
Is Dick Stealing from the US and Giving to His Friends, Again?
Remember the Minerals Management Service? That’s the Department of Interior agency that is supposed to make sure that when oil companies drill on US or Native American lands, the landowner gets a sufficient return for the oil or gas they take out of the land, or, alternately, that a sufficient amount of oil to account for the royalty on the drilling rights is given back to the US. It’s been at the center of scandal before:
For a while, when oil companies drilled oil on federal land, one of three things would happen:
The oil companies would cheat and tell the government they drilled less oil than they had
When such fraud was identified, DOI would order its auditors to overlook the cheating
The byzantine rules governing royalties would make it hard to collect the money you and I are owed
So DOI started a new program. We’d let someone drill oil, and in exchange, the oil company would put a similar amount of oil into the strategic reserve. But when the strategic reserve filled up, the government started using brokers to sell our oil.
It turns out that Susan Wooldridge and Steven Griles had some close ties (as in, sharing a house) to one of the companies bidding to be that broker company, and that that company got to sell our oil even though another broker was willing to charge a higher rate (and therefore pay taxpayers more money). So basically, these two lovebirds accepted a bribe and sold our oil to the lowest bidder.
To fix that problem, they established a Royalty Management Subcommittee, which was supposed to watch out for our interests:
it’s supposed to study:
The extent to which existing procedures and processes for reporting and accounting for federal and Indian mineral revenues are sufficient to ensure that the Minerals Management Service receives the correct amount.
The audit, compliance and enforcement procedures and processes of the Minerals Management Service to determine if they are adequate to ensure that mineral companies are complying with existing statutes, lease terms, and regulations as they pertain to payment of royalties.
The operations of the Royalty in Kind program to ensure that adequate policies, procedures and controls are in place to ensure that decisions to take federal oil and gas royalties in kind result in net benefits to the American people.
Though the Royalty Management Subcommittee proved it wasn’t really interested in transparency and oversight, seeing as how it had a penchant for meeting in secret.
Now, to be fair, the Royalty Management Subcommittee just got started last year, and it takes a long time to reverse Dick Cheney’s corrupt ways. But an IG audit by the Department of Energy has discovered that there are completely inadequate controls on the oil that’s supposed to go into our Strategic Public Reserve, and over a quarter of the oil is disappearing.
To help add to the reserve, DOE receives a portion of the royalty oil that the Department of the Interior gets in return for allowing petroleum companies to drill on government lands and waters.
The department’s Inspector General Gregory H. Friedman and his auditors found that in 28 percent of the oil transfers they examined, the amount received did not match the estimated amount to be shipped by the Interior Department’s Minerals Management Service.
"To illustrate our findings regarding discrepancies, during a four-month period in Fiscal Year 2005, two Department contractors reported receiving 308,000 barrels of royalty oil less than the amount that MMS had scheduled for delivery to the market center. Yet, despite this significant shortfall, the Department took no action to resolve the discrepancy and to ensure that it had received all of the oil shipped by MMS," according to the audit. [my emphasis]
If you’re not vomiting up dinner yet, let me add this detail. Last year, as the Administration was putting together this year’s budget together, there was a bit of a squabble, which Dick (as is typical) won:
No, if there’s anything about the economy that keeps Dick Cheney up at night, it’s the prospect of sabotage aimed at disrupting the oil market, he told FORTUNE.
"Clearly the world depends on a global supply of oil, and that will continue to be true for some considerable period of time. Efforts to shut down the flow of oil could conceivably have a significant impact."
So when President Bush’s 2008 budget was coming together, with the goal of balancing the budget in five years, Cheney nevertheless insisted on a $947 million line item: a speedup of the flow of crude into the Texas and Louisiana salt caverns housing the nation’s Strategic Petroleum Reserve.
The budget guys pushed back: Can’t we wait until crude prices level off? No, the word came back from Cheney, this was urgent. That was all it took. "He doesn’t weigh in on a ton of issues," said a person close to those negotiations. "But when he does . . ."
When he does, the Vice President tends to get his way. "He’s an extremely effective bureaucratic operator," says Peter Wehner, formerly Bush’s director of strategic initiatives.
You see, the SPR had been full already–filled up when oil was at then-record prices (before now, when oil is again at record prices). But the Administration, under Shock Doctrine cover of Katrina, went ahead and expanded the SPR, environmental impacts be damned.
So let’s see. Dick Cheney’s buddies have, for years, outright refused to charge oil companies fair amounts for the right to drill on my and your land. When the excesses of corruption were discovered, they implemented other ways to try to fix the corruption; we would just get the oil, rather than quibble over an appropriate royalty. But come to discover that that method, too, is apparently at least ripe for massive corruption, if not already being exploited for graft. And Dick Cheney’s response?? Expand the opportunity!! I want all my buddies to get an opportunity to steal from the American government, and I’m not above invoking national security to do so!!!
Typical.
Originally Posted @ https://www.emptywheel.net/energy-policy/page/15/
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Australasian Engineering Heritage Conference 2020
Engineering New Zealand’s Otago Heritage Chapter has been selected to host next year’s Australasian Engineering Heritage Conference.
Date: 19 – 25 November 2020
Location: Dunedin
More information and registration will be open closer to the conference date. For more updates join the mailing list.
Titled ’Engineering in a 2020 World – The Future of the Past’, the conference will spotlight how heritage engineering and technology has endured, developed and undergone restoration and repurposing, and its place in the future.
The conference organisers invite submissions of abstracts and will accept them along with formal conference papers and proposals for presentations until 6 March 2020.
Papers will be published in the Conference Proceedings. Presentations will be programmed into 30-minute increments including a 5-minute allowance for Q&A sessions. Papers selected for keynote presentations will be allotted longer time slots.
Conference themes include (but are not limited to):
Recreation/Entertainment
Engineering of Heritage
People, businesses, communities
Submission guidelines:
Provide sufficient evidence of alignment to the conference’s theme.
Include the paper’s title, your full name, and your position or affiliation (or a brief bio).
Don’t exceed 300 words.
Send inquiries, submissions and presentation ideas to ehconference2020@engineeringnz.org
The conference will focus on heritage engineering or technology which has endured, undergone development, restoration and repurposing to claim its place in the future.
It’s a theme that aligns well with the story of the Otago region of New Zealand.
Situated at the southern end of New Zealand, Otago is bordered in the west by the Southern Alps and in the east by the Pacific Ocean. Abundant natural resources supported a population of Māori who were joined by small numbers of European sealers and whalers through the early 19th century. Scottish settlers founded the city of Dunedin in the 1840s, and in 1861, gold was discovered in Central Otago, fuelling a further influx of migrants, supercharging the region’s economy and creating a demand for engineering infrastructure which has not been seen since. Our distance from other manufacturing and industrial centres necessitated both local ingenuity and industrial capacity.
Times change, but some things endure. Much of our past has a future.
Three of New Zealand’s largest construction companies were incorporated in Dunedin – two of these well over 100 years ago. The entirely Dunedin-built steamer TSS Earnslaw still plies Lake Wakatipu after 106 years of service. A vast network of water races built to provide water for gold mining now carry the water which irrigates much of the Central Otago farmland, while Dunedin City has just finished the overhaul of a 151-year-old water supply dam.
Dunedin’s economy is increasingly underpinned by its considerable information and communications technology (ICT) resource and even this has strong links to the past. A 105-year-old engineering company has become a world leader in assembly line, meat processing and robotics technology. Once a staging post for exported wool and grain or imported goods, the city’s re-purposed warehouse precinct now houses companies creating real-time animations for globally televised sports events such as the America’s Cup or Masters golf, building fine instrumentation for the life sciences or creating genetics management software for farmers.
The future of the past. This conference theme not only fits our region, it provides a platform for a wide range of papers across the full spectrum of engineering and technological endeavour in what promises to be an engaging and enlightening event.
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Lorry driver pleads not guilty after two women killed on M25
Lorry driver pleads not guilty in court after two Luton women killed in fatal collision on M25 near Waltham Abbey
The fatal incident happened between junctions 26 and 27 on M25 near Waltham Abbey, on Tuesday, March 19, 2018
A man has pleaded not guilty to causing the death of two women from dangerous driving in a collision on the M25.
Krzystof Zarebski, 34, of Gordon Street, Coventry, appeared at Chelmsford Crown Court today, June 17, and entered his pleas in relation to the incident and one count of causing serious injury.
Mother and daughter 68-year-old Ayse and 49-year-old Sevim Ustun, both from Northdrift Way, Luton, were sadly pronounced dead at around 11.30pm on Tuesday, March 19, 2018.
The incident occurred between junctions 26 and 27 of the motorway near Waltham Abbey when Zarebski’s articulated lorry collided into the family who were pedestrians.
A 10-year-old girl was also taken to hospital with serious injuries after the lorry overturned and crashed down onto an embankment.
Zarebski will next appear at Chelmsford Crown Court for his trial, which is listed for Monday, February 24, 2020.
Essex Police would like to note to when they announced Zarebski’s charges (issued on Sunday, April 12, 2019) his surname was spelt incorrectly. Essex Police apologise for any inconvenience caused and ask that the surname is corrected to Zarebski.
In previous press releases, Essex Police also referred to the collision being between an Audi and an articulated lorry.
We would like to clarify that all victims were pedestrians at the time of the collision and Essex Police asked for this to be reflected in its reporting.
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Erste AM expects emerging economies to continue growing
Emerging economies: GDP growth per capita of 32% expected for 2017-2022
Positive for the capital markets: fall in inflation
China: soft landing
Increased resilience due to flexible currencies
Limited risk as a result of the rate hike cycle in the USA
Corporate bonds benefit from ongoing deleveraging and higher spreads than are paid for comparable companies from the developed economies
Emerging economies are outperforming developed economies
Erste AM expects to see solid growth rates in the emerging markets also in the future. According to the International Monetary Fund, GDP per capita should increase by 32% in the coming five years. At 64%, this growth rate has been significantly above that recorded by the developed economies (24%) in the past ten years (source: IMF). The emerging economies in Asia excel as growth engine: GDP per capita has more than doubled over the same period of time in Asia (+111%). Emerging and developed economies have thus continued to converge. For example, GDP per capita (in USD, adjusted for purchase power) in the emerging economies amounts to USD 11,800, that in the developed economies to USD 49,000.
Positive for the capital markets: falling inflation
Year / inflation rate (emerging markets globally)
1997: 12.8 %
2007: 6.5 %
(Source: IMF)
Almost as remarkable as the strong real growth is the decrease in inflation we have seen. “This is due to the successful monetary policy of the central banks, among other reasons”, as Erste AM chief economist Gerhard Winzer explains. Overall, the low inflation makes forecast models more precise. Also, it represents a good indicator for improved resource allocation.
China: soft landing expected
China plays a crucial role for the development of the emerging markets. However, growth rates of 20% y/y were not sustainable. The current trend is towards a gradual slowdown of economic growth. It comes with a structural transition of the economy, as exemplified by the internationalisation of the renminbi. The economic cycles remain dominated by a classic stop-and-go policy: a period of economic stimulus is followed by a period of restrictive measures.
Resilience due to flexible currencies
The flexible currencies have a positive impact on the economic development of emerging markets. In case of crises, they can depreciate, which takes care of a significant part of domestic adjustment that is needed in such a situation (e.g. Greece). This is also beneficial for the default risk of the respective country. The falling commodity prices in the first half of this decade have played an important part in the depreciation of the Russian rouble and the Brazil real. This has helped overcome the respective recessions. India, too, has been faced with imbalances at the beginning of this decade. The current account deficit was elevated, among others. The weakening of the rupee helped cut the deficit and step up economic growth.
Decreased interest rates in the USA and the rest of the developed world
Not only have the actual nominal interest rates fallen, but the natural interest rate is also clearly below previous levels. The natural interest rate is the rate which neither stimulates nor dampens economic growth or inflation. For the status quo, this concept can be resorted to for an assessment of how much interest rates can rise. In the USA, the real, natural interest rate is currently 0% (according to a working paper by the Federal Reserve Bank of San Francisco). The nominal, natural interest rate at 2% inflation is therefore only 2%. Given the current key-lending rate of 1%-1.3%, the potential for rate hikes is limited.
Corporate bonds benefit from ongoing deleveraging and higher spreads than for comparable companies from the developed economies
In its asset allocation, Erste AM currently prefers emerging markets corporate bonds. The ongoing deleveraging and the low leverage to start with are among the strengths of this asset class. This translates positively into the rating of the respective countries and thus the individual companies.
Emerging markets corporate bonds: issue volume quintupled
Péter Varga, Senior Professional Fund Manager Emerging Market Corporates with Erste AM: “Since we launched this asset class, the investment universe of emerging markets corporate bonds has matured noticeably. While we were one of the first asset managers to engage with this asset class back then, the market volume has quintupled in the past years. At a volume of USD 1.7 trillion, the market for emerging markets corporate bonds is now almost as big as that for US high-yield bonds.”
Emerging markets corporate bonds are an attractive asset class particularly for investors with a long-term investment horizon and the willingness to assume a certain degree of risk. Companies in the emerging markets are by far less leveraged than companies in the developed economies. The average credit rating is BBB- to BB+, i.e. at the threshold to the high-yield segment, while the combined debt load of all emerging markets companies combined amounts to only half of that carried by the US high-yield issuers, as Varga points out.
Long-term yield of 5-6% realistic for emerging markets corporate bonds
Taking into account demographic shifts, Erste AM fund manager Péter Varga expects retail investors to step up their allocation to emerging markets corporate bonds: “People want to reduce their shareholdings and instead generate ongoing return from interest income as they are getting older.” Emerging markets corporate bonds with a long-term yield of 5-6% would lend themselves to this purpose. And even in times of rising yields, the spreads are still high enough to absorb negative effects.
Since the launch of ERSTE BOND EMERGING MARKETS CORPORATE (AT0000A05HQ5; distributing fund) in 2007, Varga and his team have achieved a compound annual growth rate of 6.4%. This track record has earned them multiple awards, among them a Morningstar rating of five out of five stars. Assets under management amount to EUR 426mn (as of 30 June 2017). The fund management team in charge manages close to EUR 1.7bn worth of mutual funds invested in emerging markets corporate bonds and institutional mandates.
*) The ratio “yield” equals the average yield of the securities held in a fund, portfolio, or index prior to fees resulting from foreign exchange hedging transactions; please bear in mind that the ratio “yield” is not tantamount to performance. For a performance overview of the funds mentioned, please visit our website. The aforementioned yield does also not include costs reducing the rate of return such as management fees or individual account or depositary fees.
Please note that forecasts are no reliable indicator for future developments.
For legal documents and further information on the aforementioned funds, please visit www.erste-am.at.
ERSTE BOND EMERGING MARKETS CORPORATE EUR R01
Also have a look on our investment blog: http://blog.en.erste-am.com/
This document is an advertisement. All data is sourced from Erste Asset Management GmbH, unless indicated otherwise. Our languages of communication are German and English.
The prospectus for UCITS (including any amendments) is published in Amtsblatt zur Wiener Zeitung in accordance with the provisions of the InvFG 2011 in the currently amended version. Information for Investors pursuant to § 21 AIFMG is prepared for the alternative investment funds (AIF) administered by Erste Asset Management GmbH, pursuant to the provisions of the AIFMG in connection with the InvFG 2011.
The fund prospectus, Information for Investors pursuant to § 21 AIFMG, and the key investor document/KID can be viewed in their latest versions at the web site www.erste-am.com or obtained in their latest versions free of charge from the domicile of the management company and the domicile of the custodian bank. The exact date of the most recent publication of the fund prospectus, the languages in which the key investor document is available, and any additional locations where the documents can be obtained can be viewed on the web site www.erste-am.com.
This document serves as additional information for our investors and is based on the knowledge of the staff responsible for preparing it at the time of preparation. Our analyses and conclusions are general in nature and do not take into account the individual needs of our investors in terms of earnings, taxation, and risk appetite. Past performance is not a reliable indicator of the future performance of a fund. Please note that investments in securities entail risks in addition to the opportunities presented here. The value of shares and their earnings can rise and fall. Changes in exchange rates can also have a positive or negative effect on the value of an investment. For this reason, you may receive less than your originally invested amount when you redeem your shares. Persons who are interested in purchasing shares in investment funds are advised to read the current fund prospectus(es) and the Information for Investors pursuant to § 21 AIFMG, especially the risk notices they contain, before making an investment decision.
Please consult the corresponding information in the fund prospectus and the Information for Investors pursuant to § 21 AIFMG for restrictions on the sale of fund shares to American citizens. Misprints and errors excepted.
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Guidance, Not Governance - Rabbi Solomon B. Freehof and Reform Responsa
By Joan S Friedman
Guide to the Archaeological Museum of Thessalonike (English language edition)
By Julia Vokotopoulou
The Museum, one of the most important in Greece, houses masterpieces of Greek art associated with the history of Ancient Macedonia, from the 2nd millennium BC to the 4th century BC and the reigns of Philip II and Alexander the Great. The Guide presents the rich, varied finds from important Macedonian sites. 240 col illus.
Guide to the Archaeological Museum of Thessaloniki (French language Edition)
The Museum, one of the most important in Greece, houses masterpieces of Greek art associated with the history of Ancient Macedonia, from the 2nd millennium BC to the 4th century BC and the reigns of Philip II and Alexander the Great. The Guide presents the rich, varied finds from important Macedonian sites. 240 col illus. French language text.
Guide to the Archaeological Museum of Thessaloniki (German language Edition)
The Museum, one of the most important in Greece, houses masterpieces of Greek art associated with the history of Ancient Macedonia, from the 2nd millennium BC to the 4th century BC and the reigns of Philip II and Alexander the Great. The Guide presents the rich, varied finds from important Macedonian sites. 240 col illus. German language text.
Guide to the Archaeological Museum of Thessaloniki (Italian language edition)
The Museum, one of the most important in Greece, houses masterpieces of Greek art associated with the history of Ancient Macedonia, from the 2nd millennium BC to the 4th century BC and the reigns of Philip II and Alexander the Great. The Guide presents the rich, varied finds from important Macedonian sites. 240 col illus. Italian language text.
Guillaume de Machaut, The Complete Poetry and Music, Volume 1 - The Debate Poems: Le Jugement dou Roy de Behaigne, Le Jugement dou Roy de Navarre, Le Lay de Plour
With Domenic Leo, Yolanda Plumley and Uri Smilansky Edited and translated by R Barton Palmer
Guillaume de Machaut is the most important poet and composer of late medieval France. His unique and inventive output is the subject of this new, integrated edition of Machaut's complete poetry and music. Includes the French originals and facing English translations.
Guillaume de Machaut, The Complete Poetry and Music, Volume 2 - The Boethian Poems Le Remede de Fortune and Le Confort d'Ami
Commentaries by Domenic Leo Edited by Uri Smilanksy Edited and translated by R. Barton Palmer
The second volume of the thirteen in preparation that will offer the first complete scholarly edition of the poetry and music of Guillaume de Machaut. New edition based on the most reliable manuscript of two of Machaut's best known dits, the Remede de Fortune (Remedy for Fortune) and the Confort d'ami (Consolation from a Friend).
Guillaume de Machaut, The Complete Poetry and Music, Volume 9 - The Motets
Edited by Jacques Boogaart Translated by R Barton Palmer
New edition of Guillaume de Machaut's 23 motets, is based on the most authoritative of the surviving manuscripts and is designed to meet the needs both of advanced scholars and musicians as well as students and performers. User-friendly format indicates variants on the scores. The lyrics, with full English translation, are included.
Guy of Saint-Denis, Tractatus de tonis
Edited and translated by John N. Crossley, Catherine Jeffreys, Constant J. Mews and Carol J. Williams
The Tractatus de tonis of Guy of Saint-Denis (written ca. 1300-10) differs from other treatises on plainchant in the depth of its analysis of the various tones into which chant was traditionally classified.
H Ellada tou Taki Tloupa
By Antonis Karkayannis and George Ch Chourmouziadis
Photographer Takis Tloupas was born in Thessaly, grandson of a coppersmith and son of a carpenter, and lived and worked there in Larisa. He toured Greece, first by Vespa then in a Deux Chevaux, taking over 30,000 photographs of what he saw, but it was Larisa that he photographed most as time went by. 574 b&w photographs. Greek language text.
Hardback Out of stock
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GameTimePA
FlipSidePA
'We just couldn’t get his heart to beat again': Son loses heroin battle 3,000 miles from home
Logan Minnich moved from Pa. to California to continue his heroin recovery. His mom never saw the 23-year-old again.
'We just couldn’t get his heart to beat again': Son loses heroin battle 3,000 miles from home Logan Minnich moved from Pa. to California to continue his heroin recovery. His mom never saw the 23-year-old again. Check out this story on eveningsun.com: https://www.ydr.com/story/news/2019/03/11/heroin-epidemic-son-loses-battle-addiction-3-000-miles-home-pennsylvania-california/3099639002/
Shelly Stallsmith, York Daily Record Published 8:42 a.m. ET March 11, 2019 | Updated 11:06 a.m. ET March 12, 2019
Jamie Minnich had been helping her son, Logan, fight his addiction to heroin for years. In January 2019, He relapsed, suffered an overdose and died. Cameron Clark, York Daily Record
Jamie Minnich spent six years sleeping fitfully, listening for movement as her son slept.
She spent six years making sure he texted her when he went out, when he came home, and times in between.
She spent six years waiting for a call she didn’t want to answer.
That call came Jan. 14, when a California doctor told her Logan, her 23-year-old son, was dead.
“You are either waiting for phone calls from the police, you are waiting for phone calls from the hospital, friends,” Jamie said. “I made him text me nonstop. If he slept for too long, I’d be checking on him.”
Jamie was afraid her son would go to sleep and not wake up. That the heroin his brain said his body needed would shut him down for good.
It’s exactly what happened.
Logan’s six-year battle with drugs came to an end less than a month after he checked into Pacific Palms, a recovery house in Oceanside, California.
Living in Los Angeles was Logan’s dream. His first time on an airplane was the Dec. 15 trip from St. Joseph Institute for Addiction near State College, Pennsylvania, to Pacific Palms.
More: 'I was so clueless': How parents can recognize drug addiction in teenagers
Jamie saw her son for the last time on Dec. 13, when she spent about 90 minutes with Logan and his counselor as they prepared for his journey. She took him the electronics he couldn’t have in rehab, but could use in recovery, and traded his winter clothes for some better suited to southern California.
“He seemed good when he left,” Jamie said. “He had a layover in Phoenix, and I talked to him. He was good the first two weeks in California. I could tell from his Facebook stuff and messages on his iPad.
“Something happened in that last week or so.”
This is the most recent picture of Logan Minnich. He had just moved to California, and began living in a recovery house. According to his mother, he was doing well, February 14, 2019. (Photo: Cameron Clark, York Daily Record)
Jamie might not ever know why things changed for Logan, but she is trying to find out. She has hired a private investigator to look into his password-protected laptop and phone. She is hoping for a phone number or name of the person who provided the drugs that Logan took. That information could lead to a criminal investigation.
Until then, Jamie is telling Logan’s story in the hopes that it can keep another family from traveling the road she and her late husband, Tim, had to travel.
York County coroner Pam Gay is familiar with the end of that road. After seeing a spike in drug-related deaths in 2017, there were fewer in 2018. Gay sees that as a positive.
“We jump at every silver lining we can find,” Gay said. “It could totally be a fluke, it could be different next year.”
She believes the use of Narcan, and the fact that it’s more readily available, is a big reason for the slight decline in heroin deaths in 2018, even though the overdose reversal drug has been in use in York County since 2015.
Hidden secret
Jamie Minnich learned about her son’s drug use six years ago, during his junior year at Spring Grove Area High School. She came home to find a step stool in the middle of her bathroom floor. There was no logical reason for the stool’s location. At least not until she climbed it and started to poke around the ceiling tiles.
“I had a drop ceiling, I hit it and heard things fall,” she said. “I took it away and there was drug paraphernalia. Bags of pot. Nothing worse than that.”
After talking to her son, she bagged her findings and threw them away.
But it didn’t end there. Attendance became an issue in Logan’s senior year of high school. By then he was driving himself to school - at least that’s what his parents thought.
“We both left for work before Logan,” Jamie said. “So, if he didn’t go [to school] I didn’t know. If he wasn’t there, if he left, I didn’t know.”
Jamie and Tim noticed things were missing from around the house, from Tim’s work truck.
A picture of (left to right) Logan, Jamie and Tim Minnich sits on the desk in Logan's room, February 14, 2019. (Photo: Cameron Clark, York Daily Record)
A month before Logan graduated from Spring Grove in 2013, Jamie was called to the high school. The police received a tip from Crimestoppers that Logan was dealing drugs from his car. They needed a parent to be present because he was 17.
The police searched his car and his locker. Logan was strip searched and warned that he would be watched. A short time later, Logan turned 18 and graduated from high school.
By the end of the year, Logan went from attending classes regularly at Penn State York to sitting in Central Booking for DUI with drugs in his system and possession of Molly.
“We got a bail bondsman, my husband went in and bailed him out,” Jamie said. “We got a lawyer. You know our court system, everything drags out.”
In four months’ time, Logan got three DUIs – all for drugs – and lost his driver’s license for 14 years. He was put on house arrest and wore an ankle bracelet. His curfew was 10 p.m. because he was working.
He found ways to drive. In April 2015, he totaled a car and told police he didn’t want his parents to bail him out. Logan went to jail.
“We combined all of the DUIs, all of the charges in between and took a plea agreement for Logan to stay in jail for six months,” Jamie said. “I was OK with him going to jail. It was the felony I worried about because you have that forever.”
Logan got out of York County Prison in October 2014, and his mother said things went downhill from there.
Jamie Minnich has pictures of Logan and her late husband, Tim, throughout her house, February 14, 2019. (Photo: Cameron Clark, York Daily Record)
Seeing dollar signs
Logan’s parents didn’t know about the money he owed to drug dealers or the threats he received to make him pay. Jamie received his iPad after he died and learned his car windows were broken by the same drug dealers who told him he had seven targets on his back.
She read text messages warning Logan that people would come after him and his family to get their money.
“Logan’s only 19, and he’s trying to come up with money,” Jamie said. “Don’t get me wrong, he’s responsible for all of this. He made these choices, but this is how it spirals out of control.”
Jamie doesn’t know how much her son owed, but she knows the dealers wanted $300 to keep his family safe. This was just the beginning.
He totaled five cars, but never hurt anyone. The last car belonged to his mother. He took it in December 2017 while she slept and was back home playing video games when she discovered it was gone. Logan didn’t admit to the crash until he learned she could be held accountable if police thought she was covering for her son.
Logan wanted to return to college. He wanted to try and make something of himself even though he had a felony hanging over him and the knowledge that he couldn’t drive until he was in his early 30s.
Jamie Minnich (left) did everything she could to help Logan (right) beat his addiction. She encouraged him to seek help and was by his side every step of the way, February 14, 2019. (Photo: Cameron Clark, York Daily Record)
The family learned it’s hard to find a four-year college that will accept someone with a felony.
“IUP agreed,” Jamie said. “That’s where I graduated from.”
But a month before Logan was to leave for school, Tim was diagnosed with cancer on top of the congestive heart failure they already knew about. He was given three to six months to live.
“I told [Logan] he needed to go,” Jamie said. “And, actually, I wanted him to go. I thought it’s best Logan go away and I told him anytime he wanted to come home, we’ll get him home.”
So Logan left. He went to class and he blew through his student loan money to the tune of $27,000 in less than three semesters. He took out credit cards and maxed them with cash advances.
Tim Minnich died in March 2016, at the end of Logan’s spring break. In October, Logan was caught shoplifting an $8 item in Indiana, Pa., and after spending three days there in jail, was sent to Central Booking in York on an outstanding warrant.
Getting clean
Photos: Remembering a York County man who died of a heroin overdose
Logan Minnich died of a heroin overdose on January 14, 2019 after relapsing in California. He was 23. Cameron Clark, York Daily Record
Logan Minnich had been struggling to with a heroin addiction which cost him his license and eventually lead to jail time, February 14, 2019. Cameron Clark, York Daily Record
Jamie Minnich remembers her son, Logan, while holding his ashes, February 14, 2019. Cameron Clark, York Daily Record
Jamie Minnich keeps Logan's ashes in the living room of her home, February 14, 2019. Cameron Clark, York Daily Record
This is Logan Minnich's room. It's same as the day he left for California, February 14, 2019. Cameron Clark, York Daily Record
In Logan Minnich's room is an Evening Sun newspaper article highlighting him and his team when he was younger. Logan was very proud of this, February 14, 2019. Cameron Clark, York Daily Record
A picture of (left to right) Logan, Jamie and Tim Minnich sits on the desk in Logan's room, February 14, 2019. Cameron Clark, York Daily Record
Logan Minnich played lacrosse and other sports at Spring Grove high school before graduating in 2013. Cameron Clark, York Daily Record
Jamie Minnich has pictures of Logan and her late husband, Tim, throughout her house, February 14, 2019. Cameron Clark, York Daily Record
Jamie Minnich (left) did everything she could to help Logan (right) beat his addiction. She encouraged him to seek help and was by his side every step of the way, February 14, 2019. Cameron Clark, York Daily Record
This is the most recent picture of Logan Minnich. He had just moved to California, and began living in a recovery house. According to his mother, he was doing well, February 14, 2019. Cameron Clark, York Daily Record
Logan hit rock bottom in July 2018 after 18 months of struggling to find a job with a felony record and no driver’s license on top of student loan and credit card debt.
“July 11, it was 90 degrees and he was wearing sweats,” Jamie said. “This is how addicts dress. They are cold all of the time through addiction. If they’re not high, they’re suffering from chills.”
A week later he started outpatient rehab. He rode his bike or walked there two or three times a week to try and kick the heroin addiction.
After her husband’s death, Jamie sold their house with an acre of land in the Spring Grove School District. She moved with Logan to a two-bedroom apartment in Hanover that was close enough to the outpatient rehab facility, stores, restaurants and their jobs that Logan could walk or ride his bike.
She was trying to give her son an element of independence and pull him out of the depression that heroin had sunk him into. Logan relapsed three weeks into outpatient rehab, but returned to the program a week later.
Jamie said it was a constant struggle for her son. He was frequently sick and would sleep in the hall of their apartment building so he wouldn’t wake her up when he got home from working third shift.
By September, Logan had given up on outpatient rehab and was looking for something residential.
“I don’t know how he picked St. Joe’s,” Jamie said of the rehab facility near State College. “He did all of the leg work, made all of the phone calls. He said I found a place that’s going to take me, they are going to pick me up tomorrow.”
When he was near the end of his 30-day treatment, Logan called his mom and asked if she would pay for two more weeks (insurance paid for the first 30 days). He didn’t feel like he was ready to leave.
“They get scared to come back into society,” Jamie said. “They feel very protected and in a bubble when they are in rehab.
“He’s five miles out in the woods, there are no drug dealers trying to get ahold of him. The place is gated and locked, they can’t get in.”
After six weeks in rehab, Logan transferred to a recovery house in the City of York. Within three weeks he relapsed in the house and was immediately kicked out. He got into a fight during his days on the street and went to jail, but didn’t call his mom until he made the decision to return to St. Joe’s.
“He called me and said, ‘St. Joseph’s is coming to get me, I had a bad day today,’” Jamie said. “Later I found out through a message that he had been using Thursday, Friday, Saturday and Sunday, took off Monday and relapsed Tuesday and called St. Joe’s. I’m surprised, honestly, that he made it through that.”
One last slide
Logan Minnich played lacrosse and other sports at Spring Grove high school before graduating in 2013. (Photo: Cameron Clark, York Daily Record)
Logan knew heroin addicts don’t get many recovery attempts. So, when he made it through a second stint at St. Joseph’s and was looking for a recovery house, his counselors didn’t want him to come back to York.
He knew too many people in York. He relapsed a month earlier when he came to York. They wanted a fresh start for Logan, who had dreams of southern California.
That’s where he went. He left Dec. 15 to live in a million-dollar house a block from the beach in Oceanside. The first few weeks were positive as he continued with his counseling and got settled.
By the second weekend of January, everything had changed.
“It’s hard when you are 3,000 miles away,” Jamie said. “Days before [the overdose] he had deleted Facebook, he sent a group message to about 12 people. He told the people at St. Joe’s that if he relapsed again he was just going to make himself disappear.”
The first phone call came just after Jamie got to work at RH Sheppard Wabco in Hanover at 6 a.m. on Jan. 14. It was a California phone number and she knew the news wasn’t going to be good. The Pacific Palms house manager said Logan had overdosed and was on his way to the hospital. They had given him two doses of Narcan.
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“They didn’t tell me that he didn’t respond to the Narcan,” she said. “I figured at that point, they were taking him as a precautionary measure to the hospital because sometimes they have respiratory problems. They sent me the information about what hospital he was at, and that was it.”
She told her boss and coworkers about the call and that she wasn’t sure what was going on. And she went back to work.
An hour later, a doctor called from St. Joseph’s Missionary Hospital and told her about the breathing tube and the pulmonary people who tried to get Logan’s heart beating.
Jamie asked if it was beating now. The doctor replied, “No, Logan didn’t make it.”
“And I said, ‘did he die?’ And he said, ‘yes,’” Jamie remembered from her Hanover apartment. “He said, ‘we’re sorry, but we just wanted to let you know that everybody tried, but we just couldn’t get his heart to beat again.’”
Logan took his last ride on an airplane just over a month after he took his first. This time he was coming home.
Jamie Minnich remembers her son, Logan, while holding his ashes, February 14, 2019. (Photo: Cameron Clark, York Daily Record)
Jamie has had plenty of time to look back and rethink how she and her late husband handled things. Would they do things differently if given the chance? Did she feel they enabled him?
The answer to both questions is no.
“I helped him get back on his feet for those six years,” she said. “I never got him out of any trouble. He served his time. We knew what was going on. I just couldn’t get him help because he didn’t want help.
“I had to wait for him to come dragging to me this summer and say, ‘I need your help, I’m done with this. I want out. I want to start a new life.’”
Logan Minnich was an athlete, he played baseball, soccer and lacrosse. He did well in school. He wanted to be an engineer.
He liked to hang out with his friends. And when those hangouts involved pot, his mother said, Logan joined. Somewhere on the journey, pot became Molly, which became heroin.
“They were just partying, it was fun,” Jamie said. “And then he got sucked in and things just spun out of control for him. When you mess with heroin, it messes with your brain. It becomes addictive almost right away.”
Jamie has done a lot of research in the last six years. She said it’s easier now with groups like Not One More than it was in the beginning. They educate and support, the exact things Jamie hopes to do in local schools.
She wants to walk into schools carrying the small wooden box that holds Logan’s ashes, the one she purchased with contributions from her coworkers. It sits on the TV stand in a corner of her living room.
“I would love to walk into Spring Grove with this and sit it there with me, and say, this is how you are going to go home to your parents if you even go down the heroin route.”
Read or Share this story: https://www.ydr.com/story/news/2019/03/11/heroin-epidemic-son-loses-battle-addiction-3-000-miles-home-pennsylvania-california/3099639002/
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SEPTEMBER II, 1914. I7HE9 THE " ROUND BRITAIN " MACHINES. THE machine numbered 6 in the Circuit of Britain, and which was to have been piloted by Capt E. C. Bass, is The White and Thompson Curtiss Flying Boat. This machine, although following standard Curtiss practice in its general lay out, differs in numerous details from the American-built Curtiss boats. One of the side area of the boat. Six pairs of spruce struts separate the main planes, the whole wing structure being made rigid by diagonal cross bracing. Mounted on strong ash bearers resting on a structure of steel tubes sloping upwards from the lower main spars is the engine—a 120 h.p. Beardmore A.D.—which drives a four-bladed propeller situated behind the planes, the ROUND BRITAIN MACHINES, No. 6.—Three-quarter front view of the White and Thompson flying boat. innovations incorporated, which is apt to be overlooked by the casual observer, but which is nevertheless of the greatest importance, is the new wing section. Instead of the usual Curtiss section, one like the R.A.F. 6 has been chosen, and appears to have several advantages over the original Curtiss. The wings are rectangular, as seen in plan, and the top plane is of considerably greater span than the lower one, the weight of the extensions being trailing edge of which has been cut away in the centre to provide the necessary clearance. The main petrol tank is placed inside the boat, whence petrol is pumped by means of a pressure pump to a smaller service tank mounted on the bearers in front of the engine. The capacity of the petrol tank is 60 gallons, or sufficient for a flight of about six hours' duration. The boat, which has been constructed by Messrs. ROUND BRITAIN MACHINES, No. 6.-Three-quarter rear view of the "White and Thompson flying boat. taken, when the machine is at rest, by steel tubes sloping downwards and inwards to the lower extremities of the outer inter-plane struts. Interconnected balancing flaps are hinged to the rear spar of the upper plane, and not, as in the original Curtiss machines, to the plane struts. A vertical fin is fitted above the upper main plane in order, no doubt, to counteract the comparatively large Saunders of Cowes, is a beautiful piece of work, as is to be expected from a firm of such standing. It is built up of two skins of mahogany, copper sewn, over a frame work of ash and spruce. In front the boat is of roomy proportions, and affords ample accommodation for pilot and passenger, who sit side by side inside a very com fortable cockpit. From the nose to the step, which is placed 933
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Coca-Cola Company won’t ditch stevia in the UK
By Nicholas Robinson contact
Related tags: Stevia, The coca-cola company, Uk
A backlash against stevia in the US led Coca-Cola to do a U-turn on its Vitawater recipe
Sugar reduction campaigners have praised the Coca-Cola Company’s (CCC’s) refusal to drop the natural sweetener stevia in its Glaceau Vitaminwater in the UK, as it has done in the US.
Earlier this week, CCC announced it would ditch stevia as a sweetener for its Glaceau Vitaminwater in the US and revert to crystalline fructose and cane sugar.
The U-turn followed pressure from Vitaminwater’s US consumers on Facebook, who called for the drink to be reverted back to its original form, just months after the stevia version was rolled out in May.
Would not be reformulated
However, Vitaminwater on the UK market would not be reformulated to remove stevia, which has been used in the product since 2012, a CCC spokesman told FoodManufacture.co.uk.
“We have no current plans to adapt the range further in the UK,” he said.
“Our focus is on delivering great-tasting products that meet consumer demand.”
“We conducted extensive taste tests at [the UK launch of Vitaminwater], which found that people felt the new stevia-based formulations were as good or better than the existing range of drinks,” said the spokesman.
Tam Fry, advisor to the campaign group Action on Sugar and a National Obesity Forum spokesman, praised CCC’s decision to stick with stevia in the UK.
“I think that consumers in the UK are starting to say that we don’t like lots of sugar in our drinks at all,” he told FoodManufacture.co.uk.
“They will, however, stomach a certain amount of sugar in order to enjoy a drink, and that’s part of the joy.”
‘Not against sugar’
Fry, who said he was not against sugar, rather the overuse of it in some food and drinks products, previously called some food and drink companies “sugar barons”. He accused them of risking children’s health to make a profit.
CCC’s decision to leave stevia in the UK product also highlighted the stark contrast in taste preferences between UK and US consumers, claimed Fry.
“That’s the main problem with sugar reduction in the US,” he said. “They are finding it more difficult [than UK consumer] to wean themselves off sugar.
“They have been dosed-up over the years and it’s been a shock to find themselves drinking less sugar.”
Fry, who is an advocate of stevia, said the UK’s openness to it in Vitaminwater would also be beneficial for CCC when it launches its stevia-sweetened Coca-Cola Life drink this autumn.
“Coca-Cola has managed to achieve a one-third reduction in calories and sugar because of stevia,” he said.
But, the question was not whether it would be a success in the UK, rather whether it would be a success in the US, he added.
“Coca-Cola may be launching it in the UK and Europe to gauge response, but if US consumers want sugary products, will Coke Life have life there?”
Related topics: Ingredients, Sweeteners (intense, bulk, polyols), Healthy foods, Obesity Debate, Food Ingredients, Health & Nutrition
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10 Ways Playing Video Games Benefits the Soul and Society (No, seriously! It’s science!)
In our post 10 Science-Backed Benefits of Playing Video Games on the Mind and Body, we brought you ten totally rad ways gaming improves your physical and mental health and capabilities. (Spoiler alert: a couple of them are pretty wild.)
But what about the rest of us? Not to get too new-agey on you, but people are more than just mind and body. Is it possible gaming can have a positive impact on your spirit, personal motivation, and world views too?
Well, it certainly depends on what you’re playing, but, according to a handful of forward-looking scientific studies, the answer is yes.
As more and more people who grew up playing video games enter adulthood, more and more studies are focusing on the potential benefits of gaming, instead of just the negatives. The result is a far more balanced view of gaming from a scientific perspective, and a lot of it looks pretty darn good. So, the next time you feel like you need an excuse to crash on the couch or behind your PC for a few hours of gaming, here are some really good ones.
1. Gaming improves happiness.
Video games are fun. Sort of obvious, right? Who would dedicate so much time to them if they were a drag to play? The thing about fun, though, is it isn’t just a drain on time. Fun actually generates positive emotions, which helps to negate negative emotions, thereby making us happier overall.
And what difference does it make whether you feel happy or not? Quite a lot, according to research.
In a roundup of happiness studies, researchers found that happier people lead better lives. They are physically and mentally healthier, have fuller relationships, and achieve greater financial success. Well, of course they do, you might think. If you’re healthy, have good relationships, and have money, you’re bound to be a happier person.
But researchers took that reverse-correlation into account, determining definitively that the positive outcomes didn’t cause people’s happiness, it was the happiness that caused the positive outcomes. Basically, playing video games (specifically quick, easy games with consistent rules, like Candy Crush and Angry Birds) makes you happy, and happiness matters.
2. Gaming decreases anxiety.
Those same quick, simple games that make you happier? One way they help to do that is by decreasing your anxiety levels. And not just the everyday sort of anxiety most people experience, but the oppressive, ongoing kind of anxiety that leads to diagnosis and drug therapy for many.
In a study done at East Carolina University, researchers found that supplementing the primary medical treatment (a serotonin reuptake inhibitor) of clinically depressed study participants with casual video games, including Bejeweled 2 and Bookworm Adventures, lowered anxiety levels of those participants 20% more effectively than taking a secondary medication. If that’s not a good enough reason to pick up a controller or smart phone before calling your doctor, I don’t know what is.
3. Gaming relieves stress.
If playing video games reduces anxiety, it goes to reason it should also reduce stress levels, and, according to a study of 66 American employees, as reported by Science Daily, that’s exactly what it does.
The study, in which participants took five-minute breaks from a task that was designed to simulate the mental fatigue produced by work, measured the effects of three different rest activities on participants’ moods. The first activity, a silent, actionless break, left participants’ minds unoccupied, which, in turn, caused them to worry about work. The second activity, a guided relaxation activity, did produce some reduction in stress. But it was only the participants who played a simple puzzle game, Sushi Cat, who claimed to actually feel better after their breaks.
So, the next time you get caught sneaking in a game of Minesweeper at work, tell the boss you aren’t slacking, you’re just recharging your mental processors.
And if you’re wondering if only simple, non-violent video games provide relief from stress, according to Dr. Christopher J. Ferguson of Texas A&M the answer is no. Ferguson’s study found that violent video games provide similar stress release, but, perhaps, for a different reason. Ferguson suggests violent video games may allow players to work through their real-life frustrations in a fictional format.
4. Gaming helps fight depression.
Let’s see, increase in happiness, decrease in anxiety, stress relief, could it be gaming is just an overall heavy-duty depression-fighting cocktail? Well, yes, yes it is. If you ask the right people.
As pinpointed by scientists, and perfectly summarized by researcher Jane McGonigal, Ph.D. in this 2015 Slate article, gaming hyperstimulates two regions of the brain, the reward center, associated with goal-setting and motivation, and the hippocampus, associated with memory and learning. These are the same two areas of the brain that are “chronically understimulated,” according to McGonigal, and can actually shrink in someone suffering from clinical depression.
Then, McGonigal takes it on home mic-drop style, stating “Video game play is literally the neurological opposite of depression.”
Freakin’ whoa.
5. Gaming makes you more resilient.
Because her mind-blowing insights can’t be relegated to just a single number, Jane McGonigal is back at number 5 with this article in the Harvard Business Review to let us know those mind-blowing effects gaming has on depression aren’t just temporary. Playing video games is one of those casual uses of time that can have positive long-term effects.
Apparently, trying to defeat the same boss (or level two in Ghost ‘n Goblins, am I right?) twenty-five times in a row doesn’t just make you a glutton for punishment, it actually makes you more resilient, and that resilience translates to the real world. Evidence suggests regular gamers are simply less likely to give up in the face of real-life difficulties. How badass is that?
6. Gaming can enhance self-esteem.
Feeling a little unsure of yourself? Need a boost in confidence? Well, you can always post a selfie and wait for the compliments to roll in (though that works best for people who already have an abundance of self-confidence), or you can take a time out and do some gaming.
In a study by researchers at the University of Rochester and Immersyve, Inc, gaming was found to increase self-esteem under certain conditions. The first condition is that gameplay is autonomous, meaning a player is free to play and make decisions as they choose, such as in world-building games like Minecraft. The second, and most important, condition is that players experience “competence need satisfaction,” basically the feeling they have accomplished what they wanted to or played the game well.
The increase in self-esteem is immediate (actually occurring while the player is playing), and it may not be a life-changer, but could prove time well-spent right before a job interview, test, or other event that could benefit from a small uptick in confidence levels.
7. Gaming with others makes you more helpful.
Do you enjoy multi-player games that require cooperation to accomplish a goal? Chances are, they’ve made you a better person. Or at least a more helpful one.
A study conducted at Texas Tech University found people who played video games cooperatively with other players showed more pro-social behaviors after playing than those who played competitively against other players or who played the same games on their own.
What’s more, cooperative playing decreased players’ aggression, even when playing violent games, potentially negating the increase in aggression that violent video games can produce in some people.
And these pro-social behaviors? They weren’t just directed toward a player’s teammates. Players were also nicer to opposing players without expectation of opposing players being nice to them in return.
The takeaway theory by researchers is that playing with others leads to a belief that “helpful behaviors are valuable and commonplace.”
8. Gaming might make you a better leader.
Could millennials hold an advantage in leadership over previous generations simply because they grew up playing video games? It’s possible, according to researchers who have studied the correlation between gaming and employment skills. At the very least, gamers possess a unique set of attributes, including greater self-confidence and the abilities to multi-task and creatively solve problems. Together, these characteristics are thought to make gamers ideal candidates for the highest levels of leadership.
So, those hours a week you spend gaming just because it’s fun can be providing you more than leisure. They can be adding up to legitimate skills that enhance your employability and promotability in the real world.
9. Gaming is a powerful learning tool.
People don’t just play games, they also learn from them. Some of the lessons are simple, such as learning to switch up your technique when you fail to clear a level. Some of these lessons, however, especially those taken from world-building games and RPGs, teach higher-level skills and datasets that can be hard to grasp as abstract concepts alone.
In a study of community-based, multiplayer games (games in which players inhabit a shared world that is separate from the real world, but often equally complex), researchers found players can learn a lot about city-planning through games in which they build online worlds, or about politics by participating in political campaigns within their gaming communities.
It’s a “learn by doing” scenario where the skills one picks up during gameplay can translate into real life capabilities. Corporations, governments, and militaries have already harnessed the power of video games to teach and to train, so the main question the study’s researchers pose is: why aren’t we seeing more video games in other learning environments, such as our schools?
10. Gaming can actually promote a desire to learn.
Teaching kids is one thing. Getting them interested enough to learn is a whole different matter.
But a joint study by researchers at New York University and the City University of New York found that, not only do video games help students pick up material more readily, they actually make kids want to learn. Specifically, they can give school-age students the desire to practice subjects that are notoriously unpopular, like math.
In the study, students were more interested in playing a math-based video game when they played with another student, either competitively or cooperatively, and, when playing alongside another student, they also adopted a mastery goal orientation (or the actual desire to improve their math skills, as opposed to just looking as if they knew what they were doing) that is thought to be crucial to learning.
Video games aren’t going to make you a genius. Not on their own. They’re not going to cure your depression, or give you the confidence of a Kardashian. But video games have been shown to have a lot of positive effects in a lot of different areas. If they make you feel better, boost your self-esteem, and help you grasp theorems, play up I say.
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Tags: celebrity smiles bone grafting tooth pain
When they’re introducing a new movie, actors often take a moment to pay tribute to the people who helped make it happen — like, you know, their dentists. At least that’s what Charlize Theron did at the premiere of her new spy thriller, Atomic Blonde.
"I just want to take a quick moment to thank my dentists," she told a Los Angeles audience as they waited for the film to roll. "I don’t even know if they’re here, but I just want to say thank you."
Why did the starring actress/producer give a shout-out to her dental team? It seems she trained and fought so hard in the action sequences that she actually cracked two teeth!
“I had severe tooth pain, which I never had in my entire life,” Theron told an interviewer from Variety. At first, she thought it was a cavity — but later, she found out it was more serious: One tooth needed a root canal, and the other had to be extracted and replaced with a dental implant — but first, a bone grafting procedure was needed. “I had to put a donor bone in [the jaw] to heal,” she noted, “and then I had another surgery to put a metal screw in there.”
Although it might sound like the kind of treatment only an action hero would need, bone grafting is now a routine part of many dental implant procedures. The reason is that without a sufficient volume of good-quality bone, implant placement is difficult or impossible. That’s because the screw-like implant must be firmly joined with the jawbone, so it can support the replacement tooth.
Fortunately, dentists have a way to help your body build new bone: A relatively small amount of bone material can be placed in the missing tooth’s socket in a procedure called bone grafting. This may come from your own body or, more likely, it may be processed bone material from a laboratory. The donor material can be from a human, animal or synthetic source, but because of stringent processing techniques, the material is safe for human use. Once it is put in place your body takes over, using the grafted material as a scaffold on which to build new bone cells. If jawbone volume is insufficient for implants, it can often be restored to a viable point in a few months.
Better yet, when grafting material is placed in the tooth socket immediately after extraction, it can keep most of the bone loss from occurring in the first place, enabling an implant to be placed as soon as possible — even before the end of a movie’s shooting schedule.
Will Atomic Blonde prove to be an action-movie classic? Only time will tell. But one thing’s for sure: When Charlize Theron walks down the red carpet, she won’t have to worry about a gap in her smile.
If you have questions about bone grafting or dental implants, please contact our office or schedule a consultation. You can read more in the Dear Doctor magazine articles “Dental Implant Surgery” and “Immediate Dental Implant.”
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Crisis Mapping Technology Boosts Relief Efforts In Nepal
Adam Forrest Contributor
I write about nonprofits, social businesses and inspiring causes.
Kathmandu Living Labs is a small nonprofit that needs to get bigger in a hurry.
The data-driven team has been leading efforts to “crisis map” Nepal over the past six weeks, using online tools to work out which neighborhoods are in need of medical help and supplies following April’s devastating earthquake.
The largely rural country is still coming to terms with the 7.8 magnitude earthquake which took more than 8,000 lives. And government and international charities have faced a major challenge in their relief efforts: a lack of reliable information on where help is needed.
Thankfully, the Kathmandu Living Lab (KLL) has produced the Quakemap.org site, allowing people in the field to report in real time exactly what is needed and where. In their makeshift situation room, staff and volunteers continue to process hundreds of reports coming in from towns and villages across Nepal.
Reports highlight what supplies or help are needed and where (Photo: KLL)
Back in 2010, KLL executive director Nama Budhathoki was doing a PhD in open data and mobile media at the University of Illinois when the Haiti earthquake hit.
He realized his own country, Nepal, which sits in a zone vulnerable to earthquakes, should be better mapped in preparation for the next crisis. And so at the end of 2013 he and a team of volunteers started mapping Nepal using open data software called OpenStreetMap.
Within 24 hours of the initial earthquake on April 25, the ongoing mapping exercise became an emergency tool.
And although executive director Nama Budhathoki says his is “a small organization not designed to cope with a crisis of this scale,” the evolving digital maps have been extremely useful to NGOs, local government and even the Nepalese Army in the past six weeks.
Sadly, the building the KLL team has been working from suffered structural damage in the initial earthquake. Some of the 36 staff members and volunteers have been forced to work outside. It’s why the KLL is now trying to crowdfund $50,000 to pay for more people, more equipment and relocation costs.
“A map provides a better mirror of reality,” said Budhathoki. “All the funding will be used to better map and bridge the information gap in Nepal’s relief and rebuilding.”
Some members of the Kathmandu Living Labs team continue to work outside (photo: KLL).
“The reconstruction process will take quite a bit of time - certainly a few years and perhaps up to a decade,” he added. “It will be crucial to track this process and give people a visibility into what is happening on the ground.”
Budhathoki is quick to hail the power of the crowd. Vital information has been sourced from thousands of ordinary Nepalese people, and assistance has also come from almost 5,000 remote contributors using OpenStreetMap around the world.
“The process of engaging citizens to map their own communities is equally a part of our work,” Budhathoki explained. “We firmly believe in the power of the collective.”
For more on the KLL crowdfunding campaign, click here.
Adam Forrest
I'm a London-based freelance journalist and I've written for The Guardian, VICE and The Huffington Post. I also work for The Big Issue UK, one of Britain's leading socia...
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California Becoming World's Second Largest Carbon Market
Erica Gies Contributor
Independent environment reporter, founder of ThisWeekInEarth.com
Mary Nichols, Chairman, California Air Resources Board
While world leaders jostle to make or hinder progress on international climate policy in Durban, South Africa, California’s cap-and-trade program — part of the state’s groundbreaking Global Warming Solutions Act — won an important victory this week on the path to implementation in 2013.
On Tuesday a San Francisco superior court approved the state’s recently submitted environmental impact analysis, confirming that California has adequately studied alternatives for how to meet its climate goals. In May the court had affirmed the California Air Resources Board’s (CARB) authority to pursue a market-based program but, in response to a lawsuit, sent it back to the drawing board to study alternatives in more detail.
In October CARB submitted an expanded analysis to the court, which the court approved on Tuesday.
Since it was passed in 2006, the law has overcome a series of attacks, including a political campaign funded by oil interests that strove to paint the act as a job killer. In fact, the opposite seems true:
According to Environmental Defense Fund (which co-sponsored the law):
Since California passed AB 32, the state has received more than $9 billion in venture capital investments that have grown the state’s clean energy economy. Between 2008 and 2009, its green sector grew three times as fast as other industry sectors and it has the largest domestic clean energy economy in the country (PDF).
A new report from Next 10, a nonpartisan research organization, also found that California took in $467 million in global venture capital investment for electric vehicles in the first half of 2011, or 69 percent of total dollars.
California is the world’s eighth largest economy, and the cap-and-trade component of the law will establish North America's largest carbon market and the world’s second largest, after Europe’s. The market, along with other policies included in the act, aim to cut climate pollution to 1990 levels by 2020.
Yesterday I caught up with Mary Nichols by phone. She is chairman of California Air Resources Board that has been implementing the Global Warming Solutions Act and was at the COP-17 negotiations in Durban. Please note the interview has been edited slightly for space and clarity.
EG: It’s looking unlikely that Durban will produce meaningful international legislation. The Northeast Regional Greenhouse Gas Initiative market in the United States has been having problems. Countries have been talking about backing out of the Kyoto Protocol. Given that backdrop, what does it mean that California is continuing to make progress toward creating a carbon market?
MN: The court decision clears the way for us to implement the cap-and-trade program, which is only one portion of our overall plan to reduce our emissions of greenhouse gas emissions. We have a number of other regulations in place, including our clean cars rules, our low carbon fuel standards, our renewable energy standards.
So this is just one piece of the overall program, but it’s of great interest to people here in Durban because there are many other states and countries that are looking at legislation to put a cap on emissions and to allow for some phasing in of allowances.
And we’re getting a lot more support now from our federal agencies than we were when we first began on this because, having come to a point where there’s an impasse with Congress over pursuing any kind of climate program, increasingly, the federal government realizes that they have to do whatever they can to help this program be a success because our country is committed: the president has made agreements to demonstrate actual reductions in greenhouse gas emissions by 2014. So there’s a lot of work to be done, and California is at the center of it.
EG: Do you see piecemeal efforts ultimately being effective at reducing emissions? Or is it a matter of leading by example?
MN: Well, California is only 2 percent of the emissions globally, and various countries are coming up fast. But we are looked to because of our leadership in working out the many complicated details of running a program like this.
We’re not the only people who have ideas in this area. The European Union is moving ahead with its program, the E.U. Emissions Trading Scheme. It’s been in effect for a number of years, but they’re now tightening the caps down and dealing with some of the problems they’ve had in the past. The Australians have a slightly different approach, several Canadian provinces are working on their own cap-and-trade legislation, and each of them faces slightly different issues and may work out the problems in slightly different ways.
But one of the things that we’re all agreed on is that we have to cut a hard path on emissions, and we have to find the most cost-effective mechanisms to use to try to reduce this pollution. And of all the methods that have been put forth, this is clearly one of the most flexible and cost-effective because, by putting the price on carbon allowances, it creates the incentives for the private sector to come up with a myriad of solutions on their own.
So our interest in this is not about creating a market. It’s about having a market work in a way that will help us reduce pollution as efficiently and cost-effectively as possible.
EG: You say you’re not interested in creating a market. But do you think it’s possible to reduce pollution when the price on carbon has been quite low, as it is in some of the other markets?
MN: We’re assuming that prices will go up because of scarcity or because of the market working as it’s supposed to. But the answer is that we have the evidence in now from the E.U. program that it has actually cut emissions somewhere in the 8 or 9 percent range. It has not cut them to the levels that are going to be needed to avert the worst effects of global warming. But that is a very significant step at a time when emissions in other areas have been rising. And so it’s not the answer to all questions, but it’s a very important tool.
EG: Do you expect further opposition in the courts?
MN: I can’t say. At every step, when we initiate new programs and new requirements, there’s always some litigation. We’re very happy to have this phase of it resolved and to have the court agree with us: that we did the appropriate environmental reviews, that we followed the health and environmental quality laws in developing our plan. So that’s an important step along the way. But I’m sure that at other points there will be other challenges.
Erica Gies
I cover energy, water, clean tech, waste of many kinds, green business, green building, and more for The New York Times, Wired News, International Herald Tribune -- and ...
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Effective: May 25, 2018 – Last Modified: June 27, 2019
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privacy@foundationmedicine.com
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dpo.fmi-germany@foundationmedicine.com
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Foundation Medicine uses Protected Health Information to deliver medical information to physicians to assist them in the treatment of their patients.
Foundation Medicine is committed to obtaining, maintaining, using and disclosing patient protected health information in a manner that protects patient privacy. We urge you to read this Notice of Privacy Practices (“Notice”) carefully in order to understand both our commitment to the privacy of your protected health information and your rights.
Foundation Medicine is required by law to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. The Notice also describes your rights with respect to your protected health information. “Protected health information” or “PHI” is information about you, including basic demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to follow the terms of this Notice. We will not use or disclose your PHI without your permission, except as described in this Notice. We reserve the right to change our practices and this Notice as and to the extent permitted by law and to make a new Notice effective for all PHI we maintain. Upon your request, we will provide you with a copy of the revised Notice.
Examples of How We Use and Disclose Protected Health Information About You
Your PHI may be used and disclosed for treatment, payment, healthcare operations, and other purposes permitted or required by law. If we wish to use or disclose your PHI for other
purposes, we would have to obtain your authorization. We may, however, use or disclose your PHI without specific authorization or permission for certain purposes, including:
Treatment: We may use your health information to provide and coordinate the treatment and services you receive. For example, we may use your information to perform diagnostic tests, or provide your test results to your physician.
Payment: We may use and disclose your health information to others for purposes of billing and receiving payment for treatment and services that you receive. For example, we will submit a claim to you or your health plan/insurer that includes information that identifies you and the type of services we performed for you.
Health Care Operations: We may use or disclose your PHI in order to support the operations of our laboratories and monitor, evaluate and improve the quality of the services we provide, and for other internal management purposes. For example, we may use information in your health record to evaluate the services our laboratories provide or to train our staff.
To Communicate with Individuals Involved in Your Care or Payment for Your Care: We may disclose to a family member, other relative, close personal friend or any other person you identify, PHI directly relevant to that person’s involvement in your care or payment related to your care.
Minors’ Protected Health Information: As permitted by federal and state law, we may disclose PHI about minors to their parents or guardians.
Business Associates: There are some services provided by Foundation Medicine through contracts with business associates (e.g., billing services), and we may disclose your PHI to our business associate so that they can perform the job we have asked them to do. To protect your information, however, we require the business associate to appropriately safeguard your information.
Food and Drug Administration (FDA): We may disclose to the FDA, or persons under the jurisdiction of the FDA, PHI relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Worker’s Compensation: We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose your PHI for law enforcement purposes as permitted by law, or in response to a valid subpoena or court order.
As Required by Law: We will disclose your PHI when required to do so by federal, state, or local law.
Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, and inspections
necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or by us to tell you about the request or to obtain an order protecting the information requested.
Research: Researchers may be given limited access to your PHI on-site at Foundation Medicine so that they can develop research projects and identify patients who may potentially qualify to participate in research studies. Any other uses or disclosures of your PHI for research purposes are only permitted once an institutional review board or privacy board has reviewed the research proposal, determined whether you need to provide specific consent for the research use of your PHI and established protocols to ensure the privacy of your information, or determined that the researcher will be provided only with information that does not identify you directly.
De-Identified Information: We may use your health information to create “de-identified” information, which means that information that can be used to identify you will be removed. There are specific rules under the law about what type of information needs to be removed before information is de-identified. Once information has been de-identified as required by law, it is no longer subject to this policy, and we may use it for any purpose without any further notice or compensation to you.
Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
Organ or Tissue Procurement Organizations: Consistent with applicable law, we may disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Personal Representative: We may use or disclose your PHI to your personal representative, as established under applicable law, or to an administrator, executor or other authorized individual associated with your estate.
Correctional Institution: If you are or become an inmate of a correctional institution, we may disclose to the institution or its agents PHI necessary for your health and the health and safety of other individuals.
To Avert a Serious Threat to Health or Safety: We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Military and Veterans: If you are a member of the armed forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
Specialized Government Functions: Under certain circumstances, we may disclose your PHI to units of the government with specialized functions such as the U.S. Military or the U.S. Department of State in response to requests as authorized by law.
Victims of Abuse or Neglect: We may disclose PHI about you to a government authority if we reasonably believe you are a victim of abuse or neglect. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent serious harm to you or someone else.
Other Uses and Disclosures of PHI
We will obtain your written authorization before using or disclosing your PHI for purposes other than those described above, including uses and disclosures of PHI for marketing purposes and disclosures that would constitute a sale of PHI. You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
Breach Notification: We are required by law to notify you if we discover a breach of unsecured PHI, unless we can demonstrate, based on a risk assessment, that there is a low probability that the PHI was compromised. If a breach happens, we will notify you as soon as we can, and are required by law to notify you within 60 days after we learn of the breach. We will let you know what happened and what you can do to mitigate any potential harm.
Your Health Information Rights
Obtain a paper copy of the Notice upon request. You may request a copy of our current Notice at any time from the Privacy Officer. Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy.
Request a restriction on certain uses and disclosures of PHI. You have the right to request additional restrictions on our use or disclosure of your PHI for treatment, payment or health care operations activities, or to individuals involved in your care, by sending a written request to Foundation Medicine’s Privacy Officer. We are not required to agree to those restrictions, unless the disclosure is not required by law and you paid for the service in full out of pocket.
Request an amendment of PHI. If you feel that PHI we maintain about you is incomplete or incorrect, you may request that we amend it. To request an amendment, you must send a written request to the Privacy Officer. You must include a reason that supports your request. In certain cases, we may deny your request for amendment. For example, in circumstances under which the patient would be denied access to his/her PHI, we may deny a request for amendment.
Receive an accounting of disclosures of PHI. You have the right to receive an accounting of the disclosures we have made of your PHI. The right to receive an accounting is subject to certain exceptions, restrictions, and limitations. To request an accounting, you must submit a request in writing to the Privacy Officer. Your request must specify the time period for which you would like an accounting, but this time period may not be longer than six years, and a shorter period may apply for some disclosures.
Request communications of PHI by alternative means or at alternative locations. You have a right to request to receive communications of PHI by alternate means or at alternate locations. For instance, you may request that we contact you about medical matters o
different residence or post office box. To request confidential communication of your PHI, you must submit a request in writing to the Privacy Officer. Your request must state how or where you would like to be contacted. We will accommodate all reasonable requests.
For More Information or to Report a Problem
If you have questions or would like additional information about our privacy practices, you may contact:
Foundation Medicine, Inc. Privacy Officer 150 Second Street Cambridge, MA 02141 privacy@foundationmedicine.com
If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the United States Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Privacy Shield Certification:
The Privacy Shield includes two frameworks, a European Union/United States program implemented to ensure the protection of personal information (PI) transferred from European Union Member States to the U.S and a similar Swiss-U.S. program for similar transfers of PI from Switzerland to the U.S. The types of PI protected under the Privacy Shield frameworks include Human Resources (HR) PI for employees and Non-HR PI. An organization in the U.S. intending to receive PI from E.U. Members or Switzerland can self-certify to the respective Privacy Shields; this is recognized by E.U. Members and Switzerland as meeting the minimum requirements of data protection for PI transfers from any of those jurisdictions to the U.S. We comply with the E.U.-U.S. and Swiss-U.S. Privacy Shield Frameworks, and commit to adhering to the seven Privacy Shield Principles when receiving Non-HR and HR PI from E.U. Members or Switzerland. For our Privacy Shield participation, we are subject to the investigatory and enforcement powers of the U.S. Federal Trade Commission. Information on the Privacy Shield program and a list of participants may be found at www.privacyshield.gov. Among the requirements of the Principles, we will adhere to the following:
• We will only use the select Non-HR PI and HR PI (such as name, address, date of birth, gender, and certain health information) we collect for the purposes of providing our products and services or other purposes consistent with your authorization or consent. We will notify patients whose Non-HR PI may be transferred to the U.S. from E.U. Members and/or Switzerland of our self-certification to the Privacy Shield, including what steps we take to protect such PI. We will also notify patients whose Non-HR PI may be transferred to the U.S. from E.U. Members and/or Switzerland that we may be required to disclose PI in response to lawful requests by public authorities, including to meet national security or law enforcement requirements. We will provide the same types of notice to employees whose HR PI may be transferred to the U.S. from E.U. Members and/or Switzerland;
• We will provide patients & employees whose PI will be transferred to the U.S. from E.U. Members and/or Switzerland an opportunity to opt into and/or out of certain disclosures, including transfer of PI to a third party. If any E.U. Member/Swiss PI is transferred to a third party, such third party will also adhere to the Principles and enter into any required contractual arrangements as provided in the Privacy Shield. We remain liable under the Privacy Shield Principles if our agents process Non-HR PI or HR PI inconsistent with the principles, unless we are not responsible for the event giving rise to the damage;
• We will ensure that patients & employees whose PI has been transferred to the U.S. from E.U. Members and/or Switzerland have the opportunity to review and amend their own PI (where it remains PI, i.e., in identifiable form) by contacting us at privacy@foundationmedicine.com or in writing at Foundation Medicine, Inc., Privacy Officer, 150 Second St., Cambridge, MA 02141;
• We will adhere to an independent recourse mechanism for cases of complaints regarding the handling of Non-HR PI transferred to the U.S. from E.U. Members and/or Switzerland. Complaints may first be directed to Foundation Medicine at the contact information provided below. Should your complaint fail to be resolved, you may file a complaint, free of charge, with the US-based independent recourse mechanism JAMS at https://www.jamsadr.com/eu-us-privacy-shield. Should your complaint fail to be resolved through the independent recourse mechanism, you may file a complaint with your data protection authority which will raise the matter with the U.S. Department of Commerce. Should your complaint still fail to be resolved, you may have a right to invoke binding arbitration. Please contact us at the information provided above for more information; and
• We have committed to cooperate with EU data protection authorities (DPAs) and Swiss Federal Data Protection and Information Commissioner (FDPIC) with regard to unresolved Privacy Shield complaints concerning HR PI transferred to the U.S. from E.U. Members and/or Switzerland in the context of the employment relationship. If you do not receive timely acknowledgment of your complaint from us, or if we have not addressed your complaint to your satisfaction, please contact the EU DPAs or FDPIC for more information or to file a complaint. The services of EU DPAs and FDPIC are provided at no cost to you. Should your complaint fail to be resolved by the EU DPAs or FDPIC, you may have a right to invoke binding arbitration. Please contact us at the information provided above for more information.
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Home > Remondi, Christopher
Remondi, Christopher
Coming out of university 20 years ago, Christopher Remondi considered a number of firms, but in his words, “I was attracted to the culture and uniqueness of Brown Brothers Harriman. I really hadn’t come across any place like it."
Inducted: 2013
Christopher Remondi
Partner and Global Head of Markets • Brown Brothers Harriman
Coming out of university 20 years ago, Christopher Remondi considered a number of firms, but in his words, “I was attracted to the culture and uniqueness of Brown Brothers Harriman. I really hadn’t come across any place like it. My first job interview was with one of the firm’s owners, and that was pretty special.” That owner was BBH partner and Global Custodian Legend, the late Stokley Towles. “The personal interaction with Stokley gave me immediate confidence that BBH was a firm I could work for and one where I could have an impact, even at the most junior level.”
Remondi cites BBH’s partnership structure, its flat organizational model and collaborative culture as the reasons he has had the opportunity to try his hand at various roles and across a range of businesses within BBH. “I have been able to work through the ranks and work closely with people in almost every one of our departments,” he says.
Today, Remondi’s greatest impact is made through his role as partner responsible for the BBH Markets businesses, including foreign exchange, securities lending and brokerage. But over his near 20 years at BBH, Remondi has also been the firm’s chief information officer responsible for systems infrastructure, application development and technology strategy, as well as the head of BBH Infomediary, a connectivity and messaging platform that provides a single connectivity point between clients and their external service providers and internal systems.
Another benefit of BBH’s partnership structure is the lack of shareholder pressure, which enables the firm to take a long-term view when servicing the needs of their clients. This long-term focus was particularly relevant when in 2001 BBH established its Infomediary business. “That was a very difficult economic year, but because the firm could look further down the road than other institutions, we made the $50 million investment that was required to start this business. We were investing with a 10-12 year horizon while most were managing by quarter,” says Remondi. “It’s proved to be a very worthwhile investment but required considerable conviction and financial commitment when the market was in a significant downturn.”
Remondi and the BBH team continue to evolve the Infomediary product. “Every time we take on a new client the application gets bigger and better because the infrastructure is shared across 250 organizations around the world,” he says. “That’s a terrific business model for us, as it allows us to grow not just the client base but also the application each time we take on a new client. We’ve grown Infomediary horizontally across our client bases. When we started the business we were really focused on trade messaging. Now we’re focused on a number of different areas, including foreign exchange and corporate actions.”
What makes Infomediary and its applications so unique, says Remondi, is that they marry technology with deep market expertise. “Looking at InfoFX for example, we took a highly operational product, Infomediary, and a highly sophisticated trading service, FX, and combined the best of both—a little like combining peanut butter and chocolate,” he says. “At many firms, the head of a currency desk may not have taken the time to work with an operational junkie like me, and that’s probably the most unique part about how this product developed. Today InfoFX is growing at over 40% per year.”
The latest Infomediary innovation, InfoAction, is a Software-as-a-Service application, which provides clients the benefits of a multimillion-dollar corporate actions system without all of the headaches of installing it and maintaining it. “Having things like a hosted corporate actions platform will be critical to BBH’s clients going forward,” says Remondi. “That’s how we’ve grown—it is really that horizontal view across all of our clients’ investment flows, message types and workflows in the market,” says Remondi. In addition to these developments, BBH has extended its interactions with industry utilities with the view of further integration, whether it’s a depositary or matching utility, he adds.
Remondi describes the horizontal approach to meeting client needs as an evolved strategy. “We run with our clients and we’ve learned with them that their requirements are more comprehensive than ever,” he says. “They are looking for more applications that leverage Infomediary technology, so we continue to work off of this base.”
As far as what is next on Remondi’s agenda, he is looking forward to what lies ahead in his new role as head of BBH Markets. “The past six months have been a great learning experience and a great opportunity to take bits of my prior roles and continue to build on them,” he says. “Markets is really all about technology right now—it allows us to redefine performance and put our ideas for improved execution, transparency, operational efficiency and risk reduction into practice. Having a technical aptitude and background is a great foundation for this role.”
–Janet Du Chenne
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Pack the House Saturday as Women’s Basketball Welcomes Columbia, Cornell
Columbia (4-17, 1-6 Ivy) 22 42 64
Harvard (16-5, 6-1 Ivy) 48 51 99
Pts: Tori Oliver - 11
Reb: TEAM - 6
Ast: Tori Oliver - 3
Pts: Christine Clark - 21
Reb: Annmarie Healy - 10
Ast: Jasmine Evans - 5
Harvard vs. Columbia
Ivy League Digital Network
Bill Spaulding, Andy Towne
Harvard vs. Cornell
Saturday, Feb. 15
Scott Sudikoff, Bill Spaulding
The Storyline
Alone atop the Ivy League standings and defending a 19-game home winning streak, Harvard women's basketball readies to take on Columbia and Cornell at Lavietes Pavilion this weekend. Both games can be seen on the Ivy League Digital Network. The Crimson and Lions are set for a Valentine's Day tip at 7 p.m. Harvard will 'Pack the House' against Cornell (6 p.m.), wearing pink warm-ups and shoelaces for its annual Pink Zone and Play4Kay day.
Harvard went 2-0 last weekend, handily defeating Brown, 91-71, before holding on to escape Yale with a 58-57 win. Junior forward Erin McDonnell exploded in the second half against the Bulldogs, posting her first career double-double with 17 points and 11 rebounds. Earning the program's 600th victory in Providence, senior captain Christine Clark posted 19 points and five rebounds to lead the Crimson to its second 90-plus point outing this season.
First to 600
Harvard recorded the 600th win in program history on Feb. 7, 2014 against Brown. Harvard was the first Ivy League school and first Division I program in Massachusetts to accomplish the feat. The Crimson was also the first Ivy program to 500 wins (Jan. 30, 2009 against Penn). The Crimson currently sits at 601-437.
The Hunt For #12
Through five-plus games of the Ivy League season, three teams have recorded just one loss, with Harvard sitting alone atop the Ancient Eight standings. The Crimson owns a 5-1 conference record, while Penn and Princeton sit at 4-1. After traveling for much of the months of January and February, the Crimson can settle in – playing six of the final eight conference games at home.
Just Keep Winning
Harvard owns a home win streak of 19 games, marking the second-longest run all-time. From 1996-98, the Crimson ripped off 22-straight wins at Lavietes – the record for the Crimson. Harvard posted a perfect 11-0 record at home in 2012-13 and has not lost in Cambridge since Feb. 11, 2012. Before 2012-13, the last time Harvard went unbeaten at home was in 1997-98 when the team went 13-0 en route to a 23-5 overall mark.
Scouting Columbia
2013-14 RECORD: 4-16, 1-5 Ivy League
SERIES HISTORY: Harvard leads, 54-2
LAST MEETING: W, 71-26 (March 12, 2013)
LAST WIN: Same
Streak: W9
• Columbia has lost four-straight after defeating Cornell to open Ivy League play. The Lions nearly edged Penn in their last game out, falling 70-63 Saturday night. Columbia scored more field goals and outrebounded the Quakers, but Penn put away 24 free throws to account for the edge.
• Freshman forward Tori Oliver (10.1) leads a quartet of scorers posting nine-plus points, while pulling down 5.7 boards per game. Classmate Carolyn Binder ranks second on the squad with 9.4 points per game, while senior Courtney Bradford grabs a team-best 6.0 rebounds per game.
• In her first season, head coach Stephanie Glance comes to Columbia after 25 years of collegiate coaching experience, including the last three seasons at Illinois State. The Redbirds appeared in three-straight WNIT appearances, winning 24 games twice.
• Harvard holds a 54-2 all-time series advantage over Columbia, last dropping a game to the Lions on Feb. 14, 2009. A year ago, the Crimson made history at the defensive end of the court, downing the Lions 71-26. The 26 points allowed stands as the fewest ever during Delaney-Smith's tenure, and are the fewest given up since Feb. 24, 1978 when the Crimson defeated Holy Cross, 73-19. In game one of the series, Temi Fagbenle turned in her sixth double-double to pace Harvard with 14 points and 12 rebounds, while also adding two assists and two blocks. Victoria Lippert contributed 15 points and seven boards as nine different Crimson scored.
Scouting Cornell
2013-14 RECORD: 11-9, 3-3 Ivy League
SERIES HISTORY: Harvard leads, 58-11
LAST MEETING: W, 66-56 (March 9, 2013)
Streak: W11
• Cornell comes into the weekend sitting fifth in the Ivy League standings at 3-3 after dropping two home games to Penn (67-57) and Princeton (71-56) last weekend. The Big Red defense is giving up a stingy 62.8 points per game, a mark good for second overall in the conference.
• Senior forward Allyson DiMagno paces the Big Red with 13.4 points and 8.4 boards per game. Freshman Nia Marshall, coming off her fifth Ivy League Rookie of the Week selection, ranks second on the squad, racking up 12.7 points and chipping in 6.2 rebounds.
• In her 11th season at the helm of Cornell, head coach Dayna Smith is the winningest coach in Cornell history.
• The Crimson leads the all-time series with the Big Red 58-1, including winning 11-straight. Last year, Harvard swept Cornell, winning the first matchup 69-60 in overtime and the second 66-56. A 20-point night from Christine Clark and a double-double by Temi Fagbenle helped lift the Crimson in game two, while Victoria Lippert was the star in game one, posting 19 points, all after halftime.
Milestone Watch
The winningest coach in Ivy League women's basketball history with 510 career victories, head coach Kathy Delaney-Smith ranks second only to Princeton's legendary coach Pete Carril (514) for wins by an Ancient Eight coach on either the men's or women's side. Delaney-Smith also eclipsed 300 career wins in the conference with her 300th coming against Yale Feb. 8.
Delaney-Smith, in her 32nd season at the helm of the Crimson, earned her 500th win at Colgate Nov. 23, joining a group of 28 active coaches in Division I with at least 500 wins. She is also one of six active Division I head coaches to spend 32 years at one institution.
Crimson Colored Ivy
Since women's basketball joined the Ivy League in 1974-75, the Crimson owns a 601-437 record, tops of all Ancient Eight schools. Harvard is the only Ivy League school with a winning record against all other Ivies.
School Overall Wins Harvard vs.
Brown 484 44-33
Columbia 224 54-2
Cornell 370 58-11
Dartmouth 543 43-32
Penn 449 49-23
Princeton 572 40-33
Yale 461 45-30
Averaging 12.6 points and 9.6 rebounds, Temi Fagbenle has already recorded eight double-doubles through 20 games this season (including six in the last 12 games), the most since Reka Cserny in 2004-05. Fagbenle posted five-straight games with 10-plus in points and rebounds (Dec. 7-Dec. 30), recording the longest consecutive streak of double-doubles since Hana Peljto '04 in 2003-04 (nine).
Fagbenle's first career double-double came opening weekend at North Dakota, making her the first Crimson rookie to record a double-double in her first weekend of action since Peljto went for 21 points and 10 rebounds in the season opener against Saint Peter's on Nov. 17, 2000.
Clark Rises
Shooting up the scoring list, Christine Clark sits at No. 6 in program history with 1,542 points over her three-plus year career. She needs 41 points to pass Erin Maher '93, who sits at fifth all-time with 1,582 points. Clark became the 18th member of Harvard's 1,000 point club Jan. 2, 2012, as she scored 19 points against UMass. Clark reached the milestone in just her 71st career game, making her the fastest Crimson to reach 1,000 points since Reka Cserny '05 did so in her 60th career appearance.
Including this year, Harvard has had at least one 1,000 point scorer on the floor in five of the last six seasons. Additionally, each of Harvard's 18 1,000 point scorers has been coached by head coach Kathy Delaney-Smith.
What a Start
For the second-straight year, Harvard started the season 7-3 record through the first 10 games of the season. It matched the second-best start for the Crimson all-time through 10 games. Harvard has gone 8-2 three times, most recently in 1997-98 en route to a 23-5 overall record and an Ivy League title.
Ivy Openers
Harvard improved to 23-17 all-time in Ivy League openers and 20-12 under head coach Kathy Delaney-Smith with its 73-63 victory over Dartmouth on Jan. 11. It marked the 14th-straight season that the Crimson and Big Green met in the first game of the Ivy League schedule, with Harvard holding a 9-5 edge in those contests.
You Can Count on Clark
Christine Clark has started 105-straight games that she has appeared in over the last three-plus years. Clark ranks first in the Ivy League in most consecutive career games started.
Clark has scored in double-digits 88 times, including 15 times this season. The senior from Tucson, Ariz., is on a run of eight-straight double-digit games. Clark put on a streak of 21 consecutive 10-plus point performances (March 5, 2011-Feb. 4, 2012) and has had 19 games in which she has scored at least 20 (last at Princeton). Clark has posted 20-plus points in seven games in 2013-14.
For the first time ever, all of Harvard's home games and road Ivy League contests will be streamed in HD quality featuring a live scoreboard, new graphics package and play-by-play commentary through the Ivy League Digital Network. Subscribers to the network can watch games both live and On-Demand on their computers, tablets or smart phones, and will have access to live and On-Demand content for all Harvard events throughout the duration of their subscription.
PURCHASE YOUR SUBSCRIPTION TODAY!
Follow Harvard Athletics on Facebook, Twitter and Instagram to stay connected with all the breaking news from around Cambridge and to get inside access to your favorite Crimson programs.
Ancient Eight Accolades
Two Crimson student-athletes have earned three Ivy League Player of the Week accolades thus far this season.
Christine Clark earned the honor after pacing the Crimson with 21.0 points per game for the week ending Nov. 18. Temi Fagbenle was tabbed player of the week for Nov. 25 and Dec. 8 after averaging a double-double in both weeks.
Clark now owns eight conference weekly honors for her career, which stands good for seventh in Ancient Eight history. After tying for the most Ivy Rookie of the Week honors a season ago, Fagbenle has been selected for best player over a seven-day stretch four times.
Through 20 games this season, 10 Crimson student-athletes have matched or bested their career highs in points and/or rebounds. The athletes include: Christine Clark (28 points), Erin McDonnell (19 points, 11 rebounds), Temi Fagbenle (15 rebounds), Ali Curtis (16 points, 5 rebounds), AnnMarie Healy (13 points, 9 rebounds), Jasmine Evans (17 points, 13 rebounds), Melissa Mullins (12 rebounds), Shilpa Tummala (14 points), Kit Metoyer (17 points, 3 rebounds), Taylor Finley (six points, 3 rebounds) and Kaitlyn Dinkins (3 points).
November Numbers
The Crimson was 6-1 in the month of November, setting a new program record for wins before December. Last season, Harvard won five of seven games, which had been a program best.
Winning January
Harvard did not lose in the month of January, posting a 4-0 record. The Crimson last accomplished that feat in 2002-03, recording a 4-0 mark in the first month of the year. Teams led by head coach Kathy Delaney-Smith have gone undefeated in January play four times.
Double Dip
The 60-41 win over Hofstra served as part of a doubleheader, as the men's team downed Vermont, 74-68. It marked the third-straight year Harvard has played a men's and women's doubleheader. Last year, the women defeated BYU (71-65) and the men downed Manhattan (79-45). Prior to 2011-12 the last time Harvard played a men's and women's doubleheader was January 5, 2008 when the women lost to Dartmouth, 52-47, before the men took down the Big Green, 82-56. Harvard owns a 5-1 record when playing at Lavietes in the same day.
You're in Good Hands
Junior captain Kaitlyn Dinkins was nominated for the 2014 Allstate WBCA and NABC Good Works Teams®. The award recognizes a select group of college basketball student-athletes who have made significant contributions to the greater good of their communities through volunteerism and civic service.
Dinkins has become very involved with Athletes in Action at Harvard, co-leading the group this year. Last year, the Atlanta, Ga., product was a member of the Servant team, an organization that plans events and leads a weekly, freshmen bible study.
The Crimson sits atop many Ivy League categories, both as a team and individually. As a unit, Harvard holds the No. 1 spot in overall win percentage (.750), rebounding offense (43.0) and offensive rebounding percentage (38.7). Individually, Temi Fagbenle ranks first in rebounding (9.7) and defensive rebounds (7.1).
Sturdy Sophomores
After averaging a combined 1.63 points per game in 4.6 minutes a game, the sophomore class seems to have found its stride in 2013-14. AnnMarie Healy (13), Kit Metoyer (17) and Shilpa Tummala (14) have all matched or bested their career highs in points and are contributing 11.6 points per game as a class.
Non-Conference Nonsense
The Crimson won 10 of its 14 non-conference matches this season, signaling the third-best nonconference record under head coach Kathy Delaney-Smith and fifth-best all-time. Harvard has earned 11 out-of-league victories twice under Delaney-Smith, turning in an 11-3 record in 1997-98 and going 11-4 in 1985-86. The 1976-77 squad owns the program record for non-conference wins at 13-4, while the 1978-79 Crimson went 12-9 away from the Ivy League.
Harvard has posted at least eight non-conference wins in six-straight seasons.
Harvard sits at 7-4 in true road games and 10-5 overall when playing outside Lavietes Pavilion. The Crimson will play 17 games away from Cambridge in 2013-14. Last year, Harvard was 10-7 in true road games. It marked the most road victories for the Crimson since 2008-09 and was the second-straight year the team posted a winning record away from home.
• Harvard has won its last 19 contests at Lavietes Pavilion. The Crimson's last loss at home was to Princeton on Feb. 11, 2012.
• Erin McDonnell has scored in double-digits 12 times this season and in nine of the last 11.
• Kathy Delaney-Smith has used the same starters – Ali Curtis, Christine Clark, Temi Fagbenle, Melissa Mullins and Erin McDonnell – in 17 games this season and in nine-straight.
• Harvard's 21 wins last season were the most since winning 22 in 2001-02 and 2002-03.
• The Crimson sits at 13-2 when leading at the half.
• Harvard has not lost (9-0) when allowing 63 points or fewer.
• When scoring 80-plus points, the Crimson is 5-0 this season.
Boards on Boards
Temi Fagbenle, averaging a conference-best 9.7 boards a game, has pulled down 10-plus rebounds in 10 games this season. Fagbenle has paced the Crimson in boards in 10 of the last 16 games.
Owning the Boards
Senior Melissa Mullins has paced the Crimson in rebounding in six games this season, ranking fourth in the Ivy League with 6.6 boards per game. The swing player has grabbed 10-plus boards three times. Harvard has had a player pull down 10-plus boards in 12 games and two players tally double-digit rebounds in four contests.
Cleaning the Glass
As a team, the Crimson has outrebounded its opponent 15 times this year. Harvard owns a 13-2 mark when controlling the glass.
Opening Act
Harvard is 19-21 all-time in season openers and 16-16 under head coach Kathy Delaney-Smith. The Crimson has lost three straight season openers, including a 99-75 defeat at DePaul this year.
In 40 seasons of Ivy League play, Harvard is 23-17 in conference openers and 20-12 under head coach Kathy Delaney-Smith.
20 Times 10
At 21-9, the Crimson recorded the 10th 20-win season in program history a year ago. All 10 of the 20-win seasons have come under the guidance of Kathy Delaney-Smith.
Home Court Advantage
The Harvard men's and women's basketball teams have combined for a 104-12 record at home in Lavietes Pavilion since 2009-10 while going 54-8 against the Ivy League. The Crimson women are 46-7 (.867) overall and 25-4 (.862) in conference while the men hold a 58-5 (.921) overall record and are 29-4 (.879) against the Ancient Eight. The women have currently won 19-straight and are looking to match the longest streak in program history (22 games). The men's team's run of dominance includes a program record 28-game home win streak that lasted more than two calendar years between Feb. 19, 2010 and Feb. 24, 2012.
D-Fence
Dating back to the start of 2011-12, the Crimson is 33-2 when holding opponents to less than 60 points and 47-10 when allowing fewer than 70 points.
Comeback Kids
The Crimson overcame a 13-point deficit to defeat Florida International Nov 19, its largest comeback since Dec. 6, 2009 (vs. BU). Harvard won four games a season ago when trailing at the half. The Crimson most recently overcame a 31-23 halftime deficit to earn a 58-57 victory over Yale Feb. 8.
The Crimson owned a 2-1 record in overtime games last season. Harvard did not play a single overtime game in 2011-12 and had not played multiple overtime games in the same season since 2009-10. The Crimson is 12-6 in overtime under head coach Kathy Delaney-Smith and is 13-6 all-time in overtime.
It's Up, and It's Good
Harvard has made at least one three-point field goal in 148 consecutive games dating back to 2008-09, the second-longest streak in program history. The record for consecutive games with at least one three-pointer stands at 172, a streak which began during the 1989-90 season and concluded in 1996-97.
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Alan Jackson’s Hall of Fame Career Profiled in New Documentary
story of a country music icon
Shania Twang
Alan Jackson: Small Town Southern Man is a brand new feature-length documentary, comprised of archival interviews with Alan Jackson that tell the story of his career. Celebrating the work of this country music icon, the film reveals the stories behind songs such as “Chasin’ That Neon Rainbow,” “(Who Says) You Can’t Have It All,” “Someday” and his signature classic “Chattahoochee.”
Tracing his steps from childhood to membership in the Country Music Hall of Fame and the Songwriters Hall of Fame, the film explores Jackson’s journey from his early Nashville days through the present (as evidenced in exclusive concert footage from his triumphant 25th anniversary tour, previously released on DVD via Eagle Rock Entertainment as Alan Jackson: Keepin’ It Country – Live at Red Rocks).
Rare interviews with wife Denise Jackson, his mother, father, and sisters, as well as collaborators such as Jim McBride and producer Keith Stegall, music industry executives like Tim Dubois, Mike Dungan and Barry Coburn and a list of artists and admirers that includes Alison Krauss, Lee Ann Womack, Easton Corbin and Carrie Underwood are also showcased.
An essential component of country music’s evolution, singer-songwriter Jackson blended traditional honky-tonk and mainstream country, ushering the genre into a new era. His insightful lyrics reflecting the “every man” sentiment continue to garner generations of fans, cementing an immeasurable legacy that still reverberates within the current musical landscape.
Alan Jackson: Small Town Southern Man is available via digital video services, including Apple iTunes and Amazon now.
Make sure you download the Triple M app on iTunes or Google Play to stay across all our best stuff!
ALAN JACKSON SMALL TOWN SOUTHERN MAN
MORE FROM Gold FM 92.5 Gold Coast
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U2 Are Bringing The Joshua Tree Tour Down Under
And it's fair to say we're excited!
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Time to shop
Saturday 11 June was a date which I will cherish as two big events happened at Haven House. We had a spectacular Mad Hatters Tea Party for our families at the hospice, to coincide with HM The Queen’s 90th birthday celebration, and we also opened a new charity shop at 52 South Street in Romford which complements our three shops in Chingford, Epping and Leytonstone. I was fortunate to be able to visit Romford after the party and saw how our retail team had transformed what was previously an empty shell into a bustling, colourful space packed with high quality pre-loved items, including designer clothes, contemporary home furnishings and children’s toys for a wide range of different ages.
One of the most inspiring comments from customers experiencing the shop for the first time was how they didn’t feel it looked or felt like a ‘traditional’ charity shop - and that’s because it isn’t! Charity shops have historically had a reputation as places where you may not necessarily want to spend time browsing for bargains which is why we introduced a boutique format for our shops. We wanted to make sure they felt upmarket, special and modern. By paying attention to the decor and small things, such as making sure all clothing items have the same swing tickets, size cubes and hangers, and of course providing excellent customer service, this can all help to enhance a shopping experience and hopefully means our customers return time and again.
Romford is a continuation of our boutique approach
Our shop in Leytonstone, which opened last year, was the first to receive the boutique treatment and it was subsequently nominated for a Time Out Love London Award and even received praise from retail guru Mary Portas on Twitter. Romford is a continuation of our boutique approach and I’m delighted to announce that on Saturday 16 July, Sam Faiers from The Only Way Is Essex will visit our shop for an official opening ceremony. Shoppers will have the chance to meet Sam and receive fashion advice from the TV star who runs her own boutique with her sister, Billie.
We wanted to open a charity shop in Romford for many years and as someone who lives a short distance away in Hornchurch, I have long seen the commercial importance of having a retail presence in the town. Retail is a vital and growing area for charitable fundraising, but charity shops also serve an additional purpose as they will often be the first point of contact that communities have with a charity.
As customers visit our new shop we want to let them know about all of the different ways they can support our children and their families. We also need volunteers to help in the shop and appeal for residents who are interested to get in touch today.
To find out more about volunteering in our Romford charity shop on 52 South Street please contact Volunteer Development Manager Andrea Thorogood on 020 8505 9944 or email [email protected].
Published: 13th June, 2016
Updated: 3rd February, 2017
Author: Mike Palfreman
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Things to Consider Before Letting Your Child Play Football
August 16th, 2016 by Guajardo & Marks, LLP
Football is far and away the most popular sport in the United States. In Texas, football is not just popular, it’s part of our state’s identity.
As we learn more and more about how the brain is affected by the repeated collisions that occur on the field, many parents are asking themselves a tough question – should I let my child play football?
This question is posed as soon as a child is old enough to play tackle football. When contact is introduced into the sport, the risks for serious injuries begin. Many of the reservations that parents have stem from the damage that can be suffered to a player’s brain, and there is certainly enough evidence to make the fears of parents completely legitimate.
Impact of Concussions and Repeated Impact on the Brain
There are many ways in which contact sports can impact a child’s health, especially in regard to the brain. Around 135,000 children ages five to 18 are treated in emergency rooms for sports-related brain injuries every year, the majority of which are concussions. Concussions can have immediate effects on children, such as dizziness, headaches, cognitive impairment and mood swings. Long-term effects of concussions are the subject of more debate, though a recent study linking certain types of severe concussions to the development of Parkinson’s disease highlights the fact that we are just beginning to understand the consequences of concussions on a person’s long term health.
Another growing concern for parents who are grappling with the decision of letting their child play football is the frequent occurrence of “sub concussive” head injuries. One study found that after a series of serious hits, a player could experience long-term brain damage, even when those hits did not cause concussions.
Dr. Bennet Omalu, best known for his work on this topic and for the being the subject of the movie “Concussion,” was the first person to identify the presence of Chronic Traumatic Encephalopathy (C.T.E.) in athletes who have suffered repetitive head trauma. Dr. Omalu says that children who play multiple seasons of football can develop symptoms of C.T.E. that include depression, suicidal tendencies, memory loss, loss of intelligence and the risk for dementia and substance abuse later in life. It is his opinion that children should not be playing contact football until they are old enough to comprehend the risks and to make the decision for themselves.
It Isn’t Just Football
One of the reasons that so much attention has been focused on football is because it’s incredibly popular in our country. Around 1.5 million children in the United States participate in youth football. However, it is perhaps unfair, or at the very least inaccurate, to say that football is the only sport that presents a risk to children. Any contact sport, even those that aren’t typically considered “contact” by nature, pose many of the same risks for head and brain injuries.
Though the risks might not be quite as extreme as they are in a sport like football, sports such as hockey, basketball, soccer and boxing also put children at risk for receiving brain injuries. Even activities like cycling cause a significant number of brain injuries to children every year.
In Texas, where football is a way of life for so many families, the question parents face will ultimately be answered by a personal decision. There are many factors parents will consider before coming to a conclusion on the matter, but the risk of brain injury inherent in contact sports like football will undoubtedly be a significant one.
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Most searched related results
Boris Becker auctions trophies to pay off debts
Trophies, medals and other memorabilia of Boris Becker put up for auction. Wyles Hardy/AFP
Trophies and personal souvenirs belonging to German tennis star Boris Becker will be auctioned online from Monday by British firm Wyles Hardy to partially clear the bankrupt champion's debts.
The youngest winner in Wimbledon's history, who claimed the first of three titles aged just 17, is auctioning off 82 items including medals, cups, watches and photographs.
The sale will end on July 11, Wyles Hardy said on its website.
Some of the trophies up for grabs include a replica of a Challenge Cup awarded to Becker following one of his Wimbledon wins, and the three-quarter size replica of the Renshaw Cup presented after he became the youngest ever Grand Slam singles champion.
His Wimbledon finalist medal from 1990, when he was beaten by Swede Stefan Edberg, and a replica of the US Open silver cup made by jeweller Tiffany for his 1989 victory over Ivan Lendl, will also be included in the sale.
Germany's Boris Becker hits a return to Spaniard Emilio Sanchez during their match.
The indebted 51-year-old champion was declared bankrupt in 2017.
In June 2018, he claimed he had diplomatic status and therefore immunity, thus stopping the sale of his trophies and personal souvenirs at the last minute.
The former world number one claimed that he had been appointed by the President of the Central African Republic as a sporting, cultural and humanitarian "attache" to the European Union.
But the Central African Ministry of Foreign Affairs replied that the passport brandished by Becker was a fake one, coming from a batch of "blank passports stolen in 2014."
Very substantial bids
Becker finally ended this bizarre episode in December by waiving his right to immunity in a London court specialising in insolvency cases, leading the auction house to put the trophies back on the market.
Former German tennis player Boris Becker. File photo/AFP
The first attempt "attracted very substantial bids," Mark Ford, one of the three trustees of Becker's bankruptcy estate, said in a statement.
However, the sales will not be enough to cover debts valued at millions of pounds.
Becker has already had legal difficulties with the Spanish courts over unpaid debts for work carried out on his villa in Mallorca.
The pastor who married him in 2009 also took him to court in Switzerland and the German courts in 2002 gave him a two-year suspended sentence and a fine of 500,000 euros ($570,000) over 1.7 million euros in unpaid taxes.
The six-times Grand Slam winner, nicknamed "Boom Boom" Becker for his devastating serve, won 49 titles and more than 20 million euros in prize money during his career.
He now focuses on his tennis activities, particularly commentating, as he attempts to use his fame to wipe out his debts.
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Cure Eczema Naturally
Eczema Free Forever Ebook
By Pamela Sadler on Fri, 12 Jul 2019
Eczema Free Forever program is the result of efforts by Rachel Anderson who herself was a sufferer of eczema and her son also suffered from eczema. The generally available treatments in the market for the treatment of eczema are consisted of the cream and lotions which bring relive it only on temporary basis while Eczema Free Forever system offers completely natural remedies which end eczema on permanent basis. This book offers a variety of foods which can work to heal effected areas, tips about what to avoid, advice on childhood ezcema, as well as a variety of detox diets which have been proven to work on those who suffer from this skin condition. This book is ideal for those who have been through dose after dose of doctor prescribed medication without any long lasting results, or for those who wish to avoid prescriptions and are seeking a more holistic cure for their eczema issues. Read more here...
Eczema Free Forever Summary
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Author: Rachel Anderson
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Irritant Contact Dermatitis Irritation
Last Updated on Sun, 15 Sep 2013 | Contact Dermatitis
Irritant contact dermatitis (ICD) is a term given to a complex group of localized inflammatory reactions that follow nonimmunological damage to the skin. The inflammation may be the result of an acute toxic (usually chemical) insult to the skin, or of repeated and cumulative damage from weaker irritants (chemical or physical). There is no definite laboratory test for ICD diagnosis is by clinical morphology, of course, and appropriate negative patch-test results. Acute Irritant Contact Dermatitis An irritant reaction is a transient noneczematous dermatitis characterized by erythema, chapping, or dryness, and resulting from exposure to less potent irritants. Repeated irritant reactions may lead to contact dermatitis. Cumulative Irritant Contact Dermatitis Cumulative irritant contact dermatitis or chronic ICD develops as a result of a series of repeated and damaging insults to the skin. The insults may be chemical or physical. Delayed Acute Irritant Contact Dermatitis ALLERGIC CONTACT...
Photoallergic Contact Dermatitis
Photoallergic contact dermatitis (PACD) is an immunological response to a substance that requires the presence of light. The substance in the skin absorbs photons and is converted to a stable or unstable photoproduct, which binds to skin proteins to form an antigen, which then elicits a delayed hypersensitivity response. Examples of photoallergens present in cosmetics are musk ambrette and 6-methylcoumarin, which are present in fragrances. Photopatch testing is the diagnostic procedure for photoallergy.
Allergic Contact Dermatitis From Fragrances Epidemiology
In dermatitis patients seen by dermatologists, the prevalence of contact allergy to fragrances is between 6 and 14 only nickel allergy occurs more frequently. When tested with 10 popular perfumes, 6.9 of female eczema patients proved to be allergic to them 10 and 3.2 to 4.2 were allergic to fragrances from perfumes present in various cosmetic products 11 . In cosmetics causing contact allergic reactions, perfumes account for up to 18 and deodorants antiperspirants for up to 17 of all cases. When patients with Contact allergy to fragrances usually causes dermatitis of the hands, face, and or armpits 16-18 , the latter site being explained by contact allergy to deodorants and fragranced antiperspirants. In the face, the skin behind the ears and neck is exposed to high concentrations of fragrances in perfumes and aftershaves. Microtraumata from shaving facilitates (photo)contact allergy to aftershave fragrances. The sensitive skin of the eyelids is particularly susceptible to developing...
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Photoirritant Contact Dermatitis Photoirritationphototoxicity
Last Updated on Thu, 26 Mar 2015 | Contact Dermatitis
Photoirritant contact dermatitis (PICD) is a chemically induced nonimmunological skin irritation requiring light. This reaction will occur in all individuals exposed to the chemical-light combination. The clinical picture is that of erythema, edema, or vesiculation in sun-exposed areas, resembling an exaggerated sunburn. This may be followed by hyper-pigmentation, or if the exposure is repeated, scaling and lichenification may occur. Bergap-ten, a component of bergamot oil, which used to be a popular ingredient in perfume, is a potent photoirritant that causes berloque dermatitis.
Skin rash and HHV6 reactivation in hematopoietic stem cell transplant recipient
Last Updated on Thu, 21 Aug 2014 | Human Herpesvirus
Several clinical conditions such as skin rash resembling acute GVHD, bone marrow suppression, interstitial pneumonitis, and encephalitis, may be related to HHV-6 infection after HSCT (Yoshikawa, 2004b). Moreover, an association between HHV-6 infection and acute GVHD was suggested in HSCT recipients. HHV-6 and human
Atopic dermatitis OMIM 603165
Last Updated on Thu, 11 Feb 2016 | Common Diseases
Atopic dermatitis (AD) is a clinical syndrome characterized by an itchy rash with a variety of morphological cutaneous features that change with age, in association with a positive family history and concomitant presence of other atopic diseases (atopic asthma, hay fever, and occasionally urticaria) (Williams, 1997). The atopic immunological state is characterized by a propensity to develop type 1 IgE mediated responses in response to certain antigens, but the cutaneous immuno-pathology of atopic dermatitis is characterized by the presence of a T cell and inflammatory cell infiltrate resembling the pattern seen in type IV hypersensitivity reactions (rather than the type 1-like response seen in urticaria). The onset of the rash is typically in early life, peaking at age four years and tending to improve with age, although a large proportion of subjects may develop other forms of eczema later in life (Williams, 1997). Drawing the boundary between mild atopic dermatitis and normality is...
Atopic Dermatitis And Eczema
Sun, 12 Feb 2017 | Beta Carotene
Probiotics have the potential to moderate inflammatory and immune responses and strengthen the intestinal barrier function, three actions that are useful in addressing the underlying pathophysiological processes involved in atopic dermatitis (AD) and eczema (Rosenfeldt et al 2004). The use of probiotic therapy to prevent allergic disease has been demonstrated in studies using L. rhamnosus GG in neonates, whereas studies in infants and children with established AD have found that probiotics reduce the severity of the condition (Fume 2005, Weston et al 2005). Prevention of allergy A randomised, double-blind placebo-controlled study Probiotics 953 development of atopic eczema In children by 50 during the first 2 years of life. Some 1 59 mothers were randomly allocated to receive 2 capsules of placebo or 1010 viable L. rhamnosus GG daily for 4 weeks before expected delivery. After delivery, capsules were taken for 6 months. During lactation either the mother or the infant consumed the...
Mon, 30 Sep 2013 | Beta Carotene
A novel use for B12 in a topical cream for atopic dermatitis has recently been tested. A prospective, randomised, placebo-controlled phase III multicentre trial involving 49 patients was conducted. Subjects applied the B12 cream twice daily to one side of the body and a placebo cream to the contralateral side, according to the randomisation scheme, for 8 weeks. The B12 cream was reported to significantly improve the extent and severity of atopic dermatitis and was considered safe and very well tolerated (Stucker et al 2004).
Sat, 09 Apr 2016 | Contact Dermatitis
Neurodermatitis, also called atopic dermatitis, is a skin disease that may occur at a very early age. It can be identified by the so-called milk crust on the reddened, damp skin of the head and cheeks of the newborn. As the first indication of an outbreak of neurodermati-tis, the milk crust often provides the starting point for other skin disorders. The skin becomes cracked and transparent, and the permeability increases. Once the skin is damaged, the risk of infection is higher. The skin becomes increasingly dry, transparent, and irritated, with intensified itchiness. The temptation to keep on scratching the skin is usually almost irresistable for small children. Atopic dermatitis is an immunological reaction that affects the skin to an especially large extent. More than 10 of children in industrialized countries are already afflicted, with a rising tendency. The combination of the genetic predisposition and environmental influences as well as psychological and neurovegetative...
Cosmetic And Occupational Skin Irritants Occupational Skin Irritants
A broad definition of occupational contact irritant dermatitis is contact dermatitis caused wholly or partially by the occupation of the subject. Occupational irritants may cause an acute response that may take from 1 hour to 1 day to appear, and is usually traceable to a single factor. Chronic irritant contact dermatitis may take months or years to appear and is often multifactorial 33 . Hands are involved in 80 to 90 of all cases of occupational contact dermatitis, and in the minority of cases the wrist, forearm, lower leg, or face is the primary site. The clinical features are described as follows. Many cases of occupational irritant contact dermatitis start as erythema and scaling on the back of joints and adjacent parts of the back of the fingers, as well as in the web spaces between the fingers. A generalized, rather shiny, superficially fissured, scaly fingertip dermatitis is also characteristic of certain forms of irritancy. Exclusive or more severe involvement of the thumb,...
Adverse Reactionstoxicity
Last Updated on Wed, 30 Dec 2015 | Contact Dermatitis
Subjective irritation associated with burning or stinging without objective erythema from some organic UV filters 27 is the most frequent sensitivity complaint associated with sunscreen use. This is most frequently experienced in the eye area. Longer lasting objective irritant contact dermatitis may be difficult to distinguish from true allergic contact dermatitis. In a postmarket evaluation of sunscreen sensitivity complaints in 57 patients, 20 of the patients had short-lasting symptoms, 26 long-lasting, and 11 mixed or borderline symptoms 28 . Half of the patients were patch and photopatch tested, and only three showed positive reactions to sunscreen ingredients. Virtually all sunscreen ingredients reported to cause contact allergy may be photoallergens 31 . Although still relatively uncommon, sunscreen actives seem to have become the leading cause of photocontact allergic reactions 32,33 . Individuals with pre-existing eczematous conditions have a significant predisposition to...
The Nature Of Cosmetic Allergens Fragrance Ingredients
Fragrance ingredients are the most frequent culprits in cosmetic allergies 11-15 . Katsarar et al., who investigated the results of patch testing over a 12-year period, found an increasing trend in sensitivity to fragrance compounds, which reflects the effectiveness of the advertising of perfumed products 16 . Common features of a fragrance contact dermatitis are localization in the axillae, localization on the face (including the eyelids) and neck, and well-circumscribed patches in areas of dabbing-on perfumes (wrists, behind the ears) and hand eczema or its aggravation. Airborne or connubial contact dermatitis should be considered as well. much more important, particularly as concerns quaternium-15 21 although its incidence seems to have recently slightly decreased 27 . Parabens are rare causes of cosmetic dermatitis. When a paraben allergy does occur, the sensitization source is most often a topical pharmaceutical product, although its presence in other products can be sensitizing...
Home Remedies for Psoriasis
Nature Of Interactions Between Products And The Superficial Epidermis
The intended, beneficial interactions of cosmetic products with the epidermis are the traditional ones, namely improvement of scaling, improvement of skin color, improvement of wrinkles (fine and coarse), improvement of elasticity, and a range of beneficial effects on the specialized superficial epidermis, namely the hair and nails. These effects are well known. However, interactions of products with the epidermis may also be innocent or irrelevant or directly harmful, with adverse events such as irritant or allergic contact dermatitis or special events such as development of comedoes and acne. Fragrance allergy is now the number two allergy in industrialized countries, with increasing prevalence. Fragrances are, however, contained not only in cosmetic products, but also in a broad range of household products. Harmful effects on the epidermis may be direct or indirect, acute short term or chronic long term, predictable and dose dependent (AHA products, urea, and others), or...
Hair Color Safety and Regulatory Issues
Last Updated on Sat, 03 Nov 2018 | Contact Dermatitis
It should be noted that allergic contact dermatitis to hair dyes appears to be far less common today than decades ago. It has been suggested that PPD, although a strong sensitizer, is not likely to produce skin sensitization because of the short contact time with skin and rapid reaction of PPD with the oxidizing agent and couplers 13 .
Frequent Skin Problems In Newborns Diaper Dermatitis
Last Updated on Mon, 04 May 2015 | Contact Dermatitis
At the beginning of this century, in 1905, a French pediatrician by the name of Jacquet gave the peculiar frequently occurring skin rash in the diaper area the name diaper dermatitis 16 . The skin alterations subcategorized under the diagnosis diaper dermatitis can have a variety of causes. They can be directly related to the contact dermatitis, which is diaper dermatitis in a narrow sense. The occurence can also be unrelated to the use of diapers. Today the factors that enhance this irritating contact dermatitis are known
Tests for Skin Protection Barrier Effect
Barrier creams (BC) may play an important role in the prevention of contact dermatitis 1-6 , and various in vitro and in vivo methods have been developed to evaluate their efficacy. In practice, their use remains the subject of lively debate some reports suggest that inappropriate BC application may exacerbate, rather than prevent, irritation 1-3, 69 . The accuracy of measurements depends on the use of proper methodology. This chapter reviews the investigative details of pertinent scientific literature, and summarizes the methodology and efficacy of BC.
In Vivo Studies Of The Antiirritation Properties Of Some Cosmetic Ingredients
Last Updated on Thu, 04 Oct 2018 | Contact Dermatitis
In vivo evaluation of the anti-irritant and or anti-inflammatory effect of dermatocosmetic formulations on human skin is usually based on the quantification of the inhibition presented by these products against an artificially induced contact dermatitis 42 . The model irritant for this purpose can be selected out of a wide range of skin-aggravating factors. Irritation of the skin can be provoked after topical application of Peru balsam 43 , solutions of anionic surfactants 44,45 , nicotinates 46,47 , after exposure to UV-B radiation 48,49 , skin abrasion 50 , or tape stripping 51,52 . There is clearly a difficulty in identifying the conditions under which these various irritants can be used for inducing a ''suitable'' irritation. The induced irritation should be great enough to be measurable with good reproducibility and to allow quantification of its inhibition by the tested products. The anionic surfactant sodium lauryl sulphate (SLS) has lately become the model irritant of choice,...
Assessing Moisturizer Efficacy Overview of Lotion Function
Last Updated on Tue, 12 Sep 2017 | Contact Dermatitis
Hand and body moisturizers have two primary functions. The traditional view of moisturizer function is that they alleviate pre-existing dry skin and prevent its return. Recently, however, reports in the scientific literature have shown that moisturizers can prevent the induction of some signs of irritant contact dermatitis 9,10 . The ability to prevent irritant contact dermatitis has relevance to a significant segment of the population. Epidemiological studies have shown that the prevalence of diag-nosable hand and forearm eczema can be as high as 5.4 of the population at any one time, and from 8 to 11 in the preceding year 11,12 . This often has an irritant component especially from repeated exposure to surfactant solutions. Being able to prevent irritation may provide a significant benefit to these individuals, as well as those with dry skin (xero-sis), which frequently affects the arms and legs of consumers. Although symptoms are usually less intense than eczema, dry skin probably...
Immunological Contact Urticaria
This term is a neologism for consumers' feelings about their intolerance to a variety of topical agents, be it topical medicaments or cosmetics and toiletries. Individuals present with very similar complaints, such as burning, stinging or itching sensations, on contact with certain cosmetic products that most people do not seem to react to, sometimes accompanied by slight erythema or edema. They frequently complain of a ''tight feeling'' in their skin, secondary to associated dry skin. Sensitive skin describes the phenotype noted by the consumer mechanisms include sensory irritation, suberythematous irritation, acute and cumulative irritation, contact urticaria, allergic contact dermatitis, as well as photoal-lergic and phototoxic contact dermatitis. Sensory irritation and suberythematous irritation are believed to be far more common than the remaining mechanisms. The term cosmetic intolerance syndrome (CIS) is applied to the multifactorial syndrome in which certain susceptible...
Cosmetic Skin Irritants
Intolerance to some ingredients is related to symptoms of contact dermatitis and allergic dermatitis. There is not always a clear distinction between these problems. Some cosmetic ingredients present both an irritant character with the additional possibility of allergic reaction (e.g., cinnamic acid derivates). An overview of cosmetic categories causing irritant side effects in descending importance has been given by A. C. de Groot and coworkers 1-3 and are summarized briefly in Table 3. It has clearly been shown that certain categories of cosmetics, taking into account their composition, frequency of use, mode of application on the skin, and skin area to be treated, are more specific candidates for causing symptoms of skin irritation.
Factors Predisposing To Cutaneous Irritation
Last Updated on Sun, 18 Feb 2018 | Contact Dermatitis
Of 4 years, lack of dishwashing machine 30 , and preference for high-risk occupations contribute to the higher incidence of ICD in females 27 . The most established individual risk factor, out of several studies about occupational hand eczema, is probably atopic dermatitis 28,31-33 . On the other hand, experimental studies concerning the reactivity of atopics and nonatopics to standard irritants have given contradictory results 34,35 and, as shown in a Swedish study, about 25 of the atopics in extreme-risk occupations, such as hairdressers and nursing assistants, did not develop hand eczema 36 . Age is as well related to irritant susceptibility insofar as irritant reactivity declines with increasing age. This is true not only for acute but also for cumulative irritant dermatitis 37,38 . Fair skin, especially skin type I, is supposed to be the most reactive to all types of irritants, and black skin is the most resistant 39,40 .
Individual Uv Filters
Wed, 05 Jun 2019 | Contact Dermatitis
TiO2 was the first micropigment extensively used. Advantages include a broad spectrum of protection and inability to cause contact dermatitis. The use of rutile as opposed to anatase crystal forms of titanium dioxide lessens photoactivity. Newer materials are am-phiphilic, designed to be dispersed in both water- and oil-emulsion phases. Particle size and uniformity of dispersion is key to achieving SPF. Primary particle size may be 10 to 15 nm with secondary particle assembly to 100 nm. Particle size needs to be less than 200 nm to achieve transparency.
In Vivo Irritation
Skin irritation is a localized nonimmunologically mediated inflammatory process. It may manifest objectively with skin changes such as erythema, edema, and vesiculation, or subjectively with the complaints of burning, stinging, or itching, with no detectable visible or microscopic changes. Several forms of objective irritation exist (see Table 1). Acute irritant dermatitis may follow a single, usually accidental, exposure to a potent irritant and generally heals soon after exposure. An irritant reaction may be seen in individuals such as hairdressers and wet-work performing employees, who are more extensively and regularly exposed to irritants. Repeated irritant reactions may develop into a contact dermatitis, which generally has a good prognosis. Other forms of irritant dermatitis include delayed acute irritant contact dermatitis, which occurs when there is a delay between exposure and inflammation, and cumulative irritant dermatitis, which is the most common form of irritant contact...
Population-based data on the incidence and prevalence of ICD are rare, but there is agreement that incidence of ICD is higher than that of ACD in general. The figures on the incidence of ICD vary considerably, depending on the study population. Most data stem from studies about occupational hand dermatoses, and in this an overview is given about the important findings of these studies. In general, it can be assumed that nonoccupational contact dermatitis attributable to all causes is more frequent in comparison to occupational contact dermatitis 29 . Coenraads and Smit reviewed international prevalence studies for eczema attributable to all causes conducted with general populations in different countries (England, The Netherlands, Norway, Sweden, the United States) and found point prevalence rates of 1.7 to 6.3 , and 1- to 3-year period prevalence rates of 6.2 to 10.6 44 . An extensive study of Meding on hand eczema in Gothenburg, Sweden, included 20,000 individuals randomly selected...
In Vivo Methods
Mon, 04 Jan 2016 | Contact Dermatitis
Zhai et al. 5 introduced a facile approach to screening protectants in vivo in human subjects. Two acute irritants and 1 allergen were selected 1) sodium lauryl sulfate (SLS), representative of irritant household and occupational contact dermatitis, 2) the combination of ammonium hydroxide (NH4OH) and urea to simulate diaper dermatitis, and 3) Rhus to evaluate the effect of model protective materials. Test materials were spread onto test area, massaged, allowed to dry for 30 minutes, and reapplied with another 30-minute drying period. The model irritants and allergen were applied with an occlusive patch for 24 hours. Inflammation was scored with an expanded 10-point scale at 72 hours after application. Most test materials statistically suppressed the SLS irritation and Rhus allergic reaction rather than NH4OH and urea-induced irritation.
Acute ICD
Stinging, and soreness of the skin, and are accompanied by clinical signs such as erythema, edema, bullae, and even necrosis. Lesions are usually restricted to the area that came into contact, and sharply demarcated borders are an important sign of acute ICD. Nevertheless, clinical appearance of acute ICD can be highly variable and sometimes may even be indistinguishable from the allergic type. In particular, combination of irritant and allergic contact dermatitis can be troublesome. Prognosis of acute ICD is good if irritant contact is avoided. Exsiccation Eczematid Exsiccation eczematid is a subtype of ICD that mainly develops on the extremities. It is often attributable to frequent bathing and showering as well as extensive use of soaps and cleansing products. It often affects elderly people with low sebum levels of the stratum corneum. Low humidity during the winter months and failure to remoisturize the skin contribute to the condition. The clinical picture is typical, with...
Wed, 01 Feb 2017 | Contact Dermatitis
The visible color change associated with the use of artificial tanning products might suggest to some users that these products are hazardous. Based on the chemistry of DHA and its toxicological profile, it can be considered nontoxic. It reacts quickly in the stratum corneum minimizing systemic absorption. The acute toxicity of DHA was investigated for diabetics in the 1920s with their oral intake well tolerated 6 . The phosphate of DHA is found naturally as one of the intermediates in the Kreb's cycle. Contact dermatitis to DHA has only rarely been reported 16 . As with other topical products with active ingredients, such as sunscreens, much of the reported sensitivity is secondary to other ingredients in the vehicle 17 . Adverse reactions are more likely to occur on the basis of irritation
In Japan it is used in nonprescription skincare products up to a concentration of 1 . To increase percutaneous absorption and thus therapeutic activity, it is usually used at the highest concentration allowed 31 . Because it is used intensively in foods (e.g., bean paste, soy, and sake) in some countries, particularly Japan, its oral safety has been studied. Shibuya et al. 28 , investigating the mutagenicity of kojic acid by the Ames test, forward mutation test in cultured Chinese hamster cells, and dominant lethal test in mice, concluded that, although kojic acid is a weak mutagen in bacteria, it is nonmutagenic in eukaryotic system either in vivo or in vitro. Abdel-Hafez and Shoreit 30 tested the mycotoxins using the dilution-plate method. Results showed that kojic acid may induce some toxins. Fujimoto et al. 32 examined the tumorigenicity of kojic acid in B6C3Fj mice. Three groups of animals were given 0, 1.5, and 3.0 kojic acid-containing food for 6 weeks kojic acid groups...
Answers To Patients Frequently Asked Questions
Last Updated on Mon, 03 Sep 2018 | Beta Carotene
Albizia is a traditional Ayurvedic medicine used to reduce allergic conditions, such as allergic rhinitis and urticaria. It is also used for atopic conditions, such as eczema and asthma, when indicated. Controlled trials have not been conducted, so it is uncertain whether it is effective. When will it start to work
Last Updated on Wed, 30 Dec 2015 | Beta Carotene
A study of over 1000 patients randomly chosen from several different patch test clinics identified only one who reacted to calendula (Bruynzeel et al 1992). Patch test results need to be carefully interpreted because false positives can occur, as the following case shows. A 35-year-old woman with recalcitrant atopic dermatitis, with a positive patch-test reaction to Compositae mix, was told she was allergic to calendula. However, it turned out that she followed a self-devised diet consisting largely of food products of the Compositae family (which includes lettuces and artichoke). On excluding these foods her skin condition improved quickly. This case report underscores the difficulty in determining the relevance of positive patch tests, and shows that thorough analysis of positive patch tests, by both patient and physician, may reveal unexpected or less common sources of contact allergens (Wintzen et al 2003).
Dpk Be Study Protocol Protocol and Subject Selection
Last Updated on Sun, 15 Sep 2013 | Drug Administration
Healthy volunteers with no history of previous skin disease or atopic dermatitis and with a healthy, homogeneous forearm (or other) skin areas sufficient to accommodate at least eight treatment and measurement sites (time points) should be recruited. The number of subjects to be entered may be obtained from power calculations using intra- and intersubject variability from the pilot study. Because skin stripping is highly sensitive to specific study site factors, care should be taken to perfecting the technique and enrolling a sufficient number of subjects. The following study design is based on a crossover study design, where the crossover occurs at the same time using both arms of a single subject. A crossover design in which subjects are studied on two different occasions may also be employed. If this design is employed, at least 28 days should be allowed to rejuvenate the harvested stratum corneum.
Dermatitis And Psoriasis
Last Updated on Sun, 15 Sep 2013 | Beta Carotene
Research from the 1930s to the 1950s established that a deficit of n-6 EFAs leads to an inflammatory skin condition in both animals and humans. More recently, it has been established that there is no deficit of LA in atopic eczema. Instead, concentrations of LA tend to be elevated in blood, milk and adipose tissue of patients with atopic eczema, whereas concentrations of LA metabolites are substantially reduced. This suggests reduced conversion of LA to GLA (i.e. delta-6-desaturase) is responsible In most studies, but not all, administration of GLA has been found to improve the clinically assessed skin condition, the objectively assessed skin roughness, and the elevated blood catecholamine concentrations of patients with atopic eczema. Atopic eczema may be a minor inherited abnormality of EFA metabolism in some cases (Horrobin 2000). Clinical studies While early results appear promising, including a meta-analysis published in 1998 that found that oral EPO provided significant...
Adverse drug reactions
Last Updated on Thu, 21 Aug 2014 | Back Pain
An adverse drug effect is defined as 'any unwanted effect of treatment from the medical use of drugs that occurs at a usual therapeutic dose'. Almost every drug can cause an adverse reaction, which must be elicited in the history. Any substance that produces beneficial therapeutic effects may also produce unwanted, adverse or toxic effects. The severity of the reaction may range from a mild skin rash or nausea to sudden death from anaphylaxis. A study has shown that the incidence of adverse reactions increases from about 3 in patients 10-20 years of age to about 20 in patients 80-89 years of age. 1 Reactions can be classified in several ways, e.g. side effects, overdosage, intolerance, hypersensitivity and idiosyncrasy. However, a useful classification of unwanted effects is divided into type A and type B. Type A reactions are the most common and involve Augmented pharmacology, i.e. they are caused by unwanted, albeit predictable, effects of the drug. Examples
Studies by Molecular Methods
Last Updated on Wed, 30 Dec 2015 | Intestinal Microbiota
Results obtained by molecular-based culture-independent techniques are largely supportive of the findings presented above. In another prospective follow-up, the fecal microbiota in Finnish neonates was studied prior to the expression of atopy as detected by a positive skin prick test at year one (n 12). The microbiota of these sensitized children tended to contain lower numbers of bifidobacteria and significantly higher numbers of Clostridium histolyticum than those in samples from infants with a negative prick test (n 17) (48). The Clostridium species detectable with the oligonucleotide-probe used in that study include common infant gut colonizers such as C. paraputrificum, C. butyricum and C. perfringens but not C. difficile. However, another study indicated that relatively high fecal levels of rarely detected i-caproic acid indicative of C. difficile activity was associated with presence of IgE mediated allergic condition in Swedish infants at around one year of age (49). The...
Reflection of Atopic Genotype
Last Updated on Tue, 12 Apr 2016 | Intestinal Microbiota
Immunological deviancies that could result in impaired recognition of specific bacterial groups and thus allow them to flourish. These defects include compromised expression of Toll-like receptor (TLR) 4 and its soluble co-receptor CD14 (sCD14), albeit the results regarding sCD14 are conflicting (59-64). However, also low breast-milk levels of sCD14 have been associated with subsequent development of eczema in children irrespective of atopy (65). TLR4 and sCD14 are pattern recognition receptors of innate immune systems that are important in detection of components in both Gram-positive and Gram-negative bacteria but especially the cell-wall lipopolysaccharides (LPS) in the latter (66,67). Notably, CD14-independent recognition of LPS would seem to be defective during the neonatal period (68). Compromised recognition may facilitate colonization by bacteria which would otherwise be cleared or reduced in numbers due to immune responses mounted against them. This could partly explain why...
Reflection of Effects on Th1 Th2 and Treg Differentiation
Last Updated on Mon, 03 Sep 2018 | Intestinal Microbiota
Also Lactobacillus strains have been shown to confer differential effects on cytokine production and expression of surface markers on murine dendritic cells (85). Furthermore, lactobacilli induced in vitro, in a strain dependent manner, Treg-like low proliferating Th population producing TGF-b and IL-10 (86). TGF-b is the key cytokine in induction of T-cell differentiation towards Tregs (Fig. 2) (87). In a clinical study, improvement in atopic eczema symptoms following oral administration of lactobacilli was accompanied by increased serum concentrations of TGF-b (17). Interestingly, oral supplementation of lactobacilli in breast-feeding mothers was followed by increased TGF-b concentrations in breast-milk (88). This increase may have contributed to subsequently lower prevalence of atopic eczema in children. It should be noted, however, that allergic sensitization was not affected and allergic rhinitis and asthma may have increased in frequency (89). Nevertheless, these studies are not...
Reflection of Allergic Symptoms
The possibility that allergic symptoms either affect, or are affected by, the microbiota is supported by an observation that alleviation in atopic eczema and allergic inflammation following oral administration of bifidobacteria was accompanied by modified dynamics in the microbiota (i.e., restriction in the growth of E. coli and Bacteroides) (18). Also, earlier findings attest to this possibility implicating direct correlation between numbers of Enterobacteriaceae family bacteria and severity of atopic eczema symptoms (39). The compositional characteristics associated with the severity of symptoms may be caused by intestinal inflammation exacerbated in some allergic conditions (95,112-115).
Reflection of Environmental Factors
Last Updated on Wed, 24 Oct 2018 | Intestinal Microbiota
Amongst the best examples of factors which have been clearly shown to influence the development of the gut microbiota and have also been implicated in allergic diseases include the mode of delivery and breast-feeding (116-123). Indeed, it is plausible that the characteristics of fecal microbiota associated with atopic eczema and allergic sensitization may partly reflect dietary factors. It is well known that changes in diet may dramatically affect the microbial composition of the gut. Then again, in allergic infants the diet can reflect the child's health status due to food restrictions. In 39-63 of all infants and young children, atopic eczema is triggered by one or more challenge-confirmed food allergies (124-126). Moreover, the development of manifestations of allergic diseases in children correlates with differences in the composition and immunological characteristics of breast-milk, which on the other hand are affected by maternal gut microbiota and atopy (127-133). For example,...
Phenobarbital Luminal Solfoton
Last Updated on Tue, 11 Jun 2019 | Adverse Effects
Infant and children < 12 yrs 10-20 mg kg IV in a single or divided dose, may give additional 5 mg kg dose every 15-30 minutes until seizure is controlled or a total dose of 40 mg kg is reached maintenance infants 5-8 mg kg day IV PO in 1-2 divided doses, children 1-5 yrs 6-8 mg kg day in 1-2 divided doses, children 5-12 yrs 4-6 mg kg day in 1-2 divided doses. Neonates 15-20 mg kg IV in single or divided dose maintenance 2-4 mg kg day in 1-2 divided doses, increase by 5 mg kg day if needed. Clearance hepatic metabolism, 25-50 renal elimination unchanged. Therapeutic level 15-40 mg L. Contraindications preexisting CNS depression, severe uncontrolled pain, porphyria, severe respiratory disease with dyspnea or obstruction. Adverse effects hypotension, drowsiness, cognitive impairment, ataxia, hepatitis, skin rash, respiratory depression, apnea, megaloblastic anemia. Comments multiple drug interactions through induction of hepatic enzyme systems use caution in hepatic or renal disease...
Pathogenesis of skin manifestations due to HHV6 infection
Patients with exanthem subitum as well as the absence of suitable animal models of primary HHV-6 infection. Recently, we reported the absence of rash after the resolution of fever in immunocompromised infants during primary HHV-6 infection (Yoshikawa et al., 2001a,b). Thus, the host immune response against the virus appears to play an important pathogenic role in the skin rash in patients with exanthem subitum. In addition to this in vivo data, we infected an epidermal cell line (A431 cells) with HHV-6 and examined the expression of several surface molecules to understand the pathogenesis of skin manifestations (Yoshikawa et al., 2003) HHV-6 can infect this epidermal cell line, and HLA-A, -B, and -C, HLA-DR, and ICAM-1 expression were upregulated in HHV-6-infected cells. Tissue culture supernatant did not affect the expression of these three surface molecules, and, therefore, direct viral infection probably causes the changes observed in these cells. When considered with a previous...
General Aspects of Therapy
Last Updated on Wed, 16 Dec 2015 | Herpes Zoster
Herpes zoster at any site of the body in patients beyond the age of 50 Herpes zoster in the head neck area of patients at any age Severe herpes zoster on the trunk and on the limb Herpes zoster in immunodeficient patients Herpes zoster in patients with severe atopic dermatitis and severe eczema and zoster oticus (table 1). Severe herpes zoster of the trunk and extremities as well as herpes zoster in immunodeficient patients and patients with atopic dermatitis or other eczema are also indications for antiviral therapy. Furthermore, zoster ophthalmicus and zoster oticus as well as age over 50 years are major risk factors for the development of PHN. Some authorities consider antiviral treatment to be only optional in patients younger than 50 years of age with shingles on the trunk or on the extremities. Nevertheless, antiviral therapy has potential benefit and bears a limited risk. The same is true for immunocompetent children. However, as a rule patients younger than 50 years should be...
Last Updated on Sat, 08 Sep 2018 | Hearing Loss
Letterer-Siwe disease (systemic LCH) is the rarest (approximately 10 of all LCH cases) and most severe form of LCH. Affected individuals are typically under the age of two years and present with diffuse eczema, draining ears, lymphadenopathy, and hepatosple-nomegaly. Failure to thrive, weight loss, and pancytopenia are also present and portend a poor prognosis (2).
Last Updated on Mon, 03 Sep 2018 | Human Herpesvirus
Protocol for allogeneic transplants is considerably more aggressive than autologous transplants, there is no apparent significant difference in the incidence of HHV-6 recurrence between these transplants nor sibling versus unrelated donor grafts in a pediatric population (Yoshikawa et al., 2002 Savolainen et al., 2005). HHV-6 reactivation is common in BMT transplant patients (Wang et al., 2002) and associated with skin rash and fever, the same symptoms often manifested at the time of primary infection in children. Idiotypic myelosuppression is characterized by delayed ne-utrophil and platelet engraftment and is highly associated with the reactivation of HHV-6 (Dobryski et al., 1993 Carrigan and Knox, 1994). Bethge et al. (1999) has reported two cases of BMT patients with HHV-6 PCR-positive spinal fluid who display neurological symptoms, including disorientation, sleepiness, and short-term memory loss and showed improvement following treatment with foscarnet. Appleton et al. (1995)...
Effects Of Immunosuppressants On Coagulation During
Last Updated on Tue, 12 Apr 2016 | Anti Coagulant
Campath 1H (C1H) is a humanised monoclonal antibody directed against the CD52 antigen that is present on the surface of T cells, B cells, NK cells, and monocytes. It depletes the peripheral blood lymphocytes, preventing an aggressive lymphocytic immune response after transplantation. Adverse events include acute first-dose administration-related reactions (attributed to antibody-induced cytokine release), infectious complications (due to immuno-suppression), and haematological toxicities. Rigor, fever, nausea, vomiting, skin rash, dyspnea, and hypotension are among the most commonly reported infusion-related reactions with alemtuzumab. thrombocytopenia, anaemia, and neutropenia are the most common haematological alterations.35
Presentation And Clinical Course
Last Updated on Thu, 21 Aug 2014 | Emergency Medicine
After an incubation period of 2-20 days (10 days on average), patients typically experience the sudden onset of fever, chills, nausea, vomiting, headache, and myalgia. This corresponds to the septicemic phase, which lasts 3-7 days. Physical exam findings at this time are relatively nonspecific, and include maculopapular skin rash, pharyngeal injection, lymphadenopathy, organomegaly, and muscle tenderness. The presence of conjunctival suffusion or muscle tenderness involving the calves and lumbar region should raise the suspicion of leptospirosis.
HHV6 association with other liver disease
Last Updated on Mon, 09 Mar 2015 | Human Herpesvirus
Hemophagocytic syndrome (HSP) is a clinicopathologic syndrome characterized by the systemic activation of macrophages leading to the phagocytosis of hematopoietic cells. HSP is characterized by the association of fever, he-patosplenomegaly, lymphadenopathy, skin rash, lung infiltration, and jaundice. Laboratory findings frequently demonstrate pancytopenia, elevated levels of hepatic transaminase, coagulopathy with low fibrinogen, hypertriglyceridemia, and elevated ferritin levels. Several viral infections, such as Epstein-Barr virus, have
Last Updated on Sun, 16 Sep 2018 | Placebo Controlled
OEP is regulated as a dietary supplement in the United States. It is approved in Canada as an over-the-counter product for use in EFA-deficiency conditions and as a dietary supplement to increase EFA intake. In the United Kingdom, it is on the General Sales List. In Germany, OEP is approved for use as food and is approved there in the treatment and symptomatic relief of atopic eczema. In Sweden, OEP is classified as a natural product. OEP has a Class 1 Safety Rating with the American Herbal Product Association (1,2,7).
Relation Between Atopy and Metal Hypersensitivity
Last Updated on Wed, 30 Dec 2015 | Toxicology
The relation between atopy, a condition with inherited predisposition to develop IgE-mediated hyper-sensitivity to small quantities of inhaled or ingested environmental agents, and metal immunotoxicology was discussed at the workshop of Immunotoxicity of Metals and Immunotoxicology in 1989 (Cattaneo, 1990). Although case reports of type I hypersensitiv-ity caused by sensitization to chromium (Section 5.2), cobalt (Section 5.3), nickel (Section 5.6), and platinum (Section 5.7) have been published, only platinum allergy is sufficiently frequent to be assessed for the influence of atopy. A recent review found no association between atopy and type I allergy to platinum salts (Merget et al., 2003). With regard to metal-induced type IV allergy, allergic contact dermatitis, no increased predisposition was reported as a result of atopy at the workshop in 1989 (Cattaneo, 1990). No conclusive new information has been published since then. For example, with regard to the most frequent clinical...
Other Special Situations
Last Updated on Wed, 30 Dec 2015 | Intraocular Pressure
The word panallergic can be used to describe patients who simply cannot tolerate virtually any medication for one reason or another. Allergic reactions to every topical glaucoma agent have been reported. Contact dermatitis is not uncommon with alpha-2 agonists, miotics, CAIs, and beta blockers. Also included in this category are patients who have multiple side effects to medications or who just cannot tolerate the baseline level of burning and stinging associated with their instillation.
The Platinum Group of Elements Palladium Platinum Rhodium
Pt is a highly corrosive-resistant, catalytic, and strong metal, which has been used for a long time in various applications, mainly in the form of complex salts, for example, platinum chloride, platinum dichloride, platinum dioxide, and platinum sulfate. Platinum complexes, in the form of platinum (II) compounds, cisplatin and carboplatin, are among the most important chemothera-peutic drugs. Biological reactivity, especially hypersen-sitivity, is limited to charged compounds that contain reactive ligands, halogenated Pt salts, and the sensitizing potential increases with the number of chlorine atoms. The sodium and potassium salts of hexachlorplatinic (IV) acid and tetrachlorplatinite (II) are the most potent sensitizers (Ravindra et al., 2004). Symptoms of allergic-like reactions such as lacrimation, sneezing, rhinorrhea, cough, dyspnea, and frank asthma in workers exposed to soluble complex platinum salts have been observed since the early 19th century and were called platinosis...
Studies by Traditional Plate Culture Methods
Last Updated on Tue, 15 Mar 2016 | Intestinal Microbiota
The first reports associating allergy with characteristic microbial composition in the gut appear to be from studies in the former Soviet Union in the early1980s (38-40). One of these studies, reported also in English, involved an assessment of 60 under one-year-old infants with food allergy and atopic eczema. It was claimed that the severity of the disease was in direct correlation with the stage of aberrancy in the fecal microbiota. This aberrancy was characterized as low prevalence of bifidobacteria and lactobacilli and high prevalence of Enterobactericeae, pathogenic species of staplylococci and streptococci as well as Candida species (39). Indication that such differences may persist beyond infancy was provided a few years later by Ionescu and co-workers (1986) who studied 10- to 45-year-old subjects. Subjects with atopic eczema (n 58) were shown to have lower prevalence of lactobacilli, bifidobacteria, and enterococci species than the healthy subjects (n 21) but higher...
Last Updated on Wed, 13 Sep 2017 | Hearing Loss
SLE is a common autoimmune connective-tissue disease affecting 1 in 1000. It is much more prevalent in young females, with a female-to-male incidence of 9 1. It affects many organ systems. Skin rash is a very common presentation, typically appearing in the malar areas following sun exposure. Oral ulcerations develop in 40 of patients. Other systemic manifestations include myocarditis, nephritis, pneumonitis, and central nervous system (CNS) involvement.
Solid organ transplant recipients
Clinical sequelae of HHV-6 may result from symptoms directly attributable to the virus or from its immunomodulatory effects. Table 1 shows a summary over the clinical syndromes that has been suggested being associated with HHV-6. Symptomatic infections seem to be more common in SCT than in SOT patients although published reports vary from very limited clinical effects of HHV-6 to a contributing effect on overall mortality. A fever of unknown origin with or without a skin rash bone marrow suppression, and encephalitis are the most frequently observed clinical features of HHV-6 (Carrigan et al., 1991 Drobyski et al., 1993 Carrigan and Knox, 1995 Wang et al., 1999 Ljungman et al., 2000 Zerr et al., 2001). Less commonly, interstitial pneumonitis, gastrointestinal disease, and hepatitis have been reported (Cone et al., 1993 Singh et al., 1997 Rossi et al., 2001 Hentrich et al., 2005).
Significance to humans
Last Updated on Sat, 06 Jul 2019 | Reproductive Biology
Holothuroids are a food item in several Asian and Pacific Island countries. The widespread use of holothuroids as food and medicine in Asia extends to at least the late sixteenth century, when detailed Chinese and European accounts of commerce first began mentioning trade in beche-de-mer. This long-term, domestic familiarity with holothuroids in the region is reflected in a small role for the animal in northern Asian culture as an object of poetry and popular cartoons. Several thousand individuals of colorful tropical species are harvested annually as part of the worldwide marine aquarium trade. Holothuroids are of minor medical significance because the potent dermal toxins of some species cause severe contact dermatitis in some people. These same toxins are of commercial interest because of their pharmacological properties. Compounds extracted from holothuroids exhibit antimicrobial, anticoagulating, tumor-inhibiting, and antiinflammatory activity. Other compounds are potent...
Pro Inflammatory Chemokines
Wed, 29 Jul 2015 | Hidradenitis Suppurativa
Skin-pathogenic microorganisms such as S. aureus, B. burgdorferi or C. albicans together with several PAMPs (e.g., LPS or PGN) induce the abundant expression of IL-8 a chemokine now referred to as CXC chemokine ligand 8 (CXCL8) in a TLR-NF-kB-pathway-dependent manner 15, 47, 49, 59, 75 . Pathogen-induced secretion of keratinocyte-derived IL-8 initiates neutrophil chemoattraction and transendothe-lial migration. In addition, IL-8 is selectively involved in the transendothelial migration of CLA+ T cells, emphasizing the role of IL-8 in the homing of specific T cells to inflamed skin (Fig. 13.2). In addition to IL-8, pathogens and microbial products, such as heat-killed S. aureus and staphylococcal PGN, stimulate the expression of other chemokines in keratinocytes, such as RANTES CCL5 (regulated on activation, normal T expressed and secreted, RANTES) or MCP-1 CCL2 (monocyte chemoattractant pro-tein-1) 47 . RANTES-expressing keratinocytes were detected in the lesional skin of patients...
Dean Filandrinos Thomas R Yentsch and Katie L Meyers
John's wort has demonstrated clinical efficacy for mild to moderate depression and compares favorably to other more potent or toxic antidepressants. Low side effects and potential benefits warrant its use as a first-line agent for select patients with mild to moderate depression or anxiety-related conditions. Benefits related to other reported uses such as an antimicrobial, agent to treat neuropathic pain, antiinflammatory, treatment alternative for atopic dermatitis, and antioxidant are either not well documented or evidence is encouraging but not conclusive and further study is needed. St. John's wort has an inherently wide margin of safety when taken by itself, with most reported adverse drug reactions (ADRs) being related to skin reactions. Isolated, but more significant ADRs have been reported in relation to neurological effects, impact on thyroid function, and increased prothrombin time. Of greatest concern is the potential for interactions between St. John's wort and...
Allergy and Dermatitis
Last Updated on Sun, 16 Sep 2018 | Hearing Loss
Contact allergy to chemicals used in ear drops is the most common type of dermatologic otitis externa. Hairsprays, dyes, and cosmetics can also result in an eczematoid and draining otorrhea. If the source of external canal weeping is not obvious, routine patch testing is strongly suggested (20). The autoeczematization (ID) reaction, which is an autoimmune reaction that may involve only the external auditory canal, has been recorded for over 70 years in the otolaryngology literature. Recent studies confirm that this is due to a local reaction to distant fungus infections, most commonly dermatophytid in the feet and inguinal area. Control of the primary fungal infection with prolonged antifungal systemic treatment will nearly always control the ear reaction (21,22). There are other less-common dermatologic conditions that may focus on the ear. Atopic dermatitis, which has recently been found to result from a superantigen reaction to Staphylococcus aureus exotoxin, has been implicated in...
Pharmacological Toxicological Effects
Last Updated on Tue, 11 Jun 2019 | Placebo Controlled
Atopic Dermatitis After it was found that St. John's wort, and more specifically hyperforin, has an inhibitory effect on epidermal langerhan cells, there was speculation that it may treat atopic dermatitis. A 4-week trial was conducted in which 21 patients with mild to moderate atopic dermatitis were treated twice daily with a cream standardized to 1.5 hyperforin on one side of their body and placebo on the other side. The primary end point of the study was severity scoring of atopic dermatitis (SCORAD) index, based on extent and intensity of erythema, papulation, crust, excoriation, lichenification, and scaling. Among the 18 participants that completed the study, the SCORAD index fell from a baseline score of 44.9 to 23.9 in the hyperforin group. The SCORAD index also fell from 43.9 to 33.6 in the placebo group. These results show statistically significant superiority of hyperforin cream over placebo, with no difference in skin tolerance to the two treatments. Of note, a...
Measure of Quality of Life Quantitative Approach
Tue, 22 Nov 2016 | Hidradenitis Suppurativa
A quantitative approach for measuring QoL in HS was performed 2 . Questionnaires widely used in other skin diseases such as the Dermatology Life Quality Index (DLQI) questionnaire, Skindex and VQ-Dermato 1, 4, 5 were chosen. This approach allows a direct comparison of the results with those from previous studies on other skin diseases. We will discuss two studies, one already published and our unpublished data 2 . In both studies, in addition to this questionnaire, basic demographic data and aspects of the history of HS were collected 114 patients participated in the first one 2 and 61 in the second. In the study of der Werth and Jemec 2 the recorded mean DLQI score was 8.9, higher than scores found in several other dermatological conditions such as alopecia, acne, psoriasis, Hailey-Hailey disease, vascular anomalies of face, and atopic dermatitis. In our center (unpublished data) using two other skin-disease-specific QoL questionnaires (Skindex and VQ-Dermato) 1, 5 , the scores...
Spatiotemporal patterns of common skin diseases
Sun, 22 Jan 2017 | Common Diseases
Despite the absence of systematic data there are important secular and geographical differences in disease burden that (to this author) seem robust. Atopic dermatitis incidence appears to have increased by a factor of two or more in the last three decades in many developed countries (Williams, 1997). Cancers of the skin in many world populations (chiefly those with pale skin) have also increased two to three-fold over a similar time course (Marks, 1995). By contrast psoriasis incidence seems to have stayed constant. For other
Regulation of the Immune Responses
Last Updated on Fri, 16 Feb 2018 | Intestinal Microbiota
It is interesting to compare these experimental results to those described in human neonates by Lodinova-Zadnikova and coworkers (85). In their study, they colonized the digestive tract of babies just after birth with a given strain of E. coli. In these conditions E. coli is able to establish durably in the digestive tract of newborns as described previously (86). After 10 years (preterm infants) and 20 years (full-term infants), differences in occurrence of food allergies between colonized and control subjects were statistically significant 21 versus 53 , and 36 versus 51 respectively. Furthermore, recent clinical trials using ingestion of a strain of probiotic, Lactobacillus rhamnosus GG, during the last month of pregnancy to women and after birth to babies during 6 months, reduced the incidence of atopic eczema in at-risk children during the first 4 years of life (87). However, in this case, IgE levels were not decreased in the treated group as compared with the placebo group. The...
Anticoagulation During Cardiopulmonary Bypass
Mon, 28 Aug 2017 | Anti Coagulant
Protamine sulphate is a simple protein and is a strong base in characteristics, as against heparin which is acid. Therefore, it forms electrostatic complexes with the molecules of heparin and neutralises its action by inhibition of anti-thrombin III. It acts on all stages of the coagulation cascade. Protamine is extracted from a fish sperm and can show cross-immunity by giving a hypersensitivity reaction in patients who are allergic to fish protein. Protamine can also, by the same mechanism, give rise to allergic reactions in those who have a history of testicular trauma or procedures like vasectomy, in which there is a breach in the blood-sperm barrier. Patients, who are on protamine containing insulin preparations (PZI, NPH insulin), can also elicit strong reactions to protamine. Apart from minor reactions like skin rash, nausea, and lassitude it can give rise to some major reactions like hypotension, hypertension, bradycardia, and severe bronchospasm. Urticaria with severe...
Pharmacological Toxicological Effects 51 Dermatological Effects
Wed, 25 Oct 2017 | Placebo Controlled
A defect in the capability of the enzyme 8-6-desaturase to convert linoleic acid to y-linolenic acid is known to occur in patients with atopic dermatitis (9). Patients with atopic eczema have a dietary deficiency in metabolites of linoleic y-linolenic acid, dihomo-y-linolenic acid, arachi-donic acid, adrenic acid, and docosapentaenoic acid caused by a reduced rate of activity in the 8-6-desturase enzyme (8). Galli et al. compared blood samples from babies born to parents who suffered from atopic eczema. Results showed that dihomo-y-linolenic acid and arachidonic acid were consistently and significantly lower in children who later had atopic eczema (10). Some studies have shown that OEP administration can improve the percentage of body surface involvement, itch, dryness, scaling, and inflammation associated with atopic eczema. A meta-analysis (11) of nine controlled trials involving OEP in the treatment of atopic eczema showed a highly significant improvement in the symptom of itch...
Special Techniques and Considerations
Thu, 09 Nov 2017 | Lymph Nodes
Immunofluorescence immunofluorescent examinations are required for the diagnosis of chronic blistering diseases and are useful in connective tissue diseases. The site of biopsy is important for immunofluorescence, particularly in the blistering disorders. In dermatitis herpetiformis a biopsy for immunofluorescence should be taken from clinically normal skin away from the area of blistering. In the other blistering disorders, perilesional skin is submitted. The skin should have an intact epidermal dermal junction. In most of the connective tissue disorders lesional skin is submitted for immunofluorescence except for the lupus band test, where normal non-sun-exposed skin is used. Most patients having skin submitted for immunofluorescence should
Ginseng In Cosmetic Preparations
Last Updated on Sat, 29 Jun 2019 | Panax Ginseng
Ginseng saponins are structurally near chemical relatives of the antiinflammatory compounds such as steroids and glycyrrhetinic acid from liquorice (Glycyrrhiza glabra L.). It is thus not surprising that antiinflammatory properties have been reported for ginseng extracts and ginseng has been suggested as an ingredient of cosmetic creams with non-allergenic, cutaneous bioactivity for the treatment of wrinkles and eczema. The many recent patent applications involving cosmetic creams, anti-wrinkle creams, acne applications and hair growth preparations with supporting claims of efficacy suggest probable effectiveness (cf Chapter 9). Curri et al. (1986) had reported that ginseng extract applied topically as a phospholipid liposomal formulation produced a favourable effect on skin ageing, moisturisation of the stratum corneum and improved skin elasticity. Saponins of ginseng, the ginsenosides Rb1, Rb2, Rc, Re and Rg 1, as well as 70 per cent methanolic extract of P. ginseng, increased the...
Developmental Immunodeficiency Disorders
Sun, 05 May 2019 | Immune System
Wiskott-Aldrich syndrome is a sex-linked (male) disorder occurring mainly in children. The syndrome has three main features thrombocytopenia (manifested by bleeding), eczema, and recurrent infections. An increased incidence of lymphoreticular malignancies or lymphomas may occur.
Allergic rhinosinusitis
Mon, 08 Jul 2019 | Hearing Loss
Allergic rhinosinusitis is a diagnosis made clinically, as there are no definitive objective tests available for routine clinical use to confirm this entity. There are two major forms of this disorder seasonal and perennial. Thus, it is a diagnosis based on history (often by questionnaire) and physical examination. In some epidemiological studies, the presence of allergy is confirmed by results of skin prick tests or in vitro allergy testing. The prevalence of this disorder varies widely in the literature, based upon the different sources of the data (i.e., questionnaires, phone interviews, and direct examination), but the majority of the literature suggests that 20 to 25 of children and about 15 of adults suffer from this condition (1). Peak prevalence is between 10 and 30 years in most countries (2). Atopic individuals are at much increased risk for this disorder and there is a significant correlation between the report of nasal symptoms and the prevalence of allergen-specific IgE....
Altered Self Reported Health Qualitative Approach
Mon, 08 Jul 2019 | Hidradenitis Suppurativa
Many dermatologists rate HS as a heart-sink condition and would agree that it ranks among the most unpleasant of skin diseases. When looking at patients' statements about their disease they emphasize that the soreness and pain are the cause of their disability. Patients suffer from embarrassment and self-consciousness caused by the frequent occurrence of boils with malodorous discharge. One study in Denmark has shown impairment of self-reported health in HS 6 the general self-reported level of health is poorer among HS patients. The soreness, discharge, and appearance of lesions are described as problems for both work and leisure activities by 51 of all patients. In the same study, Jemec et al. 1996 found that patients with HS had lost an average of 2.7 days of work in 1 year specifically because of HS. This suggests an overall higher morbidity, as other days lost to other causes were not included in the data. The duration of 2.7 days however ranked below the average number of work...
Last Updated on Wed, 16 Mar 2016 | Beta Carotene
Dry-coated aloe vera gloves were tested by 30 women suffering from dry, cracked hands, with or without contact dermatitis due to occupational exposure, in an open contralateral comparison study (West & Zhu 2003). Women wore a glove on one hand for 8 hours daily for 30 days followed by a rest period for 30 days and then 10 more days of treatment. Results indicated that the aloe vera glove significantly Aloe vera 23
Last Updated on Mon, 15 Feb 2016 | Hearing Loss
Autoimmune disorders such as those discussed in this chapter are generally treated with immunosuppressive therapy. Corticosteroids are a mainstay of therapy in all of these disorders, but doses may vary widely, depending on the severity of disease manifestations. Among other immunosuppressives, those with more serious potential side effects are reserved for more severe disease manifestations. Often, however, the dermatologic manifestations of SLE and DM can be treated by hydroxychloroquine. This is a long-acting anti-inflammatory agent, not generally considered immunosuppressive, whose precise mechanism of action remains unclear. Hydroxychloroquine is frequently used alone or in combination with immunosuppressive therapy when skin rash is present however, it is not effective for the skin changes of scleroderma or the myositis of DM PM.
Clinical Safety
Last Updated on Tue, 24 Sep 2013 | Tumor Cells
There is extensive data regarding the overall safety of the vaccinia virus, which was generated during its use in the eradication of smallpox. The complications associated with vaccinia virus include encephalitis, vaccinia necrosum, and eczema vaccinatum. These complications are more prevalent in immunocomprimised individuals and infants (see Fig. 2) (34-36). Eczema vaccinatum originates from the infection of eczematous skin throughout the body by vaccinia. It causes a large viral load that induces viremia with fever and malaise and can sometimes progress to death. Although rare, the side effects of vaccinia virus have been the focus of multiple laboratory experiments and animal models suggest a role of inflammatory cytokines in the pathogenicity of viral infection.
Malignant Tumours
Last Updated on Thu, 11 Feb 2016 | Lymph Nodes
Paget's disease of the nipple Paget's disease of the nipple is characterised by infiltration of malignant ductal epithelial cells into the epidermis of the nipple-areolar complex. Clinically, it presents as an itchy and scaly rash which may be mistaken for eczema but gradually gives rise to ulceration, crusting and bloody nipple discharge in advanced cases. Of breast cancers, 1-2 have associated Paget's disease. In patients presenting with features of Paget's disease without a clinically palpable mass, high nuclear grade DCIS is nearly always detected in the large subareolar lactiferous ducts and up to 40 will have an occult invasive tumour within the breast. An excision biopsy of the nipple is performed to confirm Paget's disease and treatment is usually by mastectomy.
Atopic dermatitis A double-blind multicentre study involving 145 patients with moderate to severe atopic dermatitis showed that n-3 fatty acids (6 g day) improved clinical symptom scores by 30 after 4 months' treatment (Soyland et al 1994). The results were confirmed by the total subjective clinical score reported by the patients. An earlier, 12-week, prospective double-blind study produced similar results with a dose of 10 g day (fish oil) improving overall severity of atopic dermatitis and reducing scaling (Bjorneboe et al 1989).
Allergiesan Overview
Allergies are by definition immunological hypersensitivity reactions to substances (allergens), usually proteins, tolerated in defined dose by normal individuals (21). Allergic reactions are manifested in allergic diseases such as asthma, eczema, and rhinoconjuncti-vitis, each defined by a group of symptoms and signs. The life-impairing effect of these diseases varies from subtle to dominant. In addition to impairing physical health there may be an impact on social and emotional health, especially in childhood (22). Allergic symptoms can significantly disturb productivity in school and work where they are among the major causes of absenteeism. The personal and social economic burden is considerable (22-24). During the second half of the twentieth century the prevalence of allergic diseases has increased in epidemic proportions. The highest prevalence is in children and teenagers. With, on average, every fourth child affected, allergic diseases represent the most common chronic...
Exanthem subitum
Last Updated on Thu, 14 Apr 2016 | Human Herpesvirus
Fig. 1 Typical skin eruption observed in patient with primary HHV-6 infection. Maculopapular skin rash is observed on the trunk and extremity. (for colour version see colour section on page 352). Fig. 1 Typical skin eruption observed in patient with primary HHV-6 infection. Maculopapular skin rash is observed on the trunk and extremity. (for colour version see colour section on page 352).
Last Updated on Tue, 13 May 2014 | Induced Thrombocytopenia
Lepirudin administration during prospective studies in patients with HIT was associated with a low incidence of allergic events, as well as during the much larger clinical trials in patients with ACS. Among the adverse events reported were eczema, rash, pruritus, hot flushes, fever, chills, urticaria, bronchospasm, cough, stridor, dyspnea, angioedema (face, tongue, larynx), and injection-site reactions. Any causal relationship of lepirudin to these adverse events is unclear.
Last Updated on Tue, 12 Apr 2016 | Beta Carotene
Considering that the gut microflora is an important factor in regulating both the intestinal and systemic immune system, probiotics are used to promote endogenous barrier mechanisms, reduce gut permeability and alleviate intestinal inflammation in patients with atopic dermatitis and food allergy (Majamaa & Isolauri 1997). A 1 -month study of 10 breastfed infants who had atopic eczema and cow's milk allergy found that L GG reduced certain faecal inflammatory markers. closely observed cohort of 329 Finnish children it was shown that the earlier an acute respiratory infection occurred, the greater the protective effect was against atopic eczema (Vanderhoof & Young 2003). The obvious solution for increasing microbial exposure without increasing the health risk is the use of prebiotics and probiotics. Supplementation with probiotics has been shown to both reduce the risk and treat the symptoms of childhood eczema (see later).
Last Updated on Wed, 24 Oct 2018 | Beta Carotene
Historical note Red clover has been used for a long time as an animal fodder as well as a human medicine. Traditionally, it is considered an alternative remedy with good cleansing properties useful in the treatment of skin diseases such as psoriasis, eczema and rashes. A strong infusion was used to ease whooping cough and other spasmodic coughs due to measles, bronchitis and laryngitis. It was recommended for 'ulcers of every kind, and deep, ragged-edged, and otherwise badly-conditioned burns. It possesses a peculiar soothing property, proves an efficient detergent, and promotes a healthful granulation'. Combined with other herbs, red clover was recommended for syphilis, scrofula, chronic rheumatism, glandular and various skin affections (Felter & Lloyd 1 983). Interestingly, red clover was not traditionally used for the treatment of menopausal symptoms.
Other Skin Tumours
Last Updated on Thu, 19 Mar 2015 | Lymph Nodes
Paget's disease of nipple presents as an eczematous area on the nipple or areola. It is associated with underlying malignancy in the breast. Leukaemia and lymphoma leukaemias and lymphomas may affect the skin in two main ways (a) as an inflammatory skin rash as a consequence of the underlying malignancy and (b) as a lymphoma leukaemia involving the skin, either as a primary skin lesion or spread to the skin as part of systemic disease. Lymphoma and leukaemia involvement of the skin may present as a skin rash, plaques or nodules of tumour. Usually, a small diagnostic biopsy is taken in such cases, either as a punch or an ellipse.
(British Thoracic Society Scottish Intercollegiate Guidelines Network, 2003). Asthma is strongly associated with atopy as demonstrated by the link with eczema and hay fever and the detection of IgE, or a positive skin prick test, to a specific allergen (Witt et al., 1986 Woolcock et al., 1987). Asthma is termed extrinsic if it is associated with atopy and intrinsic if it occurs in the absence of atopy.
Last Updated on Wed, 18 Sep 2013 | Toxicology
Cobalt (Co) is an essential element necessary for production of vitamin B12 (Barceloux, 1999). Two valence states exist Co(II) and Co(III) the former is often used in the chemical industry, whereas metallic Co is used in the metal industry to produce alloys, especially hard metals (Barceloux, 1999). Immunological reactions to Co include sensitization, which is quite unusual in the common population (< 1 ) but may occur concomitantly with sensitization to Ni in women and Cr in men. The most common hypersensitivity reaction to Co is allergic contact dermatitis, a type IV reaction (Garner, 2004), although occupational asthma with increased serum IgE antibodies to Co indicative of a type I reaction has also been reported (Shirakawa and Morimoto, 1997).
Last Updated on Thu, 26 Feb 2015 | Toxicology
Hg is a well-known inductor of allergic contact dermatitis, which was first recognized at the end of the 19th century (Boyd et al., 2000). Heavy proteinuria, usually a nephrotic syndrome, has been described during Hg exposure since the 19th century. In modern times, Kazantzis et al. (1962) described four cases of occupa-tionally mercury-exposed workers with a nephrotic syndrome among a cohort of similarly exposed individuals. Stewart et al. (1977) described proteinuria in 9 of 21 technicians occupationally exposed to mercury after spillage of corrosive sublimate and with a wide excretion rate of Hg. In these case reports, the heavy proteinuria dominated by albumin suggests a glomerular damage in contrast to the more modest, low-molecular weight proteinuria associated with the tubulotoxic effect of Hg. A number of case reports have described an IC-mediated membranous GN after occupational exposure to Hg, after use of skin-lightening creams and laxatives containing Hg, as well as other...
Scope of chapter
Last Updated on Tue, 02 Sep 2014 | Common Diseases
I will take a selective approach dealing with the most common diseases acne, dermatitis, psoriasis and skin cancer account for over half the dermatology cases seen in primary care and around 80 of the workload of a secondary care dermatologist (Harris et al., 1990). What (little) we know of the genetics of acne, atopic dermatitis and psoriasis will be summarized briefly, and the role of genetic factors in skin cancer dealt with in more detail.
Aminoglutethimide
Last Updated on Thu, 21 Aug 2014 | Prostate Cancer
In patients refractory to first-line hormonal therapy with castration or estrogens, aminog-lutethimide with hydrocortisone produces a symptomatic and biochemical response up to 48 of the time, with responding patients often experiencing clinical improvement for some months and occasionally up to 3-4 years.159-162 Side effects include adrenal insufficiency (in the absence of corticosteroid-replacement therapy), skin rash, hypothyroidism, and less commonly thrombocy-topenia.159,163,164 Another troublesome side ef
Other potential applications of ginseng in anticancer treatment, as liver protective agents, in alcohol intoxication therapy, for morphine, cocaine and amphetamine withdrawal problems, in topical preparations for skin affections such as acne and eczema and in cosmetics still require careful clinical trials to demonstrate indisputably that standardised ginseng phytochemicals or formulations are really effective in human subjects.
Teratology
Last Updated on Tue, 11 Jun 2019 | Clinical Correlations
Treponema pallidum is a spirochete that causes syphilis. It is transmitted to the fetus transplacentally. This spirochete can cause miscarriage, perinatal death, he-patosplenomegaly, joint swelling, skin rash, anemia, jaundice, metaphyseal dystrophy, abnonnal teeth (Hutchinson teeth), and changes in cerebrospinal fluid. Antibiotics given to the affected mother usually provide adequate therapy for the fetus.
Garlic Allergy
Last Updated on Mon, 03 Sep 2018 | Placebo Controlled
Allergic reactions to garlic have also been reported in the literature. Garlic allergy can manifest as occupational asthma, contact dermatitis, urticaria, angioedema, rhinitis, and diarrhea. A 35-year-old woman experienced several episodes of urticaria and angioedema associated with ingestion of raw or cooked garlic, as well as urticaria from touching garlic. Two garlic extracts as well as fresh garlic produced a 4+ reaction on skin prick tests (SPTs) in this patient, but no other food allergens produced positive results. The patient's symptoms were immunoglobulin E (IgE)-mediated, but she also produced specific IgG, which confounded the results of IgE testing (90). A group of 12 garlic workers with respiratory symptoms associated with garlic exposure underwent SPTs using garlic powder in saline, commercial garlic extract, and various other possible allergens bronchial provocation tests with garlic powder oral challenge with garlic dust and specific IgE testing using the CAP (CAP...
Infection Viral
Mon, 20 May 2019 | Hearing Loss
Epstein-Barr virus (EBV) is the causative agent of infectious mononucleosis. EBV is a double-stranded DNA virus in the herpesvirus family. It is transmitted by direct contact or by aerosolized viral particles. The virus infects B lymphocytes, and symptom manifestation consists of the triad of fever, lymphadenopathy, and pharyngitis. A white exudate on the tonsils is characteristic of EBV infection, and a skin rash may occur in patients treated with antibiotics, especially amoxicillin. Other symptoms include hepatosplenomegaly, hepatomegaly, encephalitis, pericarditis, and autoimmune hemolytic anemia. In rare cases, patients may present to an otolaryngologist with airway obstruction or cranial nerve palsies.
Mon, 08 Jul 2019 | Beta Carotene
A RCT of scalp massage using thyme, rosemary, lavender and cedarwood essential oils in 86 patients with alopecia areata found a significant improvement in hair growth after 7 months (Hay et al 1998). Although the efficacy of lavender as a stand-alone treatment was not clarified with this trial, it is known that the herb has some antibacterial and antifungal activity that may play a role. In a single case study, topical application of lavender, together with other essential oils, was reported to assist in treating scalp eczema (De Valois 2004).
14 Days Eczema Cure
Curing Eczema Naturally
Do You Suffer From the Itching, Redness and Scaling of Chronic Eczema? If so you are not ALONE! It strikes men and women young and old! It is not just
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2019 State of the System
Hamilton County Schools » Newsroom » 2019 State of the System
State of the System sets a direction of promise
Dr. Bryan Johnson, superintendent of Hamilton County Schools, presented the State of the System address to the community on Thursday at Chattanooga School for the Arts and Sciences. An excellent crowd of parents, students, community leaders, teachers, administrators, and staff gathered to hear about successes, challenges and the promise of the future for Hamilton County Schools. “We want to talk tonight about promise. The promise that exists within our school system,” Johnson said. “We want kids to reach their highest and fullest potential.”
Hamilton County Mayor Jim Coppinger introduced Dr. Johnson to the gathered crowd calling him the “right man at the right time” for the future of the schools in the community. Christy Gillenwater, president, and CEO of the Chattanooga Area Chamber of Commerce, also shared the stage in the presentation expressing her support for Dr. Johnson and the work taking place in the school system. She also encouraged the community to get involved in the future of our schools. “I think it is also a responsibility for all of us to be a part of this process,” Gillenwater said.
The presentation by Dr. Johnson outlined successes with examples of individual stories of student and staff success. The district has celebrated 17 state Reward Schools, 25 state Level 5 growth schools, 17 digital fabrication labs that makes Hamilton County Schools a national leader, ten merit finalists, and 53 National Board Certified teachers. Johnson noted that more than 40 school choice options including 27 Future Ready Institutes in the fall and 15 unique magnet schools were available in the system and the district had the highest graduation rate at 86.5 percent since the method for calculating the rate was adjusted in 2013. Zavier Chavez, a senior at Chattanooga High Center for Creative Arts, was recognized for his work on the Student Superintendent’s Advisory and his acceptance to Harvard for the fall. Jack Poss and Max Burke, seniors at Signal Mountain Middle/High were recognized for scoring a perfect score of 36 on the ACT. Tiffany Earvin, principal at Orchard Knob Middle, was honored for academic improvements at her school, Tammy Baxter was recognized for contributions by a parent, and Brittany Harris and Colleen Ryan were noted for their work to take education to the community on their bus they call the Passage. The superintendent also noted the improvement across the district in student growth as the district moved from the lowest state level of Level 1 across all areas of measure in 2015 to only one Level 1 in Numeracy today. All other subject areas scored a 3,4, or 5 with an overall composite of 3 from the state.
“Successes are important and must be celebrated,” stated Dr. Johnson. “However, we are not where we want to be, and there is much difficult work to be done for our children to be successful and our community to prosper.” He noted that only two in five kindergartners are deemed “ready” for school when they enter our school buildings. Only one in three third-graders are at or above grade level on the state literacy assessment. Also, only one in three 2018 graduates completed advanced coursework while in high school. Another challenge is the facilities in our school system. The average age of a school building in Hamilton County Schools is 40 years. “We do not shy away from these challenges, but boldly seek solutions,” stated Johnson. “With the continued support of Mayor Coppinger, the Hamilton County Commission, parents, and the business community, we will move forward to realize the great promise this school district possesses.”
Superintendent Johnson outlined Future Ready 2023 the five-year action plan adopted by Hamilton County Schools this year to reach the promise our system holds for the future. The five priorities of accelerating student achievement, future ready students, great teachers and leaders, an engaged community, and efficient and effective operations are the key components of the plan the superintendent discussed. He pointed out five performance targets that will help the district and community know if the plan is on track to make a difference for children. The targets include at least half of all third-grade students on track or mastered state standards, 90 percent of students graduating by 2023, double the percentage of students on track in Algebra I across all grades, 75 percent of graduates completing at least one advanced course or industry certification exam, and the district averaging 21 on the ACT by 2023.
Johnson ended with first-grade students joining him to talk about the promise of the school system and how that focus should impact the Class of 2030 upon graduation. The promise: Every graduate of Hamilton County Schools will be fully prepared to reach his or her highest potential - equipped to be academically and professionally productive, socially and civically connected, and physically and emotionally healthy. Referencing a John F. Kennedy speech played at the beginning of the presentation, Dr. Johnson said, “We choose to do these things not because they are easy. We know these advancements will be hard, but they are necessary for the success of our children and our community.” Johnson concluded,” I firmly believe that the best days of Hamilton County Schools are ahead!”
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Home/Learning and Resources/French/
Extended French
FSL programs and Students with Special Needs
List of FSL school programs
Policy: French as a Second Language (under review)
Registering for French Immersion or Extended French
Resources to support your child at home with FSL acquisition
Welcoming ELLs into FSL Programs
The Halton District School Board supports the Ontario Ministry of Education's vision and goals for French as a Second Language (FSL) programs. All programs in the French as a Second Language curriculum at the elementary and secondary levels share a common vision.
Students will communicate and interact with growing confidence in French, one of Canada's official languages, while developing the knowledge, skills, and perspectives they need to participate fully as citizens in Canada and in the world.
In all French as a Second Language programs, students realize the vision of the FSL curriculum as they strive to:
use French to communicate and interact effectively in a variety of social settings
learn about Canada, its two official languages, and other cultures
appreciate how connected and interdependent the global community is
be responsible for their own learning as they work independently and in groups
use effective language learning strategies
become lifelong language learners for personal growth and for active participation as world citizens.
Three types of French as a Second Language (FSL) programs are offered in Ontario and in the Halton District School Board:
Extended French
Framework for FSL in Ontario Schools
Online Resources to Support Your Child at Home with FSL Acquisition
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That was for the fans
Craig Levein thrilled with Derby victory in the final home game of the season.
Craig Levein was delighted to send the Hearts faithful home happy with an Edinburgh Derby win in the final home match of the season.
Goals from Kyle Lafferty and Steven Naismith helped Hearts to a deserved victory over their city rivals in the penultimate fixture of the 2017/18 campaign.
Speaking to the media after the match, the Hearts manager praised his players for going all out to win the game.
“I’ve expressed my frustration on numerous occasions this season with the way things have gone. This was our last game at home and sending our fans home was really important and I’m glad we did that tonight,” said Craig.
“I think you see tonight that there’s not an awful lot between the teams at all.
“Our players did everything they could to try and win the game. To be pegged back so soon into the second half was a real body blow and to then go and win the match after was really pleasing.”
The Jambos’ win was in no small part down to a terrific midfield performance by 17-year-old Harry Cochrane and Craig was quick to heap praise on the talented youngster.
“He was unbelievable, honestly. I don’t think he gave the ball away all evening. His touch on a slick pitch was sublime. It’s only really good players who can perform like that on a pitch like that.
“I thought he was the best player in midfield. John McGinn is a fantastic player and rightly gets loads of plaudits but I thought Harry was better than him tonight.
“I’m really excited about seeing how he develops because I’m sure he’ll be an international in the future.
“He doesn’t shirk any tackles. The best players have got that in them. It was a hot and intimidating atmosphere tonight and he was the coolest head on the pitch.”
Finally, Craig was asked about comments made by Neil Lennon after the previous derby in which the Hibs manager claimed Hearts were of no relevance to Hibs.
“Relevant? We put them out the Scottish Cup and stopped them from finishing second in the league. That’s pretty relevant to me,” said Craig.
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Heather Parry
Television and Film Producer
Heather Parry is the President of Production, Film & Television for Live Nation Productions, which is Live Nation’s film and television division. Since launching the division in 2016, she has led the production of four groundbreaking musically-driven documentaries: Eagles of Death Metal: Nos Amis (Our Friends), which debuted on HBO and was nominated for two Critics’ Choice Documentary Awards, including Best Documentary, Can’t Stop Won’t Stop: A Bad Boy Story, which premiered at the 2017 Tribeca Film Festival before becoming exclusively available on Apple where it hit No. 1 on the iTunes Documentary charts across the Globe and took home the Hollywood Documentary Award at the 2017 Hollywood Film Awards, Gaga: Five Foot Two, which premiered at the 2017 Toronto International Film Festival before becoming available on Netflix in over 190 countries and won Best Music Documentary at the 2018 MTV Movie and TV Awards and Best Music Film at the 2018 NME Awards and Believer, which was released by HBO in June 2018 and was also an Official 2018 Sundance Film Festival selection, where it won runner-up for the Festival Favorite Award out of 123 films screened. Upcoming releases include two scripted projects: A Star is Born, which will be released by Warner Bros and marks four time Oscar nominee Bradley Cooper’s directorial debut, in which he co-stars with the multiple award-winning, Oscar-nominated music superstar Lady Gaga in her first studio starring role and Netflix’s The After Party, starring Wiz Khalifa, French Montana, Kyle Harvey (better known as the artist Kyle) and Teyana Taylor.
Prior to Live Nation, Parry served as the Head of Film Production for over a decade at Adam Sandler’s Happy Madison Productions, overseeing box office hits such as The House Bunny, Just Go With It and Pixels. In addition, Parry was West Coast News Bureau Chief at MTV News and became a producer for MTV Films where she worked with some of the most sought-after artists during her 12-year span.
Parry is a member of the Producers Guild of America, Academy of Television Arts & Sciences, and the Recording Academy.
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Franz Xaver Mozart
Rondo in e minor for Flute and Piano
Karsten Nottelmann (Editor)
Rolf Koenen (Fingering)
Pages 18 (IV+11+3), Size 23,5 x 31,0 cm
HN 1180 · ISMN 979-0-2018-1180-2
Franz Xaver Wolfgang Mozart did not have an easy time of it – throughout his life his compositions were always compared to those of his father. It is only recently that he has slowly begun to come into his own. His works have their very own individual sound that already forges a link with Romanticism. The specialist Karsten Nottelmann has edited Urtext editions of all of Franz Xaver’s piano works for Henle publishers (HN 958, 959), and now he is continuing with the Rondo for Flute and Piano. Flautists greatly value this melodious work that is very suitable for teaching purposes and music at home.
Rondo e minor
Flute 5 medium
»Mozart Rondo in e minor for Flute and Piano«
Franz Xaver Wolfgang Mozart (1791– 1844) was already treading in his famous father’s footsteps from an early age: educated by renowned teachers, he made his debut as a composer and pianist in 1805. In 1808, the musician, who presented himself throughout his life as “W. A. Mozart Son”, left Vienna – his home city – in the direction of Galicia, which since 1772 had … more
Austrian composer and pianist. In addition to his compositions for piano (including concerti, sonatas, polonaises) he wrote song cycles, chamber music, and other things. His transcriptions of works by his father are important in the reception history of Wolfgang Amadeus Mozart.
1791 Born in Vienna on July 26, the youngest son of Wolfgang Amadeus Mozart. His mother Constanze set him on an early path toward a career in music. In Prague he receives his first piano lessons from Franz Xaver Niemetschek, and in Vienna he is taught by Johann Nepomuk Hummel, Antonio Salieri, and Johann Georg Albrechtsberger, among others.
1802 His Piano Quartet in G minor, op. 1, is published.
1808–10 In Pidkamin, Galicia, near Lemberg (Lviv), he is appointed personal music teacher to the children of Count Baworowski.
from 1813 Works as a freelance composer and teacher.
1818 Genesis and publication of his Piano Concerto in E-flat major, op. 25.
1819–22 An extended artistic tour takes him through the metropolises of Europe, including Prague, Copenhagen, Warsaw, Berlin, Venice, and Salzburg.
1826 He founds the St Cecilia Choir of Lviv.
1838 Back in Vienna he gives concerts and teaches. Ernst Pauer is among his pupils.
1841 He is named honorary music director of the Salzburg Cathedral Music Society, and of the Mozarteum. His inaugural winter concert that year popularizes Chopin’s works in Vienna.
1842 He performs in Salzburg as part of ceremonies to consecrate the monument honoring his father.
1844 Dies in Carlsbad (Karlovy Vary) on July 29.
As a pupil, Prof. Rolf Koenen, born in 1946 in Duisburg, had already had contact with Ewald Zimmermann, the first editor at the young publishing house. He studied the piano at the Folkwangschule in Essen with Detlef Kraus, with Ludwig Hoffmann in Munich and with Maria Tipo in Florence.
He gave concerts in a permanent duo partnership with Hansjörg Schellenberger, who was later to become the solo oboe player with the Berlin Philharmonic, and made several recordings with the Deutsche Grammophon-Gesellschaft, with Denon and Sony. Other chamber music partners included András Adorján, Stefan Dohr, Wolfgang Schulz, Claes H. Ahnsjö. Following a teaching position in Munich, Rolf Koenen was appointed as a professor at the Berlin University of the Arts in 1982.
This beautifully presented edition maintains Henle's reputation for scholarly editing, with clear and interesting notes referring to the manuscript sources. As one of a relatively small number of flute works from the early 19th century, this piece deserves to be taken seriously as a part of the repertoire, and this edition may play some part in its becoming better known. [The Flutist Quaterly, 2014]
Die Urtextausgabe des Henle Verlages editiert den Sonatensatz gewohnt qualitativ hochwertig, was die äußeren aber auch die inhaltlichen Faktoren wie Vorwort, Satz sowie Kritischer Bericht im Anhang betrifft. [Flöte aktuell, 2013]
Andante C major K. 315 for Flute and Orchestra
Michel Blavet
Concerto C major K. 299 (297c) for Flute, Harp and Orchestra
Fantaisie op. 79 and Morceau de lecture for Flute and Piano
Flautino Concerto (Recorder/Flute) C major op. 44 no. 11 RV 443
Flute Concerto d minor
Flute Concerto no. 1 G major K. 313
Flute Concerto no. 2 D major K. 314
Flute Sonatas Volume II, "Halle Sonatas"
Flute Sonatas, Volume I (The four authentic Sonatas)
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Car Rental Birmingham
Hertz in Birmingham
Known as ‘Brum’ by the locals, Birmingham makes hiring a car essential due to its sprawling size, and there are enough attractions in the outlying areas to make driving a desirable and pleasant experience. Car rental in Birmingham is one of the best ways to get around and explore the city and the wider region and its made simply by Hertz having several branches in and around the city.
Birmingham is Britain’s second largest city after the capital and it has more than its fair share of attractions with the Bullring Shopping Centre, Symphony Hall and the National Sea Life Centre easy to access by road. It’s also well connected to the rest of the UK, sitting at the very heart of England’s motorway network and making it as easy to travel to cities in all directions such as London, Liverpool, Cardiff and Edinburgh.
Driving and Parking in Birmingham
You will need a full driving licence and must be over 25 to rent a car in Birmingham, or over 23 with a young driver surcharge. If you are from outside the European Union you will also need an International Driving Permit (IDP). For more information about driving regulations in Birmingham, take a look at our page about renting a car in the United Kingdom.
Driving in the centre of Birmingham is easy, if a bit slow. The one-way system makes the city easy to navigate, but the sheer size means congestion is a regular occurrence, particularly at rush hour times. The heart of the city is pedestrianised, so bear in mind you will need to find nearby parking to visit anywhere in this area.
Parking is plentiful though, with many private options such as the car park at the Bullring Shopping Centre. There are also lots of council-run car parks and on-street parking spaces to choose from. You can either pay for your parking with cash at the meter, or use the council’s online system that allows you to pay using a mobile app.
Pickup Locations Birmingham
Address: 40 Upper Gough Street
Birmingham New Street Railway Station
Birmingham International Railway Station
Opening hours: Mo-Su 0630-2400
Address: Airport Way,
Elmdon
Birmingham International Airport
Address: Airport Way
Birmingham- Watson Road COSTCO
Address: 100 Watson Road, , Nechells
Birmingham- Wednesbury B&Q
Address: Axletree Way, , West Midlands
Birmingham- Wednesbury IKEA
Address: Park Lane, , West Midlands
Birmingham- Wednesbury Storagebase
Address: Axeltree Way
Driving in and around Birmingham
Key Routes
If you rent a car in Birmingham, the main route you will need to get to know is the A540 Birmingham ring road. This circles the outskirts of the city centre, allowing you to bypass a lot of the city traffic and get to most of the key neighbourhoods. It also connects, via a series of A-roads, to the motorway network.
The A38, the A56 and A4400, on the other hand, join together and cut through the heart of the city centre, allowing you to get from one side of the city to the other, while still connecting to the wider city. From here you will get a chance to see much of Birmingham’s architecture, which is a contrasting mix of old and new.
Birmingham is one of the best connected cities in the UK thanks to its central location. It immediately connects to the M6, the M5, the M40 and the M42, which in turn connect to the wider network, giving accessibility to pretty much anywhere in England, Wales and Scotland.
When driving on UK motorways, remember that British drivers drive on the left and pass on the right. So, on a three-lane stretch of motorway, slower vehicles use the left lane to allow faster vehicles to pass in the middle and right lanes. When approaching entrance slip roads, you move over to the middle to allow traffic joining the motorway to get on, and move over to the left lane in plenty of time for your exit, which will be well signposted.
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Home News Breaking News Starwood Hotels Ends 2014 with 74 New Hotels, Continued Growth in 2015
Starwood Hotels Ends 2014 with 74 New Hotels, Continued Growth in 2015
STAMFORD, Conn. — Starwood Hotels & Resorts Worldwide, Inc. is celebrating a year of growth with news it opened 74 new hotels in 2014, representing approximately 15,000 rooms in 26 countries; it’s also recorded a 15-per-cent increase in new hotel management and franchise agreements.
“With more than 1,200 hotels in 100 countries, we’re on the frontlines of global change and continue to see increasing demand for innovative, design-led brands, playing to Starwood’s strength,” said Frits van Paasschen, president, CEO of the Stamford, Conn.-based Starwood Hotels & Resorts Worldwide, Inc. “Our nine lifestyle brands continue to attract owners as does our loyalty program, Starwood Preferred Guest, which brings high-value guests to our hotels from around the world, driving more than half of our occupancy on any given night.”
In 2015, Starwoods will celebrate its 300th hotel in Asia-Pacific and China; its 90th hotel in Africa and the Middle East; its 175th luxury hotel; its 75th upper-upscale hotel; and its 300th mid-market hotel worldwide.
Starwood’s Specialty Select Brands account for 35 of the new openings, and its Aloft, Element and Four Points by Sheraton brands account for almost half of the company’s overall new hotel openings in 2015.
Frits van Paasschen
Starwood Hotels & Resorts Worldwide
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Canadian Hotel Occupancy Down 0.1 Per Cent
Thomas Mangas Named EVP, CFO at Starwood
kostuch - August 27, 2014
STAMFORD, Conn. — Thomas Mangas has been appointed EVP, CFO for Starwood Hotels & Resorts, effective Sept. 29. Mangas most recently served as EVP and...
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History of Rap Music
Learn about the history of rap music from hip-hop performer Chris Kazi Rolle in this Howcast video.
Alright. So, everybody wants to be a rapper nowadays. But one thing that a lot of people don't know is how the rapper became the most popular part of the hip hop culture. In the early days of hip hop culture, the focus was the DJ. And, to introduce the DJ, the MC was the sidekick, or the rapper. But, in the early days, they just called him an MC, master of ceremony. And so they would come out and hype the crowd up to prepare for the man or woman of the hour. So, when the MC would come out, the goal would be to get the crowd engaged, so the MC found creative ways to put the words together that would prepare the crowd for the DJ.
Through that evolution, MCs started to battle each other in the way that they would introduce the DJ. And to a point that the portion of time that the MC had on stage began to get larger and larger until now they were doing long verses, or long sets. And producers began to try to figure out, "How do I get this experience, this jam, this party on a record?"
And you just couldn't capture the whole record, so they focused on the time that the MC was on there, because there was a communication that was happening. So, in the early 70's, a group by the name of The Sugar Hill Gang, a group of MCs, made a record called "Rapper's Delight". And "Rapper's Delight" was one of the first times the commerce was introduced in hip hop. And that is how the rapper began to be the focal point of hip hop.
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Home> Publications & Directories> Perspectives on History> Issues> October 2017> AHA Today> AHA Member Spotlight: Frank (Francis) Daniel McCann
AHA Today
AHA Member Spotlight: Frank (Francis) Daniel McCann
Matthew Keough | Oct 17, 2017
Frank (Francis) Daniel McCann is a professor of history emeritus at the University of New Hampshire. He lives in Durham, New Hampshire, and has been a member, off and on, since 1960 or 1961.
Frank Daniel McCann is a professor of history emeritus at the University of New Hampshire.
Alma maters: AB (cum laude), Niagara University, 1960; MA, Kent State University, 1962; PhD, Indiana University, 1967
Fields of interest: Latin America, Brazil (foreign relations, military, culture), Mexico (revolution), Catholic Church, Native American (esp. Iroquois and Pueblos)
Describe your career path. What led you to where you are today? As a senior ROTC cadet I taught a section of American military history which confirmed my desire for graduate studies. Initially I was interested in Panama, then Mexico, and finally Brazil. Much of my research focused on the 20th century, especially the era of Getúlio Vargas. Army service led me to the Brazilian military and a desire to understand the military regime of 1964–85. As a teacher of history I started at the University of Wisconsin-River Falls, then I was called to active duty at the United States Military Academy at West Point, followed by a postdoctoral fellowship at Princeton working on the Wilson Papers, thence to the University of New Hampshire. Over the decades I taught at four Brazilian universities, at New York University, and at the University of New Mexico as a visiting professor. I had the good luck of four Fulbrights for work in Brazil as well as some other fellowships.
What do you like the most about where you live and work? The New Hampshire department is quite collegial and supportive. New Hampshire has often been a bit odd politically and lukewarm about public higher education, but it has beautiful geography and is about six hours to New York to the south and Montreal to the north.
What projects are you currently working on? I recently completed a study of the Brazilian armed forces and articles about Brazilian-American relations and military support for dictatorship in 1937. Each of these has been published in Brazil. I am nearing completion of a book entitled Negotiating Alliance: The United States and Brazil which Palgrave Macmillan is publishing.
Have your interests evolved since graduation? If so, how? In graduate school at Indiana one of my fields was in western US with emphasis on native peoples. Clearly I got deflected elsewhere. At one point UNH needed to have a course on native people and I was the only one with any background. So for 30 years I gave a course entitled Native Peoples of the Americas. This provided an excuse to visit reservations all over the US and archeological sites from Mexico and Brazil to Peru and Chile. My research on the Brazilian army led to visits to military posts all over Brazil, most notably units on its borders in Amazonia.
What’s the most fascinating thing you’ve ever found at the archives or while doing research? I have found many interesting things, but probably the single most interesting document was one by the Brazilian foreign minister as preparation for President Vargas to meet FDR at Natal in January 1943 that set out Brazil’s aims in World War II. Those aims became an outline of Brazil’s foreign policy objectives for the next decades.
Is there an article, book, movie, blog etc. that you could recommend to fellow AHA members?
Louis S. Warren, God’s Red Son: The Ghost Dance Religion and the Making of Modern America (New York: Basic Books, 2017).
Durval Lourenço Pereira, Operação Brazil: O ataque alemão que mudou o curso da Segunda Guerra Mundial (São Paulo: Editora Contexto, 2015).
The new film Dunkirk (2017) for war from the perspective of servicemen.
What do you value most about the history discipline? At base it is the study of everything and its only limits are our imaginations. It has given me opportunities to see a lot of the world.
Why is membership in the AHA important to you? Membership is a constant reminder not to get completely buried in our own specialties.
AHA members are involved in all fields of history, with wide-ranging specializations, interests, and areas of employment. To recognize our talented and eclectic membership, AHA Today features a regular AHA Member Spotlight series.
This post first appeared on AHA Today.
Tags: AHA Today Member Spotlight
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CW Journal : Autumn 00 : Richman, Poorman, Beggarman, Thief
Richman, Poorman, Beggarman, Thief:
Down but Not Out in Colonial Virginia
by Martha W. McCartney
Seventeenth-century writers often described Virginia as a land of boundless opportunity, but for many colonists, life was hard. For the sick, the disabled, or people simply down on their luck, it was doubly tough. In the early years, the mortality rate was high, and hapless immigrants succumbed to disease, starvation, or violent death.
A Virginia vagabond, portrayed by interpreter Willie Balderson, accepts a cup of kindness from Tenant House residents James and lucy Atherton, interpreted by John J. Templin and Valli Anne Trusler.
--Dave Doody
Virginia's first colonists often opened their homes to the less fortunate, and conditions in the early colony forestalled some of the usual hardships of life. For example, few people reached old age. Because women were in short supply, widows rarely stayed long single. Orphans were valued for their labor and any property they inherited.
Sometimes the orphans were exploited; churchwarden Richard Kingsmill of Jamestown, guardian of the Reverend Richard Buck's retarded son, Benomi, was accused of enriching himself at his young ward's expense. An opportunistic clergyman from the lower side of the James River reportedly had designs upon Benomi's twelve-year-old sister, or at least upon her inheritance. One orphan, mistreated by his guardian, deprived of food, and clad in rags, ran away repeatedly. Neighbors finally intervened on the boy's behalf.
Forced by empty bellies to take food where they found it, vagabonds sometimes turned rogues and chicken thiefs, as demonstrated by interpreter Balderson. Virginia's legislature allowed counties to bind out such people as appretices.
In any case, the churchgoing colonists knew that "the poor shall never cease out of the land," and that charity required the authorities to ease the burdens of those less fortunate. By 1643, Virginia's assembly decided to grant tax relief to longtime residents unable to work "by reason of sicknes, lamenes or age," if local church officials agreed. Even the poor, however, had to pay parish levies.
In 1646 Virginia's burgesses, like their counterparts in England, decided poor children should be bound out in trades so that they could be educated. This could be done with or without the parents' consent. The burgesses authorized each of Virginia's county courts to send two poor or orphaned children to Jamestown to live and work in houses built for the manufacture of cloth. There, the youngsters, who had to be at least seven or eight years old, were to be taught to make cloth of flax. Child labor was commonplace; in England, philosopher John Locke recommended putting poor three year olds to work to encourage them to mature into productive members of society. Many agreed.
In 1662 parish vestries were assigned the task of providing for the indigent in general. In accord with English tradition, those too old or too sick to work were taken into the homes of friends or family, who were compensated from parish levies. A look at vestry books suggests most people on the dole wre disabled.
Vestries usually saw to it that the able-bodied poor were bound out as servants or apprentices. People of African descent increasingly were relegated to what amounted to de facto slavery. The enslaved, like indentured servants who became ill or infirm, were their master's responsibility and weren't supposed to be turned out to fend for themselves. Some undoubtedly were.
By 1668 an alarming number of people were in need of public assistance. Virginia's burgesses, perhaps drawing upon the rationale of English economists, empowered but did not require, county justices and parish vestries to build workhouses in which poor or orphaned youngsters could be schooled in useful trades "for the encrease of artificers." As far as we know, however, church officials continued to provide for the poor by farming them out to parishioners. It was a humane but financially burdensome solution to the problem.
As time passed and indentures expired, so the number of landless freemen grew, folks with little capital and no credit. A steadily expanding labor market absorbed some, and others became tenants or sharecroppers, swapping their labor for a place to live. The daring ventured into the wilderness, established small homesteads, and eked out an existence despite the dangers of the frontier.
But many landless people, mostly young males, simply wandered about the colony. Such vagabonds eluded the tax collector, depriving the colony of revenue; some were deranged or had criminal inclinations. Many were beyond the reach of the law. As the seventeenth century drew to a close, three Tidewater counties asked the House of Burgesses to enact legislation that would "punish Vagrant, Vagabond, and Idle Persons."
The population increased, economic conditions fluctuated, and the problems of caring for the poor became more vexing. In 1723 the Assembly authorized churchwardens to send vagrants back to their home parishes, where they could be bound out and made self-supporting. If a vagabond were "of such ill repute that no one will receive him or her into Service," then "thirty-nine lashes well laid on" could be administered for each offense of vagrancy.
In 1727 the colony's poor laws were updated. Vagabonds, or rogues, and orphaned or neglected children could be bound out as apprentices. Sick or disabled sailors, jettisoned by their ships' masters, became the legal responsibility of those who abandoned them. Lewd women who gave birth to bastard children had to pay a hefty fine or suffer a public whipping.
In May 1755, the Reverend Thomas Dawson of Bruton Parish and his churchwardens sought the House of Burgesses' permission to convert a dwelling on a parcel of parish-owned land near Capitol Landing into "a Workhouse, where the Poor might be more cheaply maintained and usefully employed." They said that "providing for the Poor of the said Parish hath always been burdensome," and that in "late Years hath much increased." The minister and his wardens attributed the "great Number of Idle persons" that "Lurk about the Town" to an influx of poor during Public Times: the courts met, and people poured in from the countryside. They said the needy often lingered afterward to become wards of Bruton Parish. Bruton's vestry not only wanted a workhouse, it asked for the right "to compel the Poor of their Parish to dwell and work in the said House" under whatever restrictions the House might impose.
Bruton Parish Church took initial responsibility for Williamsburg's poor.
The burgesses acknowledged that "the number of poor people hath of late years much increased throughout the colony" and authorized all Virginia parishes to build, purchase, or rent houses for the lodging, maintenance, and employment of the poor. They agreed that the establishment of workhouses was a suitable means of providing for such people and would prevent "great mischiefs arising from such numbers of the unemployed poor."
Neighboring but sparsely populated parishes were allowed to operate workhouses jointly, although no more than one hundred acres of land could be used as a poor farm. The children who resided in almshouses-what we would call poorhouses-were to be educated until they were old enough to be apprenticed. Adult inmates could be hired out as laborers, and churchwardens could apply their earnings toward their keep. Vestries could purchase raw materials, tools, and implements that could be used to produce marketable goods or items for poorhouse inmates' consumption. County sheriffs were responsible for rounding up beggars and transporting them to the nearest parish poorhouse, where they could be put to work for up to twenty days.
Not every county built an almshouse, but each that was raised was entrusted to the care of one or more overseers, usually a man selected by the vestry. He was supposed to assign the needy to tasks best suited to their abilities and to make the rules governing their conduct. He was allowed to inflict corporal punishment upon those who were disobedient or dissident, or who simply refused to work, and there were ample opportunities for the abuse of power. Anyone unwilling to live at the parish almshouse was deemed ineligible for other forms of public assistance unless adjudged too old or too sick to work. Thus, an almshouse was a place of last resort for vagrants and others who offended society's sensibilities.
The capital's almshouse stood in the area above, somewhat north of the city near Queen's Creek.
The 1755 act for maintaining the poor marked the colony's indigent with a social stigma, too, for all almshouse inmates were directed to wear a blue, green, or red cloth badge that identified them as wards of the parish. These badges, imprinted with the name of the parish to which the pauper belonged, were to be worn upon the right sleeve, near the shoulder, "in an open and visible manner." Anyone who neglected or refused to wear the badge could be whipped-up to five lashes-and lose his food allowance. Conversely, an imposter found wearing a poorhouse badge-for instance, a runaway servant or slave, or someone fleeing the authorities-could be punished. The act also required the vestry to keep a register of the poor, but none seems to exist, raising questions about how closely the act was followed.
Requiring paupers to wear badges was nothing new. A 1697 English law required all recipients of poor relief to display a red or blue cloth "P" upon their right shoulder. This method of social shaming, also used in eighteenth-century Maryland, separated the poor from the mainstream of society, which found them "nasty," "despicable," and "nauseous to the Beholder."
Because Bruton Parish's vestry records are fragmentary, we are left to ponder what it would have been like to live in its poorhouse. Were the men, women, and children housed there adequately fed and clothed? What were their accommodations like? Was the overseer humane, or someone with a cruel streak? Were the helpless victimized? If we had visited Williamsburg during the 1760s, 1770s, and 1780s, would we have seen people on the streets wearing badges signifying that they were inmates of the Bruton Parish poorhouse?
Records from other parishes in colonial Virginia show that some poorhouses were, in fact, workhouses. Others were almshouses that merely provided food and shelter. One parish's officials hired a teacher to instruct very young residents. The inmates of some poorhouses were obliged to manufacture cloth; others raised food crops. At least one parish vestry leased church-owned land and slaves to tenants, using that income to provide care to the poor in private homes.
Vestry records show that throughout Virginia, orphaned children and the elderly usually received custodial care from people who befriended them and that parish poorhouses mainly were for those who, as Thomas Jefferson said, "had no possessions, jobs, or friends." It is probable that many of the destitute were sick, malnourished, or otherwise infirm when they arrived at the parish poorhouse.
The Public Hospital in Williamsburg, which opened in 1773, siphoned off the seriously disturbed who posed a danger to society. Alcoholics, however, and people with chronic mental disorders who were considered harmless, were excluded.
Revolutionary War-era maps show that the Bruton Parish poorhouse, a complex of four or five buildings, was near Capitol Landing, on a hilltop overlooking Queens Creek. It stood upon a tract that Jonathan Druitt bequeathed to "the poor of the parish" in 1717, stipulating that his gift be used for the maintenance of a free school.
Bruton Parish's poorhouse apparently was a losing proposition, financially. In 1762 the vestry received the House of Burgesses' permission to sell three Williamsburg lots to "lay out the money for the benefit of the poor." It was authorized to use all income derived from the Druitt land for chariy. Three years later, the vestry won approval to sell some additional parish-owned real estate.
This satirical eighteenth-century print suggests some of the hazards of living on London's streets. Note the apparently homeless waifs sheltering beneath the barber and dentist office window.
--Colonial Williamsburg
By 1769 Bruton Parish's vestry had decided to allow a joint stock company to use the Druitt property for what was called the Williamsburg Manufactory: a facility for cotton and linen cloth production. Some of project's investors, prominent local citizens, also served on the board of directors for the Public Hospital. Governor Norborne Berkeley, Lord Botetourt, subscribed £100 sterling toward construction of "the workhouse," raising the possibility that whatever buildings were on the Druitt property were being converted to another use.
In 1776, officials of the Williamsburg Manufacturing Society advertised for apprentices in order to make "some provision for the better maintenance of poor Children." A year later the society sought young people of African descent. John Crawford, Williamsburg Manufactory manager, announced that a hemp mill was being built and that the society would pay a fair price for cotton, wool, flax, and hemp. People also could have their own raw materials processed at the manufactory in exchange for a share of the finished product. Weavers and spinners were in demand, and those interested in working in their own homes would be furnished with flax. In 1777 a quantity of solid and striped linen, produced at the Williamsburg Manufactory, was auctioned before the Raleigh Tavern.
The poor were sometimes confined to madhouses like Williamsburg's Public Hospital. This 1763 Hogarth engraving satirized conditions in a similar institution, London's Bedlam.
Builder Humphrey Harwood undertook structural improvements at "the Factory," where he built a foundation for a cutting-machine and erected a pillar "in the mill room." In 1780, John Blair, Williamsburg Manufacturing Society chairman, announced that the group intended to disband. Four years later, however, society members were still talking about it.
By the late 1780s all references to "the Factory" and the poorhouse cease. Since both establishments were in use concurrently, it is probable that the cloth factory provided employment to the needy until its doors closed.
In 1978 when state archaeologists visited the site of the Bruton Parish poorhouse, which is owned by the Colonial Williamsburg Foundation, they found the remains of a brick foundation, evidence of other buildings, and a millstone. Later, the Bruton Parish Poorhouse Site was listed on the National Register of Historic Places. In 1986, the Colonial Williamsburg Foundation's department of archaeological research, under the direction of Marley R. Brown III, conducted a preliminary archaeological survey of the tract so that subsurface cultural features could be identified and preserved. The millstone, once used at the Williamsburg Manufactory for grinding hemp, was moved to the Historic Area for display.
Dave Doody
Inmates of Williamsburg's workhouse worked hemp for their keep, a process depicted at left in Diderot's encyclopedia. At right, interpreter SuCarter examines the workhouse hempstone.
The close of the American Revolution brought disestablishment of Virginia's state church, effectively ending the Anglican Church's role in public welfare. In 1780 the General Assembly created county overseers of the poor, who were authorized to see that orphans and the children of the poor were trained. Poor farms also were established to provide institutional care.
The parish poorhouse or workhouse, as a social experiment, was a failure. As an economic endeavor, it fared worse. Although poorhouses purportedly were intended "for the reformation of vagrants," where the needy could be made self-supporting, they became places where those rejected by society could be secluded. For the destitute who had no other recourse, the poorhouse may have offered a modicum of comfort. But it is likely that the poor, if given a choice, would have preferred to live almost anywhere else.
Martha W. McCartney, who wrote "Jean-Nicolas Desandrouins and His Overlooked Map of 18th-Century Williamsburg" for the December 1999/January 2000 journal, acknowledges the information contributed to this article by Andrew Edwards of Colonial Williamsburg's department of archaeological research.
About the Magazines
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John Alessi
Emily Dinsmore
Elizabeth Holden
Richard Kaiser
Michael Logan
Michael Maxwell
Paul Meosky
Michael Risman
A. Joseph Scott, III
Daniel Spitzer
Richard Weisz
Sujata Yalamanchili
New York Eliminates Religious Exemptions to Immunization Mandates for Students
Education Alert
On the evening of June 13, 2019, Governor Andrew Cuomo signed into law legislation that removed a parent’s legal right to obtain a religious exemption from immunization requirements for their children. In large part, this action is attributed to the recent measles outbreak in the State – the worst in more than 25 years – a disease that the Center for Disease Control (CDC) had declared eliminated in the United States in 2000. Indeed, the Department of Health recently shuttered a number of schools in New York City and Rockland County for failure to provide proof of immunity for students at school and/or allowed unvaccinated children and staff on site in violation of the New York State Public Health Law. In Upstate New York, we have seen a rise in pertussis cases (whooping cough) and even reported cases of measles.
The Public Health Law and its corresponding regulations require every student entering or attending public, private or parochial school in the State to be immune to certain communicable diseases; namely, diphtheria, tetanus, pertussis, measles, mumps, rubella, poliomyelitis, hepatitis B, varicella, Haemophilus influenza type B (Hib), meningococcal disease, and pneumococcal disease. Public Health Law Section 2164 previously permitted parents to request an exemption from immunization requirements for students based on either sincerely held religious beliefs or whether such immunization may be detrimental to a child’s health (medical exemption).
Religious exemption requests required school administrators to perform the Herculean task of assessing the credibility and sincerity of a parent’s request, whether the parent’s purported beliefs were religious and if so, whether they were genuinely and sincerely held. This often resulted in communications and meetings with parents to ask questions or request other supporting documentation. At times, parents took issue with this process and would engage in adversarial interactions. If the school administrator found that the parent’s beliefs were not genuine and sincerely held and/or that the parent’s beliefs were founded upon medical or purely moral considerations, scientific or secular theories, or philosophical and personal beliefs, such exemption request would be denied. At times, these denials would result in litigation causing schools to expend more time and financial resources on this issue. Thus, the elimination of religious exemptions assists schools in protecting their students, staff and community against dangerous communicable diseases and also relieves them of this administrative burden.
This new law does not change the previously existing exemption granted to students who cannot receive vaccines for medical reasons. We suspect that this new law may prompt students and their families who previously enjoyed the religious exemption to now request an exemption based upon medical reasons. We note, however, that it is imperative for school districts to critically examine such medical exemption requests. For example, a parent or physician stating that a child “does not react well” to an immunization would not be sufficient. In order to receive a medical exemption, parents must provide schools with acceptable medical evidence from a State licensed physician which certifies the (1) vaccines the medical exemption is referring to; (2) complete contraindication information (i.e. how the vaccine is detrimental to the student’s health); (3) date on which the exemption ends; and (4) complete medical provider information.
Since this new law takes effect immediately, schools must promptly review their records to determine which students currently receive a religious exemption, including nonpublic school students and those students who receive your transportation services. After this process is complete, schools must advise those parents that the religious exemption is no longer valid. The new law does not change the 14-day “grace period” for a limited period of attendance granted to parents of unvaccinated children who make a good faith effort to obtain the necessary documentation and immunizations. Therefore, students who currently receive a religious exemption will not be affected for the remainder of this school year. Unvaccinated students transferring from another state or country will have up to thirty (30) days after they enter a school to demonstrate that he or she has received the first dose of each required immunization.
This new law will likely prove to be a large undertaking for our school clients and our attorneys are ready to assist you with this change. We will provide more information as it becomes available. In the interim, please contact one of our education law attorneys if you have questions.
If you received this alert from a third party or from visiting our website, and would like to be added to our Education mailing lists or any other of our mailing lists, please visit us at: https://contact.hodgsonruss.net/signup/BrandedFormNew.aspx.
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Hogan Lovells Publications | 4 July 2018
Projects and energy snippets
Bilateral nuclear agreement signed between Russians and Rwandans
Russian state-owned nuclear group Rosatom has announced that it has signed a memorandum of understanding (MoU) with the Ministry of Infrastructure of Rwanda.
This is the first agreement between the two countries regarding the peaceful uses of atomic energy.
The MoU sets out the legal foundations for the institution of nuclear cooperation between the two parties, which will include the development of nuclear infrastructure in the African country. It will also include the creation of public awareness programmes regarding nuclear technologies and their uses, as well as the role of radioisotopes and radiation technologies in agriculture, health care and manufacturing.
Engineering News, 25 June 2018
UK firm to connect Kenyan households with off-grid energy
UK-based pay on the go solar company, Azuri Technologies, is aiming to connect over 150 000 Kenyan households to off-grid energy over the next three years.
The 2018 Innovative Technology award winner from African Utility Week has so far connected about 150 000 homes with PayGo solar systems in the last five years, which also includes a solar-powered 24-inch satellite-TV.
According to the “Renewables 2018 Global Status Report”, off-grid solar-based systems have increased access to electricity in most rural areas in East Africa with 51% of the off-grid population in Kenya being served by distributed renewables for energy access systems, which are mostly solar.
ESI Africa, 29 June 2018
World Bank approves US$2.1bn loans for Nigerian projects
The World Bank approved a total of US$2.1 billion in concessionary loans to fund projects in Nigeria aimed at improving access to electricity and promoting governance.
The projects approved by the International Development Association are expected to support Nigeria's economic growth plan.
The World Bank said more than half of the loans would be used to fund power and climate change projects and boost fiscal transparency.
Eskom signs loan treaty with KfW to facilitate grid of renewable energy
Eskom and KfW, the German Development Bank on behalf of the German government, have signed a US$100 million (ZAR1.35 billion) loan facility to support further investments in the transmission network in the Northern Cape.
The objective is to facilitate the grid integration of renewable energy independent power producer (IPP) projects under the recently-signed power purchase agreements (PPAs).
This funding will also allow for the continuation of the second phase of capacity and reliability improvements in the areas of Harrismith in the Free State and the Greater East London region in the Eastern Cape; these projects will largely enhance network reliability and load-growth.
Tunisia to boost its economy and shift to green energy
The World Bank recently announced a new US$500 million operation to support key reforms in Tunisia aimed at promoting private investment and creating opportunities for small businesses, while protecting vulnerable households and increasing energy security.
The operation is based on three components, whereby the third component will support reform of the energy sector to make it more financially viable and sustainable, and to create the conditions for achieving the goal of generating 30% of all electricity generation from renewable sources by 2030.
The above reflects a summary of certain news articles published during the preceding week. It is not an expression of opinion in respect of each matter, nor may it be considered as a disclosure of advice by any employee of Hogan Lovells.
For more information contact Charles Marais.
98SHc42/Fo0TuOypSOglKFwDaQYaUEgVFhKsAZCzoXY= {7FD42412-5FEA-4000-A3C9-EDD6F1AB147B} 98SHc42/Fo0TuOypSOglKFwDaQYaUEgVFhKsAZCzoXY= {42F775E9-F4E4-4299-BAD2-980F8CBB90E9} What would you like to discuss?
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Media Release: Annual Results 2011
Holcim sold more cement, aggregates and ready-mix concrete, despite some adverse market conditions. On a like-for-like basis, the Group increased net sales, and operating EBITDA reached the previous year’s level. Cash-neutral impairments reduced Group net income. Clearly improved fourth quarter. Organic growth expected at operating EBITDA level in 2012.
Annual results 2011
Higher sales volumes for cement, aggregates and ready-mix concrete
Consolidated net sales decreased 4.2 percent (like-for-like: +7.5 percent)
Operating EBITDA decreased 12.3 percent (like-for-like: -0.2 percent)
Cash-neutral impairments of CHF 775 million reduced Group net income to CHF 682 million
At CHF 2.8 billion, cash flow from operating activities remained solid
Strong balance sheet and high liquidity
Proposal for a payout from capital contribution reserves of CHF 1.00 (2011: 1.50) per registered share
Fourth quarter 2011
Positive volume developments for cement, aggregates and ready-mix concrete
Net sales increased 3.9 percent (like-for-like: +13.1 percent)
Operating EBITDA increased 5.3 percent (like-for-like: +15.5 percent)
Cash flow from operating activities increased 13.5 percent (like-for-like: +28.4 percent)
Europe: stable demand
North America: slightly higher sales volumes
Latin America: increased demand for construction materials
Africa Middle East: market conditions unchanged
Asia Pacific: growing demand for construction materials
Organic growth at operating EBITDA level
To view a larger version of this table click here.
Emerging markets continue on growth course
Financial year 2011 was characterized by markedly varied economic conditions. While construction activity in mature markets was rather sluggish, emerging economies in Asia and Latin America remained on a solid growth course. Cost inflation increased around the world, which led in particular to higher raw material, energy and transport costs. Natural disasters such as the heavy floods in eastern Australia and Thailand, as well as the earthquake in New Zealand, affected construction activity.
Sales increase in all segments and in the four large Group regions
In four of its five Group regions, Holcim once again sold more cement, aggregates and ready-mix concrete. Only the Group region Africa Middle East saw slight declines in sales volumes. Increases were strongest in aggregates, especially in Latin America and Asia Pacific. In cement, Holcim also sold larger amounts in Latin American markets, followed by Asia. As a result of acquisitions, increases in ready-mix concrete were particularly strong in North America. The greatest organic growth, however, was achieved in Latin America.
In the fourth quarter, cement deliveries increased 6.7 percent to 36.2 million tonnes. The largest sales increases came from the Group regions Asia Pacific and Latin America. Aggregates sales developed positively during this period as well, rising 8.9 percent to 42.6 million tonnes, with Europe and North America achieving the highest level of increases. With the exception of Asia Pacific, deliveries of ready-mix concrete were up in all Group regions, amounting to a consolidated increase of 6.5 percent to 12.2 million cubic meters. Important contributions to this result came from Europe and North America.
Continued cost reduction measures show results
At the beginning of the financial crisis in 2008, Holcim introduced measures to reduce fixed costs. In 2011, further efficiency improvements were undertaken. This primarily involved the temporary or permanent closing of production facilities almost exclusively in developed markets, and not only in cement, but in all segments. Spain, Italy, several Eastern European markets and the US were particularly affected by closures and restructuring.
Capacity increases continued in important markets
In countries with rising demand – primarily in the emerging markets – Holcim continued to increase capacity. In 2011, the new Shurovo plant in Russia began operations. It is currently considered one of the most modern facility in the country and supplies the booming Moscow construction market. Shortly before the end of the year, Garadagh Cement in Azerbaijan produced its first clinker. The newly built kiln line will strengthen the Group company in this attractive market for construction materials. In Latin America, cement capacity was substantially increased in Ecuador. In Asia, which has large deficits in residential and infrastructure construction, Holcim is also in the process of adapting existing capacity to developments on the demand side. In India, ACC began operating what is currently the largest clinker kiln in the world at its Wadi plant. The Chanda plant was also significantly expanded, while Ambuja Cements added additional clinker capacity in Rauri and Bhatapara, as well as two new grinding stations.
The Group company ACC will increase cement capacity in east India by additional 5 million tonnes by early 2015. At Jamul, the existing facility will be replaced by a state-of-the-art clinker plant and grinding capacity increased simultaneously. In addition, the capacity of the existing Sindri grinding plant will be increased, and a new grinding plant will be built at Kharagpur. Both installations will source clinker from the new Jamul plant. Therewith, overall capacity of ACC will increase to 35 million tonnes. The Tuban plant in Indonesia, a dynamic market with great potential, is another installation under construction and will produce cement starting in 2013. Finally, Holcim Brazil will bring a new kiln line on stream at its Barroso plant in 2014.
Like-for-like higher turnover and operating EBITDA at last year’s level
The strong Swiss franc, weaker construction materials markets in certain areas and increased competitive pressure led to consolidated net sales of CHF 20.7 billion, a 4.2 percent decrease. On a like-for-like basis, not taking into account exchange rate and consolidation changes, consolidated net sales actually increased 7.5 percent. While operating EBITDA decreased 12.3 percent, on a like-for-like basis it remained virtually stable at minus 0.2 percent. The substantially improved financial results of Holcim Russia and Holcim Australia, as well as of the Group companies in Indonesia, Singapore, Colombia and Switzerland, had a positive effect on the year-end results. In many markets, increased costs due to inflation, especially for raw materials and energy, could not be completely passed on to sales prices. This, combined with various local factors, negatively affected performance above all in the Philippines, India, North America and Great Britain.
In the fourth quarter, despite strong exchange rate volatility, which reduced operating results by CHF 98 million, operating EBITDA rose by 5.3 percent compared to the same quarter a year before. On a like-for-like basis the increase was 15.5 percent, above all thanks to Group companies in Asia Pacific and Europe. In Europe, the sale of CO2 emissions certificates added CHF 52 million to operating EBITDA (fourth quarter 2010: 20). In Asia Pacific, operating EBITDA rose 28.3 percent on a like-for-like basis.
Cash-neutral impairments affect net income
As part of the South African policy to support Black Economic Empowerment (BEE), Holcim in 2007 sold its majority stake in AfriSam (formerly Holcim South Africa) to a BEE-compliant consortium. Since then the Group has held a 15 percent stake in the company. As demand for construction materials has heavily decreased since 2010, AfriSam found itself forced to carry out far-reaching financial restructuring measures during the reporting year. In this connection, Holcim had to write-off CHF 415 million, which is made up of a notes issue, accrued interest and foreign currency movements, of its investment. The stake in AfriSam is now at 2 percent.
In Spain, parts of Eastern Europe and in the US, Holcim has also been forced, due to unsatisfactory demand, to make value adjustments on property, plant and equipment, as well as goodwill, of a total of CHF 360 million.
Due to these cash-neutral impairments totaling CHF 775 million, net income has been reduced by 57.9 percent to CHF 682 million, and the share of net income attributable to shareholders of Holcim Ltd to CHF 275 million. Cash flow from operating activities came to CHF 2.8 billion. Cash flow generation was particularly strong in the fourth quarter 2011.
Continued solid balance sheet
Holcim continues to show a solid balance sheet and good liquidity. Although new plants came on line and others are under construction, net financial debt only rose by 1.6 percent to CHF 11.5 billion.
Payout to be proposed to Annual General Meeting
Despite the above-mentioned cash-neutral impairments, the Board of Directors will propose to the Annual General Meeting on 17 April 2012 in Zurich, a payout from capital contribution reserves of CHF 1.00 per registered share (2011: 1.50).
Change in Group leadership
The change of CEO, which was announced in September 2011 with effect from the beginning of February 2012, was part of a generational change in the Group’s leadership. Markus Akermann, who has been with Holcim since 1978, was elected to the Executive Committee in 1993, and took over the function of CEO in 2002. Under his leadership the Group experienced considerable growth. Through important acquisitions Holcim was more clearly positioned towards future-oriented markets, and as part of the "Twin Leg" strategy, the aggregates segment was expanded. On top of this there was the "Passion for Safety" initiative, which put workplace health and safety at the center of the whole Group, as well as the great efforts to strengthen sustainable development at the Group. Markus Akermann will remain a member of the Board of Directors. The Board and the Executive Committee would like to take this opportunity to thank him for his successful efforts throughout the years.
On 1 February 2012, Bernard Fontana, 50, took over as CEO from Markus Akermann. He began his career at Groupe SNPE, where he was a member of the Executive Committee from 2001 to 2004. He subsequently moved to the steel company ArcelorMittal where, as a member of the Executive Committee from 2006 to 2010, he was initially responsible for the overall automotive business, and subsequently for Human Resources as well as the alliance with Nippon Steel. Since 2010 Bernard Fontana has been CEO of Aperam, a listed company domiciled in Luxembourg which was spun off from ArcelorMittal and which produces stainless steel in Europe and overseas.
Holcim expects demand for building material to rise in emerging markets in Latin America and Asia, as well as in Russia and Azerbaijan in 2012. A slight improvement for North America can also be expected. In Europe, demand should remain stable, provided that the situation is not undermined by further systemic shocks. In any case, Holcim will accord cost management the closest attention and pass on inflation-induced cost increases. Holcim’s approach to new investments will be cautious. Holcim expects that the Group will achieve organic growth in terms of operating EBITDA.
Further documents such as the Annual Report 2011 including detailed information on the Group regions (p. 82-103) are available at www.holcim.com/results
Holcim is one of the world's leading suppliers of cement and aggregates (crushed stone, sand and gravel) as well as further activities such as ready-mix concrete and asphalt, including services. The Group holds majority and minority interests in around 70 countries on all continents.
Media conference:
29 February 2012, 9:30 am, Hagenholzstrasse 85, Zurich
Analyst presentation and webcast:
29 February 2012, 12:00, Hagenholzstrasse 85, Zurich
Key figures Group Holcim
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Rewrites, Infighting and No "Urgency": Behind Sony's Lackluster 'Men in Black' Relaunch
June 17, 2019 1:37pm by Borys Kit
From left: F. Gary Gray, Kumail Nanjiani, Chris Hemsworth, Tessa Thompson, Walter F. Parkes and Laurie MacDonald attend the 'Men in Black: International' photocall on June 2 in London. | Jeff Spicer/Getty Images
Director F. Gary Gray nearly exited as producer Walter Parkes attempted to remake the script on the fly while the studio tried to limit its own financial exposure. "The movie needed a greater reason to be," says a Sony exec.
In 2016, Sony Pictures’ top executives, including chief Tom Rothman, faced a dilemma: Should they greenlight a reboot of Men in Black or pursue a Men in Black crossover with a second franchise, 21 Jump Street? The stakes were high. A misstep could kill a franchise. Or two.
Initially, Sony tried to make deals for the crossover route. That plan was ambitious, requiring names such as Steven Spielberg and Walter Parkes on the Black side, and Chris Miller and Phil Lord on the Jump Street side to forgo rich producing deals. But when Jump Street producer Neal Moritz refused to compromise on his customary first-dollar pact, according to several sources with knowledge of the talks and development of both projects, the studio pivoted to the straight Men in Black reboot.
That Sony would attempt to relaunch the franchise without Will Smith was a roll of the dice. The studio was already trying to cut a deal with the megastar for Bad Boys 3 and, internally, getting the actor along with original trilogy co-star Tommy Lee Jones for a fourth MIB film was seen as both expensive and not a forward-looking proposition, sources tell The Hollywood Reporter.
That choice, to relaunch the franchise with new stars, would lead to a battle between director and producer and, ultimately, a crash landing at the box office. Men in Black: International — a hoped-for relaunch of a franchise whose three previous films, released in 1997, 2002 and 2012, grossed over $1.6 billion — opened to only $30.1 million stateside. It was, if not a franchise killer, a franchise freezer.
The Smith-Jones MIB films all bowed in the low-to-mid-$50 million range. In the months prior to International's release, Sony and industry experts had given up on the pic debuting near those numbers, with some anticipating a low $30 million debut and high-end estimates coming in at $38 million. Sony was hoping to bring in a new fan base for MIB, thinking that International would be able to capitalize on Tessa Thompson and Chris Hemsworth’s combined star power following their team-up in the critically and commercially successful Marvel Studios sequel Thor: Ragnarok.
The studio was also initially high on the screenplay by Art Marcum and Matt Holloway. “The script was good,” says one insider. “You don’t attract Chris Hemsworth and Tessa Thompson if the script isn’t good.” It’s a sentiment echoed by several insiders familiar with the development of International who spoke to THR on condition of anonymity.
But when the Sony executive overseeing the project, exec vp production David Beaubaire, exited the studio in summer 2018 and was never replaced, a tug-of-war began. Director F. Gary Gray, who helmed Straight Outta Compton and The Fate of the Furious, and Walter Parkes, the veteran producer and Spielberg confidant who helped make the original movie, clashed on the vision for the film, a source says. Parkes produced the movie with his wife and longtime business partner, Laurie MacDonald.
Early drafts of the script were described as being edgier and more timely, tying the story to the current debate surrounding immigration. At one point, a music group a la The Beatles were to be the bad guys, with four people merging into one villain. Multiple sources describe Parkes, who had final cut on the film and who had written movies such as the 1983 classic WarGames and the 1992 Robert Redford thriller Sneakers, as having a heavy hand in overseeing rewrites not only during the preproduction process but during production as well.
One source says new pages arrived daily for the actors, causing a certain amount of confusion, as well as stripping away what some considered the more modern sensibilities. Thompson and Hemsworth then hired their own dialogue writers. (Both Marcum and Holloway were on set even as Parkes looked to dictate rewrites, another source notes, seconding that multiple dialogue writers served stints on set for the actors.)
Two sources say that Parkes at times also stepped in on helming duties, although no Directors Guild of America rules were said to have been violated. Gray tried to exit the production several times but was convinced to stay by the studio, a source says.
Even color-correcting was a source of contention between the director and producer. "Walter is both the arsonist and the fireman," contends an insider.
Remarkably, the postproduction process was relatively smooth. There were no major reshoots and test screenings were mainly limited to friends and family on the lot, says one source. “It wasn’t a Dark Phoenix situation,” says the studio source, referring to the recent X-Men movie that faced reshoots and major retooling after principal photography had wrapped.
The studio tested two cuts — one by Gray, the other by Parkes — with the version by Parkes, who has final cut, being chosen. “The studio was an absentee landlord. They were nowhere to be found,” says one International insider, pointing to the lack of guidance from Sony over multiple disagreements that had broken out between Parkes and Gray.
What Rothman did ensure, however, was that the studio’s exposure was limited. The movie cost in the $110 million range, and the executive brought in Chinese conglomerate Tencent and several other co-financiers. The marketing and publicity budget spend was said to be on the lower side due to various tie-ins.
In the end, Men in Black: International was met with a lowly 25 percent freshness rating on Rotten Tomatoes and a B CinemaScore, indicating that audiences — those that did show up — shrugged. “The urgency to see this was never there, and the movie needed a greater reason to be,” says a Sony exec.
Yet, in these franchise-hungry days at studios, even a failure like this won't kill the franchise, executives agree. “Aliens walking among us is at its core a great idea,” this Sony exec adds. “Men in Black will be revisited again at one point, either as a series, as streaming, or as another movie.”
June 25, 4:30 pm PST. Update: After the publication of this article, producers Laurie MacDonald and Walter Parkes provided the below statement. THR stands by the story, which is based on interviews with nine people who worked on Men in Black: International.
Recently an article appeared in The Hollywood Reporter which purportedly presented the reasons why Men In Black: International underperformed. One of the basic arguments was that we, as producers, insisted upon last minute rewrites which unwound the script. What the article failed to mention was that the script that we supposedly unwound was in fact developed by us with the writers over a nearly two year period. This was only one of many misleading or false statements that permeated the piece.
In some ways this is not surprising in that the reporter did not attribute sources and never spoke to us or other key people with actual knowledge of what occurred on set, including our writers. Had they spoken to us, we would have described what actually happened: Art Marcum and Matt Holloways excellent first draft was greenlit with a scant 17 weeks of prep time. This all but assured substantial writing would occur throughout the production. The rewrites largely dealt with three issues: production/budget constraints (including changing several major locations), punch-ups for the actors, and reconceiving our villains to accommodate the casting of Larry and Laurent Bourgeois, aka “Les Twins,” who were Gary Gray’s choice to play the antagonists of the film. A couple of other writers were brought on during this period, but ultimately everything was filtered through Art and Matt who were on set for the entire production period. Most importantly -- all final pages were then approved by the studio before shooting—which is the case on any studio franchise film.
As anyone conversant with the process knows, there is only one time in the making of a movie in which the producers and writers have complete control: during development. It’s only after a movie is greenlit that a script’s original intention is modified to respond to the legitimate needs of the various stake holders, including the studio, the director and the actors. As producers, it was our job to manage these issues as best we could – but to suggest that the very parties largely responsible for the script in the first place would somehow arbitrarily unwind that very script defies logic and is simply untrue.
It’s important to note that when a film fails to meet expectations, it can often obscure the level of contribution made by its cast and crew. We have had the honor of having developed and produced all four Men In Black movies, and with that came the extraordinary opportunity to work with some of the most talented people in our business. No piece of inaccurate reporting can diminish the work of the artists who contributed to this movie, nor the pride and gratitude we feel for having shepherded the franchise from its inception.
– Laurie MacDonald and Walter Parkes
Seth Rogen Drops New 'Good Boys' Trailer, Tells Young Stars They Can't Watch Preview
Nina Tassler, Denise Di Novi's PatMa Signs First-Look Deal at CBS
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Columbia Encyclopedia >
Literature and the Arts >
Biographies >
Music: History, Composers, and Performers: Biographies >
Garden, Mary
Garden, Mary, 1874–1967, Scottish-American operatic soprano, b. Aberdeen, Scotland, studied in Paris. Her debut (1900) occurred when she replaced, without rehearsal, the star of Charpentier's Louise, at the Opéra-Comique, Paris. In 1902 she created the role of Mélisande in Debussy's Pelléas et Mélisande. In the title role of Massenet's Thaïs she made her American debut (1907) with the Manhattan Opera Company, New York City, and was a member of the Chicago Opera Company from 1910 to 1931.
The Columbia Electronic Encyclopedia, 6th ed. Copyright © 2012, Columbia University Press. All rights reserved.
See more Encyclopedia articles on: Music: History, Composers, and Performers: Biographies
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Home/Ideas/Does Propaganda Incite Violence?
Does Propaganda Incite Violence?
Understanding the effects of hate speech
By Richard Ashby Wilson and Christine Lillie · Published 2015
Sketch pool/The Miami Herald
Ali al-Bahlul waves a sign, "Boycott," printed in Arabic and English during his arraignment for war crimes related to his work as al-Qaeda media secretary.
Over the last ten years, national and international courts have prosecuted a greater number of political leaders and their propagandists who incite others to commit acts of war, terrorism, and genocide. The United States government, a self-avowed promoter of freedom of speech, has pursued al-Qaeda propagandists such as Ali al-Bahlul and Sulaiman Abu Ghaith, and in 2014 a federal court sentenced Ghaith to life in prison for what his defense attorney called “just talk.” The International Criminal Tribunal for Rwanda has convicted eight defendants, including radio broadcasters and a Rwandan pop star, of direct and public incitement to commit genocide. Combatting election propaganda is a priority of the International Criminal Court’s chief prosecutor, Fatou Bensouda, who warned in advance of the recent Nigerian elections that “any person who incites or engages in acts of violence by ordering, requesting, encouraging, or contributing in any other manner to the commission of crimes … is liable to prosecution either by Nigerian courts or by ICC.”
Intuitively, we may feel that leaders and media figures who incite genocide and crimes against humanity should bear criminal responsibility. Yet there does not exist any conclusive body of social science evidence demonstrating that extreme speech directly influences attitudes and behavior. Anthropologists and political scientists interviewed hundreds of convicted perpetrators of the 1994 genocide in Rwanda, and they reported that peer pressure from male neighbors and kin influenced their decisions to participate in genocide more than government and radio propaganda. Of course, listeners are not always consciously aware of their motivations, and quantitative approaches have yielded divergent findings that identify the harmful effects of hate speech. Economist David Yanagizawa-Drott used an econometric analysis of prosecution rates and radio coverage and found that approximately ten percent of the participation in the Rwandan genocide can be attributed to radio broadcasts, corresponding to an estimated 50,000 murders.
These mixed findings justify the use of other social science methods to understand the phenomenon of inciting propaganda. We designed psychological and physiological studies to test the concrete effects of propaganda, drawing on the actual speeches of Vojislav Šešelj, a Serb political leader presently awaiting judgment in The Hague for instigating murder, torture, and deportation of Croat civilians in the early 1990s. Šešelj is not charged with committing material acts of murder or deportation, but the prosecution alleges that over nine hundred people died as a result of his public calls for the persecution of other ethnic groups. We obtained 242 of his public speeches during the time period of the indictment and coded them into eight sub-categories: calls for revenge, extreme nationalist sentiments, negative stereotyping of other groups, dehumanizing language, demands for justice, references to past atrocities, victimization of his own group, and warnings of a direct threat to his group.
As with much war propaganda, two of the most frequent types of speech Šešelj used were dehumanizing language and calls for revenge. Dehumanizing speeches referred to Croats as animals devoid of human qualities, for example: “We, Serbs, as a people, let a poisonous snake bite our heart three times after holding it in our arms. That poisonous snake, that’s the Croats…. Now we need to smash its head so it never bites anyone again.” The revenge speeches called for retribution on behalf of past victims: “But, if the Croats try to massacre us, the Serbs will not forgive nor forget. Our revenge will be horrific.… Those who survived have no right to forgive in the name of the slaughtered.”
Over four hundred participants from the United States read either one of the propagandistic speeches or a control speech. Subsequently, they were asked questions about their empathy for the in-group and the out-group, their perceptions of the intentions of the in-group and the out-group, and whether violence is ever morally justifiable. Some of the results we anticipated. All of the types of speech, with the exception of nationalism, reduced the propensity of the participants to empathize with the out-group. Nationalism, revenge, and warnings of a direct threat raised empathy levels for the in-group. Nationalism, revenge, negative stereotyping, dehumanization, and references to justice systems all elevated positive attitudes toward the in-group.
Other results were unexpected. Only revenge speech increased overall negative attitudes toward the out-group. Significantly, only the speeches that called for revenge and that referenced past atrocities led the participants to morally justify violence. Not only did revenge speech increase moral justifications of violence, but it also consolidated in-group identity to the same extent as highly nationalistic rhetoric. Dehumanizing speech, generally seen by criminal courts and experts as the most extreme form of hate speech, did not have the same effect on participants’ willingness to justify violence. Intriguingly, dehumanization speech increased participants’ belief that the aggressors are morally responsible for their acts, while revenge speech had exactly the opposite effect—they were judged as not morally responsible. We theorize that revenge speech disposes people to view the opposing group as lacking in any moral capacity, i.e., no longer made up of cognizant individuals capable of moral thought. This may explain intercommunal violence where aggressors turn against neighbors and colleagues with whom they had previously enjoyed close social bonds.
At the personality level, those who believe the world is not a just place, are more politically conservative, and engage more in violent media are more predisposed to justify violence. Male participants were more susceptible to the effects of propaganda than females. Further research is needed, as we were not able to examine the interactions among different types of speeches, nor were we able to ascertain the effects of repetition, one of the hallmarks of propaganda. We have just conducted the survey in Belgrade, Serbia, and are presently analyzing the similarities and differences between the U.S. and Serbian populations’ responses to inciting speech. The results of this comparison will provide insights into some of the variations between political communities that have distinct public cultures and histories of armed conflict.
The next question is, what is the mechanism through which denigrating and inciting speech influences the listener? We followed up our psychological study with a physiological experiment using facial electromyography, which measures emotional reactions through facial muscle activity. We utilized only the revenge and dehumanization speeches, and we expected that revenge speech would elicit anger and the dehumanization speech would elicit disgust, but our expectations were confounded. In response to the speeches calling for revenge, our participants showed physiological indicators of disgust rather than anger. Neither disgust nor anger registered in response to speech that dehumanized the out-group. This suggests that the response of “moral disgust” is central to understanding how revenge speech affects empathy and enhances justifications of violence.
What do these findings mean for the criminalization of propaganda for terrorist and extreme nationalist causes? First of all, the results tell us that propaganda has demonstrable conditioning effects that lead to greater in-group solidarity and opposition towards the out-group, as well as inculcating a greater tolerance toward violence against another population. These general findings do not determine whether a specific individual speaker incited particular listeners to commit certain crimes. However, they do indicate that certain types of speech will have probabilistic effects on a proportion of listeners. Specifically, they tell us that revenge speech is more likely to lead to violence than other forms of speech. Previous international criminal courts, as well as social scientists, have emphasized the role of dehumanizing propaganda during genocide; however, our results suggest that dehumanization may not be the most egregious form of inciting speech. Rather, prosecutors at international tribunals may be able to construct a more compelling case against political leaders inciting violence on the basis of revenge, since the causal link to subsequent violence is better supported by the evidence. Prevention of genocide has always been a weakness of the international system, and our findings could guide prosecutors regarding whom to indict, and when to indict, as part of a wider effort to forestall mass atrocities.
Ultimately, it is up to the courts to decide how they will judge the zealous advocates and recruiters for extreme and violent causes. The social science of inciting speech, however, is becoming more conclusive and may contribute to evidencebased policy-making at the national and international levels. It points toward the negative and damaging effects of revenge speech and can guide policy-makers and international prosecutors who attempt to restrain the propagandists of discriminatory hatred and violence.
Richard A. Wilson, Friends of the Institute for Advanced Study Member (2014–15) in the School of Social Science and Gladstein Professor at the University of Connecticut School of Law, studies the effects of denigrating speech. Christine Lillie is a postdoctoral fellow at Duke University in the Department of Psychology & Neuroscience and the Kenan Institute for Ethics. Their full paper may be accessed at http://bit.ly/1EjV8rA.
Published in The Institute Letter Summer 2015
Christine Lillie
Richard Ashby Wilson
Liberal Democratic Legacies in Modern Egypt: The Role of the Intellectuals, 1900–1950
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Conspiring with the Enemy and Cooperating in Warfare
By Yvonne Chiu
Britain’s Moment in Palestine
By Michael Cohen
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President Trump signs pair of executive orders on immigration
Jamie Dupree Blog
Jamie Dupree, Cox Washington Bureau
Fulfilling a campaign promise, President Donald Trump signed two executive orders on Wednesday designed to tighten security along the southern border with Mexico, and to get tough with those who are living illegally in the United States by fully enforcing existing immigration laws.
The first executive order is an effort to push ahead with Mr. Trump's plans to finish construction of a U.S.-Mexico border wall, one of the most popular campaign pledges he made in 2016.
"We are going to restore the rule of law in the United States," the President told a receptive audience at the Department of Homeland Security.
"We're in the middle of a crisis along the southern border," Mr. Trump added.
"The first order in that will be to build a large, physical barrier along the southern border," said White House Press Secretary Sean Spicer.
"This will stem the flow of drugs, crime and illegal immigration into the United States," Spicer added.
"And yes, one way or the other, as President Trump has said, Mexico will pay for it," he added.
A second executive order was focused on ensuring the full enforcement of existing immigration laws, as the Trump Administration will end what's known as "catch and release" of illegal aliens.
The plan would also seek to block federal funding that goes to so-called sanctuary cities in the U.S., where governments do not help the feds arrest or detain illegal immigrants.
"Federal agencies are going to uanpologetically enforce the laws, no ifs, ands or buts," said Spicer.
One thing that was not acted on by the President was any change in President Obama's immigration actions related to DACA, the program that allows younger people brought to the U.S. illegally by their parents to stay here, without the threat of deportation.
Spicer said again today that DACA could be dealt with at a later date.
Opponents of illegal immigration hailed the President's moves.
"President Trump’s executive actions are an historic, much-needed course correction in America’s approach to immigration policy, which has been on autopilot for decades," said Dan Stein, the head of the Federation for American Immigration Reform.
"For the past eight years, our country suffered under the Obama Administration’s lax enforcement of immigration laws," said Rep. Robert Goodlatte (R-VA).
Democrats were not impressed.
"Donald Trump's executive orders are an attack on immigrant communities," said Rep. Rosa DeLauro (D-CT).
"Congress should pass comprehensive immigration reform, not build a wall of hate," said Rep. Steny Hoyer (D-MD).
Here are the full details of the two Trump orders related to immigration:
Trump - Immigration 1
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Jamie Dupree
General Acceptance Policy
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Royal Baby: Kate Middleton gives birth to a healthy baby boy
by Areej
The Duchess of Cambridge has given birth to the couple’s second royal baby boy and the latest member of Britain’s royal family, Kensington Palace have announced.
Kate Middleton and Prince William introduced their healthy baby boy to the world, who were patiently waiting to catch a glimpse of the royal prince, at the doorsteps of Lindo Wing outside St. Mary’s Hospital in Paddington, Central London.
Duke and Duchess of Cambridge make their appearance to the world with their newborn son. (Image source: Twitter)
Kensington Palace announced the arrival of the newest addition to the royal family after the Duchess was admitted to St. Mary’s Hospital in Paddington earlier this morning. Born at 11:01 am and weighing 8lbs and 7oz, the royal officials claimed that the Duchess and the baby ‘are both doing well.’
Kensington Palace announced the arrival of the third royal baby. (Image source: Twitter/ Kensington Palace)
According to a previous tweet posted, the Duchess, 36, travelled by car from Kensington Palace to the Lindo Wing at St. Mary’s Hospital with her husband, the Duke of Cambridge, by her side.
Duchess of Cambridge was taken to the hospital earlier in the morning today. (Image source: Twitter/ Kensington Palace)
Prince George, 4, and Princess Charlotte, 2, were also born at the same facility as their father, Prince William.
The young royals made an appearance to the hospital earlier to meet their baby brother. They were seen walking hand-in-hand with their father, outside the hospital wing.
Prince George and Princess Charlotte arrive at St. Mary’s hospital to meet their baby brother. (Image source: Twitter)
Princess Charlotte adorably waves at the cameras, hand-on-hand, with her father on the steps of Lindo Wing. (Image source: Twitter)
Buckingham Palace officially confirmed the news of the arrival of the couple’s third royal child with a bulletin outside Queen Elizabeth’s residency in London.
A notice has been placed on the forecourt of Buckingham Palace following the announcement of the birth of The Duke and Duchess of Cambridge’s third child.@KensingtonRoyal pic.twitter.com/82ZCB7F2aQ
— The Royal Family (@RoyalFamily) April 23, 2018
The Union Flag was also waved over Buckingham Palace to celebrate the arrival of ‘The Duke and Duchess of Cambridge’s third child.’
A large Union Flag has been raised over Buckingham Palace and a State Standard over Windsor Castle to mark the birth of The Duke and Duchess of Cambridge’s third child. pic.twitter.com/hcYYluf2fF
The newborn child is the Queen’s sixth great-grandchild and is also fifth-in-line to the throne behind his older siblings, Prince George and Princess Charlotte.
Catherine, Duchess of Cambridge and Prince William, Duke of Cambridge, Prince George of Cambridge and Princess Charlotte of Cambridge arrive to attend the service at St Mark’s Church on Christmas Day in Bucklebury, Berkshire. (Photo by Andrew Matthews – WPA Pool/Getty Images)
Catherine, Duchess of Cambridge (L) and Prince William, Duke of Cambridge (R), pose with their children, Princess Charlotte (2L) and Prince George (2R), during a private break skiing at an undisclosed location in the French Alps on March 3, 2016. (Photo by JOHN STILLWELL/AFP/Getty Images)
Reportedly, before departing the hospital, the Royal Highnesses thanked the staff at St. Mary’s for ‘the care and treatment’ the royal family received during their stay.
Duchess of Cambridge Kate Middleton Queen Elizabeth Royal Baby Royal Baby Boy UK
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Prince William and Kate Middleton to visit Pakistan for the first time in Fall 2019
Priyanka Chopra denies Meghan Markle fued, proves their friendship by visiting Royal baby Archie
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Toys R Us is making a possible comeback as the bankruptcy auction is canceled
Everyone's childhood has been saved!
by Ammar Nasir
Toys R Us is set to officially make a comeback as the controlling lenders of the company choose to cancel the bankruptcy auction.
Just after a few months of liquidation of the company, the new owners have decided to make a comeback.
The names Toys R Us, Babies R Us and other associated names with the brand were closed in the spring and the announcement was made that it would sell off international operations and shut down in the US.
Toys R Us is making a comeback. (Source: Instagram/Toys R Us)
The first news of the company filing for bankruptcy came out in September, 2017. The CEO of the company, Dave Brandon, addressed the concerns of the company’s future financial status and said:
“Our objective is to work with our debtholders and other creditors to restructure the $5 billion of long-term debt on our balance sheet, which will provide us with greater financial flexibility to invest in our business, continue to improve the customer experience in our physical stores and online, and strengthen our competitive position in an increasingly challenging and rapidly changing retail marketplace worldwide.”
However, now, Toys R Us is reviving, Geoffrey LLC. will own assets, data and trademarks of the brand. We will have to wait now to see if it actually turns into toys stores or not.
Related: Fans believe The Simpsons predicted the demise of Toys R Us 14 years ago
The company announced that they are filing for bankruptcy in September, 2017 (Source: Instagram/ ToysRUs)
According to the Wall Street Journal, the anticipated auction of the company was canceled and the new controllers are all prepared to relaunch Toys R us and Babies R Us.
Previously, the news of shutting down of Toys R Us broke the heart of every millennial, but it now looks like something good is coming out of the disaster.
The new plans of Toys R Us envisions:
“A new, operating Toys “R” Us and Babies “R” Us branding company that maintains existing global licenses agreements and can invest in and create new, domestic, retail operating businesses.”
It seems there is a hope that Toys R Us will fill the gap in the market which they left months back. Their comeback is also expected to bring employment opportunities with it.
Business Company Toys R Us
Lindsay Lohan proves she is here to build an empire in a new video clip
Mother who started business to provide her son with autism with employment now employs over 40 workers like him
Fans Believe The Simpsons Predicted the Demise of Toys R Us, 14 Years ago
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Winner of the Grand Jury and Audience Awards at SXSW and nominated for two Independent Spirit Awards, including Best Actress for Rachael Harris, NATURAL SELECTION is a wonderfully irreverent comedy about a devoted Texas housewife whose carefully ordered world is turned upside...
Robbie Pickering
"[Harris is] the big reason that NATURAL SELECTION is so engaging." - Roger Ebert
Fear and Trembling
A dream job rapidly becomes a nightmare for Amelie, a Japanese-born Belgian woman, who suffers a series of increasingly humiliating demotions after she lands a job as an interpreter at a large Japanese corporation. Sylvie Testud earned the French equivalent of the Academy...
(2003) 107 min
French Black Comedy
Alain Corneau
A dream job rapidly becomes a nightmare for Amelie, a Japanese-born Belgian...
35 Shots of Rum
Widely hailed as one of the best films of 2009, the latest from the renowned director of BEAU TRAVAIL, Claire Denis’ sublime 35 SHOTS OF RUM is the moving story of a father and daughter whose close-knit, tender relationship is disrupted by a handsome young suitor. Sumptuously filmed and featuring...
French Romantic Drama
Winner of the "Special Jury Award" at the 2008 Gijón International Film Festival
Narrowly escaping her volatile ex-husband, Yella flees her small hometown in former East Germany for a new life in the West. She finds a promising job with Philipp, a handsome business executive with whom an unlikely romance soon blossoms. But just as Yella seems poised to realize her dreams, she...
German Melodrama
Christian Petzold
Narrowly escaping her volatile ex-husband, Yella flees her small hometown in former East Germany for a new...
Outside a small bar in Kingston, New York, Mark Hogancamp was beaten nearly to death, his memories wiped away. Seeking recovery, he builds Marwencol, a miniature World War II-era town filled with doll versions of his friends, fantasies and even his attackers. As he documents the town’s dramas...
Jeff Malmberg
Winner of "Best Documentary Feature" at the 2010 SXSW Film Festival.
Daguerréotypes
A classic documentary from Agnes Varda, DAGUERREOTYPES is a wonderfully intimate portrait of the small shops and shopkeepers on a short stretch of the Rue Daguerre, a picturesque street that has been the filmmaker's home for more than 50 years. As in her films THE BEACHES OF AGNES and THE...
French Documentary
"...has aged splendidly, acquiring flavors that would’ve been inconceivable at the time it was made." -...
A young couple’s relationship is pushed to the brink while vacationing in the Mediterranean in this smart, sexy drama from acclaimed new filmmaker Maren Ade. On the surface, Chris and Gitti appear blissfully in love while enjoying the sun and sand of Sardinia. But the more time they spend...
German Romantic Drama
Maren Ade
"Like Cassavetes' A WOMAN UNDER THE INFLUENCE, Ade's film is as unpredictable and ambiguous as it is raw."...
Based on true events, celebrated director Joachim Lafosse's intense, multi-layered dissection of an unorthodox family unit created an unprecedented buzz at the 2012 Cannes Film Festival and won Emilie Dequenne the prestigious Best Actress Award. Young and full of life, Murielle (Émilie Dequenne)...
Belgian Drama
Joachim Lafosse
Based on true events, celebrated director Joachim Lafosse's intense, multi-layered dissection of an...
In a small desolate town in northeastern Germany, a handsome ex-soldier, a Turkish businessman and his beautiful, restless wife find themselves in a desperate love triangle in this suspenseful reworking of the James M. Cain's novel THE POSTMAN ALWAYS RINGS TWICE from acclaimed director Christian...
German Neo-noir
Winner of "Best Film" at the 2009 German Film Critics Association Awards.
The Day He Arrives
A film director who no longer makes films, Seongjun, arrives in Seoul to meet a close friend. When the friend doesn't show up, Seongjun wanders the city aimlessly. He runs into an actress he used to know, shares a drink with some film students and against his better judgment,...
South Korean Drama
Infused with a playfulness and dry wit that recalls the films of Woody Allen...
Once Upon a Time in Anatolia
In the dead of night, a group of men (among them, a police commissioner, a prosecutor, a doctor and a murder suspect) drive through the Anatolian countryside, the serpentine roads and rolling hills lit only by the headlights of their cars. They are searching for a corpse, the...
"It needs to be long, and it needs to be indirect, because the film is about...
Neighboring Sounds
One of the most acclaimed films of the year, NEIGHBORING SOUNDS is the thrilling debut from filmmaker Kleber Mendonça Filho. On a quiet block in the coastal city of Recife, ruled by an aging patriarch and his sons, a recent spate of petty crime has rattled the nerves of the...
Brazilian Drama
Kleber Mendonça Filho
"...this isn't merely the best new movie I've seen this year; it may well be...
In the City of Sylvia
A young artist searches the winding streets of Strasbourg for an old love in Jose Luis Guerin's acclaimed and exceedingly beautiful IN THE CITY OF SYLVIA. During a languid summer, a young man spends his afternoons sketching in an outdoor café. He is looking for a woman he met...
José Luis Guerin
Official selection of the 2007 Venice Film Festival.
The Turin Horse
On January 3, 1889, in Turin, Italy, Friedrich Nietzsche steps out of the doorway of number six, Via Carlo Albert. Not far from him, a cab driver is having trouble with a stubborn horse. The horse refuses to move, whereupon the driver loses his patience and takes his whip to it. Nietzsche puts an...
Hungarian Drama
Bela Tarr
"...an experience comparable to starting down the road with an empty sack then, over the course of the...
Réponse de femmes
1975: the "Year of the Woman." A television station gives seven female filmmakers seven minutes to answer the question "What does it mean to be a woman?" Agnès Varda answers with the cine-tract, ("Our Body: Our Sex"). Women talking about sex, desire, commercials and children...
1975: the "Year of the Woman." A television station gives seven female...
Le petit lieutenant
A gripping police noir, LE PETIT LIEUTENANT tells the story of Antoine, an ambitious young cop from the provinces who joins a plainclothes crime unit in Paris. Antoine spends his days eagerly awaiting his first assignment, drinking with his fellow detectives and developing an...
French Crime
Nathalie Baye won "Best Actress" for her performance in this film at the 2006...
Agnès Varda takes a cinematic stroll through her career—and the history of French film—in this jovial first-person documentary that "walks backwards" across the beaches, landscapes, and movie sets of her life and times. For some, turning eighty may mean settling down, but for...
French Biography
Winner of "Best Documentary" ("meilleur film documentaire") at the 2009 César...
An Oversimplification of Her Beauty
With arresting insight, vulnerability and a delightful sense of humor, AN OVERSIMPLIFICATION OF HER BEAUTY utilizes a mix of live action and animation to capture the relationship between Terence (Nance) and a lovely young woman (Namik Minter) as it teeters on the divide...
Romantic Drama
Terence Nance
"...both unprecedented and familiar, with antecedents in both mainstream and...
Bob and the Monster
This award winning documentary follows outspoken indie-rock hero Bob Forrest, through his life-threatening struggle with addiction, to his transformation into one of the most influential and controversial drug counselors in the US today, appearing alongside Dr. Drew Pinsky on...
Keirda Bahruth
This award winning documentary follows outspoken indie-rock hero Bob Forrest,...
For ULYSSE, Agnes Varda grants herself the unusual screen credit of cinecrit, but the exercise in question is actually the titular photograph she took on a beach in 1954. She tracks down two of her three former models (the third is a dead goat) to find out if the picture still means as much to...
For ULYSSE, Agnes Varda grants herself the unusual screen credit of cinecrit, but the exercise in question...
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Internet changed not only our personal lives around the globe, it keeps changing dramatically itself. In a relatively short time, it changed from a free haven, full of new initiatives that were not only business-minded, but also creative and liberating, into "Big Brother" (an all encompassing...
Dutch Documentary
Eline Jongsma, Kel O'Neil
A young whiz kid has developed the so-called Vortex-project. Vortex enables the user to random-like change...
The Sniper of Kobani
Kurdish filmmaker Reber Dosky travelled through Kurdistan and visited the town of Kobani in Syria, close to the Turkish border. In Kobani, the fighting between Kurdish resistance and Islamic State has been particularly fierce. Islamic State attacked the town in October 2014...
Syrian Documentary
Reber Dosky
Kurdish fighter Haron is a sniper by profession. In the midst of the ruins, he...
Inside Foxconn
Our iPhones, iPads and, more recently, Apple Watches are made by the Chinese company Foxconn in Shenzhen, China. Tian Yu decided to work there when she was seventeen. One month later she tried to commit suicide. Today, five years later, she's campaigning for better working conditions at the factory.
Tu Qiao
Our iPhones, iPads and, more recently, Apple Watches are made by the Chinese company Foxconn in Shenzhen,...
Give Us Our Daily Water
2015 has seen the driest winter in eighty-four years in southeastern Brazil. Water shortages became extremely critical in São Paulo, home to twenty million people. At the end of winter, officials were estimating São Paolo's reserves would last a mere ninety days without...
Brazilian Documentary
Vladimir Chab, Elizabeth Rocha Salgado
2015 has seen the driest winter in eighty-four years in southeastern Brazil....
One morning on August 2012, the world-renowned Syrian photographer Issa Touma saw youths lugging sandbags along his street. It turned out to be the start of the Syrian uprising in the city of Aleppo. He grabbed his camera and spent nine days recording what was happening outside his window. The...
Issa Touma
One morning on August 2012, a world-renowned Syrian photographer saw youths lugging sandbags along his...
Biking for Yemen
Bushra Al Fusail is a young photographer living in Sana'a, the capital of Yemen. The city has been under siege for weeks now, ever since the civil war swelled into a geopolitical conflict involving Iran and Saudi Arabia. News from Yemen is scarce, images few and footage of...
Yemeni Documentary
Nina Aqlan, Bushra Al Fusail
Bushra Al Fusail invited eighty women to come for a bike riding lesson followed...
O parto
Teargas, sirens of police cars and ambulances, masked demonstrators who throw stones, military police attacking on horseback - the streets of Rio de Janeiro are on fire as anger erupts over corrupt politicians, insufficient schooling, mass unemployment, lack of basic needs such as health care. In...
Elizabeth Rocha Salgado
The streets of Rio de Janeiro are on fire as anger erupts over corrupt politicians and lack of basic needs...
Novelas do capeta
When we think of Brazil, we think of beaches, soccer, poverty and crime (the economic boom of the new millennium). What we do not think about is what everybody in Brazil thinks about: soap operas. In Brazil, they are called Telenovelas. Statistics show that eighty-seven...
Are telenovelas are a mirror of life or the opposite? That what we call real...
Frozen Zoo
Once upon a time, all animals were saved from extinction. Noah built an Ark, took all species on board and set them free after the Flood. Great story. Not so great: today, every year between 0.01 and 0.1% of all animals go extinct. There is a huge difference between these numbers, which has to do...
Two scientists have a plan is to use stem cell technology and turn animal skin cells that were frozen long...
Amsterdam's airport Schiphol is Europe's biggest "hub." It is located in the famous "polders," the land the Dutch conquered against the water. Long before there were airplanes here, there were geese. Every year, at the start of the holiday season, there is a safety issue, as thousands of geese...
Jasper Juinen, Rosanne Kropman
Every year, there is a safety issue, as thousands of geese settle in the polders around Amsterdam's...
Over the weekend of April 18th and 19th, an estimated number of between eight hundred and nine hundred people, migrants and asylum seekers that had set off from Lybia, drowned in the Mediterranean. The were packed onto a single boat that capsized. Each year, roughly twenty thousand people set...
Italian Documentary
Morgan Knibbe
Over the weekend of April 18th and 19th, an estimated number of between eight hundred and nine hundred...
Behind the Blue Screen
Dutch filmmaker Jaap van Heusden and designer Ruben Pater collected and designed this series of personal stories from Iran. With their approach they explore a new kind of journalism, a very direct narrative form combined with an artistic presentation. This series of video...
Ruben Pater, Jaap van Heusden
With an approach to explore a new kind of journalism, these personal stories...
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Switzerland and France
Embassy of Switzerland in France
Visa inquiries have to be submitted exclusively to the Embassy in Paris. The Swiss Embassy provides consular services for persons resident in: Aisne (02), Calvados (14), Charente (16), Charente-Maritime (17), Cher (18), Corrèze (19), Côtes-d'Armor (22), Creuse (23), Dordogne (24), Eure (27), Eure-et-Loir (28), Finistère (29), Gironde (33), Ille-et-Vilaine (35), Indre (36), Indre-et-Loire (37), Landes (40), Loire-et-Cher (41), Loire-Atlantique (44), Loiret (45), Lot-et-Garonne (47), Maine-et-Loire (49), Manche (50), Mayenne (53), Morbihan (56), Nord (59), Oise (60), Orne (61), Pas-de-Calais (62), Pyrénées-Atlantiques (64), Sarthe (72), Seine (Ville de Paris) (75), Seine-Maritime (76), Seine-et-Marne (77), Yvelines (78), Deux-Sèvres (79), Somme (80), Vendée (85), Vienne (86), Haute Vienne (87), Essonne (91), Hauts-de-Seine (92), Seine-St-Denis (93), Val-de-Marne (94), Val-d'Oise (95), ainsi que les départements d'outre-mer (Guadeloupe, Guyane, Martinique, La Réunion) et territoires d'outre-mer (St Pierre-et-Miquelon, Mayotte, Nouvelle Calédonie, Polynésie française, Wallis et Futuna, Terres australes, Antarctique française) où la Suisse n'a pas de représentant.
Consulate General of Switzerland in Lyon
Visa support is provided exclusively by the Embassy in Paris. The Consulate general provides consular services for persons resident in: Ain (01), Allier (03), Ardèche (07), Cantal (15), Côte d'Or (21), Doubs (25), Drôme (26), Isère (38), Jura (39), Loire (42), Haute-Loire (43), Nièvre (58), Puy-de-Dôme (63), Rhône (69), Haute-Saône (70), Saône-et-Loire (71), Savoie (73), Haute-Savoie (74), Yonne (89), territoire de Belfort (90).
Consulate General of Switzerland in Marseille
Visa support is provided exclusively by the Embassy in Paris. The Consulate general provides consular services for persons resident in: Alpes-de Haute-Prov. (04), Hautes-Alpes (05), Alpes-Maritime (06), Ariège (09), Aude (11), Aveyron (12), Bouches-du-Rhône (13), Haute Corse (20), Corse du Sud (20), Gard (30), Haute-Garonne (31), Gers (32), Hérault (34), Lot (46), Lozère (48), Hautes-Pyrénées (65), Pyrénées-Orientales (66), Tarn (81), Tarn-et-Garonne (82), Var (83), Vaucluse (84), Principauté de Monaco.
Consulate General of Switzerland in Strasbourg
Visa support is provided exclusively by the Embassy in Paris. The Consulate general provides consular services for persons resident in: Ardennes (08), Aube (10), Marne (51), Haute-Marne (52), Meurthe-et-Moselle (54), Meuse (55), Moselle (57), Bas-Rhin (67), Haut-Rhin (68) et Vosges (88).
Swiss Business Hub France
The Swiss Business Hub France links Swiss enterprises with French trading partners and supports French companies in the creation process of subsidiaries in Switzerland.
Travel advice for France
Selection Attestations and certificates Citizenship Civil status affairs (marriage, birth, death, etc.) Criminal records Driving licence and vehicles Emergency assistance (Swiss citizens in distress) Genealogical research Legalisations Legal/medical practitioner used by the representation Liechtenstein – Consular services Lost and found Military (obligations) Passport and identity card Political rights (voting rights) Registration and deregistration, change of address Relocating abroad and returning – Advice Scholarships Social insurance Social security Swiss Review Travelling abroad (registration to Itineris) Useful links
Bilateral relations Switzerland–France
This section aims to guide Swiss and French citizens who want to study in their respective neighbor country.
Cross-Border Information / Infobest
Infobest is an organisation providing information and advisory services on cross-border issues.
Tax and Legal Questions
International inheritance tax, international inheritance law, taxation of retirement pensions and incomes, dormant assets
Overview of Defence cooperation existing between the Swiss Armed Forces and the French Armed Forces.
Legal/medical practitioner used by the representation
The magazine for the Swiss Abroad appears six times a year and provides information about what is happening at home and the activities of Swiss associations abroad. It also answers administrative questions. The Organisation of the Swiss Abroad publishes the Swiss Review on behalf of the federal administration. It is supported by the FDFA delegate for relations with the Swiss Abroad, who is responsible for the official pages in the Swiss Review.
Changing a Swiss Review subscription
When moving to another country, the Swiss representation must be informed of your new address – preferably via the online desk. The representation at the new location will confirm that your file has been transferred and, if necessary, change your Swiss Review subscription so that you receive the correct edition for your new region. In addition to changing your address, phone number or email address, you can also use the online desk to manage your Swiss Review subscription and choose to receive the publication either by post or email.
Online desk for Swiss nationals residing abroad
Ambassade de Suisse
Standard +33 1 49 55 67 00
Questions d'ordre général paris@eda.admin.ch
Section consulaire et sociale par.chancellerie@eda.admin.ch
Service des visas paris.visa@eda.admin.ch
Section affaires juridiques par.juridique@eda.admin.ch
Section communication par.presse@eda.admin.ch
Section culture par.culture@eda.admin.ch
Opening hours Visa Section
@AmbassadeSuisse
Aisne (02), Calvados (14), Charente (16), Charente-Maritime (17), Cher (18), Corrèze (19), Côtes-d'Armor (22), Creuse (23), Dordogne (24), Eure (27), Eure-et-Loir (28), Finistère (29), Gironde (33), Ille-et-Vilaine (35), Indre (36), Indre-et-Loire (37), Landes (40), Loire-et-Cher (41), Loire-Atlantique (44), Loiret (45), Lot-et-Garonne (47), Maine-et-Loire (49), Manche (50), Mayenne (53), Morbihan (56), Nord (59), Oise (60), Orne (61), Pas-de-Calais (62), Pyrénées-Atlantiques (64), Sarthe (72), Seine (Ville de Paris) (75), Seine-Maritime (76), Seine-et-Marne (77), Yvelines (78), Deux-Sèvres (79), Somme (80), Vendée (85), Vienne (86), Haute Vienne (87), Essonne (91), Hauts-de-Seine (92), Seine-St-Denis (93), Val-de-Marne (94), Val-d'Oise (95), and the overseas departments (Guadeloupe, French Guiana, Martinique, Réunion) and overseas territories (Saint Pierre and Miquelon, Mayotte, New Caledonia, French Polynesia, Wallis and Futuna, Location of French Southern and Antarctic Lands) where Switzerland does not have a representation.
Remarks / Consular district
The Swiss Embassy in Paris is responsible for visa-related matters throughout France
Consulat général de Suisse
4, Place Charles Hernu
Immeuble "Le Colysée"
69100 Villeurbanne (Lyon)
Headquarters +33 472 75 79 10
Headquarters lyon@eda.admin.ch
Pour toute question de visa, de prise d’emploi, d’entrée et de séjour en Suisse, veuillez-vous adresser à l’Ambassade de Suisse à Paris, à l’adresse électronique suivante : par.visa@eda.admin.ch
or on appointment
Opening hours with a booking for the issuance of identity documents
Prises biométriques uniquement sur rendez-vous obtenu préalablement sur le site internet du Département fédéral de Justice et Police lors de la procédure de demande du passeport biométrique.
www.passeportsuisse.ch
Departments of Ain (01), Allier (03), Ardèche (07), Cantal (15), Côte-d'Or (21), Doubs (25), Drôme (26), Isère (38), Jura (39), Loire (42), Haute-Loire (43), Nièvre (58), Puy de Dôme (63), Rhône (69), Haute-Saône (70), Saône-et-Loire (71), Savoie (73), Haute-Savoie (74), Yonne (89) and the Territoire de Belfort (90).
However, for all visa-related matters please contact the Swiss Embassy in Paris.
7, Rue d’Arcole
Headquarters marseille@eda.admin.ch
13291 Marseille Cedex 6
The departments of Alpes-de Haute-Prov. (04), Hautes-Alpes (05), Alpes-Maritimes (06), Ariège (09), Aude (11), Aveyron (12), Bouches-du-Rhône (13), Upper Corsica (20), South Corsica (20), Gard (30), Haute-Garonne (31), Gers (32), Hérault (34), Lot (46), Lozère (48), Hautes-Pyrénées (65), Pyrénées-Orientales (66), Tarn (81), Tarn-et-Garonne (82), Var (83), Vaucluse (84)and Principality of Monaco.
23, rue Herder
Headquarters strasbourg@eda.admin.ch
Boîte postale 20014
67083 Strasbourg Cedex
Open hours of our desks
In the afternoon only by appointment
The establishment of identity documents is made only by appointment.
Departments of Ardennes (08), Aube (10), Marne (51), Haute-Marne (52), Meurthe-et-Moselle (54), Meuse (55), Moselle (57), Bas-Rhin (67), Haut-Rhin (68 )and Vosges (88).
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Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Rates and Costs of Graduate Medical Education: Fiscal Year 2002 Rates; Provisions of the Balanced Budget Refinement Act of 1999; and Provisions of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
A Rule by the Centers for Medicare & Medicaid Services on 08/01/2001
The provisions of this final rule are effective October 1, 2001. This rule is a major rule as defined in 5 U.S.C. 804(2). Pursuant to 5 U.S.C. 801(a)(1)(A), we are submitting a report to Congress on this rule on August 1, 2001.
39827-40102 (276 pages)
CFR:
42 CFR 405
CMS 1131-F, CMS 1158-F, and CMS 1178-F
Availability of Copies and Electronic Access
I. Background
A. Summary
B. Summary of the Provisions of the May 4, 2001 Proposed Rule
1. Changes to the DRG Reclassifications and Recalibrations of Relative Weights
2. Changes to the Hospital Wage Index
3. Other Decisions and Changes to the Prospective Payment System for Inpatient Operating and Graduate Medical Education Costs
4. Prospective Payment System for Capital-Related Costs
5. Proposed Changes for Hospitals and Hospital Units Excluded from the Prospective Payment Systems
6. Determining Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits
7. Impact Analysis
8. Capital Acquisition Model
9. Report to Congress on the Update Factor for Hospitals under the Prospective Payment System and Hospitals and Units Excluded From the Prospective Payment System
10. Recommendation of Update Factor for Hospital Inpatient Operating Costs
11. Discussion of Medicare Payment Advisory Commission Recommendations
12. Public Comments Received in Response to the May 4, 2001 Proposed Rule
C. Summary of the Provisions of the August 1, 2000 Interim Final Rule with Comment Period
1. Changes Relating to Payments for Operating Costs Under the Hospital Inpatient Prospective Payment System
2. Additional Changes Relating to Direct GME and IME
3. Payments for Nursing and Allied Health Education: Utilization of Medicare+Choice Enrollees
4. Changes Relating to Hospitals and Hospital Units Excluded From the Prospective Payment System
5. Changes Relating to CAHs
6. Changes Relating Hospital to Swing Bed Program
D. Summary of the Provisions of the June 13, 2001 Interim Final Rule With Comment Period
3. Changes Relating to Payments for Capital-Related Costs Under the Hospital Inpatient Prospective Payment System
6. Other Inpatient Costs
II. Changes to DRG Classifications and Relative Weights
A. Background
B. DRG Reclassification
2. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Removal of Defibrillator Cases from DRGs 104 and 105
b. Percutaneous Cardiovascular Procedures
c. Removal of Heart Assist Systems
3. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)
a. Refusions
b. Fusion of Cervical Spine
c. Posterior Spinal Fusion
d. Spinal Surgery
4. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)
5. MDC 12 (Diseases and Disorders of the Male Reproductive System)
6. MDC 15 (Newborns and Other Neonates With Conditions Originating in the Perinatal Period)
a. DRG 389 (Full Term Neonate with Major Problems)
b. DRG 391 (Normal Newborn)
c. Medicare Code Editor Changes
7. MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders)
8. MDC 25 (Human Immunodeficiency Virus Infections)
9. Surgical Hierarchies
10. Refinement of Complications and Comorbidities (CC) List
11. Review of Procedure Codes in DRGs 468, 476, and 477
a. Moving Procedure Codes From DRGs 468 or 477 to MDCs
b. Reassignment of Procedures among DRGs 468, 476, and 477
c. Adding Diagnosis Codes to MDCs
12. Changes to the ICD-9-CM Coding System
13. Other Issues
a. Pancreas Transplant
b. Intestinal Transplantation
c. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients
C. Recalibration of DRG Weights
III. Changes to the Hospital Wage Index
B. FY 2002 Wage Index Update
C. FY 2002 Wage Index
1. Health Insurance and Health-Related Costs
2. Costs of Contracted Pharmacy and Laboratory Services
3. Collection of Occupational Mix Data
D. Verification of Wage Data From the Medicare Cost Report
E. Computation of the FY 2002 Wage Index
F. Revisions to the Wage Index Based on Hospital Redesignation
1. Provisions of Public Law 106-554
2. Effects of Reclassification
3. Statewide Wage Index
4. Section 402 of Public Law 106-113
5. Provisions of the August 1, 2000 Interim Final Rule: Sections 152(a), 153, and 154a) of Public Law 106-113
G. Requests for Wage Data Corrections
H. Modification of the Process and Timetable for Updating the Wage Index
Mid-November *
Early December *
Early January
Early February
April/May *
Early April *
Late April *
Early May *
Early June *
August 1 *
October 1 *
IV. Other Decisions and Changes to the Prospective Payment System for Inpatient Operating Costs and Graduate Medical Education Costs
A. Sole Community Hospitals (SCHs) (§§ 412.63, 412.71, 412.72, 412.73, 412.75, 412.77, and 412.92)
B. Rural Referral Centers (§ 412.96)
1. Case-Mix Index
2. Discharges
C. Indirect Medical Education (IME) Adjustment (§ 412.105)
1. IME Adjustment Factor Formula Multiplier (Section 111 of Public Law 106-113 and section 302 of Public Law 106-554 and § 412.105(d)(3)).
2. Resident-to-Bed Ratio Cap (§ 412.105(a)(1))
Example—Part 1:
3. Conforming Changes (§ 412.105(f)(1)(ii)(C) and (f)(1)(v))
D. Payments to Disproportionate Share Hospitals (DSH) (Sections 211 and 303 of Public Law 106-554 and § 412.106)
1. Qualifying Thresholds for DSHs
2. Calculation of the DSH Payment Adjustment
3. Percentage Reduction to the DSH Payment Adjustment
E. Medicare-Dependent, Small Rural Hospitals (Section 404 of Public Law 106-113 and section 212 of Public Law 106-554 and 42 CFR 412.90(j) and 412.108)
F. Reclassification of Certain Urban Hospitals as Rural Hospitals (Sections 401(a) and (b) of Public Law 106-113 and 42 CFR 412.63(b), 412.90(e), 412.102, and 412.103)
1. Permitting Reclassification of Certain Urban Hospitals as Rural Hospitals
2. Conforming Changes under Section 401(b) of Public Law 106-113
3. Application Procedures
4. Changes in the Regulations
G. Medicare Geographic Classification Review Board (MGCRB) (New § 412.235 and Existing §§ 412.256, 412.273, 412.274(b), and 412.276)
1. Three-Year Reclassifications for Wage Index Purposes
a. Special Rule for a Hospital that was Reclassified for FY 2001 and FY 2002 to Different Areas
b. Overlapping Reclassifications Are Not Permitted
c. Withdrawals of Applications and Terminations of Approved Reclassifications
(2) Cancellation of a Withdrawal of Application or a Termination of an Approved Reclassification
d. Special Rules for Group Reclassifications
e. Administrator Authority to Cancel Inappropriate Reclassification Decisions
2. Three-Year Average Hourly Wages
H. Payment for Direct Costs of Graduate Medical Education (§ 413.86)
2. Amendments Made by Section 511 of Public Law 106-554 (§ 413.86(e)(4)(ii)(C) and (e)(5)(iv))
3. Determining the 3-Year Rolling Average for Direct GME Payments (§ 413.86(g)(4) and (g)(5))
4. Counting Research Time as Direct and Indirect GME Costs (§§ 412.105 and 413.86)
5. Temporary Adjustments to FTE Cap to Reflect Residents Affected by Residency Program Closure
July 1, 2002 through June 30, 2003
6. Conforming Change to Regulations Governing Payment to Federally Qualified Health Centers (§ 405.2468(f))
7. Provisions of the August 1, 2000 Interim Final Rule With Comment Period
a. Counting Primary Care Residents on Certain Approved Leaves of Absence in Base-Year FTE Count (Section 407(a)(1) of Public Law 106-113 and New 42 CFR 412.105(f)(1)(xi) and 413.86(g)(9))
b. Adjustments to the FTE Cap for Rural Hospitals (Section 407(b)(1) of Public Law 106-113 and 42 CFR 412.105(f)(l)(iv) and 413.86(g)(4))
c. Rural Track FTE Limitation for Purposes of GME and IME for Urban Hospitals that Establish Separately Accredited Approved Medical Programs in a Rural Area (Section 407(c) of Public Law 106-113 and new 42 CFR 412.105(f)(1)(x) and 413.86(g)(11))
(1) Rotating Residents for at Least Two-Thirds of the Program to a Rural Hospital(s)
(2) Rotating Residents for at Least Two-Thirds of the Program to a Rural Nonhospital Site
(3) Rotating Residents for Less Than Two-Thirds of the Program to a Rural Hospital(s)
(4) Rotating Residents for Less Than Two-Thirds of the Program to a Rural Nonhospital Site
(5) Conditions That Apply to All Urban Hospitals
d. Not Counting Against Numerical Limitation Certain Residents Transferred from a Department of Veterans Affairs Hospital's Residency Program That Loses Accreditation(Section 407(d) of Public Law 106-113 and new 42 CFR 412.105(f)(1)(xii) and 413.86(g)(10))
e. Initial Residency Period for Child Neurology Residency Programs (Section 312 of Public Law 106-113 and 42 CFR 413.86(g)(1))
f. Technical Amendment
I. Additional Payment to Hospitals that Operate Approved Nursing and Allied Health Education Programs
1. Provisions of the August 1, 2000 Interim Final Rule with Comment Period (Section 541 of Public Law 106-113 and 42 CFR 413.86(d) and 413.87)
2. Provisions of the June 13, 2001 Interim Final Rule with Comment Period
a. Additional Payment to Hospitals That Operate Approved Nursing and Allied Health Programs (Section 512 of Public Law 106-554 and 42 CFR 413.87)
b. Technical Amendment
J. Payment for Bad Debts (Section 541 of Public Law 106-554 and 42 CFR 413.80)
V. Changes to the Prospective Payment System for Capital-Related Costs
A. End of the Transition Period
B. Special Exceptions Process
C. Exceptions Minimum Payment Level
D. Exceptions Adjustment Factor
E. Provisions Relating to Capital Prospective Payments in the June 13, 2001 Interim Final Rule With Comment Period
VI. Changes for Hospitals and Hospital Units Excluded From the Prospective Payment System
A. Limits on and Adjustments to the Target Amounts for Excluded Hospitals and Units (§§ 413.40(b)(4) and (g))
1. Updated Caps for Existing Hospitals and Units
2. New Excluded Hospitals and Units
a. Updated Caps (§ 413.40(f))
b. Changes in Type of Hospital Classification (§§ 412.23 and 412.25)
3. Effective Date of Exclusion of Long-Term Care Hospitals
4. Payment for Long-Term Care Hospital Costs: Provisions of the June 13, 2001 Interim Final Rule with Comment Period (Section 307 of Public Law 106-554 and 42 CFR 413.40(c)(4))
a. Increase in the Limitation on the Target Amounts for Long-Term Care Hospitals
b. Increase in the Target Amounts for Long-Term Care Hospitals
5. Development of Prospective Payment System for Inpatient Rehabilitation Hospitals and Units
6. Increase in the Incentive Payment for Excluded Psychiatric Hospitals and Units: Provision of the June 13, 2001 Interim Final Rule with Comment Period (Section 306 of Public Law 106-554 and 42 CFR 413.40(d)(2))
7. Changes in the Types of Patients Served or Inpatient Care Services That Distort the Comparability of a Cost Reporting Period to the Base Year are Grounds for Requesting an Adjustment Payment in Accordance with Section 1886(b)(4) of the Act
B. Critical Access Hospitals (CAHs)
1. Permitting Certain Facilities to be Designated as CAHs (Section 401(b) of Public Law 106-113 and 42 CFR 485.610)
2. Exclusion of CAHs From Payment Window Requirements
3. Availability of CRNA Pass-Through for CAHs
4. Payment to CAHs for Emergency Room On-Call Physicians (§ 413.70(b)(4))
5. Treatment of Ambulance Services Furnished by Certain CAHs (§ 413.70(b)(5))
6. Qualified Practitioners for Preanesthesia and Postanesthesia Evaluation in CAHs
7. Clarification of Location Requirements for CAHs (§§ 485.610(b) and (c))
8. Other Legislative Changes Affecting CAHs
a. 96-hour Average Length of Stay Standard (Section 403(a) of Public Law 106-113 and 42 CFR 485.620(b))
b. For-Profit Facilities (Section 403(b) of Public Law 106-113 and 42 CFR 485.610(a))
c. Closed and Downsized Hospitals (Section 403(c) of Public Law 106-113 and 42 CFR 485.610(a)(1))
d. Elimination of Coinsurance for Clinical Diagnostic Laboratory Tests Furnished by a CAH (§§ 410.152 and 413.70))
e. Assistance With Fee Schedule Payment for Professional Services Under All-Inclusive Rate
f. Conforming Change—Conditions of Participation Relating to Compliance With Hospital Requirements at Time of Application for CAH Designation (§ 485.612)
g. Participation in Swing-Bed Program (Section 403(f) of Public Law 106-113)
C. Hospital Swing Bed Program
VII. MedPAC Recommendations
A. Accounting for New Technology in Hospital Prospective Payment Systems (Recommendations 3D and 3E)
B. Occupational-Mix Adjusted Wage Index for FY 2005 (Recommendation 4)
C. Financial Performance and Inpatient Payment Issues (Recommendations 5B, 5C, and 5D)
D. Specialties With Training Beyond the Initial Residency Period (Recommendation 10)
VIII. Other Required Information
A. Requests for Data from the Public
B. Information Collection Requirements
Section 412.230(e)(2)(ii) Criteria for an Individual Hospital Seeking Redesignation to Another Rural Area or an Urban Area; § 412.232(d)(2)(ii) Criteria for All Hospitals in a Rural County Seeking Urban Redesignation; § 412.235 Criteria for All Hospitals in a State Seeking a Statewide Wage Index; and Revised § 412.273 Withdrawing an Application or Terminating an Approved 3-Year Reclassification
Section 412.348(g)(9) Exception Payments
Section 412.103(b) Special treatment: Hospitals Located in Urban Areas and That Apply for Reclassification as Rural; Application Requirements
PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES
PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED
PART 485—CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
PART 486—CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED BY SUPPLIERS
Addendum—Schedule of Standardized Amounts Effective With Discharges Occurring On or After October 1, 2001 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2001
I. Summary and Background
II. Changes to Prospective Payment Rates for Inpatient Operating Costs for FY 2002
A. Calculation of Adjusted Standardized Amounts
1. Standardization of Base-Year Costs or Target Amounts
2. Computing Large Urban and Other Area Averages
3. Updating the Average Standardized Amounts
a. Recalibration of DRG Weights and Updated Wage Index—Budget Neutrality Adjustment
b. Reclassified Hospitals—Budget Neutrality Adjustment
c. Outliers
5. FY 2002 Standardized Amounts
B. Adjustments for Area Wage Levels and Cost of Living
1. Adjustment for Area Wage Levels
2. Adjustment for Cost-of-Living in Alaska and Hawaii
C. DRG Relative Weights
D. Calculation of Prospective Payment Rates for FY 2002
General Formula for Calculation of Prospective Payment Rates for FY 2002
1. Federal Rate
2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)
a. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates for FY 2002
b. Calculation of Hospital-Specific Rate
3. General Formula for Calculation of Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2001 and Before October 1, 2002
a. Puerto Rico Rate
b. National Rate
III. Changes to the Prospective Payment Rates for Inpatient Operating Costs for FY 2001 (Section 301 of Public Law 106-554 and 42 CFR 412.63(s))
A. Budget Neutrality
B. Outliers
III. Changes to Payment Rates for Inpatient Capital-Related Costs for FY 2002
A. Determination of Federal Inpatient Capital-Related Prospective Payment Rate Update
1. Standard Federal Rate Update
2. Outlier Payment Adjustment Factor
3. Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the Geographic Adjustment Factor
4. Exceptions Payment Adjustment Factor
5. Standard Capital Federal Rate for FY 2002
6. Special Rate for Puerto Rico Hospitals
7. Changes in the Capital Prospective Payment System Rates for FY 2001
B. Calculation of Inpatient Capital-Related Prospective Payments for FY 2002
C. Capital Input Price Index
IV. Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages
V. Tables
Appendix A—Regulatory Impact Analysis
II. Changes in the Final Rule
III. Impact Analysis for CMS-1131-F and CMS-1178-F
IV. Limitations of Our Analysis
V. Hospitals Included in and Excluded From the Prospective Payment System
VI. Impact on Excluded Hospitals and Units
VII. Graduate Medical Education Impact
A. National Average Per Resident Amount (PRA)
B. Closed Training Programs or Hospitals That Close Their Training Programs
VIII. Quantitative Impact Analysis of the Final Policy Changes Under the Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
B. Impact of the Final Changes to the DRG Reclassifications and Recalibration of Relative Weights (Column 1)
C. Impact of Updating the Wage Data and the Final Changes to the Wage Index Calculation (Columns 2, 3 & 4)
D. Combined Impact of DRG and Wage Index Changes— Including Budget Neutrality Adjustment (Column 5)
E. Impact of MGCRB Reclassifications (Columns 6 & 7)
F. All Changes (Column 8)
IX. Impact for Critical Access Hospitals (CAHs)
A. Exclusion of CAHs From Payment Window Requirements
B. Availability of CRNA Pass-Through for CAHs
C. Payment for Emergency Room On-Call Physicians
D. Treatment of Ambulance Services Furnished by Certain CAHs
E. Qualified Practitioners for Preanesthesia and Postanesthesia Evaluations in CAHs
X. Impact of Changes in the Capital Prospective Payment System
A. General Considerations
B. Projected Impact Based on the FY 2002 Actuarial Model
1. Assumptions
C. Cross-Sectional Analysis of Changes in Aggregate Payments
Appendix B:
Appendix C: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services
I. Secretary's Final Recommendations for Updating the Prospective Payment System Standardized Amounts
III. Secretary's Final Recommendation for Updating the Rate-of-Increase Limits for Excluded Hospitals and Units
https://www.federalregister.gov/d/01-18868 https://www.federalregister.gov/d/01-18868
Start Preamble Start Printed Page 39828
Centers for Medicare & Medicaid Services (CMS), HHS.
Final rules.
We are revising the Medicare hospital inpatient prospective payment systems for operating and capital costs to: implement applicable statutory requirements, including a number of provisions of the Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000 (Public Law 106-554); and implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this final rule, we describe changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes apply to discharges occurring on or after October 1, 2001. We also set forth the rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the prospective payment systems.
We are making changes to the policies governing payments to hospitals for the direct costs of graduate medical education and critical access hospitals.
Lastly, we are responding to public comments received on the following two related interim final rules that we published in the Federal Register and finalizing those interim rules:
An August 1, 2000 interim final rule with comment period (65 FR 47026, HCFA-1131-IFC) that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (Public Law 106-113), and that were effective during FY 2000. These provisions related to reclassification of hospitals from urban to rural status, reclassification of certain hospitals for purposes of payment during fiscal year 2000, critical access hospitals, payments to hospitals excluded from the prospective payment system, and payments for indirect and direct graduate medical education costs.
A June 13, 2001 interim final rule with comment period (66 FR 32172, HCFA-1178-IFC) that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in Public Law 106-554, and that were effective prior to passage of Public Law 106-554 on December 21, 2000; on April 1, 2001; or on July 1, 2001. Many of the provisions of Public Law 106-554 modified changes to the Social Security Act made by Public Law 106-113 or the Balanced Budget Act of 1997 (Public Law 105-33), or both.
Stephen Phillips, (410) 786-4548, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, Hospital Geographic Reclassifications, Sole Community Hospitals, Disproportionate Share Hospitals, and Medicare-Dependent, Small Rural Hospitals Issues; Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education and Critical Access Hospitals Issues.
Copies: To order copies of the Federal Register containing this document, send your request to: New Orders, Superintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your Visa or Master Card number and expiration date. Credit card orders can also be placed by calling the order desk at (202) 512-1800 or by faxing to (202) 512-2250. The cost for each copy is $9.00. As an alternative, you can view and photocopy the Federal Register document at most libraries designated as Federal Depository Libraries and at many other public and academic libraries throughout the country that receive the Federal Register.
This Federal Register document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. Free public access is available on a Wide Area Information Server (WAIS) through the Internet and via asynchronous dial-in. Internet users can access the database by using the World Wide Web; the Superintendent of Documents home page address is http://www.access.gpo.gov/nara_docs/, by using local WAIS client software, or by telnet to swais.access.gpo.gov, then login as guest (no password required). Dial-in users should use communications software and modem to call (202) 512-1661; type swais, then login as guest (no password required).
Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of hospital inpatient stays under a prospective payment system. Under these prospective payment systems, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.
Under section 1886(d)(1)(B) of the Act in effect without consideration of the amendments made by Public Law 105-33, Public Law 106-113, and Public Law 106-554, certain specialty hospitals are excluded from the hospital inpatient prospective payment system: psychiatric hospitals and units, rehabilitation hospitals and units, children's hospitals, long-term care hospitals, and cancer hospitals. For these hospitals and units, Medicare payment for operating costs is based on reasonable costs subject to a hospital-specific annual limit, until the payment provisions of Public Laws 105-33, 106-113, and 106-554 that are applicable to three classes of these hospitals are implemented, as discussed below.Start Printed Page 39829
Various sections of Public Laws 105-33, 106-113, and 106-554 provide for the transition of rehabilitation hospitals and units, psychiatric hospitals and units, and long-term care hospitals from being paid on an excluded hospital basis to being paid on an individual prospective payment system basis. These provisions are as follows:
Rehabilitation Hospitals and Units. Section 1886(j) of the Act, as added by section 4421 of Public Law 105-33 and amended by section 125 of Public Law 106-113 and section 305 of Public Law 106-554, authorizes the implementation of a prospective payment system for inpatient hospital services furnished by rehabilitation hospitals and units. Section 4421 of Public Law 105-33 amended the Act by adding section 1886(j). Section 1886(j) of the Act provides for a fully implemented prospective payment system for inpatient rehabilitation hospitals and rehabilitation units, effective for cost reporting periods beginning during or after October 2002, with payment provisions during a transitional period based on target amounts specified in section 1886(b) of the Act. Section 125 of Public Law 106-113 amended section 1886(j) of the Act to require the Secretary to use a discharge as the payment unit for inpatient rehabilitation services under the prospective payment system and to establish classes of patient discharges by functional-related groups. Section 305 of Public Law 106-554 further amended section 1886(j) of the Act to allow hospitals to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act. A final rule implementing the prospective payment system for inpatient rehabilitation hospitals will be published in the Federal Register shortly.
Psychiatric Hospitals and Units. Sections 124(a) and (c) of Public Law 106-113 provide for the development of a per diem prospective payment system for payment for inpatient hospital services of psychiatric hospitals and units under the Medicare program, effective for cost reporting periods beginning on or after October 1, 2002. This system must include an adequate patient classification system that reflects the differences in patient resource use and costs among these hospitals and must maintain budget neutrality. We are in the process of developing a proposed rule, to be followed by a final rule, to implement the prospective payment system for psychiatric hospitals and units, effective for October 1, 2002.
Long-Term Care Hospitals. Sections 123(a) and (c) of Public Law 106-113 provide for the development of a per discharge prospective payment system for payment for inpatient hospital services furnished by long-term care hospitals under the Medicare program, effective for cost reporting periods beginning on or after October 1, 2002. Section 307(b)(1) of Public Law 106-554 provides that payments under the long-term care prospective payment system will be made on a prospective payment basis rather than a cost basis. The long-term care hospital prospective payment system must include a patient classification system that reflects the differences in patient resource use and costs, and must maintain budget neutrality. We are planning to develop a proposed rule, to be followed by a final rule, to implement the prospective payment system for long-term care hospitals, effective for October 1, 2002. Section 307 of Public Law 106-554 provides that if the Secretary is unable to develop a prospective payment system for long-term care hospitals that can be implemented by October 1, 2002, the Secretary must implement a prospective payment system that bases payment under the system using the existing acute hospital DRGs, modified where feasible to account for resource use of long-term care hospital patients using the most recently available hospital discharge data for long-term care services.
Under sections 1820 and 1834(g) of the Act, payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services on a reasonable cost basis. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under Parts 413 and 415.
Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act; the amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year.
The regulations governing the acute care hospital inpatient prospective payment system are located in 42 CFR part 412. The regulations governing excluded hospitals and hospital units are located in Parts 412 and 413. The regulations governing GME payments are located in Part 413. The regulations governing CAHs are located in Parts 413 and 485.
This final rule implements amendments enacted by Public Law 106-554 relating to updates to FY 2002 payments for hospital inpatient services, hospitals' geographic reclassifications and wage indexes, GME costs, the payment adjustment for disproportionate share hospitals (DSHs), the indirect medical education (IME) adjustment for teaching hospitals, and CAHs. It also implements other changes affecting DRG classifications and relative weights, annual updates to the data used to calculate the wage index, sole community hospitals (SCHs), payments under the inpatient capital prospective payment system, and policies related to hospitals and units excluded from the prospective payment system. These changes are addressed in sections II., III., IV., and VI. of this preamble.
Section 533 of Public Law 106-554 requires the Secretary to establish a mechanism to recognize the costs of new medical services and technologies by October 1, 2001. We proposed a mechanism in the May 4, 2001 proposed rule. We received 61 comments on our proposed criteria to qualify for this special payment and on the proposed mechanism to pay for qualifying new technologies. Due to this large number of comments, we will publish a separate final rule to respond to comments received on our proposal, and to establish a mechanism, by October 1, 2001.
Although we intend to establish the mechanism by October 1, 2001, we will not make additional payments under the mechanism for cases involving new technology during FY 2002 because it is not feasible. This is due to the timing of the enactment of Public Law 106-554 on December 21, 2000, the requirement that we establish the mechanism through notice and an opportunity for public comment, and the requirement that the payments be implemented in a budget neutral manner. That is, it was not feasible to establish the criteria by which new technologies would qualify through a proposed rule with opportunity for public comment as part of the May 4, 2001 proposed rule, finalize those criteria in response to public comments, allow technologies to qualify under those criteria, and implement payments for any qualified technologies in a budget neutral manner. This is because making the special payments in a budget neutral manner requires an adjustment to the standardized amounts (which must be published in final by August 1 each year).Start Printed Page 39830
Representatives of new technologies seeking to qualify for special payments under this provision for FY 2003 should proceed with their application by contacting us at the telephone numbers listed in the “For Further Information Contact” section of this preamble. As indicated previously, a final rule containing the specific qualifying criteria and payment mechanism will be published shortly.
This final rule also responds to public comments on, and finalizes implementation of, provisions of Public Law 106-113 that relate to Medicare payments to hospitals for FY 2001 that were addressed in a separate interim final rule with comment period (HCFA-1131-IFC), published in the Federal Register on August 1, 2000 (65 FR 47026).
Lastly, this final rule responds to public comments on, and finalizes implementation of, other provisions of Public Law 106-554 that relate to Medicare payments to hospitals effective prior to October 1, 2001 (that is, for FY 2001 or for the period between April l, 2001 and September 30, 2001) that were addressed in a separate interim final rule with comment period (HCFA-1178-IFC), published in the Federal Register on June 13, 2001 (66 FR 32172).
In summary, this final rule responds to public comments on, and finalizes, three documents published in the Federal Register: The August 1, 2000 interim final rule with comment period, the May 4, 2001 proposed rule (HCFA-1158-P), and the June 13, 2001 interim final rule with comment period, as discussed below.
The charts below specify the effective dates of the various provisions of Public Law 106-113 and Public Law 106-554.
Effective Dates of the Provisions of Public Law 106-113 Included in This Final Rule
Section No.
111 Indirect Medical Education Adjustment Formula 10/01/1999.
121 Wage Adjustment to Caps on Target Amounts for Excluded Hospitals and Units 10/01/1999.
152(a) Reclassified Hospitals in Certain Designated Counties 10/01/1999.
153 Calculation of Wage Index for Hattiesburg, Mississippi 10/01/1999.
154 Calculation of Wage Index for Allentown-Bethlehem-Easton, Pennsylvania MSA 10/01/1999.
312 Initial Residency Period for Child Neurology Residency Programs 7/01/2000, for residency programs that began before, on, or after 11/29/1999.
401(a) Reclassification of Certain Urban Hospitals to Rural 01/01/2000.
401(b)(2) Application of Reclassifications under Section 401(a) to Critical Access Hospitals 01/01/2000.
403(a) Length of Stay Restrictions on Inpatient Stays in Critical Access Hospitals 11/29/1999.
403(b) Qualifications of For-Profit Hospitals for Critical Access Hospital Status 11/29/1999.
403(c) Qualification of Closed Hospitals or Hospitals Downsized to Health Clinics for Critical Access Hospital Designation 11/29/1999 for hospitals that closed after 11/29/1989; 11/29/1999 for hospitals that downsized to health clinics.
403(e) Elimination of Medicare Part B Deductible and Coinsurance for Clinical Diagnostic Laboratory Tests Furnished in Critical Access Hospitals 11/29/1999.
403(f) Provisions on Swing-Beds in Critical Access Hospitals 11/29/1999.
404 Extension of Medicare-Dependent, Small Rural Hospital Program 10/01/2002 through 9/30/2006.
407(a) Residents on Approved Leaves of Absence—GME and IME 11/29/1999.
407(b) Expansion of Number of Unweighted Residents in Rural Hospitals—GME and IME 04/01/2000.
407(c) Urban Hospitals with Rural Training Tracks or Integrated Rural Tracks—GME and IME 04/01/2000.
407(d) Residents Training at Certain Veterans Hospitals—GME and IME 10/01/1997
408(a) Swing Beds for Skilled Nursing Facility Level of Care Patients 07/01/1998 through the end of the facility's third cost reporting period after this date.
408(b) Elimination of Constraints on Length of Stay in Swing Beds in Rural Hospitals 07/01/1998 through the end of the facility's third cost reporting period after this date.
541 Additional Payments to Hospitals for Approved Nursing and Allied Health Education to Reflect Utilization of Medicare+Choice Enrollees 01/01/2000.
201 Clarification of No Beneficiary Cost-Sharing for Clinical Diagnostic Laboratory Tests Furnished by Critical Access Hospitals 11/29/1999.
202 Assistance with Fee Schedule Payment for Professional Services under All-Inclusive Rate 07/01/2001.
211 Threshold for Disproportionate Share Hospitals 04/01/2001.
Start Printed Page 39831
212 Option to Base Eligibility for Medicare-Dependent, Small Rural Hospital Program on Discharges during Two of the Three Most Recently Audited Cost Reporting Periods 04/01/2001.
213 Extension of Option to use Rebased Target Amounts to All Sole Community Hospitals 10/01/2000.
301 Revision of Acute Care Hospital Payment Update for 2001 04/01/2001.
302 Additional Modification in Transition for Indirect Medical Education Adjustment 04/01/2001.
303 Decrease in Reductions for Disproportionate Share Hospitals 04/01/2001.
304(a) Three-Year Wage Index Reclassifications; Use of 3 Years of Wage Data for Evaluating Reclassifications 10/01/2001.
304(b) Statewide Wage Index for Reclassifications 10/01/2001 for reclassification beginning 10/01/2002.
304(c) Collection of Occupational Case Mix Data 09/30/2003 for application 10/1/2004.
306 Payment for Inpatient Services of Psychiatric Hospitals 10/01/2000.
307 Payment for Inpatient Services of Long-Term Care Hospitals 10/01/2000.
511 Increase in Floor for Payments for Direct Costs of Graduate Medical Education 10/01/2001.
512 Change in Distribution Formula for Medicare+Choice-Related Nursing and Allied Health Education Costs 01/01/2001.
541 Increase in Reimbursement for Bad Debt 10/01/2000.
On May 4, 2001, we published a proposed rule in the Federal Register (66 FR 22646) that set forth proposed changes to the Medicare hospital inpatient prospective payment system for operating and capital-related costs for FY 2002. We set forth proposed changes to the amounts and factors used in determining the rates for these costs. In addition, we proposed changes relating to payments for GME costs and payments to excluded hospitals and units, SCHs, and CAHs.
The following is a summary of the major changes that we proposed and the issues we addressed in the May 4, 2001 proposed rule:
As required by section 1886(d)(4)(C) of the Act, we proposed annual adjustments to the DRG classifications and relative weights. Based on analyses of Medicare claims data, we proposed to establish a number of new DRGs and make changes to the designation of diagnosis and procedure codes under other existing DRGs for FY 2002.
We also addressed the provisions of section 533 of Public Law 106-544 regarding development of a mechanism for increased payment for new medical services and technologies and the required report to Congress on expeditiously introducing new medical services and technology into the DRGs.
We proposed to use wage data taken from hospitals' FY 1998 cost reports in the calculation of the FY 2002 wage index. We also proposed to implement the third year of the phaseout of wage costs related to GME or Part A certified registered nurse anesthetists (CRNA) from the FY 2002 wage index calculation.
We proposed several changes to the wage index methodology that would apply in calculating the FY 2003 wage index, and addressed new procedures for requesting wage data corrections and a modification of the process and timetable for updating the wage index.
We also discussed the collection of hospital occupational mix data as required by section 304(c) of Public Law 106-554.
In addition, we discussed revisions to the wage index based on hospital redesignations and reclassifications for purposes of the wage index, including changes to reflect the provisions of sections 304(a) and (b) of Public Law 106-554 relating to 3-year wage index reclassifications by the MGCRB, the use of 3 years of wage data for evaluating reclassification requests for FYs 2003 and later, and the application of a statewide wage index for reclassifications beginning in FY 2003.
We discussed several provisions of the regulations in 42 CFR parts 412 and 413 and set forth certain proposed changes concerning SCHs; rural referral centers; changes relating to the IME adjustment as a result of section 302 of Public Law 106-554; changes relating to the DSH adjustment as a result of section 303 of Public Law 106-554; the establishment of policies relating to the 3-year application of wage index reclassifications by the MGCRB, the use of 3 years of wage data in evaluating reclassification requests to the MGCRB for FYs 2003 and later, and the use of a statewide wage index for reclassifications beginning in FY 2003, as required by sections 304(a) and (b) of Public Law 106-554.
We discussed proposed requirements for qualifying for additional payments for new medical services and technology, as required by section 533(b) of Public Law 106-554.
Lastly, we proposed changes relating to payment for the direct costs of GME, including changes as a result of section 511 of Public Law 106-554.
We proposed payment requirements for capital-related costs, including the special exceptions payment, beginning October 1, 2001.
We discussed the following proposals concerning excluded hospitals and hospital units and CAHs:
Limits on and adjustments to the proposed target amounts for FY 2002.
Revision of the methodology for wage neutralizing the hospital-specific target amounts using preclassified wage data.
Updated caps for new excluded hospitals and units as well as changes Start Printed Page 39832in the effective date of classifications of excluded hospitals and units.
The prospective payment system for inpatient rehabilitation hospitals and units.
Payments to CAHs, including exclusion from the payment window requirements; the availability of CRNA pass-through payments; payment for emergency room on-call physicians; treatment of ambulance services; the use of certain qualified practitioners for preanesthesia and postanesthesia evaluations; and clarification of location requirements for CAHs.
In the Addendum to the proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2002 prospective payment rates for operating costs and capital-related costs. We also proposed threshold amounts for outlier cases. In addition, we proposed update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2002 for hospitals and hospital units excluded from the prospective payment system.
In Appendix A, we set forth an analysis of the impact of the proposed changes on affected entities.
In Appendix B of the proposed rule, we set forth the technical appendix on the proposed FY 2002 capital cost model.
In Appendix C of the proposed rule, as required by section 1886(e)(3) of the Act, we set forth our report to Congress on our initial estimate of a recommended update factor for FY 2002 for payments to hospitals included in the prospective payment systems, and hospitals excluded from the prospective payment systems.
In Appendix D, as required by sections 1886(e)(4) and (e)(5) of the Act, we included our recommendation of the appropriate percentage change for FY 2002 for the following:
Large urban area and other area average standardized amounts (and hospital-specific rates applicable to SCHs and Medicare-dependent, small rural hospitals) for hospital inpatient services paid for under the prospective payment system for operating costs.
Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the prospective payment system.
In the proposed rule, we discussed recommendations by the Medicare Payment Advisory Commission (MedPAC) concerning hospital inpatient payment policies and presented our responses to those recommendations. Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, not later than March 1 of each year, that reviews and makes recommendations on Medicare payment policies. We respond to those recommendations in section VII. of this preamble. For further information relating specifically to the MedPAC March 1 report or to obtain a copy of the report, contact MedPAC at (202) 653-7220 or visit MedPAC's website at: www.medpac.gov.
We received a total of 232 timely items of correspondence containing multiple comments on the proposed rule. Major issues addressed by the commenters included: additional payments for new medical services and technologies, geographic reclassifications of hospitals for purposes of the wage index, DRG reclassifications, payments for GME, and payments to CAHs.
Summaries of the public comments received and our responses to those comments are set forth below under the appropriate heading, with the exception of comments and responses pertaining to specific payments for new technologies under section 533 of Public Law 106-554. As described previously, this provision will be implemented through a separate final rule.
On August 1, 2000, we published in the Federal Register (65 FR 47026) an interim final rule with comment period that implemented, or conformed the regulations to, certain statutory provisions relating to Medicare payments to hospitals for inpatient services that were contained in Public Law 106-113, that were effective for FY 2000. The following is a summary of the policy changes we implemented as a result of Public Law 106-113:
Reclassification of Certain Counties. We implemented the provisions of section 152(a) of Public Law 106-113 that reclassified hospitals in certain designated counties for purposes of making payments to affected hospitals under section 1886(d) of the Act for FY 2000. The counties affected by this provision are identified under section III. of this preamble.
Wage Index. We implemented sections 153 and 154 of Public Law 106-113 that contain provisions affecting the wage indexes of specific Metropolitan Statistical Areas (MSA). Under section 153, the Hattiesburg, Mississippi FY 2000 wage index was calculated including wage data from Wesley Medical Center. Under section 154, the Allentown-Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was calculated including wage data for Lehigh Valley Hospital.
Reclassification of Certain Urban Hospitals as Rural Hospitals. We implemented section 401 of Public Law 106-113 which directed the Secretary to treat certain hospitals located in urban areas as being located in rural areas of their State if the hospital meets statutory criteria and files an application with HCFA. This provision was effective on January 1, 2000.
IME Adjustment. We implemented section 111 of Public Law 106-113 which provided for an additional payment to teaching hospitals equal to the additional amount the hospitals would have been paid for FY 2000 if the IME adjustment formula (which reflects the higher indirect operating costs associated with GME) for FY 2000 had remained the same as for FY 1999.
Extension of the MDH Provision. We implemented section 404 of Public Law 106-113 which extended the MDH program and its current payment methodology for an additional 5 years, from FY 2002 through FY 2006.
Initial Residency Period for Child Neurology Residency Programs. We implemented section 312 of Public Law 106-113 which provides that in determining the number of residents for purposes of GME and IME payments, the period of board eligibility and the initial residency period for child neurology is the period of board Start Printed Page 39833eligibility for pediatrics plus 2 years. This provision is effective on or after July 1, 2000, for residency programs that began before, on, or after November 29, 1999.
Residents on Approved Leaves of Absence. We implemented section 407(a) of Public Law 106-113 which provides that, for purposes of determining a hospital's full-time equivalent (FTE) cap for direct GME payments and the IME adjustment, a hospital may count an individual to the extent that the individual would have been counted as a primary care resident for purposes of the FTE cap but for the fact that the individual was on maternity or disability leave or a similar approved leave of absence. The provision relating to direct GME was effective with cost reporting periods beginning on or after November 29, 1999. The provision relating to the IME adjustment applied to discharges occurring in cost reporting periods beginning on or after November 29, 1999.
Expansion of Number of Unweighted Residents in Rural Hospitals. We implemented section 407(b) of Public Law 106-113 which provides that a rural hospital's resident FTE count for direct GME and IME may not exceed 130 percent of the number of unweighted residents that the rural hospital counted in its most recent cost reporting period ending on or before December 31, 1996. The provision relating to direct GME applied to cost reporting periods beginning on or after April 1, 2000. The provision relating to the IME adjustment applied to discharges occurring on or after April 1, 2000.
Urban Hospitals with Rural Training Tracks or Integrated Rural Tracks. We implemented section 407(c) of Public Law 106-113 which allows an urban hospital that establishes separately accredited approved medical residency training programs (or rural training tracks) in a rural area or has an accredited training program with an integrated rural track to receive an FTE cap adjustment for purposes of direct GME and IME. The provision was effective with cost reporting periods beginning on or after April 1, 2000, for direct GME, and with discharges occurring on or after April 1, 2000, for IME.
Residents Training at Certain Veterans Affairs Hospitals. We implemented section 407(d) of Public Law 106-113 which provides that a non-Veterans Affairs (VA) hospital may receive a temporary adjustment to its FTE cap to reflect residents who were training at a VA hospital and were transferred on or after January 1, 1997, and before July 31, 1998, to the non-VA hospital because the program at the VA hospital would lose its accreditation by the Accreditation Council on Graduate Medical Education if the residents continued to train at the facility. This provision applies as if it was included in the enactment of Public Law 105-33, that is, for direct GME, with cost reporting periods beginning on or after October 1, 1997, and for IME, for discharges occurring on or after October 1, 1997. If a hospital is owed payments as a result of this provision, payments must be made immediately.
We implemented section 541 of Public Law 106-113 which provides an additional payment to hospitals that receive payments under section 1861(v) of the Act for approved nursing and allied health education programs associated with services to Medicare+Choice enrollees. This provision is effective for portions of cost reporting periods occurring on or after January 1, 2000.
We implemented section 121 of Public Law 106-113 which amended section 1886(b)(3)(H) of the Act to direct the Secretary to provide for an appropriate wage adjustment to the caps on the target amounts for psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals for cost reporting periods beginning on or after October 1, 1999.
We implemented—
Section 401(b) of Public Law 106-113, which contained conforming changes to incorporate the reclassifications made by section 401(a) of Public Law 106-113 to the CAH statute (section 1820(c)(2)(B)(i) of the Act). This provision is effective beginning on January 1, 2000.
Section 403(a) of Public Law 106-113, which deleted the 96-hour length of stay restriction on inpatient care in a CAH and authorized a period of stay that does not exceed, on an annual, average basis, 96 hours per patient. This provision is effective beginning on November 29, 1999.
Section 403(b) of Public Law 106-113, which allows for-profit hospitals to qualify for CAH status. This provision is effective beginning on November 29, 1999.
Section 403(c) of Public Law 106-113, which allows hospitals that have closed within 10 years prior to November 29, 1999, or hospitals that downsized to a health clinic or health center, to be designated as CAHs if they satisfy the established criteria for designation, other than the requirement for existing hospital status.
Section 403(e) of Public Law 106-113, which eliminated the Medicare Part B deductible and coinsurance for clinical diagnostic laboratory tests furnished by a CAH on an outpatient basis. This provision is effective with respect to services furnished on or after November 29, 1999.
Section 403(f) of Public Law 106-113, entitled “Participation in Swing Bed Program,” which amended sections 1883(a)(1) and (c) of the Act.
We implemented section 408(a) of Public Law 106-113 which eliminated the requirement for a hospital to obtain a certification of need to use acute care beds as swing beds for skilled nursing facility (SNF) level of care patients; and section 408(b) of Public Law 106-113 which eliminates constraints on the length of stay in swing beds for rural hospitals with 50 to 100 beds. These provisions were effective on the first day after the expiration of the transition period for prospective payments for covered SNF services under the Medicare program (that is, at the end of the transition period for the SNF prospective payments system that began with the facility's first cost reporting period beginning on or after July 1, 1998 and extend through the end of the facility's third cost reporting period after this date).
We received a total of eight timely items of correspondence containing multiple comments on the August 1, 2000 interim final rule with comment period. Summaries of the public comments received and our responses to those comments are set forth below under the appropriate section headings of this final rule.
On June 13, 2001, we published an interim final rule with comment period in the Federal Register (66 FR 32172) that implemented changes to the Act affecting Medicare payments to hospitals for inpatient services that were made by Public Law 106-554. Some of these changes were effective before the December 21, 2000 date of enactment of Public Law 106-554, on April 1, 2001, Start Printed Page 39834or on July 1, 2001. The changes, on which we requested public comment, are as follows:
Treatment of Rural and Small Urban Disproportionate Share Hospitals (DSHs) . We implemented the provisions of section 211 of Public Law 106-554 which lowered thresholds by which certain classes of hospitals qualify for DSH payments, with respect to discharges occurring on or after April 1, 2001.
Decrease in Reductions for DSH Payments. We implemented section 303 of Public Law 106-554 which modified the previous reduction in the DSH payment to be 2 percent in FY 2001 and 3 percent in FY 2002.
Medicare-Dependent, Small Rural Hospitals (MDHs). We implemented section 212 of Public Law 106-554 which provided an option to base eligibility for MDH status on discharges during two of the three most recently audited cost reporting periods, effective with cost reporting periods beginning on or after April 1, 2001.
Revision of Prospective Payment System Standardized Amounts. We implemented section 301 of Public Law 106-554 which revised the update factor increase for the inpatient prospective payment rates for FY 2001.
Indirect Medical Education Adjustment (IME). We implemented section 302 of Public Law 106-554 which provided that for the purposes of making the IME payment for discharges occurring on or after April 1, 2001 and before October 1, 2001, the adjustment will be determined as if the adjustment equaled a 6.75 percent increase in payment for every 10 percent increase in the resident-to-bed ratio, rather than a 6.25 percent increase.
SCHs. We implemented section 213 of Public Law 106-554 which further extended the 1996 rebasing option, for hospital cost reporting periods beginning October 1, 2000, to all SCHs and provides that this extension is effective as if it had been included in section 405 of Public Law 106-113.
We implemented section 512 of Public Law 106-554 which revised the formula for determining the additional payment amounts to hospitals for Medicare+Choice nursing and allied health education costs to specifically account for each hospital's Medicare+Choice utilization.
As a result of implementing section 301 of Public Law 106-554, which provided increased inpatient operating payment rates, we recalculated the unified outlier threshold for inpatient operating and inpatient capital-related costs. Therefore, we revised the capital outlier offset which also required us to revise the capital-related rates.
Increase in the Incentive Payment for Excluded Psychiatric Hospitals and Units. We implemented section 306 of Public Law 106-554, which provided that for cost reporting periods beginning on or after October 1, 2000, for psychiatric hospitals and units, if the allowable net inpatient operating costs do not exceed the hospital's ceiling, payment is the lower of: (1) net inpatient operating costs plus 15 percent of the difference between inpatient operating costs and the ceiling; or, (2) net inpatient costs plus 3 percent of the ceiling.
Increase in the Wage Adjusted 75th Percentile Cap on the Target Amounts for Long-Term Care Hospitals. We implemented section 307(a) of Public Law 106-554, which provided a 2-percent increase to the wage-adjusted 75th percentile cap on the target amount for long-term care hospitals, effective for cost reporting periods beginning during FY 2001.
Increase in the Target Amounts for Long-Term Care Hospitals. We implemented section 307(a) Public Law 106-554, which provided a 25 percent increase to the target amounts for long-term care hospitals for cost reporting periods beginning in FY 2001, up to the cap on target amounts.
Elimination of Coinsurance for Clinical Diagnostic Laboratory Tests Furnished by a CAH. We implemented section 201(a) of Public Law 106-554, which amended section 1834(g) of the Act to state that there will be no collection of coinsurance, deductible, copayments, or any other type of cost sharing from Medicare beneficiaries with respect to outpatient clinical diagnostic laboratory services furnished as outpatient CAH services and that those services will be paid for on a reasonable cost basis.
Assistance with Fee Schedule Payment for Professional Services under All-Inclusive Rate. We implemented section 202 of Public Law 106-554, which amended section 1834(g)(2)(B) of the Act to provide that when a CAH elects to be paid for Medicare outpatient services under the reasonable costs for facility services plus fee schedule amounts for professional services method, Medicare will pay 115 percent of the amount it otherwise pays for the professional services.
Condition of Participation with Hospital Requirements at the Time of Application for CAH Designation (§ 485.612). We implemented a conforming change to correct § 485.612 to reflect that certain entities are not required to have a provider agreement prior to CAH designation.
Increase in Reimbursement for Bad Debts. We implemented section 541 of Public Law 106-554 which provided a 30 percent decrease of allowable hospital bad debt reimbursement for cost reporting periods beginning during FY 2001 and all subsequent fiscal years. This section modified section 4451 of Public Law 105-33 that reduced the total allowable bad debt reimbursement for hospitals by 45 percent.
We received a total of 13 timely pieces of correspondence containing comments on the June 13, 2001 interim final rule with comment period. A summary of these public comments and our responses to them are set forth under sections IV. and VI. of this final rule.
Under the prospective payment system, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG relative to the average resources used to treat cases in all DRGS.
Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes Start Printed Page 39835in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. Changes to the DRG classification system and the recalibration of the DRG weights for discharges occurring on or after October 1, 2001 are discussed below.
Cases are classified into DRGs for payment under the prospective payment system based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Medicare fiscal intermediaries enter the information into their claims processing systems and subject it to a series of automated screens called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before classification into a DRG.
After screening through the MCE and any further development of the claims, cases are classified into the appropriate DRG by the Medicare GROUPER software program. The GROUPER program was developed as a means of classifying each case into a DRG on the basis of the diagnosis and procedure codes and demographic information (that is, sex, age, and discharge status). It is used both to classify past cases in order to measure relative hospital resource consumption to establish the DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights.
In version 18 of the GROUPER (used for FY 2001), cases are assigned to one of 499 DRGs (including one DRG (469) for a diagnosis that is invalid as a discharge diagnosis and one DRG (470) for ungroupable diagnoses) in 25 major diagnostic categories (MDCs). Most MDCs are based on a particular organ system of the body. For example, MDC 6 is Diseases and Disorders of the Digestive System. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)).
In general, cases are assigned to an MDC, based on the principal diagnosis, before assignment to a DRG. However, there are six DRGs to which cases are directly assigned on the basis of procedure codes. These are the DRGs for heart, liver, bone marrow, and lung transplants (DRGs 103, 480, 481, and 495, respectively) and the two DRGs for tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs before classification to an MDC.
Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders individual procedures or groups of procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age. Some surgical and medical DRGs are further differentiated based on the presence or absence of complications or comorbidities (CC).
Generally, the GROUPER does not consider other procedures. That is, nonsurgical procedures or minor surgical procedures generally not performed in an operating room are not listed as operating room (OR) procedures in the GROUPER decision tables. However, there are a few non-OR procedures that do affect DRG assignment for certain principal diagnoses, such as extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones.
We proposed numerous changes to the DRG classification system for FY 2002. The proposed changes, the public comments we received concerning them, and the final DRG changes are set forth below. Unless otherwise noted, the changes we are implementing will be effective in the revised GROUPER software (Version 19.0) to be implemented for discharges on or after October 1, 2001. Unless noted otherwise, we are relying on the data analysis in the proposed rule for the changes discussed here.
Chart 1 lists the changes we are making by adding new DRGs or removing old DRGs. Chart 2 summarizes the changes we are making with respect to the reassignment of procedure codes. Chart 3 presents the changes we are making to the titles of existing DRGs.
In Chart 2 of the proposed rule, several procedure codes were erroneously included in the “Removed from DRG” column of the chart (66 FR 22650). The 11 affected codes are 37.21, 37.22, 37.23, 37.26, 88.52, 88.53, 88.54, 88.55, 88.56, 88.57, and 88.58. Inclusion of these codes in this chart made it appear as if the codes were being deleted from DRG 104. In fact, they are being additionally assigned to DRG 514. We have corrected Chart 2 in this final rule.
Chart 1.—Summary of Changes in DRG Assignments
Diagnosis related groups (DRGs)
Added as new
Pre-MDC:
DRG 512 (Simultaneous Pancreas/Kidney Transplant) X
DRG 513 (Pancreas Transplants) X
MDC 5 (Diseases and Disorders of the Circulatory System):
DRG 112 (Percutaneous Cardiovascular Procedures) X
DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization) X
DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization) X
DRG 516 (Percutaneous Cardiovascular Procedures with Acute Myocardial Infarction (AMI)) X
DRG 517 (Percutaneous Cardiovascular Procedures without AMI, with Coronary Artery Stent Implant X
DRG 518 (Percutaneous Cardiovascular Procedures without AMI, without Coronary Artery Stent Implant X
MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue):
DRG 519 (Cervical Spinal Fusion with CC) X
DRG 520 (Cervical Spinal Fusion without CC) X
MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders):
DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other Symptomatic Treatment with CC) X
DRG 435 (Alcohol/Drug Abuse or Dependency, Detoxification or Other Symptomatic Treatment without CC) X
DRG 436 (Alcohol/Drug Dependence with Rehabilitation Therapy) X
DRG 437 (Alcohol/Drug Dependence, Combined Rehabilitation and Detoxification Therapy) X
DRG 521 (Alcohol/Drug Abuse or Dependence with CC) X
DRG 522 (Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy) X
DRG 523 (Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy) X
Chart 2.—Summary of Assignment or Reassignment of Diagnosis or Procedure Codes in Existing DRGs
Diagnosis/procedure codes
Removed from DRG
Reassigned to DRG
MDC 5 (Diseases and Disorders of the Circulatory System)
Principal Diagnosis Code:
410.01 Acute myocardial infarction of anterolateral wall, initial episode of care 116 516.
410.11 Acute myocardial infarction of other anterior wall, initial episode of care 116 516.
410.21 Acute myocardial infarction of inferolateral wall, initial episode of care 116 516.
410.31 Acute myocardial infarction of inferoposterior wall, initial episode of care 116 516.
410.41 Acute myocardial infarction of other inferior wall, initial episode of care 116 516.
410.51 Acute myocardial infarction of other lateral wall, initial episode of care 116 516.
410.61 True posterior wall infarction, initial episode of care 116 516.
410.71 Subendocardial infarction, initial episode of care 116 516.
410.81 Acute myocardial infarction of other specified sites, initial episode of care 116 516.
410.91 Acute myocardial infarction of unspecified site, initial episode of care 116 516
Procedure Codes:
37.94 Implantation or replacement of automatic cardioverter/defibrillation, total system (AICD) 104, 105 514, 515.
37.95 Implantation of automatic cardioverter/defibrillator lead(s) only 104, 105 514, 515.
37.96 Implantation of automatic cardioverter/defibrillator pulse generator only 104, 105 514, 515.
37.97 Raplacement of automatic cardioverter/defibrilator lead(s) only; 104, 105 514, 515.
37.98 Replacement of automatic cardioverter/defibrillator pulse generator only 104, 105 514, 515.
Operating Room Procedures:
35.96 Percutaneous valvuloplasty 112, 116 516, 517, 518.
36.01 Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy without mention of thrombolytic agent 112, 116 516, 517, 518.
36.02 Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy with mention of thrombolytic agent 112, 116 516, 517, 518.
36.05 Multiple vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent 112, 116 516, 517, 518.
36.09 Other removal of coronary artery obstruction 112, 116 516, 517, 518.
37.34 Catheter ablation of lesion or tissues of heart 112, 116 516, 517, 518.
92.27 Implantation or insertion of radioactive elements non-OR in MDC-5 517
Nonoperating Room Procedures:
36.06 Insertion of coronary artery stent(s) 116 517.
37.26 Cardiac electrophysiologic stimulation and recording studies 112 514, 516, 517, 518.
37.27 Cardiac mapping 112 516, 517, 518.
MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)
81.02 Other cervical fusion, anterior technique 497, 498 519, 520.
81.03 Other cervical fusion, posterior technique 497, 498 519, 520.
MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period)
Diagnosis Codes:
770.7 Chronic respiratory disease arising in the perinatal period 387, 389 92, 93.
773.0 Hemolytic disease due to RH isoimmunization 387, 389 390.
773.1 Hemolytic disease due to ABO isoimmunization 387, 389 390.
Secondary Diagnosis Codes:
478.1 Other diseases of nasal cavity and sinuses 390 391.
520.6 Disturbances in tooth eruption 390 391.
623.8 Other specified noninflammatory disorders of vagina 390 391.
709.00 Dyschromia, unspecified 390 391.
709.01 Vitiglio 390 391.
709.09 Dyschromia, Other 390 391.
744.1 Accessory Auricle 390 391.
754.61 Congenital pes planus 390 391.
757.33 Congenital pigmentary anomalies of skin 390 391.
757.39 Other specified anomaly of skin 390 391.
764.08 “Light for dates” without mention of fetal malnutrition, 2,000-2,499 grams 390 391.
764.98 Fetal growth retardation, unspecified, 2,000-2,499 grams 390 391.
772.6 Cutaneous hemorrhage 390 391.
779.3 Feeding problems in newborns 390 391
794.15 Abnormal and auditory function studies 390 391.
796.4 Other abnormal clinical findings 390 391.
V20.2 Routine infant or child health check 390 391.
V72.1 Examination of ears and hearing 390 391.
Chart 3.—Summary of Retitled DRGs
DRG No.
MDC 5 DRG 116 Other Permanent Cardiac Pacemaker Implantation, or PTCA, with Coronary Artery Stent Implant Other Cardiac Pacemaker Implantation.
MDC 8 DRG 497 Spinal Fusion with CC Spinal Fusion except Cervical with CC.
MDC 8 DRG 498 Spinal Fusion without CC Spinal Fusion except Cervical with CC.
DRGs 104 (Cardiac Valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization) and 105 (Cardiac Valve & Other Major Cardiothoracic Procedures without Cardiac Catheterization) include the replacement or open repair of one or more of the four heart valves. These valves may be diseased or damaged, resulting in either leakage or restriction of blood flow to the heart, compromising the ability of the heart to pump blood. This procedure requires the use of a heart-lung bypass machine, as the heart must be stilled and opened to repair or replace the valve.
Cardiac defibrillators are implanted to correct episodes of fibrillation (very fast heart rate) caused by malfunction of the conduction mechanism of the heart. Through implanted cardiac leads, the defibrillator mechanism senses changes in heart rhythm. When very fast heart rates occur, the defibrillator produces a burst of electric current through the leads to restore the normal heart rate. An implanted defibrillator constantly monitors heart rhythm. The implantation of this device does not require the use of a heart-lung bypass machine, and would be expected to be very different in terms of resource usage, although both procedures currently group to DRGs 104 and 105.
For the proposed rule, as part of our ongoing review of DRGs, we examined Medicare claims data on DRG 104 and DRG 105. We reviewed 100 percent of the FY 2000 MedPAR file containing hospital bills received through May 31, 2000, for discharges in FY 2000, and found that the average charges across all cases in DRG 104 were $84,060, while the average charges across all cases in DRG 105 were $66,348. Carving out code 37.94 (Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD]) from DRGs 104 and 105 increased those average charges to $91,366 for DRG 104 and $67,323 for DRG 105. We identified 11,021 defibrillator cases in DRG 104 (out of 25,112 total cases), with average charges of $74,719, and 2,434 defibrillator cases in DRG 105 (out of 20,094 total cases), with average charges of $59,267.
We performed additional review on cases containing code 37.95 (Implantation of automatic cardioverter/defibrillator lead(s) only) with code 37.96 (Implantation of automatic cardioverter/defibrillator pulse generator only) and on cases containing code 37.97 (Replacement of automatic cardioverter/defibrillator lead(s) only) with code 37.98 (Replacement of automatic cardioverter/defibrillator pulse generator only). This subgrouping contained only 56 patients. The average charges for the 18 patients in DRG 104 were $58,847. The average charges for the 38 patients in DRG 105 were $54,891.
In the proposed rule, because we believed the defibrillator cases are significantly different from other cases in DRGs 104 and 105, we proposed two new DRGs: DRG 514 (Cardiac Defibrillator Implant with Cardiac Catheterization) and DRG 515 (Cardiac Defibrillator Implant without Cardiac Catheterization).
We also proposed the removal of procedure codes 37.94, 37.95 and 37.96, and 37.97 and 37.98 from DRGs 104 and 105 to form the new DRGs 514 and 515.
We received 58 comments on this proposal.
Comment: Many commenters noted that implanted cardioverter defibrillators (ICDs) or AICDs are lifesaving devices that demonstrate state-of-the-art technology for the treatment of cardiac arrhythmias by continuously monitoring, analyzing, and, if needed, restoring a patient's normal heart rhythm.
One commenter described the technology. Similar to the size of a pacemaker, the ICD is placed under the skin of the upper chest. It has the capacity to continuously monitor and analyze a patient's heart rhythm. If the ICD detects an arrhythmia, it can terminate the abnormal rhythm with either a pacemaker function or the delivery of a low-energy electrical shock to restore normal heart rhythm.
Response: We agree that ICDs and AICDs are an important addition to the treatment of cardiac disease. The creation of DRGs 514 and 515 is not meant to effect a judgement call about the efficacy or importance of this treatment, but simply to attempt to improve the accuracy of payments within MDC 5, based on the actual charge data associated with these cases.
Comment: A vast majority of the commenters expressed concern that payments associated with defibrillators will decrease for FY 2002 as a result of this change, with some commenters noting that an ICD or AICD may cost the hospital between $22,000 and $25,000 per device. The commenters stated that if this is the case, there is a limited amount for the remainder of the hospital care (for example, operating room, supplies, nursing staff salary, and typically a 7-day stay in an intensive care unit). Most commenters called for Start Printed Page 39838additional analysis prior to implementation of DRGs 514 and 515.
Response: As we described in the proposed rule and above, DRGs 104 and 105 currently include many different procedures, with a range of costs associated with these different procedures. We proposed to change the assignment of cardiac defibrillators to new DRGs 514 and 515 to more accurately pay for the more expensive procedures remaining in DRGs 104 and 105, as well as to improve the payment accuracy for cardiac defibrillators. In fact, the relative weight of DRG 104 increases from FY 2001 to FY 2002 by 9.1 percent.
Comment: Many commenters argued that using hospital charges to determine DRG relative weights can give a distorted picture of the costs of a procedure. The commenters referred to an unspecified national database indicating that the average mark-up of charges over cost for ICDs is lower than the mark-up applied to other components of care. Other commenters referred to the March 2001 Report to Congress by the MedPAC, which, in the context of evaluating available data for setting accurate relative values, stated that hospitals' billed charges “give a distorted picture of relative costliness across DRGs because they reflect systematic differences among hospitals in the average mark-up of charges over costs” (page 11).
Several commenters stated that about 66 percent of hospitals are losing $5,000 or more per case for these procedures. These commenters did not understand why payment would be reduced even further in light of those losses.
Response: Hospital charges have been the basis for recalibrating the DRG relative weights since FY 1986 (see 50 FR 24372 and 50 FR 35652). To the extent that the mark-up of charges over costs varies from one particular device or procedure to another, the relative weights will be impacted. However, due to the relativity of the DRG weights, a low mark-up associated with one device or procedure will be offset by relatively higher mark-ups associated with another device or procedure, leading to higher relative weights, and thus higher payments, for the latter device or procedure. The prospective payment system is an average-based payment methodology, where hospitals are expected to offset any losses they may incur from any individual or group of cases with payment gains incurred from other cases.
Furthermore, hospital charges are determined by each hospital on an item-by-item basis. It is not possible to account for these individual management decisions in the process of developing a national payment system based on prospectively determined average payment rates.
As demonstrated in the impact analysis in Appendix A to this final rule, hospital payments would rise (prior to the budget neutrality adjustment) by 0.3 percent as a result of all of the DRG changes we are implementing in this final rule, including this change. In addition, we note that the latest analysis by MedPAC indicates the average hospital Medicare inpatient operating margin during FY 1999 (the latest year available) was 12.0 percent (Report to the Congress: Medicare Payment Policy, page 64). Therefore, we believe that hospitals will be able to adequately adjust to these payment changes in both the short and the long term.
Comment: One commenter noted that the adjustment to DRGs 104 and 105 as reflected in Table 5, “List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean Length of Stay,” in the Addendum of the proposed rule, does not reflect the resource consumption as discussed above. The commenter recommended that we increase the relative weights to reflect the resource consumption of DRGs 104 and 105.
Response: In this final rule, the relative weight for DRG 104 is 7.8411 for FY 2002, an increase of 9.1 percent from FY 2001. The relative weight for DRG 105 in this final rule is 5.6796 for FY 2002, a 0.4 percent increase from FY 2001. These percentage changes are very similar to the percent change in average charges in DRGs 104 and 105 after removing ICD and AICD charges, as described above. We note that the final relative weight values are based on 100 percent of FY 2000 discharges in the MedPAR database as of March 2001. The analysis using average charges described above was based on an earlier sample of cases; therefore, the percentage changes do not match exactly.
Comment: Other commenters noted that this change, and the resulting increase in payments for procedures remaining in DRGs 104 and 105, is a positive step to improving the payment for heart assist devices. However, the commenters were disappointed that we did not take the opportunity to make a similar revision for cases involving mechanical heart assist devices.
Response: As described above, removing the ICDs/AICDs from DRGs 104 and 105 will have the net effect of increasing the relative weights for both DRGs, so payment for the remaining cases will increase. We will continue to evaluate our options for improving the accuracy of our payments for heart assist technologies.
After carefully reviewing all of the comments submitted, we have decided to proceed with the creation of two new DRGs to capture cases involving the implantation of cardiac defibrillators. The new DRGs 514 and 515 include principal diagnosis codes and procedure codes as reflected in Chart 4 below:
Chart 4.—Composition of New DRGs 514 and 515 in MDC 5
Diagnosis and procedure codes
Included in DRG 514
Principal Diagnosis Codes:
All of the principal diagnosis codes assigned to MDC-5 X X
Principal or Secondary Procedure Code:
37.94 Implantation or replacement of automatic cardioverter/defibrillator, total system (AICD) X X
Combination Operating Procedure Codes:
37.95 Implantation of automatic cardioverter/defibrillator lead(s) only;
37.96 Implantation of automatic cardioverter/defibrillator pulse generator only; X X
37.97 Replacement of automatic cardioverter/defibrillator lead(s) only;
37.98 Replacement of automatic cardioverter/defibrillator pulse generator only X X
Plus: One of the Following Nonoperating Room Procedure Codes:
37.21 Right heart cardiac catheterization X
37.22 Left heart cardiac catheterization X
37.23 Combined right and left heart cardiac catheterization X
37.26 Cardiac electrophysiologic stimulation and recording studies X
88.52 Angiocardiography of right heart structures X
88.53 Angiocardiography of left heart structures X
88.54 Combined right and left heart angiocardiography X
88.55 Coronary arteriography using a single catheter X
88.56 Coronary arteriography using two catheters X
88.57 Other and unspecified coronary arteriography X
88.58 Negative-contrast cardiac roentgenography X
In the May 4 proposed rule, we indicated that we had reviewed other DRGs within MDC 5 in order to determine if there were also logic changes that could be made to these DRGs. The data were arrayed in a variety of ways displaying myriad permutations, resulting in the following proposed changes.
A percutaneous transluminal coronary angioplasty (PTCA) is an acute intervention intended to minimize cardiac damage by restarting circulation to the heart. Some patients with an acute myocardial infarction (AMI) are now treated by performing a PTCA during the hospitalization for the AMI. Currently, PTCAs with a coronary stent implant are assigned to DRG 116 (Other Permanent Cardiac Pacemaker Implantation, or PTCA with Coronary Artery Stent Implant), along with pacemaker implants. The remaining percutaneous cardiovascular procedures are assigned to DRG 112 (Percutaneous Cardiovascular Procedures).
The volume of percutaneous cardiovascular procedures has grown dramatically, with 186,669 cases identified in the FY 2000 MedPAR file containing hospital bills submitted through May 31, 2000. Because of the high volume, we decided to review the DRG for percutaneous cardiovascular procedures. As a first step in the evaluation, we combined the percutaneous cardiovascular procedures from DRGs 112 and 116. We then subdivided the combined percutaneous cardiovascular procedure group into two groups based on the principal diagnosis (Pdx) of AMI.
Average charge
With Pdx of AMI 50,442 $31,722
Without Pdx of AMI 136,227 23,989
Each of these groups was further evaluated by subdividing them based on whether a coronary stent was implanted. The vast majority of patients with an AMI had a coronary stent implanted. Patients without an AMI were subdivided into two groups based on whether a coronary stent was implemented.
Without Pdx of AMI with stent 111,441 $24,745
Without Pdx of AMI without stent 24,786 20,589
In the proposed rule, based on this analysis, we proposed the removal of PTCAs with coronary artery stent from DRG 116, thus limiting DRG 116 to permanent cardiac pacemaker implantation. This removal would leave approximately 68,000 non-PTCA cases in DRG 116.
In conjunction with this evaluation, we considered a new technology, intravascular brachytherapy, that is being used to treat coronary in-stent stenosis. A gamma-radiation-impregnated tape is threaded through the affected vessel for a specified amount of dwell time, and then the tape is removed. Intravascular brachytherapy was approved by the Food and Drug Administration in November 2000.
Intravascular brachytherapy is assigned to procedure code 92.27 (Implantation or insert of radioactive elements). With the use of angioplasty, these cases are currently assigned to DRG 112 (Percutaneous Cardiovascular Procedures). Therefore, cases involving this new technology will be implicated by these changes.
Also in the proposed rule, we proposed to retitle DRG 116 “Other Cardiac Pacemaker Implantation,” remove DRG 112, and create three new DRGs: DRG 516 (Percutaneous Cardiovascular Procedures with Acute Myocardial Infarction (AMI)); DRG 517 (Percutaneous Cardiovascular Procedures without AMI, with Coronary Artery Stent Implant); and DRG 518 (Percutaneous Cardiovascular Procedures without AMI, without Coronary Artery Stent Implant). In order to be assigned to new DRG 516, cases must contain one of the principal diagnoses plus the operating room procedures listed in Chart 5. Because DRG 516 contains acute myocardial infarction, which is hierarchically ordered before DRGs 517 and 518, any AMI cases also containing codes 92.27 or 36.06 (Insertion of coronary artery stents(s)) would automatically be assigned to DRG 516. We also proposed the assignment of patients with a percutaneous cardiovascular procedure and intravascular radiation treatment to new DRG 517. As more data become available, we will reassess the assignment of intravascular radiation treatment to DRG 517. New DRG 518 would contain the same operating room and nonoperating room procedures as new DRG 517, with the exception of codes 92.27 and 36.06. We received 10 comments on this proposal.
Comment: Several commenters supported the reclassification of percutaneous vascular procedures to DRGs within this MDC. Other commenters, however, stated the proposed changes would be inappropriate because they would reduce payment overall for percutaneous cardiovascular procedures. These commenters noted that new technologies associated with these procedures are, in fact, more costly rather than less costly. In addition, commenters expressed concern that payment for pacemakers under DRG 116 would be reduced from FY 2001 levels.
Response: Based on 100 percent of FY 2000 discharges on file through March 2001, we estimate the case-weighted average relative weight for DRGs 116, 516, 517 and 518 to be 2.2236, a 4.5 percent decline from the case-weighted average relative weight for DRGs 112 and 116 for FY 2001 (2.3280). As discussed above in relation to the new DRGs 514 and 515, the calculation of Start Printed Page 39840the relative weights reflects the charges submitted by hospitals for these cases.
Comment: Five commenters addressed only the inclusion of code 92.27 (Implantation or insertion of radioactive elements, also known as brachytherapy) in new DRG 517 in cases without presence of AMI (these cases would go to DRG 516 if AMI were present). Four of the five expressed appreciation for this change, citing its clinical appropriateness and increased payment, which is close to the additional facility costs for performing the procedure.
One commenter, while commending the decision to assign these cases to DRG 517, requested clarification about our decisionmaking process in assigning this technology to the same DRG as coronary stents. The commenter requested that we outline the specific criteria we applied or the process we followed to evaluate the adequacy of the external data submitted.
Response: Although we received external data from a manufacturer of this technology, they were not the basis for our decision, as we were unable to verify the data because the data were submitted too late in the process of preparing the FY 2002 proposed rule. When we proposed to restructure DRGs 112 and 116, our decision was based on the clinical coherence of the DRGs. Intravascular radiation treatment is an invasive procedure that requires an additional 35 to 45 minutes, and requires the services of both a radiation (nuclear) physicist and a radiation safety officer in the operating room, as well as specifically trained operating room personnel, such as an ultrasound specialist.
Comment: One commenter wrote that these changes fail to account for the use of GP IIB-IIIA inhibitors for cases with acute coronary syndromes. The commenter was concerned whether the DRG assignment for these cases under the proposed DRGs would be appropriate.
Response: The administration of GP IIB-IIIA inhibitors is through intravenous infusion, and is assigned to code 99.20 (Injection or infusion of platelet inhibitor). The GROUPER does not recognize code 99.20 as a procedure and, therefore, its presence does not affect DRG assignment. As described above, the DRG assignment for these cases under the newly configured DRGs 116, 516, 517, and 518 would be determined by the presence of AMI and the presence of other procedures that would cause the case to group to one of the other DRGs besides 518. Our analysis of FY 2000 MedPAR data indicates that, among cases with code 99.20 currently assigned to either DRGs 112 or 116 for FY 2000, the majority of these cases are currently assigned to DRG 116 (317,108 discharges compared to 52,945). Therefore, the majority of these cases involve procedures that do affect DRG assignment. We will continue to evaluate these cases, however, to determine whether further revisions would be appropriate.
Comment: One commenter indicated that codes 37.27 (Cardiac mapping) and 37.34 (Catheter ablation of lesion or tissues of heart) would now be grouped to new DRGs 516, 517, and 518. Because these procedures are not usually used on patients with AMI or patients who receive a stent, the commenter indicated the cases would most likely be grouped to DRG 518. The commenter believed that we were unaware that certain procedures, such as the two previously mentioned, have greater resource utilization than other percutaneous cardiovascular procedures that do not involve AMI or stents. The commenter asserted that this is an inadvertently inappropriate classification. The commenter recommended that CMS either create a separate DRG for cardiac mapping and ablation procedures, or else assign codes 37.27 and 37.34 to DRG 516 after retitling the DRG appropriately.
Response: These cases previously were assigned to either DRG 112 or 116, depending upon whether they involved the insertion of a stent or the implantation of a pacemaker. This GROUPER assignment logic did not change, although the presence or absence of AMI is now a factor as well. We believe this is an appropriate clinical categorization. However, we will consider this issue as we continue to evaluate these DRGs.
The principal diagnosis codes and operating room and nonoperating room procedure codes that are included in the new DRGs 516, 517, and 518 are reflected in Chart 5.
Chart 5.—Composition of New DRGs 516, 517, and 518 in MDC 5
410.01 Acute myocardial infarction of anterolateral wall, initial episode of care X
410.11 Acute myocardial infarction of other anterior wall, initial episode of care X
410.21 Acute myocardial infarction of inferolateral wall, initial episode of care X
410.31 Acute myocardial infarction of inferoposterior wall, initial episode of care X
410.41 Acute myocardial infarction of other inferior wall, initial episode of care X
410.51 Acute myocardial infarction of other lateral wall, initial episode of care X
410.61 True posterior wall infarction, initial episode of care X
410.71 Subendocardial infarction, initial episode of care X
410.81 Acute myocardial infarction of other specified sites, initial episode of care X
410.91 Acute myocardial infarction of unspecified site, initial episode of care X
35.96 Percutaneous valvuloplasty X X X
36.01 Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy without mention of thrombolytic agent X X X
36.02 Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy with mention of thrombolytic agent X X X
36.05 Multiple vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent X X X
36.09 Other removal of coronary artery obstruction X X X
37.34 Catheter ablation of lesion or tissues of heart X X X
92.27 Implantation or insertion of radioactive elements X
36.06 Insertion of coronary artery stent(s) X
37.26 Cardiac electrophysiologic stimulation and recording studies X X X
37.27 Cardiac mapping X X X
DRG 121 (Circulatory Disorders with AMI and Major Complication, Discharged Alive), DRG 122 (Circulatory Disorders with AMI without Major Complication, Discharged Alive), and DRG 123 (Circulatory Disorders with AMI, Expired) are not affected by these changes.
The ICD-9-CM Coordination and Maintenance Committee considered the nonoperative removal of heart assist systems at its November 17, 2000 meeting. A device called the intra-aortic balloon pump (IABP) is one of the most common types of ventricular assist systems. A balloon catheter is placed into the patient's descending thoracic aorta, and inflates and deflates with each heartbeat. This device is timed with the patient's own heart rhythm, and inflates and circulates blood to the heart and other organs. This allows the heart to rest and recover. The IABP may be used preoperatively, intraoperatively, or postoperatively. It supports the patient from a few hours to several days.
Code 37.64 (Removal of heart assist system) already exists, and it is considered by the GROUPER to be an operative procedure. However, the nonoperative removal of a heart assist system can be done at the patient's bedside, is noninvasive, and requires no anesthesia. Therefore, the Committee created code 97.44 (Nonoperative removal of heart assist system) for use with discharges beginning on or after October 1, 2001.
In the past, we have assigned new ICD-9-CM codes to the same DRG to which the predecessor code was assigned. In the proposed rule, we explained that if this practice were to be followed, we would have proposed that code 97.44 be assigned to MDC 5, DRGs 478 (Other Vascular Procedures with CC) and 479 (Other Vascular Procedures without CC). After hospital charge data became available, we would have considered moving it to other DRGs. However, in accordance with section 533(a) of Public Law 106-554, which requires a more expeditious technique of recognizing new medical services or technology for the hospital inpatient prospective payment system, we will reconsider this longstanding practice when possible. Therefore, as code 97.44 was designed to capture heart assist system removal that is clearly nonoperative, we did not propose to designate 97.44 as a code which the GROUPER recognizes as a procedure. The GROUPER will assign these cases to a medical DRG based on the principal diagnosis, or to a surgical DRG if a surgical procedure recognized by the GROUPER is performed. This assignment can be found in Table 6B, New Procedure Codes, in the Addendum to this rule.
We received no comments on this proposal. However, we did receive comments on another issue in MDC 5, relating to DRGs 110 and 111 (Major Cardiovascular Procedures with and without CC).
Comment: One commenter submitted a case study on stent technology, noting that Medicare payments in their facility were 31.4 percent lower than total costs. This commenter made no recommendations, but stated that often surgeons must use additional stent segments to repair aneurysms, increasing total costs by thousands of dollars.
Response: We do not have a clear understanding of the commenter's statement that often surgeons must use additional stent segments to repair aneurysms, thereby increasing total costs. We are unclear because the device presented to us for new ICD-9-CM code consideration was proposed as a single device, custom-fitted to the patient's needs. We will continue to monitor this technology and the new code (used for discharges on or after October 1, 2001).
Comment: One commenter noted that aortic endografts are assigned to DRGs 110 and 111, and the cost of the device alone is greater than the entire payment for DRG 111. The commenter noted that this is a straightforward issue, and recommended that these cases be assigned specifically to DRG 110.
Response: DRGs 110 and 111 are what we refer to as paired DRGs. Paired DRGs are exactly the same as each other with regard to the principal diagnosis and procedure codes in most cases. However, other aspects of the patient's case have a bearing on DRG assignment, such as the patient's age or the secondary diagnoses (which determine comorbidities or complications in appropriate DRGs). In this case, DRGs 110 and 111 are divided based on the presence or absence of secondary diagnosis codes. If there are no secondary diagnosis codes present, the case will be assigned to DRG 111. It has been our experience that patients not having secondary diagnoses are less expensive for the hospital to treat, thereby resulting in a lower weighted DRG assignment.
Hospitals should code their records completely, recording and submitting all relevant diagnosis and procedure codes having a bearing on the current admission. As noted previously, payment for each DRG is based on the average charges for cases assigned to that DRG as submitted to us by hospitals.
We have received questions from correspondents regarding the appropriateness of the spinal fusion DRGs: DRG 496 (Combined Anterior/Posterior Spinal Fusion); DRG 497 (Spinal Fusion with CC); and DRG 498 (Spinal Fusion without CC). Several correspondents expressed concern about the inclusion of all refusions of the spine into one procedure code, 81.09 (Refusion of spine, any level or technique). The correspondents pointed out that because all refusions using any technique or level are in this one code, Start Printed Page 39842all of these cases are assigned to DRG 497 and DRG 498. They also pointed out that fusion cases involving both an anterior and posterior technique are assigned to DRG 496. Although cases with the refusion code that involve anterior and posterior techniques would appear to be more appropriately assigned to DRG 496, this is not the case.
We recognized this limitation in the refusion codes and further acknowledged that this limitation in the ICD-9-CM coding system creates DRG problems by preventing the assignment to DRG 496 even when both anterior and posterior techniques are used for refusion cases. Therefore, we referred the issue to the ICD-9-CM Coordination and Maintenance Committee and requested the Committee to consider code revisions for the refusions of the spine during its year 2000 public meetings.
After its deliberations, the Committee approved a series of new procedure codes for refusion of the spine that could lead to improvements within DRGs 497 and 498. These new codes, listed below, go into effect on October 1, 2001.
81.30 Refusion of spine, not otherwise specified
81.31 Refusion of atlas-axis spine
81.32 Refusion of other cervical spine, anterior technique
81.33 Refusion of other cervical spine, posterior technique
81.34 Refusion of dorsal and dorsolumbar spine, anterior technique
81.35 Refusion of dorsal and dorsolumbar spine, posterior technique
81.36 Refusion of lumbar and lumbosacral spine, anterior technique
81.37 Refusion of lumbar and lumbosacral spine, lateral transverse process technique
81.38 Refusion of lumbar and lumbosacral spine, posterior technique
81.39 Refusion of spine, not elsewhere classified
As previously stated, all refusions of the spine and corrections of the pseudarthrosis of the spine are assigned to code 81.09. Code 81.09, which is always assigned to DRG 497 or DRG 498, includes refusions at any level of the spine using any technique. With the creation of the new procedure codes listed above, it will be possible to determine the level of the spine at which the refusion is performed, as well as the technique used, and assign the case to a more appropriate DRG.
These new procedure codes should greatly improve our ability to determine the level and technique used in the refusion.
In the past, we have assigned new ICD-9-CM codes to the same DRG to which the predecessor code was assigned. In the proposed rule, we explained that if this practice were followed, these new codes would have been assigned to DRG 497 and 498 as they are currently. After data became available, we would have considered moving them to other DRGs. However, in accordance with section 533(a) of Public Law 106-554, which requires more expeditious methods of recognizing new medical services or technology under the inpatient hospital prospective payment system, we will reconsider this longstanding practice when possible. Since the new codes clearly allow us to identify cases where the technique was either anterior or posterior and these cases are clinically similar and, therefore, should be handled in the same fashion, we proposed to immediately assign these cases on the same basis as the fusion codes (81.00 through 81.09). We would not wait for actual claims data before making this change. These assignments are reflected in Chart 6 and also can be found in Table 6B, in section V. of the Addendum to this final rule.
Comment: One commenter supported the creation of the ICD-9-CM codes for refusions as well as their proposed DRG assignments.
Response: We appreciate the support of the commenter and are adopting the proposed DRG assignments for refusions of spine as final.
In the proposed rule we discussed an inquiry concerning the spinal DRGs that focused on fusions of the cervical spine. The inquirer stated that there was a significant difference between inpatients who undergo anterior cervical spinal fusion and other types of spinal fusion in regard to treatment, recovery time, costs, and risk of complications. Anterior cervical spinal fusions are assigned to procedure code 81.02 (Other cervical fusion, anterior technique). The inquirer pointed out that anterior cervical fusions differ significantly from anterior techniques at other levels since the anatomic approach is far less invasive. Thoracic anterior techniques require working around the cardiac and respiratory systems in the chest cavity, while lumbar anterior techniques require working around bowel and digestive system and the abdominal muscles. The inquirer recommended that code 81.02 be removed from DRGs 497 and 498 and grouped separately.
We analyzed claims data from the FY 2000 MedPAR file containing hospital bills received through May 31, 2000, and confirmed that charges are lower for fusions of the cervical spine than fusions of the thoracic and lumbar spine. This was true for both anterior and posterior cervical fusions of the spine. Our medical consultants agree that the data and their clinical analysis support the creation of new DRGs for cervical fusions of the spine. We proposed to remove procedure codes 81.02 and 81.03 from the spinal fusion DRGs (currently, DRGs 497 and 498) and assign them to new DRGs for cervical spinal fusion with and without CC. We also proposed four groupings for fusion DRGs. The net effect of this change is an increase in the weights for DRGs 497 and 498, since the lower charges for the cervical fusions would be removed. The average standardized charge for all spinal fusions with CCs was $26,957. For all spinal fusions without CCs, the average charge was $16,492. The table below also shows average standardized charges for these types of cases before and after the revisions.
Revised spinal fusion DRGs
Average charge before revisions
Average charge after revisions
DRG 497 Spinal Fusion Except Cervical with CC $26,957 $36,821
DRG 498 Spinal Fusion Except Cervical without CC 17,492 26,297
DRG 519 Cervical Spinal Fusion with CC 26,957
DRG 520 Cervical Spinal Fusion without CC 16,492
Based on the groupings, we proposed the creation of two new DRGs: DRG 519 (Cervical Spinal Fusion with CC); and DRG 520 (Cervical Spinal Fusion without CC). The procedure codes that would be included in the DRGs 519 and 520 are reflected in Chart 6 below.
We also proposed to add the new ICD-9-CM procedure codes for refusion of the cervical spine (81.32 and 81.33) to the new cervical spine fusion DRGs because they are clinically similar.
In addition, we proposed to retitle DRG 497 “Spinal Fusion Except Cervical with CC” and DRG 498 “Spinal Fusion Except Cervical without CC.” The retitled DRGs 497 and 498 would retain fusion codes 81.00, 81.01, and 81.04 through 81.08 and include the new refusion codes 81.30, 81.31, and 81.34 through 81.39, as reflected in Chart 6 below.
Comment: One commenter commended the creation of the new ICD-9-CM codes for spinal refusions and the development of the new DRGs for cervical fusions. This commenter, a manufacturer of devices used for spinal fusions, agreed that cervical fusions on average cost less than lumbar and thoracic fusions. Another commenter who supported the creation of the new DRGs mentioned that this classification would more appropriately reflect the resources used in the varying cases.
Two commenters asserted that DRGs 497 and 498 fail to take into account the cost variations when multi-level spinal fusions are performed. The commenters stated that the cost and complexity of a discharge varies substantially depending on the number of levels performed as part of a fusion procedure. Commenters recommended that new ICD-9-CM procedure codes be created for multi-level spine procedures to track and measure costs. The current ICD-9-CM codes do not differentiate between the number of levels that are fused. The commenter defined multi-level as three or more vertebral segments, either anterior or posterior, or both. In addition, the commenter recommended that these new multi-level fusion codes be assigned to the higher weighted DRG 496. The commenter recommended that DRG 496 be renamed “Multi-Level Spine Procedure Anterior and/or Posterior for Stabilization and/or Correction and/or Refusion.”
Response: We agree that the current ICD-9-CM procedure codes do not differentiate between the number of levels fused. This proposal will be addressed by the ICD-9-CM Coordination and Maintenance Committee at its November 1, 2001 meeting. A potential problem with this recommendation will be the need to avoid overlapping codes. The current fusion codes are based on an axis of the level of the fusion (cervical or lumbar) and an additional axis of the approach (anterior, posterior, or lateral transverse). Devising a modified or additional scheme that utilizes an additional axis of the number of disks fused may be quite challenging. If this scheme requires the use of a set of codes from the new Chapter 17, we could quickly use up these currently empty codes. As far as the recommendation to include these new multi-level fusion codes in DRG 496, this issue will be deferred until after the coding issue is addressed. If new codes are created, they will be included in an upcoming proposed rule along with their proposed DRG assignment.
Since there was support for the proposed changes to the spinal DRGs, these will be implemented as final changes effective October 1, 2001.
We received other correspondence regarding the current DRG assignment for code 81.07, Lumbar and lumbosacral fusion, lateral transverse process technique. The correspondent stated that physicians consider code 81.07 to be a posterior procedure. The patient is placed prone on the operating table and the spine is exposed through a vertical midline incision. The correspondent pointed out that code 81.07 is not classified as a posterior procedure within DRG 496 (Combined Anterior/Posterior Spinal Fusion). Therefore, when 81.07 is reported with one of the anterior techniques fusion codes, it is not assigned to DRG 496. The correspondent recommended that code 81.07 be added to the list of posterior spinal fusion codes for use in determining assignment to DRG 496.
In the proposed rule, we indicated that we consulted with our clinical advisors and they agreed that this addition should be made. Since we proposed to handle the new refusion codes in the same manner as the fusion codes, we also proposed to assign DRG 496 when 81.37 is used with one of the anterior technique fusion or refusion codes. This would be similar to the manner in which code 81.07 is classified. For assignment to DRG 496, we would consider codes 81.02, 81.04, 81.06, 81.32, 81.34, and 81.36 to be anterior techniques and codes 81.03, 81.05, 81.07, 81.08, 81.33, 81.35, and 81.38 to be posterior techniques.
Chart 6.—Revised Composition of DRGS 496, 497, and 498 and Composition of DRG 519 and 520 in MDC 8
Existing DRG 496
Retained in or Added to existing DRG 497
Included in DRG 519 included in DRG 520
Assigned as anterior techniques
Assigned as posterior techniques
Principal or Secondary Procedure Codes:
81.00 Spinal fusion, not otherwise specified X X
81.01 Atlas-axis fusion X X
81.02 Other cervical fusion, anterior technique X X X
81.03 Other cervical fusion, posterior technique X X X
81.04 Lumbar and lumbosacral fusion, anterior technique X X X
81.05 Lumbar and lumbosacral fusion, posterior technique X X X
81.07 Lumbar and lumbosacral fusion, lateral transverse process technique X X X
81.30 Refusion of spine, not otherwise specified X X
81.31 Refusion of atlas-axis spine X X
81.32 Refusion of other cervical spine, anterior technique X X X
81.33 Refusion of other cervical spine, posterior technique X X X
81.34 Refusion of dorsal and dorsolumbar spine, anterior technique X X X
81.35 Refusion of dorsal and dorsolumbar spine, posterior technique X X X
81.36 Refusion of lumbar and lumbosacral spine, anterior technique X X X
81.37 Refusion of lumbar and lumbosacral spine, posterior technique X X X
81.39 Refusion of spine, not elsewhere classified X X
There was no opposition expressed to the changes proposed for posterior spinal fusions; therefore, we are adopting the proposed changes as final.
The California Division of Workers' Compensation notified us of a possible problem with the following spinal DRGs:
DRG 496 (Combined Anterior/Posterior Spinal Fusion)
DRG 497 (Spinal Fusion with CC)
DRG 498 (Spinal Fusion without CC)
DRG 499 (Back & Neck Procedures except Spinal Fusion with CC)
DRG 500 (Back & Neck Procedures except Spinal Fusion without CC)
The Division of Workers' Compensation uses the DRG categories developed by CMS to classify types of hospital care. However, instead of using CMS' weights for determining reimbursement for inpatient services, the Division sets a global fee for all inpatient medical services not otherwise exempted. This fee is established by multiplying the product of the DRG weight (or revised DRG weight for a small number of categories) and the health facility's composite factor by 1.20 to get the maximum amount for worker compensation admissions.
The Division of Workers' Compensation has received reports that the formula it uses for reimbursing cases may be providing inadequate reimbursement. California hospitals and orthopedists have reported that certain spinal surgery DRGs (DRGs 496 through 500) may involve different types of care and/or technologies than those in use at the time these groups were formulated. Health care providers in California report “recent increased use of the new implantation devices, hardware, and instrumentation, coupled with requirements for intensive hospital services accompanying use of new procedures, has led to inadequate reimbursement in these DRGs.” As a short-term response to these concerns, the California Division of Workers' Compensation is exempting the costs of hardware and instrumentation from the global fee of the fee schedule for DRGs 496 through 500. The Division also requested that CMS examine these DRGs for any potential problem under the Medicare reimbursement system.
The ICD-9-CM coding system does not capture specific types of implantation devices, hardware, and instrumentation. Therefore, we were not able to verify the claim that these new devices have led to increased costs in specific cases. We believe that the adoption of a more detailed coding system, such as ICD-10-PCS, would supply greater amounts of detail on these items. However, in the short term, it is not possible to identify a specific problem that involves implantation devices, hardware, and instrumentation.
Comment: As previously stated, we received support for the proposed changes to the spinal fusion DRGs. As was also stated, one commenter pointed out that the current ICD-9-CM codes do not specify the number of levels fused, nor do they specify the types of devices used.
One commenter, who manufactures spinal fusion devices, commended the new ICD-9-CM codes for refusions and the new DRGs for cervical fusions. This commenter also requested new codes specifying the number of levels fused. The commenter stated that typically two devices are used per level and therefore, with increased levels, there would be an increase in the number of infusion devices. The commenter recommended new codes for multi-level spinal fusions, but did not recommend new codes that would specify particular types of devices.
Responses: This coding issue will be addressed at future meetings of the ICD-9-CM Coordination and Maintenance Committee. If new codes are created, their DRG assignment would be addressed in a subsequent proposed rule.
We have received correspondence from a manufacturer of an implantable vascular device requesting that code 86.07 (Insertion of totally implantable vascular access device [VAD]) be assigned as an operative procedure in MDC 11, to DRG 315 (Other Kidney & Urinary Tract O.R. Procedures). This request was inadvertently omitted from the May 4, 2001 proposed rule. Therefore, we are taking this opportunity to discuss possible designation of this procedure code as a code affecting DRG assignment in MDC 11.Start Printed Page 39845
Procedure code 86.07 describes the implantation of a VAD into the chest wall and blood vessels of a patient's upper body. Patients requiring this particular device have been diagnosed with renal (kidney) failure. Insertion of a VAD allows access to the patient's blood for dialysis purposes when other sites for hemodialysis have been exhausted. According to representatives from the manufacturer of one particular VAD used for hemodialysis, this device costs the hospitals $1,750, and is usually inserted in the outpatient setting as opposed to admission for insertion of the device.
The GROUPER program does not recognize code 86.07 as a procedure in other than MDC 9 (Disease and Disorders of the Skin, Subcutaneous Tissue and Breast), in DRGs 269 and 270 (Other Skin, Subcutaneous Tissue & Breast Procedure, with and without CC). Therefore, its presence in any other MDC does not affect DRG assignment. Patients who are admitted with renal failure and who have a VAD inserted will be assigned to DRG 316 (Renal Failure), absent any other surgical procedures. DRG 316 is a medical DRG with a lower relative weight than cases in the surgical DRGs within the same MDC.
We extensively reviewed the MedPAR data. We found that code 86.07 appeared in 358 different DRGs. Of these 358 DRGs, 173 include additional procedures recognized by GROUPER and are therefore considered surgical, while 185 are medical. Because of the space limitations of the ICD-9-CM, code 86.07 is used to describe VAD devices used for other purposes than hemodialysis.
We looked specifically at the cases within DRGs 315 and 316 as shown in the two tables below:
DRG 315 (Surgical)
With code 86.07
Without code 86.07
Number of Cases 421 19,815.
Average Length of Stay 12.5 days 6.8 days.
Average Charges $39,946 $23,061.
DRG 316 (Medical)
Number of Cases 1,020 19,815.
Cases containing code 86.07 have higher average lengths of stay as well as higher average charges than cases not containing this code. We further examined the total number of reported procedures, as well as the range of average charges across both DRGs, for cases containing code 86.07. Both DRGs contain a significant number of additional procedures. The nature of these procedures varies widely, including such divergent procedures as X-rays and scans, injections, dental extraction, cardiac catheterization, aneurysm repair, and laparoscopic cholecystectomy. We also identified 24 cases in DRG 315 and 28 cases in DRG 316 with multiple insertions of the VAD. We believe those instances where the VAD is inserted as an inpatient procedure involve cases where other complications exist, leading to the higher average charges noted above. We are not assigning code 86.07 to DRG 315 as a surgical procedure, but will continue to consider possible alternative specifications of these DRGs.
Additionally, we take this opportunity to clarify correct coding practice. It has come to our attention that a brochure is being distributed with the product that advocates coding insertion of the Lifesite® Hemodialysis Access System using ICD-9-CM procedure code 86.07 in addition to code 39.93 (Insertion of vessel-to-vessel cannula). Inclusion of code 39.93 will force these cases into DRG 315, the higher weighted surgical DRG. Our data review showed 33 such cases of double coding. We would caution hospitals that the use of code 39.93, in the absence of the actual procedure, is erroneous. According to our vascular surgeon consultant, the LifeSite® Hemodialysis Access System as presented to us is not a vessel-to-vessel cannula. It is a device inserted into a vessel. Therefore, providers submitting code 39.93 without the actual procedure having been performed are at risk for review of fraudulent coding practice and DRG upcoding.
This same product brochure contains the name and telephone number of a nationally recognized coding specialist. The addition of this specialist's name and number was included without her knowledge or consent. We take this opportunity to reiterate that LifeSite® Hemodialysis Access System is correctly coded using 86.07 alone.
At its May 11, 2000 public meeting, the ICD-9-CM Coordination and Maintenance Committee considered a request from a manufacturer to create a unique code for the procedure Penile plethysmography with nerve stimulation in DRG 334 (Major Male Pelvic Procedures with CC). The penile plethysmography is a test that can be performed during a radical prostatectomy procedure. During the course of the procedure, the physician places a probe within an area where the prostatic nerves are thought to be located and is able to detect minor changes in penile tumescence or detumescence. This reaction tells the physician that the nerve bundles have been located, which may aid the physician in performing a nerve-sparing radical prostatectomy procedure with precision. The nerve bundles can also be restimulated at the conclusion of the procedure, providing immediate feedback as to whether erectile function will be restored after surgery.
After a presentation on the nerve identifying procedure and review of existing ICD-9-CM codes, the ICD-9-CM Coordination and Maintenance Committee determined that the existing Start Printed Page 39846code 89.58 (Plethysmogram) adequately describes this test.
Radical prostatectomies for patients with cancer of the prostate are grouped in either DRG 334 (Major Male Pelvic Procedures with CC) or DRG 335 (Major Male Pelvic Procedures without CC). We have received a request from a manufacturer of a nerve-identifying device to assign cases containing code 89.58 into DRG 334 only, not into DRG 335. DRG 334 results in higher payments to hospitals. For FY 2002, DRG 334 has a relative weight of 1.5177, and DRG 335 has a relative weight of 1.1047. The manufacturer requested that we designate code 89.58 as an operating room procedure code that would be recognized by the GROUPER software, and make that code applicable only to DRG 334. The manufacturer believed that this would serve to take any cases of nerve sparing out of the lower paying DRG 335, and would make the technology more attractive to hospitals. As paired DRGs 334 and 335 are currently structured, they differ only in whether or not a secondary diagnosis identified as a CC is recorded.
We examined those cases in DRG 334 to which the procedure code for prostatectomy was assigned. Of the total 7,241 cases in DRG 334 identified, 5,611 of these cases contained procedure code 60.5 (Radical prostatectomy). Only three of the prostatectomy cases included code 89.58. There are not a sufficient number of cases on which to base an assessment of the payment for this procedure. Therefore, we did not propose to modify the assignment of code 89.58.
We received one comment on this proposal.
Comment: The commenter argued that the analysis conducted on the procedure code assignment of 89.58 was incomplete, as it did not include evaluation of DRG 335 in the calculations. The commenter added that DRG also includes radical prostatectomies for patients with cancer of the prostate.
Response: We apologize for the omission. Our review of data on DRG 335 showed that the DRG contained 8,125 total cases. There were 8,117 cases that did not contain procedure code 89.58; these cases had average total charges of $12,808. There were 8 cases in this group containing code 89.58. These 8 cases had average total charges of $16,366. We found a subset of 7,050 cases containing procedure code 60.5; these cases had average total charges of $12,772. Within this subset, only 7 cases were reported containing codes 60.5 and 89.58. These 7 cases had average total charges of $16,593.
Even including these additional cases, we identified very few cases in our analysis. Therefore, we are adopting as final our original proposed decision not to modify the assignment of code 89.58 by assigning it exclusively to DRG 334 within MDC 12. However, we will continue to monitor this procedure to determine whether a change in DRG assignment is warranted in the future.
DRG 390 (Neonate with Other Significant Problems) contains newborn or neonate cases with other significant problems not assigned to DRGs 385 through 389, DRG 391, or DRG 469. To be assigned to DRG 389 (Full Term Neonate with Major Problems), the neonate must have one of the principal or secondary diagnosis listed under this DRG. A neonate is assigned to DRG 390 when the neonate has a principal or secondary diagnosis of newborn or neonate with other significant problems that are not assigned to DRG 385 through 389, 391, or 469.
We have received correspondence suggesting a number of changes to be made to DRGs 398 and 391. These changes involve removing two codes from DRG 389 and adding 17 codes to DRG 391, as described below.
The correspondent suggested removing the following codes from DRG 389 and assigning them to DRG 390:
773.0 Hemolytic disease due to RH isoimmunization
773.1 Hemolytic disease due to ABO isoimmunization
The correspondent stated that hemolytic disease due to RH isoimmunization or due to ABO isoimmunization should not be considered a major problem. The correspondent recommended that these two conditions be classified as significant problems instead and thus assigned to DRG 390.
Our medical consultants sought additional advice from the National Association of Children's Hospitals and Related Institutions (NACHRI). (CMS contracts with the 3M Health Information Systems to maintain the DRG system. The medical experts at 3M evaluate proposed DRG changes from a clinical perspective. These medical consultants assist CMS in evaluating alternative proposals.) NACHRI and our medical consultants agree that it is appropriate to remove codes 773.0 and 773.1 from DRG 389. Therefore, we proposed to remove 773.0 and 773.1 from DRG 389 so that neonates with these conditions are assigned to DRG 390.
Comment: Several commenters supported the proposed revisions for newborns within MDC 15. One commenter stated that the code assignments mentioned in the proposed rule are more appropriately classified based on their clinical attributes. Another commenter agreed with the proposed changes, but requested that an additional code be added to those being moved to DRG 391 (Normal Newborn). Specifically, the commenter requested that code 779.3, Feeding problems in newborns, be listed under DRG 391. Currently, when this code is listed as a secondary code, it results in the assignment of the neonate to DRG 390. The commenter stated that this condition and its resource consumption should not cause the neonate to be classified under DRG 390.
Response: We discussed this additional issue with our medical consultants and they agreed that code 779.3 should also be listed under DRG 391. They concurred that the addition of this code as a secondary diagnosis should not lead to the newborn being classified as having a significant problem. Therefore, code 779.3 will be included among the codes being moved to DRG 391 as of October 1, 2001.
Comment: One commenter suggested that codes 773.0 and 773.1 be removed from DRG 387 (Prematurity with major problems) in addition to DRG 389. The list of major problems in DRGs 389 and 387 mirror each other. The only difference is that DRG 387 includes premature newborns. The commenter asked us to consider codes 773.0 and 773.1 as significant problems for newborns and classify them into DRG 390, which would make them applicable for premature and full-term newborns.
Response: We agree with the commenter. We are removing codes 773.0 and 773.1 from DRG 389 as well as DRG 387. This removal will result in these cases being assigned to DRG 390 (Neonate with Other Significant Problems).
We also have received correspondence with recommendations for changes to DRG 391. The correspondent pointed out that the following secondary codes currently lead to the assignment of the neonate to DRG 390 (Neonate with Other Significant Problems). The correspondent believed that the conditions described by these codes Start Printed Page 39847should not cause the neonate to be classified under DRG 390 when reported as a secondary diagnosis. The correspondent recommended that these conditions be listed under DRG 391 (Normal Newborn).
478.1 Other diseases of nasal cavity and sinuses
520.6 Disturbances in tooth eruption
623.8 Other specified noninflammatory disorders of vagina
709.00 Dyschromia, unspecified
709.01 Vitiglio
709.09 Dyschromia, Other
744.1 Accessory auricle
754.61 Congenital pes planus
757.33 Congenital pigmentary anomalies of skin
757.39 Other specified anomaly of skin
764.08 “Light for dates” without mention of fetal malnutrition, 2,000-2,499 grams
764.98 Fetal growth retardation, unspecified, 2,000-2,499 grams
772.6 Cutaneous hemorrhage
794.15 Abnormal and auditory function studies
796.4 Other abnormal clinical findings
V20.2 Routine infant or child health check
V72.1 Examination of ears and hearing
Our medical consultants also sought the advice of NACHRI on this recommendation. NACHRI reviewed the list of codes and agreed that none of these conditions should be considered to be a significant problem for a neonate. NACHRI concurred that neonates with these secondary diagnoses should be classified as normal newborns. Therefore, we proposed to add the codes listed above to DRG 391 and not classify them to DRG 390 when reported as a secondary diagnosis.
Comment: One commenter expressed concern that the weights assigned to five newborn DRGs (DRGs 385, 368, 387, 388, and 389) are undervalued. The commenter pointed out that legislation mandating Early Hearing Detection and Intervention (EHDI) has been passed in 35 States plus the District of Columbia. In these States, hearing screening must be performed prior to the newborn's discharge from the hospital unless prevented by medical complications. The cost per screening ranges from $15 to $30, which includes personnel, supplies, and equipment costs which are amortized over 3 years. The screening also includes costs for babies that require diagnostic evaluation.
The commenter requested that data from States that have not implemented EHDI programs be deleted from the Medicare supplemental database for, at a minimum, DRG 391 (Normal Newborn). The commenter stated that non-Medicare data used for developing the weights for the five newborn DRGs do not represent average costs if some of the 19 States that supply supplemental non-Medicare data are States that perform hearing screenings on less than 90 percent of newborns. The commenter further requested that we use data only from States that have EHDI programs that are operational at the 90 percent level. The commenter provided a list of States that meet these criteria.
Response: While we appreciate the commenter's furnishing us with information on the costs of providing services such as hearing screenings, it would be inappropriate for us to use this one service to determine whether or not to include a State's data because the State does not provide the service at a 90-percent level. The DRG weights are based on averages. As hospitals elect to include or exclude services, the weights will change over time. Therefore, we are not developing a criterion to exclude hospital data from States that do not have a 90-percent compliance level with EHDI.
Comment: One commenter noted that new procedure code 75.38, Fetal pulse osimetry, was classified as a nonoperative procedure code in Table 6B of the Addendum of the proposed rule. As a nonoperative procedure, it was not assigned to an MDC or to specific DRGs. The commenter requested that we assign code 75.38 to MDC 14 (Pregnancy, Childbirth and Puerperium), and the following DRGs:
DRG 370—(Caesarean Section with CC)
DRG 371—(Caesarean Section without CC)
DRG 372—(Vaginal Delivery with Complicating Diagnosis)
DRG 373—(Vaginal Delivery without CC)
The commenter believed it was critical that the clinical benefits and use of fetal pulse oximetry be closely tracked in order to monitor clinical outcomes and to recognize potential economic advantages. The commenter acknowledged that most labor and delivery patients are not Medicare beneficiaries. However, other third party payers benchmark hospital inpatient payment rates from Medicare DRGs. The commenter stated that if code 75.38 does not contribute or link to a DRG, it is often simply not coded. The commenter further stated that fetal oximetry is an exciting and significant emerging technology and that much knowledge can be gained by understanding its usage in the context of labor and delivery services.
Response: The commenter requested that 75.38 be assigned to the DRGs for deliveries (DRG 370 through 373). However, these DRGs are currently assigned based on the procedure codes for the specific type of delivery (caesarian or vaginal). Adding the procedure code 75.38 to these delivery DRGs would not affect the DRG assignment. The cases would still be assigned to the appropriate DRG based on the type of delivery, not whether the baby received fetal pulse oximetry. If the commenter is suggesting that the fetal pulse oximetry code, on its own, should lead to the DRG assignment, this option is not workable. Without knowing that the mother actually delivered, and the type of delivery, one would not be able to assign the case to one of the delivery DRGs. Once one knew through the procedure codes that the mother delivered, and the type of delivery, the addition of 75.38 would not add to the DRG assignment.
The commenter did not make an argument as to why 75.38 was incorrectly classified as a nonoperating room procedure. While we appreciate the commenter's desire that this new procedure code be used, assigning the code to existing DRGs is not consistent with the structure of DRGs. Procedure codes are only assigned to DRGs when they effect the DRG assignment logic. Therefore, we are not changing the operating room status of code 75.38, nor are we adding it to the delivery DRGs. Code 75.38 will be considered a nonoperative procedure.
The Medicare Code Editor (MCE) is a front-end software program that detects and reports errors in the coding of claims data. The age conflict edit detects inconsistencies between a patient's age and any diagnosis on the patient's record. A subset of diagnoses is considered valid only for patients over the age of 14 years. These diagnoses are identified as “adult” diagnoses and range in age from 15 through 124 years. Therefore, any codes included on the Newborn Diagnoses edit are valid only for patients under age 14.
It has come to our attention that cases including the ICD-9-CM code 770.7, Chronic respiratory disease arising in the perinatal period, are being rejected. However, a condition such as bronchopulmonary dysplasia always originates in the perinatal period, so regardless of the patient's age, this condition is always coded as 770.7. The age at which the diagnosis was established or the age at continuing treatment does not affect the assignment of code 770.7.Start Printed Page 39848
Because correct coding is causing these claims to be rejected, in the May 4 proposed rule we proposed to remove code 770.7 from the Newborn Diagnoses edit in the MCE, as well as remove it from DRG 387 (Prematurity with Major Problems) and DRG 389 (Full Term Neonate with Major Problems). Clinical conditions in code 770.7, such as pulmonary fibrosis, would group to DRG 92 (Interstitial Lung Disease with CC) and DRG 93 (Interstitial Lung Disease without CC). Therefore, we proposed the addition of code 770.7 to DRGs 92 and 93, as they are most similar clinically. We indicated that we would monitor these cases in upcoming MedPAR data to ascertain that the cases consume similar resources.
We received no comments on these proposals, and are, therefore, adopting the change as final.
DRG 434 (Alcohol/Drug Abuse or Dependency, Detoxification or Other Symptomatic Treatment with CC) is assigned when the patient has a principal diagnosis of alcohol or drug abuse or dependence along with a secondary diagnosis classified as a CC. If these patients do not have a CC, they are assigned to DRG 435 (Alcohol/Drug Abuse or Dependency, detoxification or Other Symptomatic Treatment without CC). When the patients receive rehabilitation and detoxification therapy during the stay, they are assigned to DRG 437 (Alcohol/Drug Dependence, Combined Rehabilitation and Detoxification Therapy). If the patients receive only rehabilitation therapy, they are assigned to DRG 436 (Alcohol/Drug Dependence with Rehabilitation Therapy).
We have received inquiries as to why the relative weight for DRG 437, which includes both rehabilitation and detoxification (for FY 2001, the relative weight is .6606, with a geometric mean length of stay of 7.5) is lower than the FY 2001 relative weight for DRG 434, which includes only detoxification (.7256, with a geometric mean length of stay of 3.9). Likewise, the FY 2001 relative weight for DRG 436, which includes only rehabilitation (.7433), is higher than the FY 2001 relative weight for DRG 437, which includes combined rehabilitation and detoxification therapy (.6606). The inquirers indicated that those patients receiving the combination therapy would be expected to have a longer length of stay, require more services, and, therefore, be more costly to treat.
We analyzed data from the FY 2000 MedPAR file and did not find support for the inquirers' assertion that combination therapy is more costly to treat. The relative weights indicate that the presence of a CC in DRG 434 leads to a significantly higher weight than is found in DRG 435, which does not have a CC. Therefore, we analyzed the alcohol/drug DRGs and focused on eliminating the distinction between rehabilitation and rehabilitation with detoxification and assessing the impact of CCs. We combined data on DRGs 436 and 437 and then subdivided the data based on the presence or absence of a CC. The following table contains the results of the analysis.
Average Charges for Cases—With and Without CCs
DRGS
With CC
Without CC
Detoxification Cases—DRG 434 and DRG 435 3,298 $8,548 5.0 9,689 $5,111 4.1
All Rehabilitation Cases—DRG 436 and DRG 437 3,298 8,117 10.1 4,473 7,407 9.6
We found that, for both the detoxification and rehabilitation DRGs, the with-CC group has higher charges than the without-CC group. However, the with-CC groups still contain the anomaly that the detoxification DRG 434 has a slightly higher average charge than the combined rehabilitation DRGs 436 and 437. It appears that any significant medical problems as indicated by the presence of a CC dominate the cost incurred by hospitals for treating alcohol and drug abuse patients. For the without-CC groups, the detoxification DRG 435 has substantially lower average charges than the combined rehabilitation DRGs 436 and 437. Because the average charges of the with-CC for both the detoxification DRG 434 and combined rehabilitation DRGs 436 and 437 have similar average charges, we proposed to combine these two groups.
Based on the results of our analysis, we proposed to restructure MDC 20 as follows. We first identified those cases with a principal diagnosis within MDC 20 where the patient left against medical advice. These cases are found in DRG 433 (Alcohol/Drug Abuse or Dependence, Left Against Medical Advice (AMA)). We next identified all remaining cases with a principal diagnosis within MDC 20 where there was a CC. We assigned these cases to a new DRG, (Alcohol/Drug Abuse or Dependence with CC). The remaining cases (without CC and did not leave against medical advice) were then divided into two new DRGs based on whether or not the patient received rehabilitation (Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy; and Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy).
The following table illustrates the number of patients and average charges for each of the four proposed DRGs.
Frequencies and Average Charges for New DRGs
Group title
Number of cases
Average charges
433 Alcohol/Drug Abuse or Dependence, Left Against Medical Advice 3,509 $3,855
521 Alcohol/Drug Abuse or Dependence with CC 18,235 8,470
522 Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy 4,473 7,407
523 Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy 9,689 5,111
This table illustrates that groups based first on the presence of CC and then on whether or not the patient receives rehabilitation therapy provide a much better explanation of differences in charges. Therefore, we proposed to retain DRG 433, make DRGs 434 through 437 invalid, and create new DRGs 521, 522, and 523 to include the diagnosis and procedure codes reflected in Chart 7 below.
Chart 7.—Restructure of MDC 20 (Alcohol/Drug Use and Alcohol/Drug-Induced Organic Mental Disorders)
Diagnosis and procedure code
Included in Existing DRG 433
Principal diagnosis:
All principal diagnosis within existing MDC 20 involving cases in which patients left against medical advice (AMA) X
All principal diagnoses within existing MDC 20 where there is a CC and where patient did not leave against medical advice (AMA) X
All principal diagnoses within existing MDC 20 without CC and where patient did not leave against medical advice (AMA)
All principal diagnoses in existing MDC 20 without CC involving cases where patients did not leave against medical advice (AMA) X
94.61 Alcohol rehabilitation X
94.63 Alcohol rehabilitation and detoxification X
94.64 Drug rehabilitation X
94.66 Drug rehabilitation and detoxification X
94.67 Combined alcohol and drug rehabilitation X
94.69 Combined alcohol and drug rehabilitation and detoxification X
Comment: One commenter was uncertain as to the intent of the reclassification of the DRGs to identify alcohol/drug use and alcohol/drug-induced organic mental disorders. The commenter expressed concern that the cases associated with alcohol/drug use would have a lower overall weight relative to the overall average weight of these cases in FY 2001. The commenter requested further information on the impact of this change in the final rule. Additionally, the commenter recommended that the title for DRG 521 be changed from “Alcohol/Drug Abuse or Dependence with CC” to “Alcohol/Drug Abuse with CC, with or without Rehabilitation Therapy.”
Response: As described above, for FY 2001, cases receiving combined rehabilitation and detoxification (DRG 437) had a lower relative weight than patients receiving only detoxification (DRG 434) or rehabilitation (DRG 436). Since these relative weights are derived from actual claims data, we decided to review the issue to determine if other factors had any impact. It would be expected that those patients receiving the combination therapy would have a longer length of stay, require more services, and therefore be more costly to treat. This was not supported by the data.
The factor that seems to contribute the greatest to the costs of these cases is the presence of a CC. The presence of a CC had a greater impact on the average charges than did factors such as detoxification or rehabilitation. Once the importance of this factor was determined, the cases not leaving against medical advice (DRG 433) were split on whether or not a CC was present. Those with a CC were assigned to new DRG 521. The remaining cases were then split based on whether or not rehabilitation was provided.
As can be seen from the FY 2002 relative weights in the chart below, MDC 20 patients who have a CC are considerably more expensive to treat. They have the highest relative weight among this set of DRGs. The second highest weight is assigned to MDC 20 cases without CC who also received rehabilitation services.
DRG title
Number of of cases
Final weights
DRG 433 Alcohol/Drug Abuse or Dependence, Left AMA 5,522 .2888
DRG 521 Alcohol/Drug Abuse or Dependence with CC 28,014 .7355
DRG 522 Alcohol/Drug Abuse or Dependence without CC, with Rehabilitation Therapy 6,852 .6249
DRG 523 Alcohol/Drug Abuse or Dependence without CC, without Rehabilitation Therapy 14,954 .3997
As can be seen from this chart, the majority of patients are assigned to DRG 521, which has the highest relative weight among the MDC 20 DRGs. As is the case for all DRGs, the relative weights reflect hospitals' actual charges submitted for bills in the FY 2000 MedPAR file. Data support the new splits based first on the presence of a CC and then on the presence of rehabilitation therapy. Therefore, we are adopting the proposed DRG classification changes as final without change.
While we appreciate the comment on modifying the title for DRG 521, we believe that it does not add to the clarity of the DRG. All MDC 20 patients who have not left AMA but who have a CC are assigned to DRG 521. The presence or absence of a code for rehabilitation therapy does not effect the DRG assignment for these cases. Therefore, we are adopting the proposed title as final without change.
Effective October 1, 2000, ICD-9-CM diagnosis codes 783.2 (Abnormal loss of weight) and 783.4 (Lack of expected normal physiological development) were made invalid (65 FR 47171). These Start Printed Page 39850two old diagnosis codes were expanded to five digits and the following new diagnosis codes were created:
783.21 Loss of weight
783.22 Underweight
783.40 Unspecified lack of normal physiological development
783.41 Failure to thrive
783.42 Delayed milestones
783.43 Short stature
These six revised codes were created in response to an industry request. Specifically, code 783.2 did not differentiate between whether the patient had lost weight recently or whether the patient was underweight. Code 783.4 was expanded to capture concepts such as failure to thrive, delayed milestones, and short stature. None of these concepts were captured in the old codes.
We listed these new codes in the August 1, 2000 final rule on the hospital inpatient prospective payment system in Table 6A—New Diagnosis Codes (65 FR 47169). At the time the final rule was published, all of these codes were assigned to DRGs 296 through 298. After the final rule was published, we received an inquiry as to why these new diagnosis codes were not included in MDC 25 as human immunodeficiency virus (HIV)-related conditions. The inquirer pointed out that the predecessor codes (783.2 and 783.4) were included in MDC 25 as HIV-related conditions and suggested that the new codes be added to MDC 25. These cases will be assigned to other MDCs if the patient does not have HIV.
In the proposed rule, we stated that we agreed that the expanded codes should have been placed in the MDC 25 as HIV-related conditions. The omission was an oversight. Therefore, we proposed to add diagnosis codes 783.21, 783.22, 783.40, 783.41, 783.42, and 783.43 as HIV-related conditions within MDC 25. When these six revised codes are reported with code 042 HIV, the patient will be classified within MDC 25.
Comment: One commenter supported the placement of codes 783.21, 783.22, 783.40, 783.41, 783.42, and 783.43, as HIV-related conditions within MDC 25.
Response: We appreciate the commenter's support and are adopting the proposed changes as final.
Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different DRG within the MDC to which the principal diagnosis is assigned. Therefore, it is necessary to have a decision rule by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most resource intensive to least, performs that function. Its application ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource-intensive surgical class.
Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibration, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications, to determine if the ordering of classes coincided with the intensity of resource utilization, as measured by the same billing data used to compute the DRG relative weights.
A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class “kidney transplant” consists of a single DRG (DRG 302) and the class “kidney, ureter and major bladder procedures” consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource-intensive surgical class involves weighting each DRG for frequency to determine the average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of “other OR procedures” as discussed below.
This methodology may occasionally result in a case involving multiple procedures being assigned to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER searches for the procedure in the most resource-intensive surgical class, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average relative weight is ordered above a surgical class with a higher average relative weight. For example, the “other OR procedures” surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the relative weight for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The “other OR procedures” class is a group of procedures that are least likely to be related to the diagnoses in the MDC but are occasionally performed on patients with these diagnoses. Therefore, these procedures should only be considered if no other procedure more closely related to the diagnoses in the MDC has been performed.
A second example occurs when the difference between the average weights for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy since, by virtue of the hierarchy change, the relative weights are likely to shift such that the higher-ordered surgical class has a lower average weight than the class ordered below it.
Based on the preliminary recalibration of the DRGs, we proposed the modification of the surgical hierarchy as set forth below. As we stated in the September 1, 1989 final rule (54 FR 36457), we are unable to test the effects of proposed revisions to the surgical hierarchy and to reflect these changes in the proposed relative weights due to the unavailability of the revised GROUPER software at the time the proposed rule is prepared. Rather, we simulate most major classification changes to approximate the placement of cases under the proposed reclassification and then determine the average charge for each DRG. These average charges then serve as our best estimate of relative resource use for each surgical class. We test the proposed surgical hierarchy changes after the revised GROUPER is received and reflect the final changes in the DRG relative weights in the final rule. Further, as discussed in section II.C. of this preamble, we anticipate that the final recalibrated weights will be somewhat different from those proposed, because they will be based on more complete data. Consequently, in the proposed rule we stated that further revision of the hierarchy, using the above principles, might be necessary in the final rule.
In the May 4 proposed rule, we proposed to revise the surgical hierarchy for the pre-MDC DRGs, MDC 5 (Diseases and Disorders of the Circulatory System), MDC 8 (Diseases Start Printed Page 39851and Disorders of the Musculoskeletal System & Connective Tissue) and MDC 20 (Alcohol/Drug Use & Alcohol/Drug Induced-Organic Mental Disorders) as follows:
In the pre-MDC DRGs, we proposed to reorder Lung Transplant (DRG 495) above Bone Marrow Transplant (DRG 481). We also proposed to reorder Simultaneous Pancreas/Kidney Transplant (DRG 512) and Pancreas Transplant (DRG 513) above Lung Transplant (DRG 495).
In MDC 5, we proposed to reorder Cardiac Defibrillator Implants (DRGs 514 and 515) above Other Cardiothoracic Procedures (DRG 108). We also proposed to reorder Percutaneous Cardiovascular Procedures (DRGs 516, 517, and 518) above Other Vascular Procedures (DRGs 478 and 479).
In MDC 8, we proposed to reorder Cervical Spinal Fusion (DRGs 519 and 520) above Back & Neck Procedures Except Spinal Fusion (DRGs 499 and 500).
In MDC 20, we proposed to order as follows: Alcohol/Drug Abuse or Dependence, Left AMA (DRG 433) above Alcohol/Drug Abuse or Dependence With CC (DRG 521); Alcohol/Drug Abuse or Dependence With CC (DRG 521) above Alcohol/Drug Abuse or Dependence With Rehabilitation Therapy Without CC (DRG 522); and Alcohol/Drug Abuse or Dependence With Rehabilitation Therapy Without CC (DRG 522) above Alcohol/Drug Abuse or Dependence Without Rehabilitation Therapy Without CC (DRG 523).
Comment: One commenter expressed support for hierarchy proposals.
Response: We appreciate the commenter's support. Based on a test of the proposed revisions using the March 2001 update of the FY 2000 MedPAR file and the revised GROUPER software, we have found that the revisions are still supported by the data, and no additional changes are indicated. Therefore, we are adopting these proposed changes as final.
In the September 1, 1987 final notice (52 FR 33143) concerning changes to the DRG classification system, we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered a valid CC in combination with a particular principal diagnosis. Thus, we created the CC Exclusions List. We made these changes for the following reasons: (1) to preclude coding of CCs for closely related conditions; (2) to preclude duplicative coding or inconsistent coding from being treated as CCs; and (3) to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. We developed this standard list of diagnoses using physician panels to include those diagnoses that, when present as a secondary condition, would be considered a substantial complication or comorbidity. In previous years, we have made changes to the standard list of CCs, either by adding new CCs or deleting CCs already on the list. We stated in the proposed rule that we did not propose to delete any of the diagnosis codes on the CC list at that time.
In the May 19, 1987 proposed notice (52 FR 18877) concerning changes to the DRG classification system, we explained that the excluded secondary diagnoses were established using the following five principles:
Chronic and acute manifestations of the same condition should not be considered CCs for one another (as subsequently corrected in the September 1, 1987 final notice (52 FR 33154)).
Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for a condition should not be considered CCs for one another.
Conditions that may not coexist, such as partial/total, unilateral/bilateral, obstructed/unobstructed, and benign/malignant, should not be considered CCs for one another.
The same condition in anatomically proximal sites should not be considered CCs for one another.
Closely related conditions should not be considered CCs for one another.
The creation of the CC Exclusions List was a major project involving hundreds of codes. The FY 1988 revisions were intended only as a first step toward refinement of the CC list in that the criteria used for eliminating certain diagnoses from consideration as CCs were intended to identify only the most obvious diagnoses that should not be considered complications or comorbidities of another diagnosis. For that reason, and in light of comments and questions on the CC list, we have continued to review the remaining CCs to identify additional exclusions and to remove diagnoses from the master list that have been shown not to meet the definition of a CC. (See the September 30, 1988 final rule (53 FR 38485) for the revision made for the discharges occurring in FY 1989; the September 1, 1989 final rule (54 FR 36552) for the FY 1990 revision; the September 4, 1990 final rule (55 FR 36126) for the FY 1991 revision; the August 30, 1991 final rule (56 FR 43209) for the FY 1992 revision; the September 1, 1992 final rule (57 FR 39753) for the FY 1993 revision; the September 1, 1993 final rule (58 FR 46278) for the FY 1994 revisions; the September 1, 1994 final rule (59 FR 45334) for the FY 1995 revisions; the September 1, 1995 final rule (60 FR 45782) for the FY 1996 revisions; the August 30, 1996 final rule (61 FR 46171) for the FY 1997 revisions; the August 29, 1997 final rule (62 FR 45966) for the FY 1998 revisions; the July 31, 1998 final rule (63 FR 40954) for the FY 1999 revisions, and the August 1, 2000 final rule (65 FR 47064) for the FY 2001 revisions.) In the July 30, 1999 final rule (64 FR 41490) we did not modify the CC Exclusions List for FY 2000 because we did not make any changes to the ICD-9-CM codes for FY 2000.
In this final rule, we are making a limited revision of the CC Exclusions List to take into account the changes that will be made in the ICD-9-CM diagnosis coding system effective October 1, 2001. (See section II.B.11. below, for a discussion of ICD-9-CM changes.) These changes are being made in accordance with the principles established when we created the CC Exclusions List in 1987.
Tables 6F and 6G in section V. of the Addendum to this final rule contain the revisions to the CC Exclusions List that will be effective for discharges occurring on or after October 1, 2001. Each table shows the principal diagnoses with changes to the excluded CCs. Each of these principal diagnoses is shown with an asterisk, and the additions or deletions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.
CCs that are added to the list are in Table 6G—Additions to the CC Exclusions List. Beginning with discharges on or after October 1, 2001, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6H—Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 2001, the indented diagnoses will be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can be obtained from the National Technical Information Service (NTIS) of the Department of Commerce. It is available in hard copy for $133.00 plus shipping and handling. A request for the FY 1988 CC Exclusions List (which should Start Printed Page 39852include the identification accession number (PB) 88-133970) should be made to the following address: National Technical Information Service, United States Department of Commerce, 5285 Port Royal Road, Springfield, VA 22161; or by calling (800) 553-6847.
Users should be aware of the fact that all revisions to the CC Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, and 1999) and those in Tables 6F and 6G of this document must be incorporated into the list purchased from NTIS in order to obtain the CC Exclusions List applicable for discharges occurring on or after October 1, 2001. (Note: There was no CC Exclusions List in FY 2000 because we did not make changes to the ICD-9-CM codes for FY 2000.)
Alternatively, the complete documentation of the GROUPER logic, including the current CC Exclusions List, is available from 3M/Health Information Systems (HIS), which, under contract with CMS, is responsible for updating and maintaining the GROUPER program. The current DRG Definitions Manual, Version 18.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 19.0 of this manual, which includes the final FY 2002 DRG changes, will be available in October 2001 for $225.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested.
Each year, we review cases assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among these DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none of the OR procedures performed are related to the principal diagnosis. These DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. DRG 476 is assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis:
60.0 Incision of prostate
60.12 Open biopsy of prostate
60.15 Biopsy of periprostatic tissue
60.18 Other diagnostic procedures on prostate and periprostatic tissue
60.21 Transurethral prostatectomy
60.29 Other transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostatic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with DRG 477 assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis. The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal diagnosis, was published in Table 6C in section IV. of the Addendum to the September 30, 1988 final rule (53 FR 38591). As part of the final rules published on September 4, 1990 (55 FR 36135), August 30, 1991 (56 FR 43212), September 1, 1992 (57 FR 23625), September 1, 1993 (58 FR 46279), September 1, 1994 (59 FR 45336), September 1, 1995 (60 FR 45783), August 30, 1996 (61 FR 46173), and August 29, 1997 (62 FR 45981), we moved several other procedures from DRG 468 to 477, and some procedures from DRG 477 to 468. No procedures were moved in FY 1999, as noted in the July 31, 1998 final rule (63 FR 40962); in FY 2000, as noted in the July 30, 1999 final rule (64 FR 41496); or in FY 2001, as noted in the August 1, 2000 final rule (65 FR 47064).
We annually conduct a review of procedures producing assignment to DRG 468 or DRG 477 on the basis of volume, by procedure, to see if it would be appropriate to move procedure codes out of these DRGs into one of the surgical DRGs for the MDC into which the principal diagnosis falls. The data are arrayed two ways for comparison purposes. We look at a frequency count of each major operative procedure code. We also compare procedures across MDCs by volume of procedure codes within each MDC.
Our medical consultants identified those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this year's review, we did not identify any necessary changes in procedures under DRG 477 and, therefore, we did not propose to move any procedures from DRG 477 to one of the surgical DRGs. However, our medical consultants have identified a number of procedure codes that should be removed from DRG 468 and put into more clinically coherent DRGs. The movements of these codes are specified in the charts below:
Movement of Procedure Codes From DRG 468
Procedure code
Included in DRG
MDC 1—Diseases and Disorders of the Nervous System
5495 Peritoneal Incision 7 Peripheral and Cranial Nerve and Other Nervous System Procedures with CC.
5495 Peritoneal Incision 8 Peripheral and Cranial Nerve and Other Nervous System Procedures without CC.
MDC 3—Diseases and Disorders of the Ear
3821 Blood Vessel Biopsy 63 Other Ear, Nose, Mouth and Throat OR Procedure.
MDC 4—Diseases and Disorders of the Respiratory System
3821 Blood Vessel Biopsy 76 Other Respiratory System OR Procedures with CC.
3929 Vascular Shunt & Bypass NEC 76 Other Respiratory System OR Procedures with CC.
3931 Suture of Artery 76 Other Respiratory System OR Procedures with CC.
5411 Exploratory Laparotomy 76 Other Respiratory System OR Procedures with CC.
7749 Bone Biopsy NEC 76 Other Respiratory System OR Procedures with CC.
8669 Free Skin Graft NEC 76 Other Respiratory System OR Procedures with CC.
MDC 5—Diseases and Disorders of the Circulatory System
3402 Exploratory Thoracotomy 120 Other Circulatory System OR Procedures.
3403 Reopen Thoractomy Site 120 Other Circulatory System OR Procedures.
3421 Transpleura Thoracoscopy 120 Other Circulatory System OR Procedures.
3422 Mediastinoscopy 120 Other Circulatory System OR Procedures.
3426 Open Mediastinal Biopsy 120 Other Circulatory System OR Procedures.
436 Distal Gastrectomy 120 Other Circulatory System OR Procedures.
437 Partial Gastrectomy with Jejunal Anastomosis 120 Other Circulatory System OR Procedures.
4389 Partial Gastrectomy 120 Other Circulatory System OR Procedures.
4399 Total Gastrectomy 120 Other Circulatory System OR Procedures.
4561 Multiple Segment Small Bowel Excision 120 Other Circulatory System OR Procedures.
4562 Partial Small Bowel Resection NEC 120 Other Circulatory System OR Procedures.
4572 Cecectomy 120 Other Circulatory System OR Procedures.
4573 Right Hemicolectomy 120 Other Circulatory System OR Procedures.
4574 Transverse Colon Resection 120 Other Circulatory System OR Procedures.
4575 Left Hemicolectomy 120 Other Circulatory System OR Procedures.
4579 Partial Large Bowel Excision NEC 120 Other Circulatory System OR Procedures.
458 Total Intra-Abdominal Colectomy 120 Other Circulatory System OR Procedures.
4593 Small-to-Large Bowel NEC 120 Other Circulatory System OR Procedures.
4603 Large Bowel Exteriorization 120 Other Circulatory System OR Procedures.
4613 Permanent Colostomy 120 Other Circulatory System OR Procedures.
4709 Other Appendectomy 120 Other Circulatory System OR Procedures.
4862 Anterior Rectal Resection With Colostomy 120 Other Circulatory System OR Procedures.
4863 Anterior Rectal Resection NEC 120 Other Circulatory System OR Procedures.
4869 Rectal Resection 120 Other Circulatory System OR Procedures.
5012 Open Liver Biopsy 120 Other Circulatory System OR Procedures.
540 Abdominal Wall Incision 120 Other Circulatory System OR Procedures.
MDC 6—Diseases and Disorders of the Digestive System
5122 Cholecystectomy 170 Other Digestive System OR Procedures with CC.
5122 Cholecystectomy 171 Other Digestive System OR Procedures without CC.
5123 Laparoscopic Cholecystectomy 170 Other Digestive System OR Procedures with CC.
5132 GB-To-Intestine Anastomosis 170 Other Digestive System OR Procedures with CC.
5136 Choledochoenterostomy 170 Other Digestive System OR Procedures with CC.
5136 Choledochoenterostomy 171 Other Digestive System OR Procedures without CC.
5137 Hepatic Duct-GI Anastomosis 170 Other Digestive System OR Procedures with CC.
5137 Hepatic Duct-GI Anastomosis 171 Other Digestive System OR Procedures without CC.
5159 Bile Duct Incision NEC 170 Other Digestive System OR Procedures with CC.
5159 Bile Duct Incision NEC 171 Other Digestive System OR Procedures without CC.
MDC 7—Diseases and Disorders of the Hepatobiliary System and Pancreas
540 Abdominal Wall Incision 201 Other Heptobiliary and Pancreas Procedure.
MDC 8—Diseases and Disorders of the Musculoskeletal System and Connective Tissue
3479 Other Chest Wall Repair 233 Other Musculoskeletal System & Connective Tissue OR Procedure with CC.
MDC 11—Diseases and Disorders of the Kideny and Urinary Tract
540 Abdominal Wall Incision 315 Other Kidney & Urinary Tract OR Procedure.
5451 Laparoscopic Periton Adhesiolysis 315 Other Kidney & Urinary Tract OR Procedure.
5459 Other Periton Adhesiolysis 315 Other Kidney & Urinary Tract OR Procedure.
We also annually review the list of ICD-9-CM procedures that, when in combination with their principal diagnosis code, result in assignment to DRGs 468, 476, and 477, to ascertain if any of those procedures should be moved from one of these DRGs to another of these DRGs based on average charges and length of stay. We look at the data for trends such as shifts in treatment practice or reporting practice that would make the resulting DRG assignment illogical. If our medical consultants were to find these shifts, we would propose moving cases to keep the DRGs clinically similar or to provide payment for the cases in a similar manner. Generally, we move only those procedures for which we have an adequate number of discharges to analyze the data. Based on our review this year, we did not propose to move any procedures from DRG 468 to DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 477 to DRGs 468 or 476.
Based on our review this year, we did not propose to add any diagnosis codes to MDCs.
We received one comment in support of the proposed changes to the procedure codes in DRG 468, 476, and 477. In this final rule, we are adopting these proposed changes without further modification.
As described in section II.B.1. of this preamble, the ICD-9-CM is a coding system that is used for the reporting of diagnoses and procedures performed on a patient. In September 1985, the ICD-9-CM Coordination and Maintenance Committee was formed. This is a Federal interdepartmental committee, co-chaired by the National Center for Health Statistics (NCHS) and CMS, charged with maintaining and updating the ICD-9-CM system. The Committee is jointly responsible for approving coding changes, and developing errata, addenda, and other modifications to the ICD-9-CM to reflect newly developed procedures and technologies and newly identified diseases. The Committee is also responsible for promoting the use of Federal and non-Federal educational programs and other communication techniques with a view toward standardizing coding applications and upgrading the quality of the classification system.
The NCHS has lead responsibility for the ICD-9-CM diagnosis codes included in the Tabular List and Alphabetic Index for Diseases, while CMS has lead responsibility for the ICD-9-CM procedure codes included in the Tabular List and Alphabetic Index for Procedures.
The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA) (formerly American Medical Record Association (AMRA)), the American Hospital Association (AHA), and various physician specialty groups as well as physicians, medical record administrators, health information management professionals, and other members of the public to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies.
The Committee presented proposals for coding changes for implementation in FY 2002 at public meetings held on May 11, 2000 and November 17, 2000, and finalized the coding changes after consideration of comments received at the meetings and in writing by January 08, 2001.
Copies of the Coordination and Maintenance Committee minutes of the 2000 meetings can be obtained from the CMS home page at: http://www.hcfa.gov/medicare/icd9cm.htm. Paper copies of these minutes are no longer available and the mailing list has been discontinued. We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, MD 20782. Comments may be sent by E-mail to: dfp4@cdc.gov.
Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination and Maintenance Committee; CMS, Center for Medicare Management, Purchasing Policy Group, Division of Acute Care; C4-07-07; 7500 Security Boulevard; Baltimore, MD 21244-1850. Comments may be sent by E-mail to: pbrooks@cms.hhs.gov.
The ICD-9-CM code changes that have been approved will become effective October 1, 2001. The new ICD-9-CM codes are listed, along with their DRG classifications, in Tables 6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) in section V. of the Addendum to this final rule. As we stated above, the code numbers and their titles were presented for public comment at the ICD-9-CM Coordination and Maintenance Committee meetings. Both oral and written comments were considered before the codes were approved. In the proposed rule, we solicited comments only on the proposed DRG classification of these new codes.
Further, the Committee has approved the expansion of certain ICD-9-CM codes to require an additional digit for valid code assignment. Diagnosis codes that have been replaced by expanded codes or other codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2001. For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A (New Diagnosis Codes). New procedure codes are shown in Table 6B. Table 6C contains invalid diagnosis codes, and Table 6D contains invalid procedure codes. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also include the DRG assignments for these revised codes. Revisions to procedure code titles are in Table 6F (Revised Procedure Codes Titles).
In September 2000, the Department implemented a policy of paying for inpatient hospital stays for Medicare beneficiaries participating in clinical trials (HCFA Program Memorandum AB 00-89, September 19, 2000). Hospitals were encouraged to identify the patients involved by reporting an ICD-9-CM code. This would allow the examination of data on the patients involved in clinical trials. However, there was no clear ICD-9-CM diagnosis code for patients who took part in a clinical trial. There was a code for patients receiving an examination as part of the control group for clinical trials. This control group code was V70.7 (Examination for normal comparison or control in clinical research). Hospitals were instructed to use V70.5 (Health examination of defined subpopulations), for patients participating in a clinical trial.
This coding directive has created some confusion because of the title and description of the two codes. Hospitals also have requested that all clinical patients be captured under one code. They indicated that the use of one code Start Printed Page 39855would be especially useful because patients frequently do not know if they are part of the control group or are receiving new therapy.
To help alleviate the confusion, the ICD-9-CM Coordination and Maintenance Committee revised code V70.7. Effective October 1, 2001, the new title of code V70.7 is “Examination of patient in clinical trial.” This revision will make it easier to capture data on Medicare beneficiaries who are participating in a clinical trial.
Comment: One commenter questioned the DRG assignment of 525.12 (Loss of teeth due to periodontal disease) listed in Table 6A of the Addendum of the proposed rule. Table 6A in the proposed rule listed the proposed DRG assignments within MDC 3 for this new code as DRGs 182, 183, and 184. The commenter stated that the DRG assignments within MDC 3 should actually be DRGs 185, 186, and 187, since these were the DRGs used for its predecessor code, 525.1. The commenter also pointed out that the other new codes within this category (525.10-525.19) were assigned to DRGs 185, 186, and 187.
Response: The commenter is correct. We are assigning code 525.12 to DRGs 185, 186, and 187 within MDC 3. This is consistent with the way the other codes in the new category were assigned. In this final rule, we are correcting Table 6A to show that 525.12 is assigned to DRGs 185, 186, and 187 within MDC 3.
Effective July 1, 1999, Medicare covers whole organ pancreas transplantation if the transplantation is performed simultaneously with or after a kidney transplant (procedure codes 55.69 (Other kidney transplantation), or diagnosis code V42.0 (Organ or tissue replaced by transplant, Kidney), along with 52.80 (Pancreatic transplant, not otherwise specified), or 52.82 (Homotransplant of pancreas)). A discussion of the history of these coverage decisions and codes can be found in the August 1, 2000 final rule on the prospective payment system for FY 2001 (65 FR 47067).
We discussed the appropriate DRG classification for these cases in both the July 30, 1999 final rule (64 FR 41497) and the August 1, 2000 final rule (65 FR 47067). Currently, cases can be assigned to one of two major DRGs depending on principal diagnosis. If a kidney transplant and a pancreas transplant are performed simultaneously on a patient with chronic renal failure secondary to diabetes with renal manifestations (diagnosis codes 250.40 through 250.43), the cases will be assigned to DRG 302 (Kidney Transplant). If a pancreas transplant is performed following a kidney transplant (during a different hospital admission) on a patient with chronic renal failure secondary to diabetes with renal manifestations, the case is assigned to DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis). This is because pancreas transplant is not assigned to MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract), the MDC to which a principal diagnosis of chronic renal failure secondary to diabetes is assigned.
In the August 1, 2000 final rule, we noted that we would continue to monitor these transplant cases to determine the appropriateness of establishing a new DRG. For the May 4 proposed rule, using data in the FY 2000 MedPAR file (updated through May 31, 2000), we analyzed the cases for which procedure codes 52.80 and 52.82 were reported. (Our data showed that 15 of the cases were coded using 52.83 (Heterotransplant of pancreas), which is not a covered procedure under any circumstances.) We identified a total of 221 cases for this time period. The United Network for Organ Sharing (UNOS) reported it had identified 270 cases through September 2000.
These 221 MedPAR cases were distributed over 6 DRGs, with the majority (158 cases or 72 percent) assigned to DRG 302, and 23 cases (10 percent) assigned to DRG 468. The remaining 40 cases were distributed between 4 other DRGs, with the majority (25 cases) being assigned to DRG 292 (Other Endocrine, Nutritional and Metabolic OR Procedures with CC). Four cases were assigned to DRG 483 (Tracheostomy with Principal Diagnosis except Face, Mouth and Neck Diagnoses) in the Pre-MDC grouping, which took precedence over any other DRG assignment.
We arrayed the data based on the presence or absence of kidney transplant; that is, pancreas transplant codes with or without 55.69. The majority of cases (166 or 75 percent) had the combined kidney-pancreas transplant in one operative episode, with 55 (25 percent) of the cases having pancreas transplant subsequent to the kidney transplant. Differences in hospital charges were significantly higher for a pancreas transplant plus a kidney transplant ($138,809) than a pancreas transplant alone ($85,972), and both were higher than average standardized charges in DRG 302 ($64,760) or DRG 468 ($39,707), although it must be noted that these figures do reflect the resource intensive patients assigned to DRG 483. Those patients in DRG 483 had average standardized charges of $377,934.
Because these categories of patients do not fit into existing DRGs from either a clinical or resource perspective, in the May 4 proposed rule, we proposed to create two new DRGs that would reflect these patients' unique clinical profiles: DRG 512 (Simultaneous Pancreas/Kidney Transplant) and DRG 513 (Pancreas Transplants). Cases grouped to either DRGs 512 or 513 must have a principal or secondary diagnosis code and procedure code or combination of procedure codes as indicated in the chart below:
Composition of Proposed DRGs 512 and 513
Principal or Secondary ICD-9-CM Diabetes Mellitus Code:
250.00 Diabetes mellitus without mention of complication, Type II or unspecified type, not as stated as uncontrolled X X
250.01 Diabetes mellitus without mention of complication, Type I, not stated as uncontrolled X X
250.02 Diabetes mellitus without mention of complication, Type II or unspecified type, uncontrolled X X
250.03 Diabetes mellitus without mention of complication, Type I, uncontrolled X X
250.10 Diabetes with ketoacidosis, Type II or Unspecified type, not stated as uncontrolled X X
250.11 Diabetes with ketoacidosis, Type I, not stated as uncontrolled X X
250.12 Diabetes with ketoacidosis, Type II or unspecified type, uncontrolled X X
250.13 Diabetes with ketoacidosis, Type I, controlled X X
250.20 Diabetes with hyperosmolarity, Type II or unspecified type, not stated as uncontrolled X X
250.21 Diabetes with hyperosmolarity, Type I, not stated as uncontrolled X X
250.22 Diabetes with hyperosmolarity, Type II or unspecified type, uncontrolled X X
250.23 Diabetes with hyperosmolarity, Type I, uncontrolled X X
250.30 Diabetes with other coma, Type II or unspecified type, not stated as uncontrolled X X
250.31 Diabetes with other coma, Type I, not stated as uncontrolled X X
250.32 Diabetes with other coma, Type II or unspecified type, uncontrolled X X
250.33 Diabetes with other coma, Type I, uncontrolled X X
250.40 Diabetes with renal manifestations, Type II or unspecified type, not stated as uncontrolled X X
250.41 Diabetes with renal manifestations, Type I, not stated as uncontrolled X X
250.42 Diabetes with renal manifestations, Type II or unspecified type, uncontrolled X X
250.43 Diabetes with renal manifestations, Type I, uncontrolled X X
250.50 Diabetes with ophthalmic manifestations, Type II or unspecified type, not stated as uncontrolled X X
250.51 Diabetes with ophthalmic manifestations, Type I, not stated as uncontrolled X X
250.52 Diabetes with ophthalmic manifestations, Type II or unspecified type, uncontrolled X X
250.53 Diabetes with ophthalmic manifestations, Type I, uncontrolled X X
250.60 Diabetes with neurological manifestations, Type II or unspecified type, not stated as uncontrolled X X
250.61 Diabetes with neurological manifestations, Type I, not stated as uncontrolled X X
250.62 Diabetes with neurological manifestations, Type II or unspecified type, uncontrolled X X
250.63 Diabetes with neurological manifestations, Type I uncontrolled X X
250.70 Diabetes with peripheral circulatory disorders, Type II or unspecified type, not stated as uncontrolled X X
250.71 Diabetes with peripheral circulatory disorders, Type I, not stated as uncontrolled X X
250.72 Diabetes with peripheral circulatory disorders, Type II or unspecified type, uncontrolled X X
250.73 Diabetes with peripheral circulatory disorders, Type I, uncontrolled X X
250.80 Diabetes with other specified manifestations, Type II or unspecified type, not stated as uncontrolled X X
250.81 Diabetes with other specified manifestations, Type I, not states as uncontrolled X X
250.82 Diabetes with other specified manifestations, Type II or unspecified type, uncontrolled X X
250.83 Diabetes with other specified manifestations, Type I, uncontrolled X X
250.90 Diabetes with unspecified complication, Type II or unspecified type, not states as uncontrolled X X
250.91 Diabetes with unspecified complication, Type I, not stated as uncontrolled X X
250.92 Diabetes with unspecified complication, Type II or unspecified type, uncontrolled X X
250.93 Diabetes with unspecified complication, Type I, uncontrolled X X
Principal or Secondary Diagnosis Code:
585 Chronic renal failure. X X
403.01 Hypertensive renal disease, malignant, with renal failure X X
403.11 Hypertensive renal disease, benign, with renal failure X X
403.91 Hypertensive renal disease, unspecified, with renal failure X X
404.02 Hypertensive heart & renal disease, malignant, with renal failure X X
404.03 Hypertensive heart & renal disease, malignant, with congestive heart failure and renal disease X X
404.12 Hypertensive heart & renal disease, benign, with renal failure X X
404.13 Hypertensive heart & renal disease, benign, with congestive heart failure and renal disease X X
404.92 Hypertensive heart & renal disease, unspecified, with renal failure X X
404.93 Hypertensive heart & renal disease, unspecified, with congestive heart failure and renal failure X X
V42.0 Organ or tissue replaced by transplant, kidney X X
V43.89 Organ or tissue replaced by other means, other (Kidney) X X
Procedure Code:
52.80 Pancreatic transplant, not otherwise specified X
52.82 Homotransplant of pancreas X
Combination Procedure Codes:
52.80 Pancreatic transplant, not otherwise specified,
55.69 Other kidney transplantation X
52.82 Homotransplant of pancreas
The logic for the DRG 512 accepts the pair of diagnosis codes in any position (principal/secondary or secondary/secondary). The pair of procedure codes must be present along with the two diagnosis codes. This DRG will be placed in the Pre-MDC GROUPER logic immediately following DRG 480 (Liver Transplant).
The logic for DRG 513 accepts the pair of diagnosis codes in any position (principal/secondary or secondary/secondary). Only one procedure code must be used along with the two diagnosis codes. This DRG will be placed in the Pre-MDC GROUPER logic immediately following new DRG 512 (Simultaneous Pancreas/Kidney Transplant).
We received two comments on this proposal. One commenter supported the creation of the two new DRGs; a summary of the other comment follows:
Comment: One commenter noted that, as pancreas transplants were approved by Medicare on July 1, 1999, a special billing procedure should be made available to hospitals to enable hospitals to bill for the transplant DRG back to the effective date of the covered service.
Response: DRGs 512 and 513 are effective for discharges occurring on or Start Printed Page 39857after October 1, 2001, for FY 2002. Discharges involving pancreas transplants occurring prior to that time are assigned to existing DRGs as described above. Therefore, there is no need for hospitals to resubmit their bills.
We are adopting the establishment of proposed DRGs 512 and 513 as final.
Effective April 1, 2001, Medicare covers intestinal transplantation for the purpose of restoring intestinal function in patients with irreversible intestinal failure (Medicare Program Memorandum Transmittal No. AB-01-58, April 12, 2001). This procedure is covered only when performed for patients who have failed total parenteral nutrition (TPN) and only when performed in centers that meet approval criteria.
Intestinal failure is defined as the loss of absorptive capacity of the small bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel syndrome. Intestinal failure prevents oral nutrition and may be associated with both mortality and profound morbidity.
If an intestinal transplantation alone is performed on a patient with an intestinal principal diagnosis, the case would be assigned to either DRG 148 (Major Small & Large Bowel Procedures With CC) or DRG 149 (Major Small & Large Bowel Procedures Without CC). If an intestinal transplantation and a liver transplantation are performed simultaneously, the case would be assigned to DRG 480 (Liver Transplant).
If an intestinal transplantation and a pancreas transplantation are performed simultaneously, currently the case would be assigned to either DRG 148 or DRG 149. Effective October 1, 2001, the case would be assigned to DRG 513 (Pancreas Transplant). We proposed to make a conforming change to the regulations at § 412.2(e)(4) and § 486.302 to include intestines (and multivisceral organs) in the list of organs for which Medicare pays for the acquisition costs on a reasonable cost basis.
Effective October 1, 2000, procedure code 46.97 (Transplant of intestine) was created. For the proposed rule, we examined our Medicare claims data to determine whether it was appropriate to propose a new intestinal transplant DRG. We examined data in the FY 2000 MedPAR file containing bills submitted through May 31, 2000. Because procedure code 46.97 was not in place during this time we focused our examination on the previous code assignment for intestinal transplant, code 46.99 (Other operations on intestines), and facilities that are currently performing intestinal transplantation. We were able to identify only one case, with an average charge of approximately $10,738 as compared to the average standardized charges for DRGs 148 and 149, which are approximately $37,961, and $16,965, respectively. We will continue to monitor these cases to determine whether it may be appropriate in the future to establish a new DRG.
Comment: One commenter recommended performing data analysis next year to determine if a separate intestinal transplantation DRG should be created based on the fact that these procedures are being performed on a more frequent basis. Another commenter suggested that the preamble specifically state that while the acquisition costs for heart, liver, lung, and pancreas transplants continue to be paid on a reasonable cost basis, the acquisition costs for intestinal transplantation will be paid through the hospital inpatient prospective payment system DRG payment mechanism.
Response: It is our intent to continue to monitor these cases to determine whether it may be appropriate in the future to establish a new DRG.
To clarify the issue of acquisition costs, Medicare Program Memorandum Transmittal No. AB-01-58, released April 12, 2001, states that Medicare will not pay transplant facilities on a reasonable cost basis for organ acquisition for intestinal or multivisceral transplants. The DRG payment will be payment in full for hospital services related to this procedure. However, in this final rule, we are implementing a conforming change to the regulations at § 412.2(e)(4) and § 486.302, to include intestines (and multivisceral organs) in the list of organs for which Medicare pays for the acquisition costs on a reasonable cost basis. This change is effective with acquisition costs incurred on or after October 1, 2001. After that date, costs associated with the acquisition of intestines and multivisceral organs will be paid on a reasonable cost basis. Costs associated with intestines procured separately will be allocated to an intestine cost center and allocated on Worksheet D-6. Multivisceral organ transplantation includes organs in the digestive system (that is, stomach, duodenum, pancreas, liver, intestine, and colon). Multivisceral procurements, including an organ(s) as defined at § 486.302 as well as the intestine (small bowel), will be allocated to the intestinal acquisition cost center. Multivisceral procurements are procured en bloc and the entire cost of procuring all of the organs will be allocated to the intestinal acquisition cost center.
Comment: Although this issue was not addressed in the proposed rule, we received one comment requesting that the add-on payment for blood clotting factors administered to hemophilia inpatients include adequate reimbursement for hospitals that treat beneficiaries with acquired hemophilia.
Response: According to section 4452 of Public Law 105-33, which amended section 6011(d) of Public Law 101-239, prospective payment hospitals receive an additional payment for costs of administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients.
Hemophilia, a bleeding disorder characterized by prolonged clotting time, is caused by a deficiency of a factor necessary for blood to clot. In the August 29, 1997 final rule implementing section 4452 of Public Law 105-33 (62 FR 46002), we stated that hemophilia was considered to encompass the following conditions: Factor VIII deficiency (classical hemophilia); Factor IX deficiency (also termed plasma thromboplastin component (PTC) or Christmas factor deficiency); and Von Willebrand's disease. The most common factors required by hemophiliacs to increase coagulation are Factor VIII and Factor IX; a small number of hemophiliacs have developed inhibitors to these factors and require special treatment. We did not receive any comments regarding this coverage until, most recently, the cases of acquired hemophilia, which affects a small subset of individuals (1 in 1 million), were brought to our attention.
We are revising our claims processing instructions to permit add-on payments for the following ICD-9-CM diagnosis codes associated with acquired hemophilia:
286.5 Hemorrhagic disorder due to circulating anticoagulants
286.7 Acquired coagulation factor deficiency.Start Printed Page 39858
We proposed to use the same basic methodology for the FY 2002 recalibration as we did for FY 2001 (August 1, 2000 final rule (65 FR 47069)). That is, we would recalibrate the weights based on charge data for Medicare discharges. However, we proposed to use the most current charge information available, the FY 2000 MedPAR file. (For the FY 2001 recalibration, we used the FY 1999 MedPAR file.) The MedPAR file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills.
The final recalibrated DRG relative weights are constructed from FY 2000 MedPAR data (discharges occurring between October 1, 1999 and September 30, 2000), based on bills received by CMS through March 31, 2001, from all hospitals subject to the prospective payment system and short-term acute care hospitals in waiver States. The FY 2000 MedPAR file includes data for approximately 11,094,323 Medicare discharges.
The methodology used to calculate the DRG relative weights from the FY 2000 MedPAR file is as follows:
To the extent possible, all the claims were regrouped using the DRG classification revisions discussed in section II.B. of this preamble.
Charges were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment.
The average standardized charge per DRG was calculated by summing the standardized charges for all cases in the DRG and dividing that amount by the number of cases classified in the DRG.
We then eliminated statistical outliers, using the same criteria used in computing the current weights. That is, all cases that are outside of 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG are eliminated.
The average charge for each DRG was then recomputed (excluding the statistical outliers) and divided by the national average standardized charge per case to determine the relative weight. A transfer case is counted as a fraction of a case based on the ratio of its transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. That is, transfer cases paid under the transfer methodology equal to half of what the case would receive as a nontransfer would be counted as 0.5 of a total case.
We established the relative weight for heart and heart-lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner consistent with the methodology for all other DRGs except that the transplant cases that were used to establish the weights were limited to those Medicare-approved heart, heart-lung, liver, and lung transplant centers that have cases in the FY 1999 MedPAR file. (Medicare coverage for heart, heart-lung, liver, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)
Acquisition costs for kidney, heart, heart-lung, liver, lung, and pancreas transplants continue to be paid on a reasonable cost basis. Unlike other excluded costs, the acquisition costs are concentrated in specific DRGs: DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant); DRG 480 (Liver Transplant); DRG 495 (Lung Transplant); and proposed new DRGs 512 (Simultaneous Pancreas/Kidney Transplant) and 513 (Pancreas Transplant). Because these costs are paid separately from the prospective payment rate, it is necessary to make an adjustment to prevent the relative weights for these DRGs from including the acquisition costs. Therefore, we subtracted the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average charge for the DRG and before eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a threshold of 10 cases as the minimum number of cases required to compute a reasonable weight. We use that same case threshold in recalibrating the DRG weights for FY 2002. Using the FY 2000 MedPAR data set, there are 37 DRGs that contain fewer than 10 cases. We computed the weights for these 37 low-volume DRGs by adjusting the FY 2001 weights of these DRGs by the percentage change in the average weight of the cases in the other DRGs.
The new weights are normalized by an adjustment factor (1.44556) so that the average case weight after recalibration is equal to the average case weight before recalibration. This adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the prospective payment system, and accounts for the gradual shift in cases toward higher-weighted DRGs over time.
We received no comments on DRG recalibration.
Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with FY 1991, reclassification and recalibration changes be made in a manner that assures that the aggregate payments are neither greater than nor less than the aggregate payments that would have been made without the changes. Although normalization is intended to achieve this effect, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payment to hospitals is affected by factors other than average case weight. Therefore, as we have done in past years and as discussed in section II.A.4.a. of the Addendum to the final rule, we make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met.
Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.” In accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New England County Metropolitan Areas (NECMAs) issued by the Office of Management and Budget (OMB). The OMB also designates Consolidated MSAs (CMSAs). A CMSA is a metropolitan area with a population of one million or more, comprising two or more PMSAs (identified by their separate economic and social character). For purposes of the hospital wage index, we use the PMSAs rather than CMSAs since they allow a more precise breakdown of labor costs. If a metropolitan area is not designated as part of a PMSA, we use the applicable MSA. Rural areas are areas outside a designated MSA, PMSA, or NECMA. For purposes of the wage index, we combine all of the rural counties in a State to calculate a rural wage index for that State.
We note that, effective April 1, 1990, the term Metropolitan Area (MA) replaced the term MSA (which had been used since June 30, 1983) to describe the set of metropolitan areas consisting of MSAs, PMSAs, and CMSAs. The terminology was changed by OMB in Start Printed Page 39859the March 30, 1990 Federal Register to distinguish between the individual metropolitan areas known as MSAs and the set of all metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes of the prospective payment system, we will continue to refer to these areas as MSAs.
Beginning October 1, 1993, section 1886(d)(3)(E) of the Act requires that we update the wage index annually. Furthermore, this section provides that the Secretary base the update on a survey of wages and wage-related costs of short-term, acute care hospitals. The survey should measure, to the extent feasible, the earnings and paid hours of employment by occupational category, and must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. As discussed below in section III.F. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating the wage index.
The FY 2002 wage index values in section V of the Addendum to this final rule (effective for hospital discharges occurring on or after October 1, 2001 and before October 1, 2002) are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 1998 (the FY 2001 wage index was based on FY 1997 wage data).
The final FY 2002 wage index includes the following categories of data associated with costs paid under the hospital inpatient prospective payment system (as well as outpatient costs), which were also included in the FY 2001 wage index:
Salaries and hours from short-term, acute care hospitals.
Home office costs and hours.
Certain contract labor costs and hours.
Wage-related costs.
Consistent with the wage index methodology for FY 2001, the wage index for FY 2002 also continues to exclude the direct and overhead salaries and hours for services not paid through the inpatient prospective payment system such as skilled nursing facility (SNF) services, home health services, or other subprovider components that are not subject to the prospective payment system.
We calculate a separate Puerto Rico-specific wage index and apply it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.) This wage index is based solely on Puerto Rico's data. Finally, section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is not located in a rural area may not be less than the area wage index applicable to hospitals located in rural areas in that State.
Because the hospital wage index is used to adjust payments to hospitals under the prospective payment system, the wage index should, to the extent possible, reflect the wage costs associated with the areas of the hospital included under the hospital inpatient prospective payment system. In response to concerns within the hospital community related to the removal, from the wage index calculation, of costs related to graduate medical education (GME) (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), which are paid by Medicare separately from the prospective payment system, the AHA convened a workgroup to develop a consensus recommendation on this issue. The workgroup recommended that costs related to GME and CRNAs be phased out of the wage index calculation over a 5-year period. Based upon our analysis of hospitals' FY 1996 wage data, and consistent with the AHA workgroup's recommendation, we specified in the July 30, 1999 final rule (64 FR 41505) that we would phase-out these costs from the calculation of the wage index over a 5-year period, beginning in FY 2000. In keeping with the decision to phase-out costs related to GME and CRNAs, the final FY 2002 wage index is based on a blend of 40 percent of an average hourly wage including these costs, and 60 percent of an average hourly wage excluding these costs.
Beginning with the FY 1998 cost reports, we revised the Worksheet S-3, Part II so that hospitals can separately report teaching physician Part A costs on lines 4.01, 10.01, 12.01, and 18.01. Therefore, it is no longer necessary for us to conduct the special survey we used for the FY 2000 and FY 2001 wage indexes (64 FR 41505 and 65 FR 47071).
In the August 1, 2000 final rule, we clarified our definition of “purchased health insurance costs” and “self-insurance” for hospitals that provide health insurance to employees (65 FR 47073). For purposes of the wage index, purchased or self-funded health insurance plan costs include the hospitals' insurance premium costs, external administration costs, and the share of costs for services delivered to employees.
In response to a comment received concerning this issue, we stated that, for self-funded health insurance costs, personnel costs associated with hospital staff that deliver the services to the employees must continue to be excluded from wage-related costs if the costs are already included in the wage data as salaries on Worksheet S-3, Part II, Line 1. However, after further consideration of this policy, particularly with respect to concerns expressed by our fiscal intermediaries about the level of effort required during the wage index desk review process to ensure hospitals are appropriately identifying and excluding these costs, in the May 4, 2001 proposed rule we proposed a revision. Effective with the calculation of the FY 2003 wage index, for either purchased or self-funded health insurance, we proposed to allow personnel costs associated with hospital staff who deliver services to employees to be included as part of the wage-related costs. We believe the proposed revised policy will ensure that health insurance costs are consistently reported by hospitals. Health insurance costs would continue to be developed using generally accepted accounting principles.
In the August 1, 2000 final rule (65 FR 47073), we further clarified that health-related costs (including employee physical examinations, flu shots, and clinic visits, and other services that are not covered by employees' health insurance plans but are provided at no cost or at discounted rates to employees of the hospital) may be included as “other” wage-related costs if, among other criteria, the combined cost of all such health-related costs is greater than one percent of the hospital's total salaries (less excluded area salaries).
For purposes of calculating the FY 2003 wage index (which will be based on data for cost reporting periods beginning in FY 1999), we proposed to revise this policy to allow hospitals to include health-related costs as allowable core wage-related costs.
Comment: One commenter supported our proposal to include health-related costs as core wage-related costs. The commenter also agreed with our proposal to include all personnel costs associated with hospital staff who deliver health services to employees. However, the commenter expressed concern that the proposed changes would require burdensome and duplicative revisions to cost reports that have already been filed.
Response: We believe that these revised policies (to eliminate the Start Printed Page 39860distinction between purchased health insurance and self-funded health insurance, and to treat costs associated with health-related services that are not part of the employees' health insurance plan consistent with costs included in the plan) will ensure that these costs are treated consistently across hospitals and fiscal intermediaries.
In response to the commenter's concern that the policy will require revisions to previously submitted cost reports, we believe the changes are not significant, particularly in light of the volume of changes submitted every year by hospitals during the wage data review process (see discussion in section III.G. of this final rule). The cost report changes necessary to implement these policy changes involve including costs previously disallowed. In the case of personnel costs associated with hospital staff who deliver services to employees, these costs would have already been identified in order to be excluded from the wage data. With respect to health services provided outside the employees' health insurance plan, we acknowledge that some hospitals may not have tracked these costs because they did not qualify for inclusion as other wage-related costs. However, due to concerns expressed by fiscal intermediaries about the difficulty of identifying these costs separate from those that are part of the insurance plan, we believe there may be inconsistencies in the current data with regard to how these costs are treated. Therefore, we believe, in the interest of improving the consistency of the data, that we should begin to allow these costs as core wage-related costs effective with the FY 2003 wage index.
Our policy concerning inclusion of contract labor costs for purposes of calculating the wage index has evolved over the years. We recognize the role of contract labor in meeting special personnel needs of many hospitals. In addition, improvements in the wage data have allowed us to more accurately identify contract labor costs and hours. As a result, effective with the FY 1994 wage index, we included the costs of direct patient care contract services in the wage index calculation. The FY 1999 wage index included the costs and hours of certain management contract services, and the FY 2000 wage index included the costs for contract physician Part A services. (The 1996 proposed rule (61 FR 27456) provided an in-depth background to the issues related to the inclusion of contract labor costs in the wage index calculation.)
We revised the 1998 cost report to collect the data associated with contract pharmacy, Worksheet S-3, Part II, Line 9.01, and contract laboratory, Worksheet S-3, Part II, Line 9.02. The cost reporting instructions for these line numbers followed that for all contract labor lines; that is, to include the amount paid for services furnished under contract for direct patient care, and not include cost for equipment, supplies, travel expenses, and other miscellaneous or overhead items (Medicare Provider Reimbursement Manual, Part 2, Cost Reporting Forms and Instructions, Chapter 36, Transmittal 6, pages 36-32). Effective with the FY 2002 wage index, which uses FY 1998 wage data, we are including in this final rule (as proposed in the May 4 proposed rule) the costs and hours of contract pharmacy and laboratory services.
Comment: Two commenters supported our proposed policy to include the costs and hours of contract pharmacy and laboratory as direct patient care contract labor in the FY 2002 wage index. However, both commenters recommended that clearer guidelines be provided to ensure consistency in interpretation by fiscal intermediaries and contract vendors.
Response: Beginning with the FY 2002 wage index, we are including the costs and hours of contract pharmacy and laboratory services in the calculation of the wage index. Further instructions for reporting contract pharmacy and laboratory costs will be included in Transmittal 8 of the cost report, due for release in early fall 2001.
Section 304(c) of Public Law 106-554 amended section 1886(d)(3)(E) of the Act to require that the Secretary must provide for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. The initial collection of these data must be completed by September 30, 2003, for application beginning October 1, 2004.
Currently, the wage data collected on the cost report reflect the sum of wages, hours, and wage-related costs for all hospital employees. There is no separate collection by occupational categories of employees, such as registered nurses or physical therapists. Total salaries and hours reflect management decisions made by hospitals in terms of how many employees within a certain occupation to employ to treat different types of patients. For example, a large academic medical center may tend to hire more high-cost specialized employees to treat its more acutely ill patient population. The argument is that the higher labor costs incurred to treat this patient population are reflected in the higher case mix of these hospitals, and therefore, reflecting these costs in the wage index is essentially counting them twice.
An occupational mix adjustment can be used to account for hospital management decisions about how many employees to hire in each occupational category. Occupational mix data measure the price the hospital must pay for employees within each category. A wage index that reflected only these market prices would remove the impact of management decisions about the mix of employees needed and, therefore, better capture geographic variations in the labor market.
We have examined this issue previously. In the May 27, 1994 Federal Register (59 FR 27724), we discussed the outcome of consideration of this issue by a hospital workgroup. At that time, the workgroup's consensus was that the data required to implement an occupational mix adjustment were not available and the likelihood of obtaining such data would be minimal. There seemed to be little support among hospital industry representatives for developing a system that would create additional reporting burdens with an unproven or minimal impact on the distribution of payments. Also, in the August 30, 1991 Federal Register (56 FR 43219), we stated our belief that the collection of these data would be costly and difficult.
In considering the format to collect occupational mix data, we looked to data currently being collected by the Bureau of Labor Statistics (BLS), which conducts an annual mail survey to produce estimates of employment and wages for specific occupations. This program, Occupational Employment Statistics (OES), collects data on wage and salary workers in nonfarm establishments in order to produce employment and wage estimates for over 700 occupations.
The OES survey collects wage data in 12 hourly rate intervals. Employers report the number of employees in an occupation per each wage range. To illustrate, the wage intervals used for the 1999 survey are as follows:Start Printed Page 39861
Hourly wages
Range A Under $6.75 Under $14,040.
Range B $6.75 to $8.49 $14,040 to $17,659.
Range C 8.50 to 10.74 17,660 to 22,359.
Range D 10.75 to 13.49 22,360 to 28,079.
Range E 13.50 to 16.99 28,080 to 35,359.
Range F 17.00 to 21.49 35,360 to 44,719.
Range G 21.50 to 27.24 44,720 to 56,679.
Range H 27.25 to 34.49 56,680 to 71,759.
Range I 34.50 to 43.74 71,760 to 90,999.
Range J 43.75 to 55.49 91,000 to 115,439.
Range K 55.50 to 69.99 115,440 to 145,599.
Range L 70.00 and over 145,600 and over.
We noted that this table is for illustrative purposes, and that we may update the data ranges in our actual collection instrument.
Although we initially considered using the OES data, section 304(c) of Public Law 106-554 requires us to collect data from every short-term, acute care hospital. The OES data are a sample survey and, therefore, as currently conducted, are not consistent with the statutory requirement to include data from every hospital. Another issue with using OES data is that, for purposes of the Medicare wage index, the hospitals' data must be reviewed and verified by the fiscal intermediaries. The OES survey is a voluntary survey for most States.
Although we decided to pursue a separate data collection effort than OES, we proposed in the May 4, 2001 proposed rule to model our format after the one used by OES. In this way, hospitals participating in the OES survey would have no additional recordkeeping and reporting requirements beyond those of the OES survey.
The OES survey of the hospital industry is designed to capture all occupational categories within the industry. For purposes of adjusting the wage index for occupational mix, we do not believe it is necessary to collect data from such a comprehensive scope of categories. Furthermore, because the data must be audited, a comprehensive list of categories would be excessively burdensome.
In deciding which occupational categories to include, we reviewed the occupational categories collected by OES and identified those with at least 35,000 hospital employees. Our goal is to collect data from a sample of occupational categories that provides a valid measure of wage rates within a geographical area. In the May 4 proposed rule, using this threshold of at least 35,000 employees within a category nationally, we proposed to collect data on the number of employees by wage range as illustrated in the above table, for the occupational categories listed below. The following data, which was also listed in the proposed rule, are based on the 1998 OES survey. (These data are no longer available on the internet.)
OES code
Percent of total hospital employees
Mean hourly wage
15008 Medicine and Health Services Manager 93,680 1.9 $27.38
27302 Social Workers, Medical and Psychiatric 53,360 1.1 16.33
32102 Physicians and Surgeons 125,640 2.6 43.76
32308 Physical Therapists 39,840 0.8 26.14
32502 Registered Nurses 1,231,980 25.0 21.12
32505 Licensed Practical Nurses 206,360 4.2 13.39
32517 Pharmacists 46,860 1.0 28.62
32911, 32928, and 32931 Clinical Technologists and Technicians 122,380 2.50 11.69
51002, 55105, 55108, 55305, 55332, and 55347 First-Line Supervisors and Clerical Workers 445,730 9.5 11.39
65038, 67002, and 67005 Food Preparation Workers and Housekeeping 218,440 4.5 8.17
66008 Nursing Aides, Orderlies, and Attendants 301,240 6.2 8.67
We proposed that this list of occupational categories provides a good representation of the employee mix at most hospitals. It has since come to our attention that the occupational categories listed in the proposed rule have been replaced by Standard Occupational Category definitions.
Because we had not yet settled on the methodology to use the occupational mix data in the wage index, we discussed in the proposed rule one option to weight each hospital's wage index by its occupational mix index. This requires calculating a national occupational mix index and then breaking it down by MSA and by hospital, similar to how the wage index is broken down. In this way, the wage index would capture geographic differences in wage rates. The decision about how to apply the occupational mix index to the wage index depends on the quality of the data collected, since this effort will be the first time wage and hour data by occupation are collected in this audited manner.
Section 304(c) directs the Secretary to provide for the collection of these data by September 30, 2003, and to apply them in the wage index by October 1, 2004. Therefore, the data are to be incorporated in the FY 2005 wage index. Under our current timetable, the FY 2005 wage index will be based on wage data collected from hospitals' cost reporting periods beginning during FY 2001. In order to facilitate the fiscal intermediaries' review of these data, we believe the occupational mix data should coincide with the data otherwise Start Printed Page 39862used to calculate the cost report. Therefore, we will conduct a special survey of all short-term acute-care hospitals that are required to report wage data to collect these data coinciding with hospitals' FY 2001 cost reports.
Comment: Several commenters expressed interest in working with us to develop an appropriate data collection tool. They suggested that the data be relatively simple for hospitals to gather and submit, and should be collected on 100 percent of hospital employees. Another commenter recommended that, at least initially, only data on nursing categories would be sufficient since nurses are 35 percent of hospital employees and can be divided into a few easily distinguishable categories. Two commenters offered examples for how these data are collected in their area. Some commenters wanted these data incorporated in the cost report to limit the number of forms hospitals must complete and to improve the response rate.
Response: We agree that it would be beneficial to work with the industry to develop a workable data collection tool, especially given the importance of the wage index in adjusting hospital payments. We appreciate the comments on the option presented in the proposed rule and believe that these comments will help initiate further thought toward the development of an occupational mix survey that can be administered without excessive burden on hospitals, the fiscal intermediaries, or CMS.
Due to time constraints in meeting the statutory deadlines, our intention at this point is to attempt to develop a survey instrument for the initial collection of occupational mix data that can be used by hospitals during calendar year 2002. Therefore, prior to January 1, 2002, we plan to work with the hospital community to develop a survey instrument. We believe issues related to the sample size of the data collected and the appropriate occupational categories to collect can best be resolved through consultation with the industry. Therefore, we will be contacting those organizations that expressed an interest in consultation in their comments. Other interested parties are encouraged to contact us as well.
After developing a method that appropriately balances the need to collect accurate and reliable data with the need to collect data hospitals can be reasonably expected to have available, we will issue instructions as to the type of data to be collected, in advance of actually requiring hospitals to begin providing the data.
Comment: Some commenters asked us to further develop the planned use of the occupation information and then decide what information is required. They requested that we publish the projected economic effects of an occupational mix adjustment upon each hospital as soon as feasible, and demonstrate tangible benefits prior to requiring hospitals to collect data. One commenter offered a specific methodology that could be employed. Other commenters want the methodology phased-in over time to allow hospitals time to adjust to different payment levels.
Response: In the proposed rule, we stated that we had not yet settled on the actual methodology for using the occupational mix data in the calculation of the wage index. We indicated the decision as to how the data will be used is dependent on the quality of the data collected. That is still the case. Furthermore, as discussed above, we intend to develop an appropriate data collection instrument in consultation with the hospital community. Therefore, until decisions are made with regard to the specific data to be collected, we cannot specify how the data will be used. However, the selection of an appropriate methodology (including a possible phase-in) will be influenced by analysis of the impacts of the method on hospital payments.
Comment: Two commenters expressed concerns that adopting the occupational mix adjustment for the wage index will lower the average hourly wage of teaching hospitals because of their mix of highly skilled, higher paid employees to treat patients with more complex conditions. These commenters argued that implementation of the occupational mix adjustment should proceed only in conjunction with the adoption of severity-adjusted DRGs. These commenters wrote that the current DRG system does not adequately recognize patient severity and pay for the higher resource costs associated with complex patients, but teaching hospitals can recoup some of these losses because their higher employee skill mix is reflected in their average hourly wage.
Furthermore, one commenter countered the argument that the higher labor costs incurred to treat a more severely ill patient population are reflected in the higher case mix of these hospitals and, therefore, reflecting these costs in the wage index is essentially counting them twice. This commenter pointed out that, because the DRG weights are based on hospital charges that are standardized by, among other factors, the area wage index, the weights of tertiary care DRGs are lower than they would be if the average charge per case were not first standardized by the wage index. However, the commenter went on to state that it is preferable to account for skill mix in the wage index rather than the case-mix index.
Response: As we stated in the August 1, 2000 final rule (65 FR 47103), we agree that severity-adjusted DRGs have potential for reducing discrepancies between payments and costs for individual cases (60 FR 29246). We have stated that, prior to implementing severity-adjusted DRGs, we would need specific legislative authority to offset any significant anticipated increase in payments attributable to changes in coding practices caused by significant changes to the DRG classification system. Section 301 of Public Law 106-554 authorized the Secretary to adjust the average standardized amounts if he determines that DRG coding or classification changes are likely to result in a change in aggregate payments. Therefore, based on this authority, we are beginning to evaluate the potential for implementing severity-adjusted DRGs. Because we are at the initial stages of that effort, we cannot yet estimate when, or if, such implementation may occur. However, we agree with these commenters' points that significant changes to any of the adjustments under the prospective payment system must be considered in light of the effects such changes may have to other such adjustments.
Comment: One commenter interpreted our proposal to suggest that the fiscal year for which the data will be collected will be closed by the time the methodology and data requirements have been established.
Response: In the proposed rule, we indicated we would conduct a special survey to collect these data to coincide with hospitals' cost reports beginning during FY 2001. We do not intend to require hospitals to retroactively adjust their payroll records to collect these data. Therefore, given our intention to gather input from the industry prior to designing the survey instrument, it likely will not be possible to completely coincide the data collection period with hospitals' FY 2001 cost reports.
Although there may be some auditing benefits to having the data overlap, this type of data is not routinely collected through the cost reports, so that the auditing benefits of such overlap may be minimal. In addition, there may be a benefit to collecting occupational mix for a more recent period in terms of reflecting current trends, such as higher wages paid to nurses during a shortage.Start Printed Page 39863
Comment: Other commenters raised specific technical concerns about the occupational mix discussion in the proposed rule.
Response: Rather than respond individually at this time to technical issues associated with the occupational mix discussion in the proposed rule, we will address these issues through direct consultation with the industry, as described above.
The data for the FY 2002 wage index were obtained from Worksheet S-3, Parts II and III of the FY 1998 Medicare cost reports. The data file used to construct the wage index includes FY 1998 data submitted to us as of July 2001. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data.
We asked our fiscal intermediaries to revise or verify data elements that resulted in specific edit failures. The unresolved data elements that were included in the calculation of the proposed FY 2002 wage index have been resolved and are reflected in the calculation of the final FY 2002 wage index. We note that, as part of this process to identify aberrant data and correct any errors prior to the calculation of the final FY 2002 wage index, we notified by letter those hospitals that were leading to large variations in the wage indexes of their labor market areas compared to the FY 2001 wage index. These hospitals were advised to review their data to identify the reason for the large increases or decreases and notify their fiscal intermediary of any necessary corrections.
Also, as part of our editing process, in the final wage index, we removed data for 30 hospitals that failed edits. For 24 of these hospitals, we were unable to obtain sufficient documentation to verify or revise the data because the hospitals are no longer participating in the Medicare program or are in bankruptcy status. Six hospitals had incomplete or inaccurate data resulting in exceptionally large, zero, or negative average hourly wages. Therefore, they were removed from the calculation. As a result, the final FY 2002 wage index is calculated based on FY 1998 wage data for 4,880 hospitals.
Comment: One commenter recommended that we incorporate additional fatal edits in the cost reporting systems to eliminate obvious errors on the Worksheet S-3 that result in incomplete or erroneous wage data that are difficult to correct 4 years later.
Response: We do not agree with the recommendation of the commenter. A separate desk review is performed for the wage index. The desk review, combined with the level two edits, is sufficient to provide fiscal intermediaries with information to identify discrepancies, such as zero or negative average hourly wage or missing hours, that can be resolved by the fiscal intermediary during the cost reporting process.
We note a technical change to the FY 2002 calculation. For the FY 2001 wage index calculation, we initially proposed to subtract Line 13 of Worksheet S-3, Part III from total hours when determining the excluded hours ratio used to estimate the amount of overhead attributed to excluded areas (65 FR 26299). However, the formula resulted in large and inappropriate increases in the average hourly wages for some hospitals (65 FR 47074), particularly hospitals that have large overhead and excluded area costs. Therefore, for the final FY 2001 wage index calculation, we reverted to the FY 2000 excluded hours ratio formula, which did not subtract Line 13.
Subsequently, we analyzed how the application of this formula resulted in overstated average hourly wages for some hospitals and how we could improve the overall accuracy of the overhead allocation methodology. We became aware that the problem was not in the excluded hours ratio formula. Rather, our wage index calculation did not also remove the overhead wage-related costs associated with excluded areas, an amount that must be estimated before it can be subtracted from the calculation. The combined effect of applying the excluded hours ratio formula, which appropriately removes salaries of lower-wage, overhead employees, and not subtracting overhead wage-related costs associated with excluded areas, resulted in overstated salary costs and average hourly wages.
For the FY 2002 wage index calculation, we are applying the excluded hours ratio formula that subtracts Part III, Line 13 from total hours. Additionally, for the first time in the wage index calculation, we estimated and subtracted overhead wage-related costs allocated to excluded areas.
After we applied this new calculation, there were still a few hospitals that experienced large increases in their average hourly wages. The intermediaries verified that the hospitals' wage data were accurate, so we kept the data in the wage index calculation. These hospitals primarily function as SNFs, psychiatric hospitals, or rehabilitation hospitals that have few acute care beds. The hospitals' higher average hourly wages reflect the costs of the higher salaried employees that remain in the wage index calculation after we subtract the costs of excluded area and associated overhead employees.
The method used to compute the final FY 2002 wage index follows.
Step 1—As noted above, we based the FY 2002 wage index on wage data reported on the FY 1998 Medicare cost reports. We gathered data from each of the non-Federal, short-term, acute care hospitals for which data were reported on the Worksheet S-3, Parts II and III of the Medicare cost report for the hospital's cost reporting period beginning on or after October 1, 1997 and before October 1, 1998. In addition, we included data from any hospital that had cost reporting periods beginning before October 1997 and reported a cost reporting period covering all of FY 1998. These data were included because no other data from these hospitals would be available for the cost reporting period described above, and because particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 1998 data. We note that, if a hospital had more than one cost reporting period beginning during FY 1998 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 1997 and before October 1, 1998), we included wage data from only one of the cost reporting periods, the longest, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we included the wage data from the latest period in the wage index calculation.
Step 2—Salaries—The method used to compute a hospital's average hourly wage is a blend of 40 percent of the hospital's average hourly wage including all GME and CRNA costs, and 60 percent of the hospital's average hourly wage after eliminating all GME and CRNA costs.
In calculating a hospital's average salaries plus wage-related costs, including all GME and CRNA costs, we subtracted from Line 1 (total salaries) the Part B salaries reported on Lines 3 and 5, home office salaries reported on Line 7, and excluded salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to skilled nursing facility services, home health services, and other subprovider components not Start Printed Page 39864subject to the inpatient prospective payment system). We also subtracted from Line 1 the salaries for which no hours were reported on Lines 2, 4, and 6. To determine total salaries plus wage-related costs, we added to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and physician Part A services (Lines 9, 9.01, 9.02, 10, and 10.01), home office salaries and wage-related costs reported by the hospital on Lines 11, 12, and 12.01, and nonexcluded area wage-related costs (Lines 13, 14, 16, 18, 18.01, and 20).
We note that contract labor and home office salaries for which no corresponding hours are reported were not included. In addition, wage-related costs for specific categories of employees (Lines 16, 18, 18.01, and 20) are excluded if no corresponding salaries are reported for those employees (Lines 2, 4, 4.01, and 6, respectively).
We then calculated a hospital's salaries plus wage-related costs by subtracting from total salaries the salaries plus wage-related costs for teaching physicians, Lines (4.01, 10.01, 12.01, and 18.01), Part A CRNAs (Lines 2 and 16), and residents (Lines 6 and 20).
Step 3—Hours—With the exception of wage-related costs, for which there are no associated hours, we computed total hours using the same methods as described for salaries in Step 2.
Step 4—For each hospital reporting both total overhead salaries and total overhead hours greater than zero, we then allocated overhead costs to areas of the hospital excluded from the wage index calculation. First, we determined the ratio of excluded area hours (sum of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours (Line 1 minus the sum of Part II, Lines 3, 5, 7, and Part III, Line 13 of Worksheet S-3). We then computed the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S-3, Part III. Next, we computed the amounts of overhead wage-related costs to be allocated to excluded areas using three steps: (1) We determined the ratio of overhead hours (Part III, Line 13) to revised hours (Line 1 minus the sum of Lines 3, 5, and 7); (2) we computed overhead wage-related costs by multiplying the overhead hours ratio by wage-related costs reported on Part II, Lines 13, 14, 16, 18, 18.01, and 20; and (3) we multiplied the computed overhead wage-related costs by the above excluded area hours ratio. Finally, we subtracted the computed overhead salaries, wage-related costs, and hours associated with excluded areas from the total salaries (plus wage-related costs) and hours derived in Steps 2 and 3. Using the above method for computing overhead salaries, wage-related costs, and hours to allocate to excluded areas, we also computed these costs excluding all costs associated with GME and CRNAs (Lines 2, 4.01, 6, 10.01, 12.01, and 18.01).
Step 5—For each hospital, we adjusted the total salaries plus wage-related costs to a common period to determine total adjusted salaries plus wage-related costs. To make the wage adjustment, we estimated the percentage change in the employment cost index (ECI) for compensation for each 30-day increment from October 14, 1997 through April 15, 1999 for private industry hospital workers from the Bureau of Labor Statistics' Compensation and Working Conditions. We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. The factors used to adjust the hospital's data were based on the midpoint of the cost reporting period, as indicated below.
Midpoint of Cost Reporting Period
Adjustment factor
10/14/97 11/15/97 1.03822
For example, the midpoint of a cost reporting period beginning January 1, 1998 and ending December 31, 1998 is June 30, 1998. An adjustment factor of 1.01973 would be applied to the wages of a hospital with such a cost reporting period. In addition, for the data for any cost reporting period that began in FY 1998 and covered a period of less than 360 days or more than 370 days, we annualized the data to reflect a 1-year cost report. Annualization is accomplished by dividing the data by the number of days in the cost report and then multiplying the results by 365.
Step 6—Each hospital was assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B) or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we added the total adjusted salaries plus wage-related costs obtained in Step 5 (with and without GME and CRNA costs) for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area.
Step 7—We divided the total adjusted salaries plus wage-related costs obtained under both methods in Step 6 by the sum of the corresponding total hours (from Step 4) for all hospitals in each labor market area to determine an average hourly wage for the area.
Because the FY 2002 wage index is based on a blend of average hourly wages, we then added 40 percent of the average hourly wage calculated without removing GME and CRNA costs, and 60 percent of the average hourly wage calculated with these costs excluded.
Step 8—We added the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in the nation and then divided the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage (using the same blending methodology described in Step 7). Using the data as described above, the national average hourly wage is $22.3096.
Step 9—For each urban or rural labor market area, we calculated the hospital wage index value by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8.
Step 10—Following the process set forth above, we developed a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (The national Puerto Rico standardized amount is adjusted by a wage index calculated for all Puerto Rico labor market areas based on the national average hourly wage as described above.) We added the total adjusted salaries plus wage-related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divided the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall average hourly wage of $10.7529 for Puerto Rico. For each labor market area in Puerto Rico, we calculated the Start Printed Page 39865Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage.
Step 11—Section 4410 of Public Law 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area may not be less than the area wage index applicable to hospitals located in rural areas in that State. Furthermore, this wage index floor is to be implemented in such a manner as to ensure that aggregate prospective payment system payments are not greater or less than those that would have been made in the year if this section did not apply. For FY 2002, this change affects 217 hospitals in 40 MSAs. The MSAs affected by this provision are identified in Table 4A by a footnote.
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural counties adjacent to one or more MSAs are considered to be located in one of the adjacent MSAs if certain standards are met. Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification for purposes of payment under the prospective payment system.
Section 304 of Public Law 106-554 made changes to several provisions of section 1886(d)(10) of the Act relating to hospital reclassifications and the wage index:
Section 304(a) amended section 1886(d)(10)(D) of the Act by adding a clause (v) to provide that, beginning with FY 2001, an MGCRB decision on a hospital reclassification for purposes of the wage index is effective for 3 years, unless the hospital elects to terminate the reclassification. Section 304(a) also provides that the MGCRB must use the 3 most recent years' average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and any succeeding fiscal year (section 1886(d)(10)(D)(vi) of the Act).
Section 304(b) provides that, by October 1, 2001, the Secretary must establish a mechanism under which a statewide entity may apply to have all of the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, for reclassifications beginning in FY 2003. Section 304(b) further requires that if the Secretary applies a statewide wage index to a State, an application under section 1886(d)(10) of the Act by an individual hospital in that State would not be considered.
We address our policy proposals relating to implementation of these three provisions of sections 304(a) and (b) of Public Law 106-554 in section IV.G. of this final rule. The following discussion of the revisions to the wage index based on hospital redesignations reflects those policies.
The methodology for determining the wage index values for redesignated hospitals is applied jointly to the hospitals located in those rural counties that were deemed urban under section 1886(d)(8)(B) of the Act and those hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Section 1886(d)(8)(C) of the Act provides that the application of the wage index to redesignated hospitals is dependent on the hypothetical impact that the wage data from these hospitals would have on the wage index value for the area to which they have been redesignated. Therefore, as provided in section 1886(d)(8)(C) of the Act, the wage index values were determined by considering the following:
If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the area wage index determined inclusive of the wage data for the redesignated hospitals (the combined wage index value) applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals increases the wage index value for the area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value.
The wage index value for a redesignated urban or rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located.
Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred.
Rural areas whose wage index values increase as a result of excluding the wage data for the hospitals that have been redesignated to another area have their wage index values calculated exclusive of the wage data of the redesignated hospitals.
Currently, the wage index value for an urban area is calculated exclusive of the wage data for hospitals that have been reclassified to another area.
For the FY 2002 wage index, we include the wage data for a reclassified urban hospital in both the area to which it is reclassified and the MSA where the hospital is physically located. We believe this improves consistency and predictability in hospital reclassification and wage indexes, as well as alleviates the fluctuations in the wage indexes due to reclassifications. For example, hospitals applying to reclassify into another area will know which hospitals' data will be included in calculating the wage index, because even if some hospitals in the area are reclassified, their data will be included in the calculation of the wage index of the area where they are geographically located. Also, in some cases, excluding the data of hospitals reclassified to another MSA could have a large downward impact on the wage index of the MSA in which the hospital is physically located. The negative impact of removing the data of the reclassified hospitals from the wage index calculation could lead to large wage disparities between the reclassified hospitals and other hospitals in the MSA, as the remaining hospitals would receive reduced payments due to a lower wage index. Our approach is to promote consistency and simplify our rules with respect to how we construct the wage indexes of rural and urban areas. As noted above, in the case of rural hospitals redesignated to another area, the wage index of the rural area where the hospitals are geographically located is calculated by including the wage data of the redesignated hospitals (unless doing so would result in a lower wage index).
Finally, we note that the Medicare Payment Advisory Commission (MedPAC), in its March 2001 “Report to the Congress: Medicare Payment Policy,” recommended this policy (p. 82). (Section VII. of this preamble includes a discussion of MedPAC's recommendations and our responses.) To illustrate the potential negative impact on hospitals in an area where reclassifications of some hospitals to another area results in a decline in the wage index after the reclassified hospitals are excluded from the wage Start Printed Page 39866index calculation, MedPAC points out that hospitals in several MSAs have organized to pay qualifying hospitals not to reclassify. Our policy change in this final rule removes this distorted incentive.
Comment: One commenter had some concerns about the reclassification of rural hospitals. This commenter had two points. The first point was that rural hospitals that seek reclassification to urban areas and end up “empty” because all the urban hospitals have successfully sought reclassification elsewhere continue to be disadvantaged because the rural hospitals continue to compete with the urban hospitals in that area, but those urban hospitals are receiving even higher payments, while the rural hospitals are not receiving the same payments. The commenter believed that the solution to this dilemma is to allow the rural hospitals that seek reclassification to an “empty” MSA to receive the same wage index as the urban hospitals that were able to reclassify out of that MSA, essentially reclassifying both the urban hospitals and the proximate rural hospitals to the same area. One other commenter made this same point about urban hospitals.
The commenter's second point was that, periodically, based on updated census data, new MSAs appear. Sometimes, a rural hospital seeking reclassification to the nearest MSA or rural area is disadvantaged when this occurs because reclassification to the new MSA does not afford the rural hospital the same advantages as reclassification to the MSA to which it formerly sought reclassification, but now is not the closest MSA. The commenter wrote that rural hospitals previously qualified for geographic reclassification to an MSA should retain the option to reclassify to that MSA despite the fact that a closer MSA is created.
Response: First, both rural and, for FY 2002, urban hospitals are advantaged by the fact that we hold all areas harmless when calculating the wage index for hospitals reclassifying into both MSAs and rural areas. While we understand the commenter's point about its competitors, we do not believe that this justifies a “piggyback” effect for reclassification purposes wherein either rural or urban hospitals that obtain reclassification into an empty MSA should then be reclassified again to an area to which these hospitals are not proximate. Since a hospital in this type of situation could not obtain reclassification on its own to the area to which the hospitals that have vacated the MSA have reclassified, we do not believe that it would be appropriate to reclassify them based on the reclassification of another hospital.
Second, a hospital that is not subject to the proximity criteria because it has a special status as either a rural referral center or a SCH already has an advantage over other reclassifying hospitals in that it can utilize a larger radius in seeking reclassification opportunities (under § 412.230(a)(3)). Rural referral centers and SCHs may also reclassify to any MSA to which they qualify under § 412.230(b). We believe these criteria provide adequate opportunity for rural referral centers and SCHs to reclassify.
Comment: Commenters generally supported our proposal to include the wage data for a reclassified urban hospital in both the area to which it is reclassified and the MSA where the hospital is physically located. The commenters expressed that this would provide more stability in the calculation of the wage index, allowing them to plan their budgets from year-to-year with more predictability.
We did not receive any negative comments on this proposal; however, we did receive one additional comment that encouraged us to extend the hold harmless provision to a further degree. This commenter believed that both rural and urban hospitals should benefit from the same hold-harmless policy. In other words, an urban hospital's wage data should be included in the area in which it is physically located if it benefits the area. However, The commenter further stated that, on the other hand, if it benefits the area to exclude that hospital's wage data in the event the hospital successfully seeks reclassification for the wage index to another area, then the hospital's data should be excluded. The commenter believed that some urban areas may be harmed by retaining the wage data of urban hospitals that are reclassifying out of those areas.
Response: We appreciate the commenters' support of our proposal to retain an urban hospital's wage data in the area in which it is physically located, even if that hospital successfully seeks reclassification to another area. As we proposed in the proposed rule, in this final rule we are calculating the wage index for urban areas effective for FY 2002 payments by including the wage data for a reclassified urban hospital in both the area to which it is reclassified and the MSA where the hospital is physically located.
In reference to the commenter who believed that we should apply the same hold-harmless policy to urban hospitals as we do to rural hospitals, we note that the rural hold-harmless policy (as described above) is dictated by section 1886(d)(8)(C)(iii) of the Act. We believe that hospitals continue to compete for services with the hospitals that are grouped with them in their respective MSAs. Therefore, it would be appropriate to continue to calculate the wage index for those areas as if those hospitals had not reclassified to another area. As a result, we intend to implement our policy to hold urban areas harmless to the extent that the wages of the hospitals that are physically located within urban areas will continue to be used in the compilation of the wage index whether or not these hospitals successfully seek reclassification elsewhere.
Comment: Several commenters expressed interest in utilizing the occupational mix data to apply for reclassification for the wage index. These commenters pointed out that, at one time, hospitals did have the option to use occupational mix data to seek reclassification for the wage index as those data were made available by the AHA. In addition to the other applicable criteria for reclassification, a hospital that applied for reclassification for the wage index using this criterion was required to show that its average hourly wage, based on occupational mix data, was 90 percent of the area to which it sought reclassification.
Response: Prior to requests for reclassification effective during FY 1999, a hospital could be reclassified for the wage index by showing that its average hourly wage weighted for occupational categories was at least 90 percent of the average hourly wage of the hospitals in the area to which it sought reclassification (in addition to the other applicable criteria for reclassification). Occupational mix data were available from the AHA; however, the AHA stopped collecting the data in 1993. Therefore, because there was no other suitable source of occupational mix data for hospitals to use, we eliminated the option for using this data effective with reclassification requests for FY 1999 (62 FR 45988).
Section 304(c) of Public Law 106-554 requires that the Secretary must provide for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. These data are to be collected by September 30, 2003. Section 304(c) also requires that the data are to be applied in the wage index by October 1, 2004. At that point, the data will be incorporated into a hospital's average Start Printed Page 39867hourly wages. Therefore, the occupational mix data will be reflected in hospital reclassifications for the wage index as it is incorporated into the wage index data. In addition, as soon as viable occupational mix data become available, we will consider providing hospitals with the opportunity to use it to support their reclassification requests.
The wage index values for FY 2002 are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this final rule. Hospitals that are redesignated should use the wage index values shown in Table 4C. Areas in Table 4C may have more than one wage index value because the wage index value for a redesignated urban or rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. When the wage index value of the area to which a hospital is redesignated is lower than the wage index value for the rural areas of the State in which the hospital is located, the redesignated hospital receives the higher wage index value; that is, the wage index value for the rural areas of the State in which it is located, rather than the wage index value otherwise applicable to the redesignated hospitals.
As mentioned earlier, section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) of the Act by adding a new clause (v) to provide that a reclassification of a hospital by the MGCRB for purposes of the wage index is effective for 3 years (instead of 1 year) unless, under procedures established by the Secretary, the hospital elects to terminate the reclassification before the end of the 3-year period. Section 304(a) of Public Law 106-554 also amended section 1886(d)(10)(D) of the Act to specify that, for applications for reclassification for the wage index for FYs 2003 and later, the MGCRB must base any comparison of the average hourly wage of the hospital with the average hourly wage for hospitals in the area in which it is located and the area to which it seeks reclassification, using data from the most recently published hospital wage survey (as of the date of the hospital's application), as well as data from each of the two immediately preceding surveys. (Our policies in this final rule to incorporate the provisions of section 304(a) of Public Law 106-554 in the regulations are addressed in section IV.G. of this final rule).
Consistent with the section 304(a) amendment, Tables 3A and 3B list the 3-year average hourly wage for each labor market area before the redesignation of hospitals, based on FY 1996, 1997, and 1998 wage data. Table 3A lists these data for urban areas and Table 3B lists these data for rural areas. In addition, Table 2 in the Addendum to this final rule includes the adjusted average hourly wage for each hospital from the FY 1996 and FY 1997 cost reporting periods, as well as the FY 1998 period used to calculate the FY 2002 wage index. Table 2 also shows the 3-year average that the MGCRB will use to evaluate a hospital's application for reclassification for FY 2003 (unless that average hourly wage is later revised in accordance with § 412.63(w)(2)). The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously in this section) across all 3 years, by the sum of the hours. If a hospital is missing data for any of the previous years, its average hourly wage for the 3-year period is calculated based on the data available during that period.
Applications for FY 2003 reclassifications are due to the MGCRB by September 4, 2001. (We note that, as of May 21, 2001, the new location and mailing address of the MGCRB and the Provider Reimbursement Review Board (PRRB) is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. Also, please specify whether the mail is intended for the MGCRB or the PRRB.)
We indicated in the proposed rule that, at the time the proposed wage index was constructed, the MGCRB had completed its review of FY 2002 reclassification requests. The final FY 2002 wage index values incorporate all 643 hospitals redesignated for purposes of the wage index (hospitals redesignated under section 1886(d)(8)(B) or section 1886(d)(10) of the Act for FY 2002. Since publication of the May 4 proposed rule, the number of reclassifications has changed because some MGCRB decisions were still under review by the Administrator and because some hospitals decided to withdraw their requests for reclassification.
Changes to the wage index that resulted from withdrawals of requests for reclassification, wage index corrections, appeals, and the Administrator's review process have been incorporated into the wage index values published in this final rule. The changes may affect not only the wage index value for specific geographic areas, but also the wage index value redesignated hospitals receive; that is, whether they receive the wage index value for the area to which they are redesignated, or a wage index value that includes the data for both the hospitals already in the area and the redesignated hospitals. Further, the wage index value for the area from which the hospitals are redesignated may be affected.
Under § 412.273, hospitals that have been reclassified by the MGCRB were permitted to withdraw their applications within 45 days of the publication of the May 4, 2001 proposed rule. The request for withdrawal of an application for reclassification that would be effective in FY 2002 had to be received by the MGCRB by June 18, 2001. A hospital that requested to withdraw its application may not later request that the MGCRB decision be reinstated.
In addition, because the 3-year effect of the amendment made by section 304(a) of Public Law 106-554 is applicable to reclassifications for FY 2001 (which had already taken place prior to the date of enactment of Public Law 106-554) and because the application process for reclassification for FY 2002 had already been completed by the date of enactment, we are deeming hospitals that are reclassified for purposes of the wage index to one area for FY 2001 and are reclassified for purposes of the wage index or the standardized amount to another area for FY 2002 to be reclassified to the area for which they applied for FY 2002, unless they elected to receive the wage index reclassification they were granted for FY 2001. Consistent with our application withdrawal procedures under § 412.273, we allowed hospitals that wished to receive, for FY 2002, the reclassification they were granted for FY 2001, to withdraw their applications by June 18, 2001 also.
Comment: Two commenters requested us to continue publishing the case-mix index because it assists hospitals in monitoring possible referral center qualifying status and in preparing applications for reclassification to use another area's standardized amount. (We also received numerous telephone calls with this request.)
Response: Prior to this year, the case-mix index was published in Table 3C. This index shows the average DRG relative weight for discharges from a prior fiscal year. Due to the requirement to publish so much additional average hourly wage data in Tables 2, 3A, and 3B, we stopped publishing the case-mix index beginning with the May 4, 2001 proposed rule.
In light of public comments and in balancing the requirements for additional publication of average hourly wage data, we will resume publishing the case-mix index, but not in the Federal Register. Beginning with the publication date of this final rule, we will make the case-mix index for FY 2000 and future fiscal years available on Start Printed Page 39868the internet at: http://www.hcfa.gov/medicare/ippsmain.htm. We intend to update the case-mix index at this website to coincide with the publication of the annual proposed and final rules.
As stated earlier, section 304(b) of Public Law 106-554 requires the Secretary to establish, by October 1, 2001, a process (based on the voluntary process utilized by the Secretary under section 1848 of the Act) under which an appropriate statewide entity may apply to have all the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, beginning in FY 2003. Section 304(b) further requires that, if the Secretary applies a statewide wage index to an area, an application by an individual hospital in that area would not be considered. We believe the reference to the voluntary process utilized by the Secretary under section 1848 of the Act refers to the process whereby we allow a State containing multiple physician fee schedule payment areas (and thus multiple geographic adjustment factors) to voluntarily convert to a single statewide payment area with a single geographic adjustment factor (see § 414.4(b), as discussed in the June 24, 1994 Federal Register (59 FR 32759).
Section IV.G. of this final rule contains our policy for implementing the provisions of section 304(b) in regulations. We are providing that hospitals that seek a statewide geographic reclassification under the amendments made by section 304(b) of Public Law 106-554 must apply to the MGCRB with the same deadlines as other hospitals. An approved application by the MGCRB will mean that the data of all the hospitals in the State will be used in computing and applying the wage index for that State. We are providing that the statewide wage index is applicable for 3 years from the date of approval or until all of the participating hospitals terminate their approved statewide wage index reclassification (effective with the next full fiscal year after their termination request), whichever occurs first.
Beginning October 1, 1988, section 1886(d)(8)(B) of the Act required us to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards published in the Federal Register on January 3, 1980 (45 FR 956) for designating MSAs (and for designating NECMAs), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs)). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage index.
During FY 1994, we incorporated the revised MSA definitions based on 1990 census population data. As a result, some counties that previously were treated as an adjacent county under section 1886(d)(8)(B) of the Act officially became part of certain MSAs. However, as specified in the Act, we continued to utilize the January 3, 1980 standards. For FY 2000, there were 27 hospitals in 22 counties affected by this provision.
On March 30, 1990, OMB issued revised 1990 standards (55 FR 12154). There has been an increasing amount of interest by the hospital industry in using the 1990 standards as opposed to the 1980 standards to determine which hospitals qualify under the provisions set forth in section 1886(d)(8)(B) of the Act. Section 402 of Public Law 106-113 provides that, with respect to FYs 2001 and 2002, a hospital may elect to have the 1990 standards applied to it for purposes of section 1886(d)(8)(B) and that, beginning with FY 2003, hospitals will be required to use the standards published in the Federal Register by the Director of OMB based on the most recent decennial census.
We worked with staff of the Population Distribution Branch within the Population Division of the Census Bureau to compile a list of hospitals that meet the March 30, 1990 standards using 1990 census population data and information prepared for the Metropolitan Area Standards Review Project. The conditions that must be met for a hospital located in a rural county adjacent to one or more urban areas to be treated as being located in the urban area to which the greatest number of workers in the rural county commute are as follows:
The rural county would otherwise be considered part of an MSA but for the fact that the rural county does not meet the standard established by OMB relating to the commuting rate of workers between the county and the central county or counties of any adjacent MSA.
The county would meet the commuting standard if commuting to (and where applicable, from) the central county or central counties of all adjacent MSAs or NECMAs (rather than to just one) were considered.
A county meeting the above commuting standards must also meet the other standards established by OMB for inclusion in an MSA as an outlying county. In order to meet these requirements, the rural county must have a degree of “metropolitan character.” “Metropolitan character” is established by meeting one of the following OMB standards, which were published in the Federal Register on March 30, 1990:
a. At least 50 percent of the employed workers residing in the county commute to the central county/counties, and either—
The population density of the county is at least 25 persons per square mile; or
At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanized area(s).
b. From 40 to 50 percent of the employed workers commute to the central county/counties, and either—
The population density is at least 35 persons per square mile; or
c. From 25 to 40 percent of the employed workers commute to the central county/counties and either the population density of the county is at least 50 persons per square mile, or any two of the following conditions exist:
Population density is at least 35 persons per square mile.
At least 35 percent of the population is urban.
At least 10 percent of the population, or at least 5,000 persons, lives in the qualifier urbanizer area(s).
d. From 15 to 25 percent of the employed workers commute to the central county/counties, the population density of the county is at least 50 persons per square mile, and any two of the following conditions also exist:
Population growth between the last two decennial censuses is at least 20 percent.
Also accepted as meeting this commuting requirement under item d. are:Start Printed Page 39869
The number of persons working in the county who live in the central county/counties is equal to at least 15 percent of the number of employed workers living in the county; or
The sum of the number of workers commuting to and from the central county/counties is equal to at least 20 percent of the number of employed workers living in the county.
e. From 15 to 25 percent of the employed workers commute to the central county/counties, the population density of the county is less than 50 persons per square mile, and any two of the following conditions also exist:
f. At least 2,500 of the population lives in a central city of the MSA located in the qualifier urbanized area(s).
When we apply the 1990 standards as opposed to 1980 standards, the number of qualifying counties increases from 22 to 31. On the basis of the evaluation of these data, effective for discharges occurring on or after October 1, 2001, hospitals listed in the first column of the following table are considered, for purposes of assigning the inpatient standardized amount and the wage index, to be located in the corresponding urban area in the second column:
Rural county
Chilton, AL Birmingham, AL
Marshall, AL Huntsville, AL
Talladega, AL Anniston, AL
Bradford, FL Jacksonville, FL
Hendry, FL West Palm Beach-Boca Raton, FL
Putnam, FL Gainesville, FL
Jackson, GA Athens, GA
Christian, IL Springfield, IL
Macoupin, IL St. Louis, MO-IL
Piatt, IL Champaign-Urbana, IL
Brown, IN Indianapolis, IN
Carroll, IN Lafayette, IN
Henry, IN Indianapolis, IN
Jefferson, KS Topeka, KS
Barry, MI Kalamazoo-Battle Creek, MI
Cass, MI Benton Harbor, MI
Ionia, MI Grand Rapids-Muskegon-Holland, MI
Shiawassee, MI Flint, MI
Tuscola, MI Saginaw-Bay City-Midland, MI
Caswell, NC Greensboro-Winston Salem-High Point, NC
Greene, NC Greenville, NC
Harnett, NC Raleigh-Durham-Chapel Hill, NC
Wilson, NC Rocky Mount, NC
Preble, OH Dayton-Springfield, OH
Van Wert, OH Lima, OH
Adams, PA York, PA
Lawrence, PA Pittsburgh, PA
Monroe, PA Newark, NJ
Schuylkill, PA Reading, PA
Jefferson, WI Milwaukee-Waukesha, WI
Walworth, WI Milwaukee-Waukesha, WI
There are 14 counties that meet the qualifying criteria using 1990 standards that did not meet the criteria using the 1980 standards. These 14 counties are:
Chilton, AL
Talladega, AL
Bradford, FL
Hendry, FL
Putnam, FL
Piatt, IL
Brown, IN
Carroll, IN
Greene, NC
Adams, PA
Monroe, PA
Schuylkill, PA.
In addition, when we apply the 1980 standards for three of the counties, the MSA assigned is different from the MSA that would be assigned using the 1990 standards. These counties are as follows:
1980 MSA designation
Ionia, MI Lansing-East Lansing, MI Grand Rapids-Muskegon-Holland, MI.
Caswell, NC Danville, VA Greensboro-Winston Salem-High Point, NC.
Harnett, NC Fayetteville, NC Raleigh-Durham-Chapel Hill, NC.
Section 402 of Public Law 106-113 states that hospitals may elect to use either the January 3, 1980 standards or the March 30, 1990 standards for payments during FY 2001 and FY 2002. We are assuming hospitals will elect to go to the MSA resulting in the highest payment amount accounting for the applicable wage indexes and standardized amounts. Based on our analysis, we believe all hospitals in the designated rural counties would benefit by being included in the respective MSAs shown above. Therefore, we proposed to assign the FY 2002 Start Printed Page 39870standardized amount and wage index of each respective MSA to the affected hospitals. Hospitals electing not to use the 1990 standards would be required to notify their fiscal intermediary in writing of such election prior to September 1, 2001, in order to allow sufficient time to reflect this change in our payment systems.
We note that five rural counties no longer meet the qualifying criteria when we apply the revised OMB standards. These rural counties are as follows: Indian River, FL; Mason, IL; Owen, IN; Morrow, OH; and Lincoln, WV. For FY 2002, we continue to treat these hospitals as attached to an MSA on the basis of the 1980 standards. Beginning FY 2003, they must meet the 1990 standards to continue to be treated as such.
We stated in the August 1, 2000 final rule that implemented changes to the prospective payment system for FY 2001 that we were in the process of working with OMB to identify the hospitals that would be affected by section 402 of Public Law 106-113 (65 FR 47076). We further indicated we would revise payments to hospitals in the affected counties as soon as data were available. Now that the affected counties have been identified, hospitals in the 14 counties identified above will be offered the opportunity to elect this designation, as previously described. We will provide further information related to this election, including recalculated wage indexes, through a forthcoming program memorandum.
Finally, three hospitals located in counties affected by the revised OMB standards also have been reclassified by the MGCRB. The affected hospitals are listed below. If the hospitals did not wish to be reclassified for FY 2002 based on their new designation as described above, they had to follow the procedures described above for requesting that their application for reclassification be withdrawn.
Provider No.
FY 2002 reclassification, MSA
34-0071 Raleigh-Durham-Chapel Hill, NC Fayetteville, NC.
34-0126 Rocky Mount, NC Raleigh-Durham-Chapel Hill, NC (wage index only).
In the August 1, 2000 interim final rule with comment period, we implemented sections 152(a), 153, and 154(a) of Public Law 106-113. These sections contained provisions under which hospitals in certain counties are deemed to be located in specified areas for purposes of payment under the hospital inpatient prospective payment system, for discharges occurring during FY 2000. For payment purposes, hospitals under section 152(a) are to be treated as though they were reclassified for purposes of both the standardized amount and the wage index. Sections 153 and 154(a) did not affect the standardized amount. In the interim final rule, we calculated FY 2000 wage indexes for hospitals in the affected counties. These wage indexes are listed below. No other hospitals' FY 2000 wage indexes were affected, including those hospitals in the areas to which these affected hospitals were reclassified, as well as nonreclassified hospitals located in the areas from which these hospitals were reclassified.
We also implemented section 152(a), which provided that, for purposes of making payments under section 1886(d) of the Act for FY 2000—
To hospitals in Iredell County, North Carolina, Iredell County was deemed to be located in the Charlotte-Gastonia-Rock Hill, North Carolina-South Carolina MSA;
To hospitals in Orange County, New York, Orange County was deemed to be located in the New York, New York MSA;
To hospitals in Lake County, Indiana and Lee County, Illinois, Lake County and Lee County were deemed to be located in the Chicago, Illinois MSA;
To hospitals in Hamilton-Middletown, Ohio, Hamilton-Middletown was deemed to be located in the Cincinnati, Ohio-Kentucky-Indiana MSA;
To hospitals in Brazoria County, Texas, Brazoria County was deemed to be located in the Houston, Texas MSA;
To hospitals in Chittenden County, Vermont, Chittenden County was deemed to be located in the Boston-Worcester-Lawrence-Lowell-Brockton, Massachusetts-New Hampshire MSA.
In accordance with section 153 of Public Law 106-113, for discharges occurring during FY 2000, the Hattiesburg, Mississippi MSA wage index was recalculated by including the wage data for Wesley Medical Center. In accordance with section 154(a), the Allentown-Bethlehem-Easton, Pennsylvania MSA FY 2000 wage index was recalculated by including the wage data for Lehigh Valley Hospital.
The following table shows the changes to the FY 2000 wage index values for the hospitals in the affected counties. Hospitals affected by section 152(a) of Public Law 106-113 were also considered reclassified for purposes of the standardized amount.
County or MSA
New MSA (for wage index and standardized amount)
New wage index
New Georgraphic Adjustment Factor (GAF)
Iredell County, NC 1520 0.9434 0.9609
Orange County, NY 5600 1.4342 1.2801
Lake County, IN 1600 1.0750 1.0508
Lee County, IL 1600 1.0750 1.0508
Hamilton-Middletown, OH 1640 0.9419 0.9598
Brazoria County, TX 3360 0.9388 0.9577
Chittenden County, VT 1123 1.1359 1.0912
Hattiesburg, MS MSA 3285 0.7634 0.8312
Allentown-Bethlehem-Easton, PA MSA 0240 1.0228 1.0156
In the May 4, 2000 proposed rule, we stated that, to allow hospitals time to construct the proposed FY 2002 hospital wage index, we would make available in May 2001 a final public data file containing the FY 1998 hospital wage data.
The final wage data file was released on May 4, 2001. As noted above in section III.D. of this preamble, this file included hospitals' cost report data obtained from Worksheet S-3, Parts II and III of their FY 1998 Medicare cost reports. In addition, Table 2 in the Addendum to this final rule contains each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 1998 data used to construct the final FY 2002 wage index.
Under revised procedures, hospitals were given an opportunity to correct any incorrectly reported FY 1998 wage data on their cost reports and submit complete detailed supporting documentation to their intermediaries by March 9, 2001. Wage data corrections had to be reviewed and verified by the intermediary and transmitted to HCFA on or before April 9, 2001. These deadlines were necessary to allow sufficient time to review and process the data so that the final wage index calculation could be completed for development of the final prospective payment rates in this final rule.
We created the process described above to resolve all substantive wage data correction disputes before we finalize the wage data for the FY 2002 payment rates. Accordingly, hospitals that did not meet the procedural deadlines set forth above were not afforded a later opportunity to submit wage data corrections or to dispute the intermediary's decision with respect to requested changes. Specifically, our policy is that hospitals that do not meet the procedural deadlines set forth above will not be permitted to later challenge, before the Provider Reimbursement Review Board, HCFA's failure to make a requested data revision (See W. A. Foote Memorial Hospital v. Shalala, No. 99-CV-75202-DT (E.D. Mich. 2001)).
As stated above, the final wage data public use file was released on May 4, 2001. Hospitals had an opportunity to examine both Table 2 of the proposed rule and the May 4 final public use wage data file (which reflected revisions to the data used to calculate the values in Table 2) to verify the data HCFA was using to calculate the wage index. Hospitals had until June 4, 2001, to submit requests to correct errors in the final wage data due to data entry or tabulation errors by the intermediary or HCFA. The correction requests considered at that time were limited to errors in the entry or tabulation of the final wage data that the hospital could not have known about before the release of the final wage data public use file.
If, after reviewing the May 2001 final data file, a hospital believed that its wage data are incorrect due to a fiscal intermediary or HCFA error in the entry or tabulation of the final wage data, it was provided an opportunity to send a letter to both its fiscal intermediary and HCFA, outlining why the hospital believed an error exists and provide all supporting information, including dates. These requests had to be received by us and the intermediaries no later than June 4, 2001.
Changes to the hospital wage data were made in those very limited situations involving an error by the intermediary or HCFA that the hospital could not have known about before its review of the final wage data file. Specifically, neither the intermediary nor HCFA accepted the following types of requests at that stage of the process:
Requests for wage data corrections that were submitted too late to be included in the data transmitted to HCFA on or before April 9, 2001.
Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 2001 wage data file.
Requests to revisit factual determinations or policy interpretations made by the intermediary or HCFA during the wage data correction process.
Verified corrections to the wage index received timely (that is, by June 4, 2001) are incorporated into the final wage index in this final rule, to be effective October 1, 2001.
Again, we believe the wage data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage data to the intermediary's attention. Moreover, because hospitals had access to the final wage data by early May 2001, they had the opportunity to detect any data entry or tabulation errors made by the intermediary or HCFA before the development and publication of the FY 2002 wage index and its implementation on October 1, 2001. If hospitals availed themselves of this opportunity, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified after that date, we retain the right to make midyear changes to the wage index under very limited circumstances.
Specifically, in accordance with § 412.63(w)(2), we may make midyear corrections to the wage index only in those limited circumstances in which a hospital can show (1) that the intermediary or HCFA made an error in tabulating its data; and (2) that the hospital could not have known about the error, or did not have an opportunity to correct the error, before the beginning of FY 2002 (that is, by the June 4, 2001 deadline). As indicated earlier, since a hospital had the opportunity to verify its data, and the intermediary notified the hospital of any changes, we do not foresee any specific circumstances under which midyear corrections would be necessary. However, should a midyear correction be necessary, the wage index-change for the affected area will be effective prospectively from the date the correction is made.
Although the wage data correction process described above has proven successful in the past for ensuring that the wage data used each year to calculate the wage indexes are generally reliable and accurate, we are concerned about the growing volume of wage data revisions initiated by hospitals during February and the first week of March. We first discussed this issue in the FY 1998 proposed rule (62 FR 29918). At that time, we noted that, in developing the FY 1997 wage index, the wage data were revised between the proposed and final rules for more than 13 percent of the hospitals (approximately 700 of 5,200). Last year, in developing the FY 2001 wage index, the wage data were revised between the proposed and final rules for more than 32 percent of the hospitals (1,605 of 4,950). This year, in developing the FY 2002 wage index, the wage data were revised between the proposed rule and the final rule for 30 percent of the hospitals (1,473 of 4,910).
In the May 4, 2001 proposed rule, we indicated that since hospitals are expected to submit complete and accurate cost report data, and intermediaries review and request hospitals to correct problematic wage data before the data are submitted to HCFA in mid-November, we believed there should be limited revisions at this stage of the process. We reminded the hospital community that the primary purpose of this file is to allow hospitals to verify that we have their correct data on file. However, according to information received from the intermediaries, these late revisions are frequently due to hospitals' lack of responsiveness in providing sufficient information to the intermediaries during the desk reviews (that is, during the Start Printed Page 39872intermediary's review of the hospital's cost report).
In the proposed rule, we proposed two changes to the wage index development process and timetable beginning with the FY 2003 wage index. We believed these changes would encourage earlier submissions of wage data revisions by hospitals and would allow intermediaries more time to address the heavy volume of revisions requested after the intermediaries have completed their desk reviews of these data. First, we proposed to release the preliminary wage data file by early January rather than early February. As with the current preliminary file, the January file would include desk reviewed wage data that intermediaries submitted to us by November of the previous year and any timely revisions we received from intermediaries prior to release of the January file. Hospitals would be allowed until early February to submit requests for wage data revisions to their intermediaries. Second, intermediaries would be allowed approximately 8 weeks from the hospitals' deadline for submitting revision requests (that is, until early March) to review and transmit revised wage data to us.
We believed that the proposed revised schedule would improve the quality of the wage index by allowing intermediaries more time to sufficiently review wage data revisions before the data are submitted to us. Further, we believed the proposed revised process would encourage hospitals to submit revisions earlier, so the proposed wage index, from which hospitals base geographic reclassification decisions, is more accurate.
The timetable for developing the annual update to the wage index is as follows (an asterisk indicates no change from prior years):
All desk reviews for hospitals wage data are completed and revised data transmitted by the fiscal intermediaries to HCRIS.
CMS compiles file of wage data, received by mid-November, and sends it to the fiscal intermediaries for verification.
Edited wage data are available for release to the public.
Deadline for hospitals to request wage data revisions and provide adequate documentation to support the request.
Proposed rule published with 60-day comment period and 45-day withdrawal deadline for hospitals applying for geographic reclassification.
Deadline for the fiscal intermediaries to submit all revisions resulting from the hospitals' requests for adjustments (as of early February) (and verification of data submitted as of early January).
Deadline for hospital's to request CMS's intervention in cases where the hospital disagrees with the fiscal intermediary's policy interpretations pertaining to the allowability of particular costs.
Fiscal intermediaries will alert hospitals to the availability of the final wage data file for their review and inform hospitals of the June deadline for hospitals to submit correction requests for corrections to errors due to CMS or fiscal intermediary mishandling of the final wage data.
Release of final wage data public use file on CMS web page and through public use files office.
Deadline for hospitals to submit correction requests to both CMS and the fiscal intermediaries to correct errors due to CMS or fiscal intermediary mishandling of the final wage data.
Publication of the final rule.
Effective date of updated wage index.
Comment: One commenter agreed, in general, with the premise of the proposed revised schedule. The commenter recommended that we publish the preliminary wage data file in August, using data from the hospitals' as-filed cost reports before fiscal intermediaries begin the wage index desk reviews. Hospitals would then have until October 1 to submit requests, along with supporting documentation, to correct errors. The commenter's proposal would give fiscal intermediaries until November 30 to complete the desk review and transmit the wage index data to us. The commenter believed that implementation of the recommended schedule eliminates the fiscal intermediary's duplication of effort (that is, reviewing the data a second time when hospitals request changes after the desk review, and then resubmitting the data to us) that exists in the current process.
Response: We appreciate the commenter's general support for our proposal to revise the wage index schedule, and we will give the commenter's recommended process careful consideration in developing future updates to the wage index. Having received no other comments opposing our proposed schedule, we will implement that schedule, beginning with the FY 2003 wage index. We believe that our revised schedule is a logical step in the evolution of the wage index development process. We will monitor the effectiveness of the revised schedule.
For the benefit of the reader, in this final rule, we are discussing and clarifying many of the rules and policies governing SCHs because of the legislative changes that have occurred in recent years. It has been several years since the SCH criteria have been published in one location. Rather than continue to refer to various Federal Register documents and sections of the Code of Federal Regulations, we are publishing a detailed discussion of these policies, making further changes to incorporate the provisions of sections 213, 302, 303, 304, and 311 of Public Law 106-554, and clarifying other related policies.
Under the hospital inpatient prospective payment system, special payment protections are provided to an SCH. Section 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, absence of other like hospitals (as determined by the Secretary), or historical designation by the Secretary as an Essential Access Community Hospital (EACH), is the sole source of inpatient hospital services reasonably available to Medicare beneficiaries. The regulations that set forth the criteria that a hospital must meet to be classified as an SCH are at § 412.92. To be classified as an SCH, a hospital must either have been designated as an SCH prior to the beginning of the prospective payment system on October 1, 1983, and must be located more than 35 miles from other like hospitals, or the hospital must be Start Printed Page 39873located in a rural area and meet one of the following requirements:
It is located more than 35 miles from other like hospitals.
It is located between 25 and 35 miles from other like hospitals, and it—
—Serves at least 75 percent of all inpatients, or 75 percent of Medicare beneficiary inpatients, within a 35-mile radius or, if larger, within its service area; or
—Has fewer than 50 beds and would qualify on the basis of serving 75 percent of its area s inpatients except that some patients seek specialized care unavailable at the hospital.
It is located between 15 and 25 miles from other like hospitals, and because of local topography or extreme weather conditions, the other like hospitals are inaccessible for at least 30 days in each of 2 out of 3 years.
The travel time between the hospital and the nearest like hospital is at least 45 minutes because of distance, posted speed limits, and predictable weather conditions.
Effective with hospital cost reporting periods beginning on or after April 1, 1990, section 1886(d)(5)(D)(i) of the Act, as amended by section 6003(e) of Public Law 101-239, provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment:
The Federal rate applicable to the hospital.
The updated hospital-specific rate based on FY 1982 costs per discharge.
Effective with hospital cost reporting periods beginning on or after October 1, 2000, section 1886(b)(3)(I)(i) of the Act, as added by section 405 of Public Law 106-113 and amended by section 213 of Public Law 106-554, provides for other options, in addition to the three bulleted options in the above paragraph, for determining which rate would yield the greatest aggregate payment. For discharges for FY 2001 through FY 2003, these additional optional rates are—
A phase-in blended rate of the updated hospital-specific rate based on FY 1982 costs per discharge and an FY 1996 hospital-specific rate; or
A phase-in blended rate of the updated hospital-specific rate based on FY 1987 costs per discharge and an FY 1996 hospital-specific rate.
For discharges beginning in FY 2004, the additional optional rate would be 100 percent of the FY 1996 hospital-specific rate.
For each cost reporting period, the fiscal intermediary determines which of the payment options will yield the highest rate of payment. Payments are automatically made at the highest rate using the best data available at the time the fiscal intermediary makes the determination. However, it may not be possible for the fiscal intermediary to determine in advance precisely which of the rates will yield the highest payment by year's end. In many instances, it is not possible to forecast the outlier payments, the amount of the DSH adjustment, or the IME adjustment, all of which are applicable only to payments based on the Federal rate. The fiscal intermediary makes a final adjustment at the close of the cost reporting period to determine precisely which of the payment rates would yield the highest payment to the hospital.
If a hospital disagrees with the fiscal intermediary's determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary's decision in accordance with the procedures set forth in Subpart R of Part 405, which concern provider payment determinations and appeals.
In calculating a hospital-specific rate for an SCH based on its FY 1996 cost reporting period, we will, to the extent possible, use the same methodology that we used to calculate the hospital-specific rate based on either the FY 1982 or FY 1987 cost reporting period. That methodology is set forth in §§ 412.71, 412.72, 412.73, 412.75 and 412.77.
If a hospital has a cost reporting period ending in FY 1982, it will be paid a hospital-specific rate based on its FY 1982 costs; or a hospital-specific rate based on its FY 1987 costs; or a hospital-specific rate based on its FY 1996 costs (which, until FY 2004, would be a blend of the greater of the FY 1982 or FY 1987 costs and the FY 1996 costs); or it will be paid based on the Federal rate.
If a hospital has no cost reporting period ending in FY 1982, it will be paid a hospital-specific rate based on its FY 1987 costs; or a hospital-specific rate based on its FY 1996 costs (which, until FY 2004, would be a blend of its FY 1987 costs and FY 1996 costs); or it will be paid based on the Federal rate.
If a hospital has no cost reporting period ending in either FY 1982 or FY 1987, it will be paid based on its FY 1996 costs; or it will be paid based on the Federal rate.
If a hospital has no cost reporting period ending in FY 1982, FY 1987, or FY 1996, it cannot be paid based on a hospital-specific rate; it will be paid based on the Federal rate.
If a hospital was operating during any or all of FY 1982, FY 1987, or FY 1996, but, for some reason, the cost report records are no longer available, the hospital will be treated as if it had no cost report for the applicable period. Section 1886(b)(3)(C) of the Act specifies the available periods that may be used.
For each SCH, the fiscal intermediary will calculate a hospital-specific rate based on the hospital's FY 1982, FY 1987, or FY 1996 cost report as follows:
Determine the hospital's total allowable Medicare inpatient operating cost, as stated on the cost report.
Divide the total Medicare operating cost by the number of Medicare discharges (without adjusting for transfers) in the cost reporting period to determine the base period cost per case.
In order to take into consideration the hospital's individual case-mix, the base year cost per case is divided by the hospital's case-mix index applicable to the cost reporting period. This step is necessary to adjust the hospital's base period cost for case mix. This is done to remove the effects of case mix from the base period costs per case. Payments using these base period costs are then adjusted to reflect the actual case mix during the payment year. A hospital's case mix is computed based on its Medicare patient discharges subject to DRG-based payment.
The fiscal intermediary will inform each SCH of its hospital-specific rate based on its applicable cost reporting period within 180 days after the start of its cost reporting period.
(The provisions of section 213 of Public Law 106-554 relating to the extension to all SCHs the option to rebase using their FY 1996 operating costs, for cost reporting periods beginning on or after October 1, 2000, were addressed in the June 13, 2001 interim final rule with comment period, and are finalized in this final rule.)
An SCH is also eligible for a payment adjustment if, for reasons beyond its control, it experiences a decline in volume of greater than 5 percent compared to its preceding cost reporting period. This adjustment is also available to hospitals that could qualify as SCHs but choose not to be paid as SCHs; that is, hospitals that qualify and successfully apply to be designated as SCHs but continue to receive payments based on the Federal rate. In addition, section 6003(c)(1) of Public Law 101-239 deleted the sunset date on the 5-percent volume decline adjustment, thus allowing SCHs to receive the adjustment indefinitely. The sunset provision was included under section 1886(d)(5)(C)(ii) of the Act. (Section 6003(c)(1) of Public Law 101-239 amended that provision and Start Printed Page 39874redesignated it as section 1886(d)(5)(D) of the Act.)
In the September 1, 1983, issue of the Federal Register (48 FR 39781), we stated that any hospital designated as an SCH would retain that status until it experienced a change in circumstances. Section 6003(e)(3) of Public Law 101-239 specifically stated that any hospital classified as an SCH as of the date of enactment of Public Law 101-239 (December 19, 1989), will retain its SCH status even if the hospital did not meet the criteria established under section 6003(e)(1) of that law. These hospitals are the “grandfathered” SCH hospitals. Therefore, we have continued to allow hospitals designated as SCHs prior to December 19, 1989, to be “grandfathered” under current criteria.
In the June 4, 1991 Federal Register, we stated that a hospital's special status as an SCH would not be retained in light of the hospital's geographic reclassification for purposes of the standardized amount. In the event the hospital's reclassification ceases, it must reapply for special status and must meet all of the applicable qualifying criteria in effect at the time it seeks requalification (56 FR 25482). However, in the event a “grandfathered” SCH was successfully reclassified, it would be reinstated as an SCH if its reclassification ceased.
Section 401(a) of Public Law 106-113 established that any subsection (d) hospital (section 1886(d) of the Act) located in an urban area may be redesignated as being located in a rural area if the hospital meets one of several criteria established by the legislation. One of these criteria is that the hospital could qualify as an SCH if the hospital were located in a rural area. Under this provision, an urban hospital that may have been “grandfathered” as an SCH could now qualify and receive payment as an SCH if it met the criteria of a rural SCH instead of as an urban SCH. Given this extension of SCH eligibility, we no longer believe it is necessary to extend special protection to “grandfathered” SCHs that successfully apply for geographic reclassification through the MGCRB for the standardized amount after their MGCRB reclassification ends. Therefore, a hospital that loses its SCH status through a change in circumstances, such as reclassification through the MGCRB for the standardized amount, will not be reinstated as a SCH unless it can meet all of the SCH qualifying criteria in effect at the time it seeks requalification. This circumstance falls under the provisions of §§ 412.92 (b)(3) and (b)(5), which state that an approved classification as an SCH remains in effect without need for reapproval unless there is a change in the circumstances under which the classification was approved. We believe that a successful reclassification by the MGCRB fits the definition of a change in circumstances.
Because some hospitals may not have understood the effect reclassification would have on their special status, in the May 4 proposed rule we permitted affected hospitals, under existing § 412.273(a), the option to withdraw their applications for reclassification for FY 2002, even if the MGCRB had issued a decision, by submitting a withdrawal request to the MGCRB within 45 days of publication of this proposed rule. Finally, just as a competing hospital that closes leaves an opportunity for an existing hospital to qualify as an SCH, a new hospital that opens in an area with an existing hospital designated as an SCH endangers the SCH status of the existing hospital.
As of October 1, 1997, no designations of hospitals as EACHs can be made. The EACHs designated by CMS before October 1, 1997, will continue to be paid as SCHs for as long as they comply with the terms, conditions, and limitations under which they were designated as EACHs.
Under § 412.92(b)(2), we define the effective dates for several situations in which a hospital gains or gives up SCH status. First, SCH status and the associated payment adjustment is effective 30 days after CMS's written notification to the SCH. Thus, 30 days after the issuance of CMS's notice of approval, the hospital is considered to be an SCH and the payment adjustment is applied to discharges occurring on or after that date.
Second, § 412.92(b)(4)(ii) defines the effective date when a hospital chooses to give up its SCH status. Our policy has always been that an SCH can elect to give up its SCH status at any time by submitting a written request to the appropriate CMS regional office through its fiscal intermediary. The change to fully national rates becomes effective no later than 30 days after the hospital submits its request. We believe that the “no later than 30 days” policy for the effective date for cancelling SCH status is in keeping with the prospective nature of the prospective payment system. In addition, the 30-day timeframe to give up SCH status provides the fiscal intermediaries with enough time to alter their automated payment systems prospectively, thus avoiding expensive and time-consuming reprocessing of claims. The variable timeframe of “no later than 30 days from the date of the hospital's request” also permits the regional office, the fiscal intermediary, and the hospital to select a mutually agreeable date, for example, at the end of a month, to facilitate the change in SCH status. We expect that hospitals will anticipate when they wish to give up SCH status and to submit their requests in sufficient time to permit the 30-day period for making the change.
In addition, § 412.92(b)(2)(ii) defines the effective date of SCH status in the situation where a final and nonappealable administrative or judicial decision reverses CMS's denial of SCH status to a hospital. In this situation, if the hospital's application was submitted on or after October 1, 1983, the effective date will be 30 days after the date of CMS's original written notification of denial.
Under § 412.92(b)(2)(iii), we define retroactive approval of SCH status. If a hospital is granted retroactive approval of SCH status by a final and nonappealable court order or an administrative decision under subpart R of part 405 of the regulations, and it wishes its SCH status terminated prior to the current date (that is, it wishes to be paid as an SCH for a time-limited period, all of which is in the past), it must submit written notice to the CMS regional office through its fiscal intermediary within 90 days of the court order or the administrative decision. This written notice must clearly state that, although SCH status was granted retroactively by the court order or by the administrative decision, the hospital wants this status terminated as of a specific date. If written notice is not received within 90 days of the court order or the administrative decision, SCH status will continue. Written requests to terminate SCH status that are received subsequent to the 90-day period will be effective no later than 30 days after the request is submitted, as discussed above.
Under § 412.92(c)(1), we define mileage. We believe that mileage should continue to be measured by the shortest route over improved roads maintained by any local, State, or Federal government entity for public use. We consider improved roads to include the paved surface up to the front entrance of the hospital because this portion of the distance is utilized by the public to access the hospital. This definition provides consistency with the interpretation of the MGCRB when considering hospital reclassification applications. The MGCRB measures the distance between the hospital and the county line of the area to which it seeks reclassification beginning with the paved area outside the front entrance of Start Printed Page 39875the hospital. This provides a consistent, national definition that is easily recognizable for each hospital. Finally, rounding of mileage is not permissible. This is also consistent with the MGCRB definition of mileage (56 FR 25483). In this final rule, we are revising the definition of “miles” under § 412.92(c)(1) to state that an improved road includes the paved surface up to the front entrance of the hospital.
Under § 412.92(c)(2), we define “like” hospital. We consider like hospitals to be those hospitals furnishing short-term acute care. That is, a hospital may not qualify for an SCH classification on the grounds that neighboring hospitals offer specialty services, thereby seeking to exclude close-by competitors as like hospitals, in order to meet the mileage criteria by measuring to a like hospital that is located further away. For example, we believe that competing hospitals within a given area may each have their own specialty services, while all the facilities continue to be considered short-term acute care hospitals. We note that under § 412.92(a)(1)(ii), a hospital with fewer than 50 beds may qualify for SCH status under a special provision if patients that it would normally serve are seeking care elsewhere due to the unavailability of specialty services. This means that, if a hospital can prove that the patients from its service area are seeking specialty services elsewhere (such as, among others, heart surgery, transplants, and burn care), rather than routine care, and, because of that fact, that it otherwise would have met the criteria of section § 412.92(a)(1)(i), it can qualify as an SCH.
We note that § 412.92(b)(1)(iii)(A) retains an outdated reference to “hospitals located within a 50 mile radius of the hospital.” With the issuance of the September 1, 1989 Federal Register (54 FR 36481, 36482), the 50 mile radius was determined to be unreasonable and all references should have been changed to 35 miles in accordance with § 412.92(a)(1)(i). In this final rule. we are revising the reference to “a 50 mile radius” in § 412.92(b)(1)(iii)(A) to read “a 35 mile radius”.
We note that the travel time and weather conditions criteria set forth in § 412.92(a)(3) were discussed in detail in the September 4, 1990 Federal Register (55 FR 36050 through 36055 and 36162 through 36163).
Under § 412.92(a)(1)(i) and (b)(1)(ii), we define the market area analysis criteria used to determine SCH status. In the May 4, 2001 proposed rule, we discussed several points concerning these requests for SCH status that we proposed to clarify.
First, a hospital seeking an SCH designation based on these criteria must make its initial request to the fiscal intermediary with all the appropriate documents as will be discussed below (§ 412.92(b)(1)(i)). The fiscal intermediary will make a recommendation on the request, based on receipt of all the appropriate documentation and its own investigation and analysis, and that recommendation will be forwarded to the CMS regional office for another level of review and final approval or disapproval. The fiscal intermediary would forward its recommendation to the CMS regional office located in the hospital's area as opposed to the fiscal intermediary's area, if there is a difference in these areas. As discussed above, an approval of the request for SCH status will be effective 30 days after CMS issues the approval letter. If a determination on the request requires the use of data that are available at CMS central office only, upon receipt of the fiscal intermediary's recommendation, the CMS regional office will forward the request and the fiscal intermediary's recommendation to the appropriate contact at CMS central office where the determination will be made.
Second, a hospital must provide patient origin data (the number of patients from each zip code from which the hospital draws inpatients) for all inpatient discharges to document the boundaries of its service area (§ 412.92(b)(1)(ii)(A)). Or, the hospital can request that CMS develop patient origin data to define its service area based on the number of patients from each zip code from which the hospital draws Medicare Part A inpatients (§ 412.92(b)(1)(iii)). Then, the lowest number of zip codes in descending percentage order of Medicare inpatients that meets the 75-percent threshold will be used to represent the hospital's service area. We note that hospitals cannot substitute zip codes elsewhere on the list in order to manipulate the service area. (See Howard Young Medical Center, Inc. v. Shalala, 207 F.3d 437 (7th Cir. 2000).)
Third, the hospital must provide patient origin data from all other hospitals located within a 35-mile radius of it or, if larger, within its service area, to document that no more than 25 percent of either all of the population or the Medicare beneficiaries residing in the hospital's service area and hospitalized for inpatient care were admitted to other like hospitals for care (§ 412.92(b)(1)(ii)(B)). Again, CMS central office can develop patient origin data for other hospitals within the requesting hospital's service area if the hospital is requesting SCH status based on an examination of Medicare Part A inpatient utilization. In either case, the requesting hospital is required to submit a comprehensive list of hospitals located within a 35-mile radius or, if larger, within its service area. This list will be checked by both the fiscal intermediary and CMS. Again, a requesting hospital cannot argue that a competing hospital should be excluded from the service area based on the existence of specialty services at that hospital if both hospitals are short-term acute care facilities. Distances between all reported hospitals will be checked by both the fiscal intermediary and CMS, through electronic geographic mapping services (such as Yahoo or Mapquest) or by physically driving the distance involved.
In addition, data will be analyzed based on the year for which the hospital requests SCH status. Subsequent hospital mergers or terminations will not be taken into consideration in processing the request. For example, if a hospital requests SCH status using data for FY 1999, and that data show that there is a competing hospital in existence that subsequently closed its doors in FY 2000, the data will be analyzed with the terminated hospital in existence, unless the hospital seeking SCH status applies using later data, such as FY 2001. This principle is consistent with how we analyze wage index data. If a terminated hospital has a viable cost report for the year of wage data that is being analyzed to produce the wage index, its data are included as part of the computation.
We received the following comments on our May 4, 2001 proposed rule and the June 13, 2001 interim final rule with comment period:
Comment: Several commenters were concerned with the following issues related to the qualifying criteria for sole community hospitals: (1) Utilizing TAC worksheets or other data sources in order to develop a base year alternative for a new SCH; (2) determining a service area; (3) recognition of hospital mergers and terminations that influence a hospital seeking SCH status; (4) including competing hospitals within a 35-mile radius of the requesting hospital as opposed to a 35-road-mile distance; (5) obtaining patient origin data from competing hospitals, (6) timeliness of SCH approvals; (7) SCH status for hospitals with fewer than 50 beds; (8) CAHs as like hospitals; (9) the effect of wage index reclassifications on a hospital's SCH status; and (10) the use of affidavits and other certifications in Start Printed Page 39876verifying time and distance when applying for SCH status.
Response: We would like to reiterate that in the proposed rule we were restating historical and current policy and criteria for SCHs. We were not proposing new SCH policies or criteria, or revisions to existing policies or criteria. Rather, we were striving to publish criteria that has been developed over the past several years in one location for the reader's benefit.
First, we appreciate the input concerning a hospital's access to alternative data when a cost report from a prior year may not be readily available. We will take this comment into consideration in working with the fiscal intermediaries in the future to adjust a SCH's payments.
Second, we believe that, using discharge data available on the MedPAR file, we can accurately determine a hospital's service area based on the zip codes that contain the highest number of discharges for that facility and rank those zip codes accordingly. Several commenters suggested that we use patient destination data that are available in some States and, also, that we not be concerned if these data were not available based on a hospital's cost reporting period. As in other aspects of the Medicare program, we must rely on data that are consistent, verifiable by the fiscal intermediaries, and nationally available so that no one hospital or group of hospitals receives a distinct advantage by using an alternative source of data that is not widely available. Therefore, we believe that it is appropriate to determine the hospital's service area based on Medicare discharges.
Third, if a hospital chooses to have a merger recognized in its request for SCH status, or, likewise, a hospital termination, then it is free to wait until its cost report data reflects these changes. Then, CMS will consider the data in light of these facts.
Fourth, we believe it is reasonable to examine a hospital's competitors within a 35-mile radius. Most competing hospitals will not be at the outer limit of the 35-mile radius, and, if these hospitals are not truly competitors, the discharge data will bear out that fact. Also, we examine a hospital's service area based on discharges within zip code areas, and, often, this will exceed a 35-mile radius. Therefore, we believe the 35-mile radius is reasonable.
Fifth, we realize that obtaining patient origin data from competing hospitals may be a difficult proposition, which is why CMS offers to provide this information for the requesting hospital in § 412.92(b)(1)(iii)(A). CMS’ data are based on Medicare discharges.
Sixth, approvals of SCH status are effective prospectively. There are several ways in which a hospital may qualify as a SCH, and fiscal intermediaries are required to collect and examine detailed documentation which sometimes requires the assistance of our regional or central office staff. We appreciate the fact that hospitals are concerned that their applications be approved in a timely manner, and we will make every effort to work diligently with our contractors as well as our regional offices to achieve that goal.
Seventh, a commenter suggested that we should be more specific when defining the criteria under which a hospital with fewer than 50 beds could qualify as an SCH at § 412.92(a)(ii). We will take this into consideration as we develop further criteria in the future. In the meantime, we will continue to work closely with our fiscal intermediaries in approving a hospital's SCH status under this provision.
Eighth, we do not consider CAHs like hospitals to be SCHs. CAHs are generally smaller with a very limited length of stay, while SCHs operate as full-service acute-care hospitals.
Ninth, a hospital's status as an SCH is not affected by a wage index reclassification approved by the MGCRB. A hospital's SCH status is affected by an approval for a standardized amount reclassification only, as a reclassification for purposes of a hospital's base payment rate changes its status for all inpatient hospital prospective payment purposes except the wage index.
Finally, hospitals are encouraged to provide as much documentation as possible to assist the fiscal intermediary and CMS in evaluating requests for SCH status. The more complete the documentation, the quicker a decision can be rendered. If a hospital can provide affidavits or other verification of mileage, distances, competing hospital locations, etc., then it is encouraged to do so.
Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at § 412.96 set forth the criteria a hospital must meet in order to receive special treatment under the prospective payment system as a rural referral center. For discharges occurring before October 1, 1994, rural referral centers received the benefit of payment based on the other urban amount rather than the rural standardized amount. Although the other urban and rural standardized amounts were the same for discharges beginning with that date, rural referral centers would continue to receive special treatment under both the disproportionate share hospital (DSH) payment adjustment and the criteria for geographic reclassification.
Section 401 of Public Law 106-113 amended section 1886(d)(8) of the Act by adding subparagraph (E), which creates a mechanism, separate and apart from the MGCRB, permitting an urban hospital to apply to the Secretary to be treated as being located in the rural area of the State in which the hospital is located. The statute directs the Secretary to treat a qualifying hospital as being located in the rural area for purposes of provisions under section 1886(d) of the Act. Congress clearly intended hospitals that become rural under section 1886(d)(8)(E) of the Act to receive some benefit as a result. In addition, one of the criteria under section 1886(d)(8)(E) of the Act is that the hospital would qualify as an SCH or a rural referral center if it were located in a rural area. An SCH would be eligible to be paid on the basis of the higher of its hospital-specific rate or the Federal rate. On the other hand, the only benefit under section 1886(d) of the Act for an urban hospital to become a rural referral center would be waiver of the proximity requirements that are otherwise applicable under the MGCRB process, as set forth in § 412.230(a)(3)(i).
In the August 1, 2000 final rule (65 FR 47089), we stated that we believed Congress contemplated that hospitals might seek to be reclassified as rural under section 1886(d)(8)(E) of the Act in order to become rural referral centers so that the hospitals would be exempt from the MGCRB proximity requirement and could be reclassified by the MGCRB to another urban area. Therefore, in that final rule we sought a policy approach that would appropriately address our concern that these urban to rural redesignations not be utilized inappropriately, and that would benefit hospitals seeking to reclassify under the MGCRB process by achieving rural referral center status. (We became aware of several specific hospitals that were rural referral centers for FY 1991, but subsequently lost their status when the county in which they were located became urban, and had expressed their wish to be redesignated as a rural referral center in order to be eligible to reclassify.) Accordingly, in light of section 1886(d)(8)(E) of the Act and the language in the accompanying Conference Report, effective as of October 1, 2000, hospitals located in what is now an urban area, if they were ever a rural referral center, were reinstated to rural referral center status.Start Printed Page 39877
In addition, as discussed in 62 FR 45999 and 63 FR 26317, under section 4202 of Public Law 105-33, a hospital that was classified as a rural referral center for FY 1991 is to be classified as a rural referral center for FY 1998 and later years so long as that hospital continued to be located in a rural area and did not voluntarily terminate its rural referral center status. Otherwise, a hospital seeking rural referral center status must satisfy applicable criteria. One of the criteria under which a hospital may qualify as a rural referral center is to have 275 or more beds available for use. A rural hospital that does not meet the bed size requirement can qualify as a rural referral center if the hospital meets two mandatory prerequisites (specifying a minimum case-mix index and a minimum number of discharges) and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or referral volume). With respect to the two mandatory prerequisites, a hospital may be classified as a rural referral center if its—
Case-mix index is at least equal to the lower of the median case-mix index for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median case-mix index for all urban hospitals nationally; and
Number of discharges is at least 5,000 per year, or if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of discharges criterion for an osteopathic hospital is at least 3,000 discharges per year.)
Section 412.96(c)(1) provides that CMS will establish updated national and regional case-mix index values in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. The methodology we use to determine the national and regional case-mix index values is set forth in regulations at § 412.96(c)(1)(ii). The proposed national case-mix index value for FY 2002 in the May 4 proposed rule included all urban hospitals nationwide, and the proposed regional values for FY 2002 were the median values of urban hospitals within each census region, excluding those with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in § 412.105). Those values were based on discharges occurring during FY 2000 (October 1, 1999 through September 30, 2000) and included bills posted to CMS's records through December 2000. (The proposed rule language erroneously cited the period as FY 1999 (October 1, 1998 through September 30, 1999.)
We proposed that, in addition to meeting other criteria, hospitals with fewer than 275 beds, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have a case-mix index value for FY 2000 that is at least—
1.3286; or
The median case-mix index value for urban hospitals (excluding hospitals with approved teaching programs as identified in § 412.105) calculated by CMS for the census region in which the hospital is located. (See the table set forth in the May 4, 2001 proposed rule at 66 FR 22687.)Based on the latest data available (FY 2000 bills received through March 31, 2001), in addition to meeting other criteria, hospitals with fewer than 275 beds, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have a case-mix index value for FY 2000 that is at least—
The median case-mix index value for urban hospitals (excluding hospitals with approved teaching programs as identified in § 412.105) calculated by CMS for the census region in which the hospital is located. The final median case-mix values by region are set forth in the following table:
Case-Mix Index Value
1. New England (CT, ME, MA, NH, RI, VT) 1.2381
2. Middle Atlantic (PA, NJ, NY) 1.2319
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 1.3055
4. East North Central (IL, IN, MI, OH, WI) 1.2588
5. East South Central (AL, KY, MS, TN) 1.2530
6. West North Central (IA, KS, MN, MO, NE, ND, SD) 1.1690
7. West South Central (AR, LA, OK, TX) 1.2443
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 1.3275
9. Pacific (AK, CA, HI, OR, WA) 1.2991
Hospitals seeking to qualify as rural referral centers or those wishing to know how their case-mix index value compares to the criteria should obtain hospital-specific case-mix values from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these case-mix index values are computed based on all Medicare patient discharges subject to DRG-based payment.
Section 412.96(c)(2)(i) provides that CMS will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. However, in the May 4 proposed rule, we proposed to update the regional standards based on discharges for urban hospitals' cost reporting periods that began during FY 2000 (that is, October 1, 1999 through September 30, 2000). (The proposed rule language erroneously cited the period as FY 1999 (October 1, 1998 through September 30, 1999.) That is the latest year for which we have complete discharge data available.
Therefore, we proposed that, in addition to meeting other criteria, a hospital, if it is to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have as the number of discharges for its cost reporting period that began during FY 2000 a figure that is at least—
5,000; or
The median number of discharges for urban hospitals in the census region in which the hospital is located. (See the table set forth in the May 4, 2001 proposed rule at 66 FR 22687.)Start Printed Page 39878
Based on the latest discharge data available for FY 2000, the final median number of discharges for urban hospitals by census region areas are as follows:
Number of Discharges
1. New England (CT, ME, MA, NH, RI, VT) 7,064
2. Middle Atlantic (PA, NJ, NY) 8,488
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA,WV) 8,562
4. East North Central (IL, IN, MI, OH, WI) 7,616
5. East South Central (AL, KY, MS, TN) 6,276
6. West North Central (IA, KS, MN, MO, NE, ND, SD) 5,210
7. West South Central (AR, LA, OK, TX) 6,196
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 8,878
9. Pacific (AK, CA, HI, OR, WA) 7,106
We reiterate that an osteopathic hospital, if it is to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 2001, must have at least 3,000 discharges for its cost reporting period that began during FY 2000.
We did not receive any comments on the criteria for rural referral centers.
Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment to reflect the higher indirect operating costs associated with GME. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at § 412.105. The additional payment is based in part on the applicable IME adjustment factor. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a multiplier, which is represented as c, in the following equation: c × [(1 + r).405−1]. The formula is traditionally described in terms of a certain percentage increase in payment for every 10-percent increase in the resident-to-bed ratio.
Section 302 of Public Law 106-554 amended section 1886(d)(5)(B) of the Act to modify the transition for the IME formula multiplier, or c, that was first established by Public Law 105-33 and revised by Public Law 106-113.
As discussed in the August 1, 2000 final rule and the June 13, 2001 interim final rule with comment period, section 111(a) of Public Law 106-113 revised the formula multiplier for discharges occurring during FY 2001 (established under Public Law 105-33 at 1.6) to 1.54. However, section 302(b) of Public Law 106-554 provides a special payment rule which states that, for discharges occurring on or after April 1, 2001 and before October 1, 2001, IME payments are to be made as if ‘c’ equaled 1.66, rather than 1.54. The multiplier of 1.54 for the first 6 months of FY 2001 represents a 6.25 percent increase in the level of the IME adjustment for every 10 percent increase in the resident-to-bed ratio, and the multiplier for the second 6 months of FY 2001 represents a 6.75 percent increase in the level of the IME adjustment for every 10 percent increase in the resident-to-bed ratio. This results in an aggregate 6.5 percent increase for every 10 percent increase in the resident-to-bed ratio for FY 2001. Section 547(a)(2) of Public Law 106-554 provides further clarification that these payment increases will not apply to discharges occurring after FY 2001 and will not be taken into account in calculating the payment amounts applicable for discharges occurring after FY 2001. In the June 13 interim final rule, we revised § 412.105(d)(3)(v) to reflect the additional payment provided for discharges occurring during FY 2001 under section 302(b) of Public Law 106-554.
As discussed in the May 4, 2001 proposed rule, section 302(a) of Public Law 106-554 provides that, for discharges occurring during FY 2002, the formula multiplier is 1.6. For discharges occurring during FY 2003 and thereafter, the formula multiplier is 1.35. As explained above, section 302(b) of Public Law 106-554 provides for a special payment rule which states that, for discharges occurring on or after April 1, 2001 and before October 1, 2001, IME payments are to be made as if “c” equaled 1.66 rather than 1.54. The multiplier of 1.6 for FY 2002 represents a 6.5 percent increase for every 10 percent increase in the resident-to-bed ratio. The multiplier for FY 2003 and thereafter (1.35) represents a 5.5-percent increase for every 10-percent increase in the resident-to-bed ratio. In the May 4 proposed rule, we proposed to revise § 412.105(d)(3)(vi) to reflect the change in the formula multiplier for FY 2002 to 1.6 as made by section 302(a) of Public Law 106-554 for discharges occurring during FY 2002. We also proposed to add § 412.105(d)(3)(vii) to incorporate the formula multiplier of 1.35 for discharges occurring on or after October 1, 2002.
We did not receive any comments on the IME formula provisions of the June 13 interim final rule with comment period or the proposed amendments under the May 4 proposed rule. Therefore, we are adopting both changes to § 412.105(d)(3) as final without change.
In the May 4, 2001 proposed rule, we indicated that it had come to our attention that there is some misunderstanding about § 412.105(a)(1) regarding the determination of the resident-to-bed ratio that is used in calculating the IME adjustment. Section 4621(b)(1) of Public Law 105-33 amended section 1886(d)(5)(B) of the Act by adding a new clause (vi) to provide that, effective for cost reporting periods beginning on or after October 1, 1997, the resident-to-bed ratio may not exceed the ratio calculated during the prior cost reporting period (after accounting for the cap on the hospital's number of full-time equivalent (FTE) residents). We implemented this policy in the August 29, 1997 final rule with comment period (62 FR 46003) and the May 12, 1998 final rule (63 FR 26323) under regulations at § 412.105(a)(1). Existing § 412.105(a)(1) specifies that “[e]xcept for the special circumstances for affiliated groups and new programs described in paragraphs (f)(1)(vi) and (f)(1)(vii) of this section, for a hospital's cost reporting periods beginning on or Start Printed Page 39879after October 1, 1997, this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period.” In the May 4 proposed rule, we proposed to clarify § 412.105(a)(1) to add a provision that this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period after accounting for the cap on the number of FTE residents.
In general, the resident-to-bed ratio from the prior cost reporting period, which is to be used as the cap on the resident-to-bed ratio for the current payment cost reporting period, should only include an FTE count subject to the FTE cap on the number of allopathic and osteopathic residents, but is not subject to the rolling average. (An explanation of rolling average appears in section IV.H.3. of this preamble.)
The following illustrates the steps for determining the resident-to-bed ratio for the current payment year cost reporting period and the cap on the resident-to-bed ratio:
Current payment year cost reporting period resident-to-bed ratio:
Step 1. Determine the hospital's number of FTE residents in the current payment year cost reporting period.
Step 2. Compare the number of allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap (§ 412.105(f)(1)(iv)). If the number of allopathic and osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the number of FTEs in the FTE cap. Add any dental and podiatry FTEs from step 1 to the capped allopathic and osteopathic FTE count.
Step 3. Determine the 3-year rolling average of the FTE residents using the FTEs from the current payment year cost reporting period and the prior two cost reporting periods (subject to the FTE cap in each cost reporting period). (Include podiatry and dental residents, and exclude residents in new programs in accordance with § 412.105(f)(1)(iv) and revised (f)(1)(v). Residents in new programs are added to the quotient of the rolling average.)
Step 4. Determine the hospital's number of beds (see § 412.105(b)) in the current payment year cost reporting period.
Step 5. Determine the ratio of the number of FTEs from step 3 to the number of beds from step 4. The lower of this resident-to-bed ratio or the resident-to-bed ratio cap (calculated below) from the immediately preceding cost reporting period is used to calculate the hospital's IME adjustment factor for the current payment year cost reporting period.
Resident-to-bed ratio cap:
Step 1. Determine the hospital's number of FTE residents in its cost reporting period that immediately precedes the current payment year cost reporting period.
Step 2. Compare the number of allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap. If the number of allopathic and osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the number of FTEs in the FTE cap. Add any dental and podiatry FTEs from step 1 to the capped allopathic and osteopathic FTE count. (If there is an increase in the number of FTEs in the current payment year cost reporting period due to a new program or an affiliation agreement, these FTEs are added to FTEs in the preceding cost reporting period after applying the FTE cap.)
Step 3. Determine the hospital's number of beds (§ 412.105(b)) in its cost reporting period that immediately precedes the current payment year cost reporting period.
Step 4. Determine the ratio of the number of FTEs in step 2 to the number of beds in step 3. This ratio is the resident-to-bed ratio cap for the current payment year cost reporting period.
Step 5. Compare the resident-to-bed ratio cap in step 4 to the resident-to-bed ratio in the current payment year cost reporting period. The lower of the resident-to-bed ratio from the current payment year cost reporting period or the resident-to-bed ratio cap from the immediately preceding cost reporting period is used to calculate the hospital's IME adjustment factor for the current payment year cost reporting period.
We note that the resident-to-bed ratio cap is a cap on the resident-to-bed ratio calculated for all residents, including allopathic, osteopathic, dental, and podiatry residents (63 FR 26324, May 12, 1998). However, as described in existing § 412.105(a)(1), the resident-to-bed ratio cap may be adjusted to reflect an increase in the current cost reporting period's resident-to-bed ratio due to residents in a new GME program or an affiliation agreement. While an exception does not apply if the resident-to-bed ratio increases because of an increase in the number of podiatry or dentistry residents or because of a change in the number of beds, the ratio could increase after a one-year delay. An increase in the current cost reporting period's ratio (while subject to the FTE cap on the overall number of allopathic and osteopathic residents) thereby establishes a higher cap for the following cost reporting period.
The following is an example of the application of the cap on the resident-to-bed ratio:
Assume Hospital A has 50 FTEs in its cost reporting period ending September 30, 1996, thereby establishing an IME FTE resident cap of 50 FTEs.
In its cost reporting period of October 1, 1996 to September 30, 1997 (the prior year), it has 50 FTEs and 200 beds, so that its resident-to-bed ratio for this period is 50/200 = .25.
In the (current year) cost reporting period of October 1, 1997 to September 30, 1998 (the first cost reporting period in which the FTE resident cap, the resident-to-bed ratio cap, and the rolling average apply), Hospital A has 50 FTEs and 200 beds.
Hospital A's FTEs do not exceed its FTE cap, so its current number of FTEs (50) is used to calculate the 2-year rolling average: (50 + 50)/2 = 50.
The result of the rolling average is used as the numerator of the resident-to-bed ratio. Thus, the resident-to-bed ratio is 50/200 = .25.
.25 is compared to the resident-to-bed ratio from the prior period of October 1, 1996 to September 30, 1997. Because the FTE resident cap and the rolling average were not yet effective in the period of October 1, 1996 to September 30, 1997, that period s resident-to-bed ratio does not have to be recalculated to account for the FTE resident cap. Accordingly, the resident-to-bed ratio cap for October 1, 1997 to September 30, 1998 is .25.
Because the resident-to-bed ratio does not exceed the prior year ratio, Hospital A would use the resident-to-bed ratio of .25 to determine the IME adjustment in its cost reporting period of October 1, 1997 to September 30, 1998.
In the (current year) cost reporting period of October 1, 1998 to September 30, 1999, Hospital A adds 1 podiatric and 1 dental resident, so that it has a total of 52 FTEs and 200 beds. Since the FTE resident cap only includes allopathic and osteopathic residents, Hospital A has not exceeded its FTE resident cap with the addition of a podiatric and a dental resident.
Accordingly, the (now) 3-year rolling average would be (52 + 50 + 50)/3 = 50.67.
50.67 is used in the numerator of the current payment year's resident-to-bed ratio, so that the resident-to-bed ratio is 50.67/200 = .253.
.253 is compared to the resident-to-bed ratio from the prior year's cost reporting period of October 1, 1997 to September 30, 1998 that is recalculated to account for the FTE resident cap. Because Hospital A did not exceed its FTE resident cap of 50 FTEs in this period of October 1, 1997 to September 30, 1998, the recalculated resident-to-bed ratio would be 50/200 = .25.
Compare the current year resident-to-bed ratio (.253) to the resident-to-bed ratio cap (.25); .253 does exceed .25.
Therefore, the resident-to-bed ratio in the period of October 1, 1998 to September 30, 1999 is capped at .25, which is to be used in calculating Hospital A s IME adjustment for October 1, 1998 to September 30, 1999.
In the cost reporting period of October 1, 1999 to September 30, 2000, Hospital A adds Start Printed Page 398802 internal medicine residents so that it has a total of 54 FTEs and 200 beds. While podiatric and dental residents are not included in the FTE resident cap, internal medicine residents are included. Hospital A has exceeded its IME FTE resident cap of 50 by 2 FTEs. Thus, 2 FTEs are excluded from the FTE count.
Accordingly, the rolling average would be (52 + 52 + 50)/3 = 51.33.
51.33 is used in the numerator of the resident-to-bed ratio, so that the resident-to-bed ratio is 51.33/200 = .257.
.257 is compared to the resident-to-bed ratio from October 1, 1998 to September 30, 1999 that is recalculated to only account for the FTE resident cap. The recalculated resident-to-bed ratio would be 50 allopathic or osteopathic FTEs plus 1 podiatric and 1 dental resident, which is 52/200 = .26.
.26 is the resident-to-bed ratio cap for October 1, 1999 to September 30, 2000. .257 does not exceed .26.
Therefore, the resident-to-bed ratio in the period of October 1, 1998 to September 30, 1999 is .257, which is to be used in calculating this period s IME adjustment.
If a hospital starts a new GME program, the adjustment to the resident-to-bed ratio cap applies for the period of years equal to the minimum accredited length for each new program started. (For example, for a new internal medicine program, the period of years equals 3; for a new surgery program, the period of years equals 5.) Within these program years, the number of new FTE residents in the current cost reporting period is added to the FTE resident count used in the numerator of the resident-to-bed ratio from the previous cost reporting period. The lower of the resident-to-bed ratio from the current cost reporting period or the adjusted resident-to-bed ratio from the preceding cost reporting period is used to calculate the hospital's IME adjustment for the current cost reporting period. If a hospital subsequently continues to expand its program, the numerator of the resident-to-bed ratio from the preceding cost reporting period would not be adjusted to reflect these additional residents. However, an increase in the ratio of the current cost reporting period would establish a higher cap for the following cost reporting period.
We also proposed to add a provision that the exception for new programs described in § 412.105(f)(1)(vii) applies for the period of years equal to the minimum accredited length for each new program.
Similarly, if a hospital increases the number of FTE residents in the current cost reporting period because of an affiliation agreement, the number of additional FTEs is added to the FTE resident count used in the numerator of the resident-to-bed ratio from the previous cost reporting period. The lower of the resident-to-bed ratio from the current cost reporting period or the adjusted resident-to-bed ratio from the preceding cost reporting period is used to calculate the hospital's IME adjustment for the current cost reporting period.
Comment: Several commenters addressed our clarifications to the regulations at § 412.105(a)(1) regarding the cap on the resident-to-bed ratio. One commenter stated that the explanation in the proposed rule regarding the resident-to-bed ratio was thorough. Another commenter expressed appreciation for the inclusion of examples in the proposed rule's preamble. One commenter noted that, in the proposed rule under step 2 of the example of the calculation of the resident-to-bed ratio cap, we indicate that the lesser of the prior year FTEs or the FTE cap is used in the numerator of the resident-to-bed ratio. The commenter noted that we do not specify that, while the FTE cap only applies to allopathic and osteopathic FTEs, dentistry and podiatry FTEs should be included in the numerator of the resident-to-bed ratio. The commenter asked that we specify that the prior year podiatry and dentistry FTEs must be added to the FTE count used in the resident-to-bed ratio after the FTE cap has been applied.
Response: We agree with the commenter concerning the inclusion of dental and podiatry FTEs in step 2, and we have clarified the language in step 2 of the examples of both the current year resident-to-bed ratio and the resident-to-bed ratio cap calculation in the preamble of this final rule. Specifically, we state, “Compare the number of allopathic and osteopathic FTEs from step 1 to the hospital's FTE cap. If the number of allopathic and osteopathic FTEs from step 1 exceeds the FTE cap, replace it with the FTE cap. Add any dental or podiatry FTEs from step 1 to the capped allopathic and osteopathic FTE count.” Furthermore, we are revising the proposed changes to the regulations text at § 412.105(a)(1) to state that “. . . this ratio may not exceed the ratio for the hospital's most recent prior cost reporting period after accounting for the cap on the number of allopathic and osteopathic residents as described in paragraph (f)(1)(iv) of this section, and adding to the capped numerator any dental and podiatric full-time equivalent residents. . . .”
Comment: One commenter noted that, in clarifying the regulations at § 412.105(a)(1) regarding the resident-to-bed ratio cap, we added that the exception to the resident-to-bed ratio cap “. . . for new programs . . . applies for the period of years equal to the minimum accredited length for that type of program” (emphasis added). The commenter asked how we would apply the exception to the resident-to-bed ratio cap in a situation where a hospital has started several new programs with varying minimum accredited lengths.
Response: The exception at proposed § 412.105(a)(1) for new programs allows a hospital to add a full complement of residents and complete the initial cycle of a program before residents in the new programs are included in the application of the resident-to-bed ratio cap. In a situation where a hospital has started several new programs under § 412.105(f)(1)(vii), we would apply the exception to the resident-to-bed ratio cap to each new program individually based on each program's minimum accredited length. For example, if a hospital simultaneously starts a new internal medicine program (which has a minimum accredited length of 3 years) and an anesthesiology program (which has a minimum accredited length of 4 years), the FTE residents in the new internal medicine program will be subject to the resident-to-bed ratio cap in the fourth program year of the internal medicine program, while the anesthesiology FTE residents would still be excluded from the resident-to-bed ratio cap in the fourth program year of the anesthesiology programs. However, in subsequent program years, the anesthesiology FTE residents would be subject to the resident-to-bed ratio cap, as well.
The rules regarding the exception from the rolling average calculation for IME are the same for direct GME. The proposed revised regulations at § 412.105(f)(1)(v) and § 413.86(g)(5) in the May 4, 2001 proposed rule state that FTE residents in a new program are excluded from the rolling average calculation for the period of years equal to the minimum accredited length for the type of program. In this final rule, we are revising the regulations regarding the exceptions to the resident-to-bed ratio cap and the rolling average calculation for both IME and direct GME to clarify that these exceptions apply to each new program individually for which the FTE cap may be adjusted based on each program's minimum accredited length (§ 412.105(a)(1), 412.105(f)(1)(v), and 413.86(g)(5)(v)).
Comment: One commenter asserted that, in the proposed rule, it is inconsistent to account for both the FTE cap and the rolling average count of residents in the current year resident-to-bed ratio, but account for only the FTE cap in the resident-to-bed ratio cap Start Printed Page 39881(which is the prior year's ratio). The commenter stated that their willingness to support the proposed rule depended on whether the residency program is increasing or decreasing its FTEs every year.
Response: Section 1886(d)(5)(B)(v)(I) of the Act, as amended by Public Law 105-33, states that the resident-to-bed ratio “may not exceed the ratio of the number of interns and residents, subject to the limit under clause (v), with respect to the hospital for its most recent cost reporting period to the hospital's available beds . . . during that cost reporting period . . .” (emphasis added). Clause (v) is the FTE cap requirement; the statute does not specify clause (vi)(II), which is the rolling average requirement, in relation to the resident-to-bed ratio cap. Accordingly, the implementing regulations require that the resident-to-bed ratio cap should only account for the cap on the number of FTEs.
In addition, we note that the commenter is mistaken in indicating that the rules regarding the determination of the resident-to-bed ratio and the resident-to-bed ratio cap are proposed rules. These rules have been in place based on the statute since the effective date of Public Law 105-33. We simply took the opportunity in the proposed rule published on May 4, 2001 to further clarify our existing policy because we realized that there was some confusion surrounding these rules.
Comment: One commenter noted that, since under the provisions of § 413.86(g)(6)(i), the FTE cap for new programs is established based on the number of residents in the third year of the first program's existence, it follows that the FTE cap on the residents in the new programs is effective in the fourth program year. The commenter asked if the application of the cap is delayed until the expiration of the minimum accredited length of the new programs.
Response: The application of the FTE adjusted caps for new programs under § 413.86(g)(6)(i) and (g)(6)(ii) are not delayed until the expiration of the minimum accredited length of the new programs. Only the application of the resident-to-bed ratio cap for IME and the rolling average for both IME and direct GME are dependent upon the minimum accredited length of each new program. The regulations at § 413.86(g)(6)(i) state that the cap for new programs will be adjusted based on “the product of the highest number of residents in any program year during the third year of the first program's existence for all new residency training programs and the number of years in which residents are expected to complete the program based on the minimum accredited length for the type of program” (emphasis added). In general, when a hospital qualifies for a cap adjustment under § 413.86(g)(6)(i), the hospital has three years from the time that a resident first begins training in the first new program to establish its FTE cap. The first day of the fourth program year, the FTE cap on that first program, and any other programs that may have been started within the initial three years of that first program, is permanently established and takes effect.
For example, if a hospital that qualifies for a cap adjustment under § 413.86(g)(6)(i) starts a newly accredited dermatology program on July 1, 2001, and then starts a newly accredited anesthesiology program on July 1, 2002, the cap for both programs, and for the hospital as a whole, will be adjusted as of July 1, 2004, the first day of the fourth program year of dermatology, which is the first program that the hospital started. The hospital's cap will be based on the sum of: (a) The product of the highest number of residents in either PGY1, PGY2, or PGY3 in the third year of the dermatology program and 4 years (the minimum accredited length of dermatology); and (b) the product of the highest number of residents in either PGY1 or PGY2 for the anesthesiology program and 4 years (the minimum accredited length for anesthesiology). Any programs begun after the first program's start date but before the fourth program year of the first program will not have a full 3 years before the hospital's cap is permanently adjusted.
The rules under § 413.86(g)(6)(ii) differ for hospitals that qualify for an FTE cap adjustment for new programs started on or after January 1, 1995 and on or before August 5, 1997. Section 413.86(g)(6)(ii) states that the FTE cap adjustment is “based on the product of the highest number of residents in any program year during the third year of the newly established program and the number of years in which residents are expected to complete the program based on the minimum accredited length for the type of program” (emphasis added). In contrast to hospitals that qualify for a cap adjustment under § 413.86(g)(6)(i), where the cap for the hospital takes effect for all programs in the fourth program year of the first program that was started by the hospital, hospitals that qualify for an FTE cap adjustment under § 413.86(g)(6)(ii) have a full 3 years to grow each new program, as long as those programs all started training residents or received accreditation between January 1, 1995 and on or before August 5, 1997. The adjustment to the cap for each of those new programs would be applied individually, beginning with the first day of the fourth program year of each new program. (We note that rural hospitals that qualify for a cap adjustment under § 413.86(g)(6)(iii) may receive an FTE cap adjustment in the same manner as hospitals that qualify for the cap adjustment under § 413.86(g)(6)(ii), except that rural hospitals may receive this adjustment for programs started after August 5, 1997).
For example, assume a hospital that qualifies for a cap adjustment under § 413.86(g)(6)(ii) started a newly accredited internal medicine program on July 1, 1996, and a newly accredited dermatology program on July 1, 1997. The adjustment to the hospital's FTE cap because of the internal medicine program was effective July 1, 1999 (the first day of the fourth program year of internal medicine), and the cap adjustment resulting from the dermatology program was effective July 1, 2000 (the first day of the fourth program year for dermatology). The hospital's ultimate FTE cap is the sum of the FTE cap based on FTEs in the hospital's most recent cost reporting period ending on or before December 31, 1996, and the cap adjustments for the internal medicine and dermatology programs. (We note that since the internal medicine program began in 1996, depending on the hospital's cost reporting period, a portion of those FTEs may have already been included in the hospital's FTE cap. That portion that was included in the FTE cap must be subtracted from the cap adjustment that was calculated for the internal medicine program to avoid any double counting of the FTEs). The hospital's adjusted cap will be based on the sum of: (a) the product of the highest number of internal medicine residents in either PGY1, PGY2, or PGY3 in the third year of the internal medicine program and three (the minimum accredited length of internal medicine); and (b) the product of the highest number of dermatology residents in either PGY1, PGY2, or PGY3 for the dermatology program and four (the minimum accredited length for dermatology).
In summary, we reiterate that the application of the FTE cap adjustments for new programs is not delayed until the program year in which the minimum accredited length of each program expires. This would even apply to a new program with a minimum accredited length that exceeds 3 years. The FTE cap adjustment takes effect on the first day of the fourth program year of the first new program that was started Start Printed Page 39882by hospitals qualifying for a cap adjustment under § 413.86(g)(6)(i). For hospitals qualifying for a cap adjustment under § 413.86(g)(6)(ii) and (g)(6)(iii), the cap adjustments take effect on the first day of the fourth program year of each new program. However, the application of the resident-to-bed ratio cap for IME and the rolling average for both IME and direct GME are dependent upon the minimum accredited length of each new program.
Comment: With regard to the counting of residents for IME payment purposes in nonhospital sites, one commenter stated that although time spent in nonhospital sites may be included in the IME FTE count effective for discharges occurring on or after October 1, 1997, the application of the 1996 FTE cap effectively disallows the current year's FTEs training in the nonhospital site, because the 1996 FTE cap was based on residents training only in the hospital. The commenter added that only those hospitals that are in a position to elect a Medicare affiliation agreement are able to “circumvent” the 1996 FTE limit; those that cannot are “penalized.” The commenter further stated that the regulatory intent of allowing nonhospital training time to be counted is not fully met by having only certain hospitals able to affiliate. The commenter recommended that we should allow hospitals to recalculate the 1996 IME FTE cap to include those FTEs training in nonhospital sites, so that hospitals will effectively be able to count residents currently training in nonhospital sites for IME purposes.
Response: The commenter is addressing a provision in Public Law 105-33 that was implemented in regulations at § 412.105(f)(1)(ii)(C). We did not propose any substantive changes to this policy; we simply were correcting an oversight in the regulations text for IME. (Comments on regulations implementing this provision were addressed in the May 12, 1998 final rule (63 FR 26323) and the July 31, 1998 final rule (63 FR 40954).)
In the August 29, 1997 final rule with comment period (62 FR 46003), the May 12, 1998 final rule (63 FR 26323), and the July 31, 1998 final rule (63 FR 40986), to implement the provisions of Public Law 105-33, we set forth certain policies that affected payment for both direct and indirect GME. Some of these policies related to the FTE cap on allopathic and osteopathic residents, the rolling average, and payment for residents training in nonhospital settings. In the May 4 proposed rule, we indicated that when we amended the regulations under § 413.86 for direct GME, we inadvertently did not make certain conforming changes in § 412.105 for IME. We proposed to make the following conforming changes:
To revise § 412.105(f)(1)(ii)(C) to specify that, effective for discharges occurring on or after October 1, 1997, the time residents spend training in a nonhospital setting in patient care activities under an approved medical residency training program may be counted towards the determination of full-time equivalency if the criteria set forth at § 413.86(f)(3) or § 413.86(f)(4), as applicable, are met.
To revise § 412.105(f)(1)(v) to specify that residents in new residency programs are not included in the rolling average for a period of years equal to the minimum accredited length for the type of program.
In addition, we proposed to revise § 412.105(f)(1)(ix) to specify, for IME purposes, a temporary adjustment to a hospital's FTE cap to reflect residents added because of another hospital's closure of its medical residency program (to conform to the May 4, 2001 proposed change for GME discussed in section IV.H.5. of this preamble).
We did not receive any comments on these conforming changes and are adopting them as final.
Effective for discharges beginning on or after May 1, 1986, hospitals that serve a disproportionate number of low-income patients (the DSH patient percentage as defined in section 1886(d)(5)(F) of the Act) receive additional payments through the DSH adjustment. Hospitals that meet the DSH patient percentage criteria are entitled to the DSH payment adjustment.
In the June 13, 2001 interim final rule with comment period, we discussed the provisions of section 1886(d)(5)(F)(v) of the Act, as it existed prior to enactment of Public Law 106-554 and under § 412.106(c) of the existing regulations, which provided that a hospital qualified for DSH if the hospital had a DSH patient percentage equal to:
At least 15 percent for an urban hospital with 100 or more beds or a rural hospital with 500 or more beds;
At least 40 percent for an urban hospital with fewer than 100 beds;
At least 45 percent for a rural hospital with 100 beds or fewer, if it is not also classified as an SCH;
At least 30 percent for a rural hospital with more than 100 beds and fewer than 500 beds or which is classified as an SCH; or
The hospital has 100 or more beds, is located in an urban area, and receives more than 30 percent of its net inpatient revenues from State and local government sources for the care of indigent patients not eligible for Medicare or Medicaid.
Section 211(a) of Public Law 106-554 amended section 1886(d)(5)(F)(v) to provide that, beginning with discharges occurring on or after April 1, 2001, the qualifying threshold is reduced to 15 percent for all hospitals. Therefore, in the June 13 interim final rule, we revised § 412.106(c) to reflect the change in DSH qualifying threshold percentages.
Comment: Several commenters responded on the subject of the calculation of the DSH payment adjustment. These commenters were concerned about how to apply the threshold changes as of April 1, 2000. They were also concerned about counting days in the calculation when a stay crosses over two cost reporting periods. Finally, these commenters were concerned about counting section 1115 expansion waiver days in the DSH payment adjustment calculation.
Response: Section 211(a) of Public Law 106-554 amended section 1886(d)(5)(F) of the Act to change the qualifying thresholds for the DSH payment adjustment to 15 percent for all hospital types, effective with discharges occurring on or after April 1, 2001. This means that the legislation is effective with discharges occurring on or after April 1, 2001, but not before. Therefore, fiscal intermediaries are required to determine whether a hospital meets the thresholds in place either before or after April 1, 2001, by applying the DSH patient percentage in the formula to each separate period. Days are counted based on the date of discharge. In other words, a hospital stay would be counted in the cost reporting year during which the patient was discharged.
Finally, counting section 1115 expansion waiver days in the DSH payment adjustment calculation was discussed in the August 1, 2000 Federal Register (65 FR 47086). This policy became effective for discharges occurring on or after January 20, 2000. Therefore, it is possible that a hospital will qualify for DSH payments as of January 20, 2000, whereas it did not qualify before January 20, 2000, and it should be paid accordingly. In other words, a hospital in that situation would receive Medicare DSH payments beginning January 20, 2000.Start Printed Page 39883
Section 211(b) of Public Law 106-554 further amended section 1886(d)(5)(F) to revise the calculation of the DSH payment adjustment for hospitals affected by the revised thresholds as specified in section 211(a) of the Act. In the June 13 interim final rule with comment period, we discussed these adjustments, which are effective for discharges occurring on or after April 1, 2001, as follows:
Urban hospitals with fewer than 100 beds and whose DSH patient percentage is equal to or greater than 15 percent and less than 19.3 percent receive the DSH payment adjustment determined using the following formula:
(DSH patient percentage − 15) (.65) + 2.5.
Urban hospitals with fewer than 100 beds and whose DSH patient percentage is equal to or greater than 19.3 percent receive a flat add-on of 5.25 percent.
Rural hospitals that are both rural referral centers and SCHs receive the DSH payment adjustment determined using the higher of the SCH adjustment or the rural referral center adjustment.
Rural hospitals that are SCHs and are not rural referral centers and whose DSH patient percentage is equal to or greater than 15 percent and less than 19.3 percent receive the DSH payment adjustment determined using the following formula:
Rural hospitals that are SCHs and are not rural referral centers and whose DSH patient percentage is equal to or greater than 19.3 percent and less than 30 percent receive a flat add-on of 5.25 percent.
Rural hospitals that are SCHs and are not rural referral centers and whose DSH patient percentage is equal to or greater than 30 percent receive 10 percent.
Rural referral centers whose DSH patient percentage is greater than or equal to 15 percent and less than 19.3 percent receive the DSH payment adjustment determined using the following formula:
Rural referral centers whose DSH patient percentage is equal to or greater than 19.3 percent but less than 30 percent receive a flat add-on of 5.25 percent.
Rural referral centers whose DSH patient percentage is equal to or greater than 30 percent receive the DSH payment adjustment determined using the following formula:
(DSH patient percentage—30) (.6) + 5.25.
Rural hospitals with fewer than 500 beds and whose DSH patient percentage is equal to or greater than 15 percent and less than 19.3 percent receive the DSH payment adjustment using the following formula:
(DSH patient percentage—15) (.65) + 2.5.
Rural hospitals with fewer than 500 beds and whose DSH patient percentage is equal to or greater than 19.3 percent receive a flat add-on of 5.25 percent.
If we calcqulate DSH patient percentages to the hundredth place (our current practice), these payment formulas result in an anomaly for some DSH patient percentages just below 19.3 percent (but greater than 19.2 percent). That is, as the percentage values approach 19.3, the DSH payment adjustment resulting from the formula exceeds 5.25 percent. This would result in a higher DSH payment adjustment for DSH patient percentages just below 19.3 than for percentages of 19.3 and above. We stated in the June 13 interim final rule that, because we believe it would be contrary to the Congress' intent for hospitals with a DSH patient percentage of less than 19.3 percent to receive a greater payment than those hospitals of the same class that have a DSH patient percentage of 19.3 or greater, we were implementing this provision so that, for DSH patient percentages below 19.3 for affected hospitals, the DSH payment adjustment will not exceed 5.25 percent.
In the June 13 interim final rule with comment period, we revised § 412.106(d) to reflect the changes in the disproportionate share adjustment.
Section 1886(d)(5)(F)(ix) of the Act, as amended by section 112 of Public Law 106-113, specifies a percentage reduction in the payments a hospital would otherwise receive under the DSH payment adjustment formula. Prior to enactment of section 303 of Public Law 106-554, the reduction percentages were as follows: 3 percent for FY 2001, 4 percent for FY 2002, and 0 percent for FY 2003 and each subsequent fiscal year.
Section 303 of Public Law 106-554 revised the amount of the percent reductions to 2 percent for discharges occurring in FY 2001, and to 3 percent for discharges occurring in FY 2002. The reduction continues to be 0 percent for FY 2003 and each subsequent fiscal year. Section 303 of Public Law 106-554 contains a special rule for FY 2001: For discharges occurring on or after October 1, 2000 and before April 1, 2001, the reduction is to be 3 percent, and for discharges occurring on or after April 1, 2001 and before October 1, 2001, the reduction is to be 1 percent. Changes made by section 303 with respect to FY 2001 discharges were implemented in the June 13, 2001 interim final rule with comment period.
We are adopting as final the revisions to § 412.106(e) to reflect the change in the percentages made by section 303 of Public Law 106-554 that were included in the May 4, 2001 proposed rule and in the June 13, 2001 interim final rule with comment period. We also are making a technical change in the heading of paragraph (e).
Section 6003(f) of the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) added section 1886(d)(5)(G) to the Act and created the category of Medicare-dependent, small rural hospital (MDH) that are eligible for a special payment adjustment under the hospital inpatient prospective payment system. Section 1886(d)(5)(G) of the Act define an MDH as any hospital that meets all of the following criteria:
The hospital is located in a rural area.
The hospital has 100 or fewer beds.
The hospital is not classified as an SCH (as defined at § 412.92).
In the hospital's cost reporting period that began during FY 1987, not less than 60 percent of its inpatient days or discharges were attributable to inpatients entitled to Medicare Part A benefits. If the cost reporting period is for less than 12 months, the hospital's most recent 12-month or longer cost reporting period before the short period is used.
(For a more detailed discussion, see the April 20, 1990 Federal Register (55 FR 15154)).
As provided by the law, MDHs were eligible for a special payment adjustment under the prospective payment system, effective for cost reporting periods beginning on or after April 1, 1990 and ending on or before March 31, 1993. Hospitals classified as MDHs were paid using the same methodology applicable to SCHs, that is, based on whichever of the following rates yielded the greatest aggregate payment for the cost reporting period:
The national Federal rate applicable to the hospital.
The updated hospital-specific rate using FY 1982 cost per discharge.Start Printed Page 39884
The updated hospital-specific rate using FY 1987 cost per discharge.
Section 13501(e)(1) of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66) extended the MDH provision through FY 1994 and provided that, after the hospital's first three 12-month cost reporting periods beginning on or after April 1, 1990, the additional payment to an MDH whose applicable hospital-specific rate exceeded the Federal rate was limited to 50 percent of the amount by which the hospital-specific rate exceeded the Federal rate.
Section 4204(a)(3) of Public Law 105-33 reinstated the MDH special payment for discharges occurring on or after October 1, 1997 and before October 1, 2001, but did not revise the qualifying criteria for these hospitals or the payment methodology.
Section 404(a) of Public Law 106-113 extended the MDH provision to discharges occurring on or after October 1, 2002 and before October 1, 2006. In the August 1, 2000 interim final rule with comment period, we revised §§ 412.90(j) and 412.108 to reflect the extension of the MDH program through FY 2006.
As specified in the June 13, 2001 interim final rule with comment period, section 212 of Public Law 106-554 provided that, effective with cost reporting periods beginning on or after April 1, 2001, hospitals have the option to base MDH eligibility on two of the three most recently audited cost reporting periods for which the Secretary has a settled cost report, rather than on the cost reporting period that began during FY 1987. According to section 212, the criteria for at least 60 percent Medicare utilization will be met if in at least “2 of the 3 most recently audited cost reporting periods for which the Secretary has a settled cost report”, at least 60 percent of the hospital's inpatient days or discharges were attributable to individuals receiving Medicare Part A benefits.
Hospitals that qualify under this provision are subject to the other provisions already in place for MDHs, that is, the payment methodology as defined in § 412.108(c) and the volume decrease provision as defined in § 412.108(d).
A hospital must notify its fiscal intermediary to be considered for MDH status under this new provision. Any hospital that believes it meets the criteria to qualify as an MDH, based on at least two of its three most recently settled cost reports, must submit a written request to its intermediary. The hospital's request must be submitted within 180 days from the date of the notice of amount of program reimbursement for the cost reporting period in question. The intermediary will make its determination and notify the hospital within 180 days from the date it receives the hospital's request and all of the required documentation.
In the June 13 interim final rule with comment period, we revised § 412.108(a)(1)(iii) to reflect the additional option provided by section 212 of Public Law 106-554.
We received one comment on the proposed regulation change.
Comment: One commenter representing a state hospital association expressed concern regarding the MDH qualifying process outlined in the interim final rule. The commenter questioned the timing of the process, especially that the hospital would be required to apply within 180 days from the date of the notice of program reimbursement and that the fiscal intermediary would have up to 180 days in which to make its decision. The commenter believed that this would not allow hospitals to qualify by the first cost reporting period beginning on or after the April 1, 2001, effective date of the new provision. The commenter also believed that this process would result in a lengthy period of time, perhaps 2-4 years while the cost report settlement and this process plays out. The commenter also believed the determination of whether or not a hospital meets the requirements to become an MDH under this new provision should be handled in manner consistent with that already in place. That is, fiscal intermediaries should automatically determine, using the cost report information they have, whether or not any additional hospitals would now qualify as an MDH under this new criteria, rather than putting the burden on the hospitals to apply for MDH status. The commenter also stated that the fiscal intermediaries require instruction regarding the calculation of the payment rates in order to determine which would most benefit the MDHs. The commenter also believed that the impact analysis understates the number of newly eligible hospitals under the new MDH provision.
Response: We disagree with the commenter that the process for approval of new MDHs could take as long as 2 to 4 years. We do agree with this commenter that hospitals' requests for consideration under this provision need not be limited to requests submitted within 180 days of the issuance of a notice of amount of program reimbursement, and we are deleting this requirement from § 412.108(b). This will eliminate any unintended delay in the time when hospitals could request MDH status. Therefore, hospitals are free to request MDH status at any time. We also are revising the time provided for fiscal intermediaries to make their determination, from 180 days to 90 days. We believe this will provide sufficient time for review while being responsive to the commenter's concern that the process not be too lengthy. Similar to the approval period for SCHs as described above, MDH status and the associated payment adjustment are effective 30 days after written notification to the MDH.
We believe it is most appropriate, and consistent with procedures for SCH and rural referral center designation, to require hospitals to request consideration as a MDH, rather than placing this requirement with the fiscal intermediaries. We will further clarify the MDH policy and process, including the change noted above, through future Program Memoranda.
With respect to the commenter's concern that our impact analysis underestimates the number of newly eligible hospitals under the new provision, we noted in the June 13, 2001 interim final rule with comment period that our most recent data available were 1998, and we were, therefore, unable to estimate the impacts using more recent data. Therefore, the actual impact of this provision may be different as the fiscal intermediaries evaluated hospitals' requests using more recent data.
Under Medicare law, the location of a hospital can affect its payment methodology as well as whether the facility qualifies for special treatment both for operating and for capital payments. Whether a facility is situated in an urban or a rural area will, for example, affect payments based on the wage index values and Federal standardized amounts specific to the area. Similarly, the percentage increase in payments made to hospitals that treat a disproportionate share of low-income patients is based, in part, on its urban/rural status, as are determinations regarding a hospital's qualification as an SCH, rural referral center, critical access hospital (CAH), or other special category of facility. Section 1886(d)(2)(D) of the Act defines an “urban area” as an area within a MSA as defined by the Office of Management and Budget. The same Start Printed Page 39885provision defines a “large urban area,” with respect to any fiscal year, as an urban area that the Secretary determines (in the publications described in section 1886(e)(5) of the Act before the fiscal year) has a population of more than 1 million as determined based on the most recent available published Census Bureau data. Section 1886(d)(2)(D) of the Act further defines a “rural area” as an area that is outside of a “large” urban area or “other” urban area. Since FY 1995, the average standardized amount for hospitals located in rural areas and “other” urban areas has been equal, as provided for in section 1886(b)(3)(B)(i)(X) of the Act.
Several provisions of the Act provide procedures under which a hospital can apply for reclassification from one geographic area to another. Section 1886(d)(8)(B) of the Act, which provides that if certain conditions are met, the Secretary shall treat a hospital located in a rural county adjacent to one or more urban areas as being located in the urban area to which the greatest number of workers in the county commute. Also, section 1886(d)(10) of the Act established the MGCRB to permit hospitals that are disadvantaged by their geographic classification to obtain a more appropriate classification to the area with which they have the most economic interaction.
In the August 1, 2000 interim final rule with comment period (65 FR 47029), we implemented section 401(a) of Public Law 106-113. Section 401(a) of Public Law 106-113, which amended section 1886(d)(8) by adding a new paragraph (E), directs the Secretary to treat any subsection (d) hospital located in an urban area as being located in the rural area of the State in which the hospital is located if the hospital files an application (in the form and manner determined by the Secretary) and meets one of the following criteria:
The hospital is located in a rural census tract of an MSA (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 FR 6725));
The hospital is located in an area designated by any law or regulation of the State as a rural area (or is designated by the State as a rural hospital);
The hospital would qualify as a rural referral center, or as an SCH if the hospital were located in a rural area; or
The hospital meets any other criteria specified by the Secretary.
The statutory effective date of this provision is January 1, 2000.
In the August 1, 2000 interim final rule with comment period, we provided a detailed discussion of the development of the Goldsmith Modifications (65 FR 47029). The Goldsmith Modification evolved from an outreach grant program sponsored by the Office of Rural Health Policy of the Health Resources and Services Administration (HRSA) in order to establish an operational definition of rural populations lacking easy geographic access to health services. Using 1980 census data, Dr. Harold F. Goldsmith and his associates created a methodology for identification of rural census tracts that were located within a large metropolitan county of at least 1,225 miles but were so isolated from the metropolitan core by distance or physical features so as to be more rural than urban in character. We utilize data based on 1990 census data, reflecting the most recent Goldsmith modification.
We also included Appendix A of that interim final rule with comment period a listing of the identified urban counties with census tracts that may qualify as rural under the most recent Goldsmith Modification (January 1, 2000). The amendments made by section 401 of Public Law 106-113 enable a hospital located in one of the areas listed in Appendix A of the August 1, 2000 interim final rule with comment period to be treated as if it were situated in the rural area of the State in which it is located.
Additionally, section 401(a) of Public Law 106-113 includes hospitals “* * * located in an area designated by any law or regulation of such State as a rural area (or is designated by such State as a rural hospital).” Since the concept of State “designation” referred to in the parenthetical clause was not explicit enough to provide a clear-cut rule for purposes of implementation, we required that a hospital's designation as rural be in the form of either State law or regulation if it is the basis for a hospital's request for urban to rural reclassification. We believe this will help ensure that the provision is implemented consistently among States.
Finally, a hospital also may seek to qualify for reclassification premised on the fact that, had it been located in a rural area, it would have qualified as a rural referral center or as an SCH. The hospital would need to satisfy the criteria set forth in section 1886(d)(5)(C) of the Act (as implemented in regulations at § 412.96) as a rural referral center, or the criteria set forth in section 1886(d)(5)(D) of the Act (as implemented in regulations at § 412.92) as an SCH.
Although the statute authorizes the Secretary to specify further qualifying criteria for a section 401 reclassification, we did not believe that additional criteria were warranted at the time the August 1, 2002 interim final rule was published. However, we invited comment specifically on whether the criteria in the interim final rule are sufficient at this time, and if not, what additional criteria should be incorporated.
A hospital that is reclassified as rural under section 1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-113, is treated as rural for all purposes of payment under the Medicare inpatient hospital prospective payment system (section 1886(d) of the Act), including standardized amount (§§ 412.60 et seq.), wage index (§ 412.63), and the DSH payment adjustment calculations (§ 412.106) as of the effective date of the reclassification.
Comment: One commenter addressed policies discussed in the August 1, 2000 interim final rule with comment period. Other commenters addressed our policy to not permit hospitals that are redesignated as rural under section 1886(d)(8)(E) of the Act to be eligible for subsequent reclassifications by the MGCRB.
Response: These policies were addressed in the May 5, 2000 proposed rule (65 FR 26308) and the August 1, 2000 final rule (65 FR 47087) implementing the updates and policy changes to the prospective payment system for FY 2001. We responded to comments on the May 5, 2000 proposed rule in the August 1, 2000 final rule. Because we addressed these concerns in that final rule, we are not readdressing those comments in this final rule.
Comment: An association of physicians commented that the interim final rule with comment period stated that a hospital that is reclassified as rural under this provision must be treated as rural for all purposes of payment under the Medicare inpatient hospital prospective payment system, including standardized amount, wage index, and the DSH payment adjustment. However, the commenter pointed out, graduate medical education is not listed. The commenter urged that these hospitals also be considered rural for purposes of graduate medical education.
Response: Section 1886(d)(8)(E) of the Act provides that affected hospitals are considered rural for purposes of section 1886(d). Therefore, these reclassifications affect payments to a hospital under the IME adjustment, which are made under section 1886(d)(5)(B) of the Act, but not payments for direct GME, which are made under section 1886(h) of the Act.Start Printed Page 39886
Section 401(b) of Public Law 106-113 sets forth conforming statutory changes relating to urban to rural reclassifications under section 401(a) of Public Law 106-113:
Section 401(b)(1) provided that if a hospital is being treated as being located in a rural area under section 1886(d)(8)(E) of the Act (for purposes of section 1886(d) of the Act), the hospital will also be treated under section 1833(t) of the Act as being located in a rural area. This provision was addressed in the final rule for the hospital inpatient prospective payment system published in the Federal Register on August 1, 2000 (65 FR 47087).
Section 401(b)(2) amended section 1820(c)(2)(B)(i) of the Act by extending the reclassification provisions of section 401(a) to the CAH program. A hospital that otherwise would have fulfilled the requirements for designation as a CAH had it been located in a rural area is now eligible for consideration as a CAH if it is treated as being located in a rural area under section 1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-113. (A list of certain existing hospitals that were identified as being located in Goldsmith areas was included in Appendix B of the August 1, 2000 interim final rule with comment period.) A more detailed discussion of the effect on the CAH program of this provision, as well as additional amendments to section 1820(c)(2)(B)(i) of the Act included in Public Law 106-113, is provided in section VI.B. of this preamble.
The statute provides that a hospital seeking reclassification from urban to rural under section 1886(d)(8)(E) of the Act must submit an application “in a form and manner determined by the Secretary.” In the August 1, 2000 interim final rule with comment period, we set forth procedures and requirements for the application for rural reclassification, including application submittal requirements, the filing and effective dates for the application, the procedures for withdrawal of applications, and cancellation of rural reclassification; and the qualifications through the Goldsmith Modification Criteria, by State designation and qualifications as a rural referral center or as an SCH. (See 65 FR 47030 through 47031 for a full discussion of these procedures and requirements.) As of early July 2001, 19 hospitals had taken advantage of this provision.
In the August 1, 2000 interim final rule with comment period, we added a new § 412.103 to incorporate the provisions on the urban to rural reclassification options set forth in section 1886(d)(8)(E) of the Act, as added by section 401(a) of Public Law 106-113, and the application procedures for requesting reclassification.
A formula for transition payments to hospitals located in an area that has undergone geographic reclassification from urban to rural is set forth in section 1886(d)(8)(A) of the Act and implemented in regulations at §§ 412.90 and 412.102. In the interim final rule with comment period, we revised existing §§ 412.63(b)(1) and 412.90(e) and the title of § 412.102 to clarify the distinction between hospital reclassification from urban to rural and the geographic reclassification (or redesignation) of an urban area to rural.
In addition, we revised § 485.610 by redesignating paragraph (b)(4) as paragraph (b)(5) and adding a new paragraph (b)(4) to reflect the conforming provision of section 401(b)(2) of Public Law 106-113.
We did not receive any comments on these changes in the regulations in the interim final rule with comment period and, therefore, are adopting them as final.
With the creation of the MGCRB, beginning in FY 1991, under section 1886(d)(10) of the Act, hospitals could request reclassification from one geographic location to another for the purpose of using the other area's standardized amount for inpatient operating costs or the wage index value, or both (September 6, 1990 interim final rule with comment period (55 FR 36754), June 4, 1991 final rule with comment period (56 FR 25458), and June 4, 1992 proposed rule (57 FR 23631)). Implementing regulations in Subpart L of Part 412 (§§ 412.230 et seq.) set forth criteria and conditions for redesignations from rural to urban, rural to rural, or from an urban area to another urban area with special rules for SCHs and rural referral centers.
As discussed in section III.F. of this final rule, section 304 of Public Law 106-554 contained several provisions related to the wage index and reclassification decisions made by the MGCRB. In summary, section 304 first establishes that hospital reclassification decisions by the MGCRB for wage index purposes are effective for 3 years, beginning with reclassifications for FY 2001. Second, it provides that the MGCRB must use the 3 most recent years of average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and subsequent years. Third, it provides that an appropriate statewide entity may apply to have all of the geographic areas in a State treated as a single geographic area for purposes of computing and applying the wage index, for reclassifications beginning in FY 2003. In the May 4, 2001 proposed rule, we presented a discussion of how we proposed to implement these three provisions. (Section III.F. of this preamble discusses the application of these policy changes to the development of the final FY 2002 and later wage indexes based on hospital reclassification under the provisions of section 304 of Public Law 106-554.)
Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) of the Act by adding clause (v), which provides that, if a hospital is approved for reclassification by the MGCRB for purposes of the wage index, the reclassification is effective for 3 years. The amendment made by section 304(a) is effective for reclassifications for FY 2001 and subsequent years. In addition, the legislation specifies that the Secretary must establish a mechanism under which a hospital may elect to terminate such reclassification during the 3-year period.
Consistent with new section 1886(d)(10)(D)(v) of the Act, in the May 4 proposed rule, we proposed to revise § 412.274(b) to provide under new paragraph (b)(2) that any hospital that is reclassified for a particular fiscal year for purposes of receiving the wage index value of another area would receive that reclassification for 3 years beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year in which a hospital files a complete application. This 3-year reclassification would remain in effect unless the hospital terminates the reclassification under revised procedures that we proposed to establish under new proposed § 412.273(b). The provision would apply to hospitals that are reclassified for purposes of the wage index only, as well as those that are reclassified for both the wage index and the standardized amount. However, in the latter case, only the wage index reclassification would be extended for 2 additional Start Printed Page 39887years beyond the 1 year provided for in the existing regulations (3 years total). Hospitals seeking reclassification for purposes of the standardized amount must continue to reapply to the MGCRB on an annual basis.
Because the 3-year effect of the amendment made by section 304(a) of Public Law 106-554 is applicable to reclassifications for FY 2001 (which had already taken place prior to the date of enactment of section 304(a) (December 21, 2000)), and because the application process for reclassifications for FY 2002 had already been completed by the date of enactment, we are establishing special procedures for hospitals that are reclassified for purposes of the wage index to one area for FY 2001, and are reclassified for purposes of the wage index or the standardized amount to another area for FY 2002. We are deeming such a hospital to be reclassified to the area for which it applied for FY 2002, unless the hospital elects to receive the wage index reclassification it was granted for FY 2001. Consistent with our procedures for withdrawing an application for reclassification (§ 412.273), we allowed a hospital that wished to receive the reclassification it was granted for FY 2001 to withdraw its FY 2002 application by making a written request to the MGCRB within 45 days of the publication date of the proposed rule (that is, by June 18, 2001). Again, only the wage index reclassification is extended for 2 additional years (3 years total). Hospitals seeking reclassification for purposes of the standardized amount must continue to reapply to the MGCRB on an annual basis.
(We note that, effective May 21, 2001, the new location and mailing address of the MGCRB and the Provider Reimbursement Review Board (PRRB) is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. Please specify whether the mail is intended for the MGCRB or the PRRB.)
Under the broad authority delegated to the Secretary by section 1886(d)(10) of the Act, in the May 4 proposed rule, we proposed that a hospital that is reclassified to an area for purposes of the wage index may not extend the 3-year effect of the reclassification under section 304(a) of Public Law 106-554 by subsequently applying for reclassification to the same area for purposes of the wage index for a fiscal year that would be within the 3-year period. For example, if a hospital is reclassified for purposes of the wage index to Area A for FY 2002, is approved to receive Area A's wage index for 3 years (FYs 2002, 2003, and 2004), and reapplies to be reclassified to Area A for FYs 2003, 2004, and 2005 (3 years) for purposes of the wage index, the hospital would not be permitted to receive Area A's wage index for FY 2005 as a result of the reapplication. Instead, we proposed that if the hospital wishes to extend the FY 2002 3-year reclassification for fiscal years beyond FY 2004, it would have to apply for reclassification for FY 2005.
We believe new section 1886(d)(10)(D)(v) of the Act replaces the current annual wage index reclassification cycle with a 3-year reclassification cycle. We believe this policy was intended to provide consistency and predictability in hospital reclassification and wage index data, as well as to alleviate the year-to-year fluctuations in the ability of some hospitals to qualify for reclassification. We do not believe it was intended to be used to extend reclassifications for which hospitals otherwise would not be eligible (by reapplying during the second year of a 3-year reclassification because a hospital fears it may not be eligible for reclassification after its current 3-year reclassification expires).
Under § 412.273(a), a hospital, or group of hospitals, may withdraw its application for reclassification at any time before the MGCRB issues its decision or, if after the MGCRB issues its decision, within 45 days of publication of our annual notice of proposed rulemaking concerning changes to the inpatient hospital prospective payment system and proposed payment rates for the fiscal year for which the application was filed. In the May 4 proposed rule, we proposed that the withdrawal procedures and the applicable timeframes in the existing regulations would apply to hospitals that would receive 3-year reclassification for wage index purposes. For example, if a hospital applied for reclassification to Area A for purposes of the wage index for FY 2002, but wished to withdraw its application, it must have done so prior to the MGCRB issuing a decision on its application or, if the MGCRB issued such a decision, within 45 days of the publication date of the proposed rule (that is, by June 18, 2001). Such a withdrawal, if effective, means that the hospital would not be reclassified to Area A for purposes of the wage index for FY 2002 (and would not receive continued reclassification for FYs 2003 and 2004), unless the hospital subsequently cancels its withdrawal (as discussed below). In other words, a withdrawal, if accepted, prevents a reclassification from ever becoming effective.
On the other hand, a reclassification decision that is terminated upon the request of the hospital has partial effect. Section 1886(d)(10)(D)(v) of the Act, as added by section 304(a) of Public Law 106-554, provides that a reclassification for purposes of the wage index is effective for 3 years “except that the Secretary shall establish procedures under which a . . . hospital may elect to terminate such reclassification before the end of such period.” Consistent with section 1886(d)(10)(D)(v) of the Act, we proposed to allow a hospital to terminate its approved 3-year reclassification for 1 or 2 years of the 3-year effective period (§ 412.273(b)). This is a separate action from a reclassification withdrawal, which occurs following the initial decision by the MGCRB. A termination would occur during subsequent years. For example, a hospital that has been reclassified for purposes of the wage index for FY 2001 is also reclassified for FYs 2002 and 2003 (3 years). Such a hospital could terminate its approved reclassification so that the reclassification is effective only for FY 2001, or only for FYs 2001 and 2002. Consistent with the prospective nature of reclassifications, we proposed to not permit a hospital to terminate its approved 3-year reclassification for part of a fiscal year. A termination would be effective for the next fiscal year. In order to terminate an approved 3-year reclassification, we would require the hospital to notify the MGCRB in writing within 45 days of the publication date of the annual proposed rule for changes to the inpatient hospital prospective payment system. A termination, unless subsequently cancelled (as discussed below), is effective for the balance of the 3-year period.
We established a special procedural rule for handling FY 2001 reclassifications. As noted above, the amendments made by section 304(a) of Public Law 106-554 are effective for reclassifications for FYs 2001 and beyond, and reclassification decisions for FY 2001 had already been implemented prior to the date of enactment of section 304(a). We deemed those hospitals that were reclassified for Start Printed Page 39888FY 2001 to be reclassified for FYs 2002 and 2003. Therefore, if a deemed hospital that was reclassified for purposes of the wage index for FY 2001 wished to terminate its reclassification for FY 2002 and FY 2003, the hospital had to notify the MGCRB in writing by June 18, 2001 (that is, within 45 days after the publication of the proposed rule).
In the May 4 proposed rule, we proposed that if a hospital elects to withdraw its 3-year reclassification application after the MGCRB has issued its decision, it may cancel its withdrawal in a subsequent fiscal year and request the MGCRB to reinstate its reclassification for the remaining fiscal years of the 3-year reclassification period. (This proposal was consistent with our proposal that 3-year reclassification periods may not overlap, as discussed in section IV.G.1.b. of this preamble.) Alternatively, a hospital may apply for reclassification to a different area (that is, an area different from the one to which it was originally reclassified), and if successful, the reclassification effect would be for 3 years.
Similarly, and for the same reasons, we proposed that if a hospital elects to terminate its accepted 3-year reclassification prior to the second or third year of that reclassification, it may cancel that termination and have its original reclassification reinstated for the duration of the original 3-year period. Alternatively, a hospital could apply for reclassification to a different area after terminating a prior 3-year reclassification and receive a new 3-year period of reclassification.
Hospital A files an application and the MGCRB issues a decision to reclassify it to Area B for purposes of wage index for FY 2002 through FY 2004 (3 years). Within 45 days after the publication of the proposed rule, Hospital A withdraws its application. Within the time for applying for a FY 2003 reclassification, Hospital A cancels its withdrawal for classification to Area B. Its reclassification to Area B is reinstated, but only for FYs 2003 and 2004.
Hospital B files an application for reclassification for wage index purposes for FY 2002 through FY 2004 and the MGCRB issues a decision for reclassification to Area C. Within 45 days after publication of the proposed rule, Hospital B withdraws its application. Hospital B does not cancel its withdrawal of the application. Hospital B timely applies and is reclassified to Area D for 3 years, beginning with FY 2003. In this case, the reclassification to Area D would be for FYs 2003 through 2005.
Hospital C is reclassified to Area A for purposes of the wage index for FY 2002, and terminates its 3-year reclassification effective for FYs 2003 and 2004. Within the timeframe for applying for FY 2004 reclassification, Hospital C cancels its termination. Its reclassification to Area A would be reinstated for FY 2004 only.
Hospital D has the same circumstances as Hospital C in Example 3, except that instead of canceling its termination, Hospital D applies and is reclassified to Area B for FY 2004. In this case, the reclassification would be for FYs 2004 through 2006.
Section 412.232 discusses situations where all hospitals in a rural county are seeking urban redesignation, and § 412.234 discusses criteria where all hospitals in an urban county are seeking redesignation to another urban county. In these cases, hospitals submit an application as a group, and all hospitals in the county must be a party to the application. The reclassification is effective both for purposes of the wage index and the standardized amount of the area to which the hospitals are reclassified.
Section 304(a) of Public Law 106-554 does not specifically address the group reclassification situations under §§ 412.232 and 412.234. However, we believe that, in the case of hospitals reclassified under these group reclassification procedures, it would be appropriate to extend the 3-year reclassification provision to these situations for the wage index only. In order to be reclassified for the standardized amount during the second and third years of a 3-year reclassification for the wage index, the hospitals located in these counties would have to reapply on an annual basis to the MGCRB either as a group or as individual hospitals and meet the criteria outlined in § 412.232, § 412.234, or § 412.230, as appropriate.
Hospitals that are part of a group reclassification would be able to terminate their 3-year wage index reclassifications in the same manner as described above. If one hospital within the group elects to terminate its 3-year wage index reclassification, the reclassification of other hospitals in the group would be unaffected. The same rules for withdrawing from a group reclassification that are in effect now would continue. That is, all of the hospitals that are party to a group reclassification application must consent for a withdrawal to be approved.
Under section 152(b) of Public Law 106-113, hospitals in certain counties were deemed to be located in specified areas for purposes of payment under the hospital inpatient prospective payment system, for discharges occurring on or after October 1, 2000. For payment purposes, these hospitals are to be treated as though they were reclassified for purposes of both the standardized amount and the wage index. Section 152(b) also requires that these reclassifications be treated for FY 2001 as though they are reclassification decisions by the MGCRB. For purposes of applying the 3-year extension of wage index reclassifications, we proposed to extend section 1886(d)(10)(D)(v) to hospitals reclassified under section 152(b) of Public Law 106-113. These hospitals also would have to apply for the standardized amount on an annual basis to the MGCRB.
In the proposed rule we indicated that, under the provisions of § 412.278(g), the Administrator has the authority to review an inappropriate reclassification decision made by the MGCRB, as discovered by either the hospital or CMS, including 3-year reclassifications in the second and third years. The statement that this authority extended to the second and third years of 3-year reclassification was in error. Under the statute and our regulations, reclassification decisions are unreviewable once they become final. This principle applies to 3-year reclassification decisions. Once such a decision becomes final, it is unreviewable thereafter.
Comment: Several commenters expressed concern that we proposed that a hospital that is reclassified to an area for purposes of the wage index may not extend the 3-year effect of the reclassification under section 304(a) of Public Law 106-554, by subsequently applying for reclassification to the same area for purposes of the wage index for a fiscal year that would be within the 3-year period. These commenters argued that there is nothing in the statutory language that prohibits hospitals that are already approved for 3-year reclassifications from reapplying within that 3-year period to extend their reclassifications into future years. These commenters also pointed out that extending their wage index reclassifications in this way allows them to make budgetary commitments further into the future and fosters a more stable operating environment for their hospitals.
Response: Under section 1886(d)(10) of the Act, the Secretary has broad authority to establish policies and Start Printed Page 39889criteria with respect to the evaluation and approval of applications for reclassification. As indicated in the proposed rule, we believe that new section 1886(d)(10)(D)(v) of the Act, as added by section 304(a) of Public Law 106-554, replaces the annual reclassification cycle with a 3-year reclassification cycle. We believe that, if a hospital is already reclassified to a given geographic area for a 3-year period, it is appropriate to avoid expending resources to evaluate an application for reclassification to that same area for the second and third years of the 3-year period. Thus, if a hospital is already reclassified for a given fiscal year, and submits an application for reclassification to the same area for the same year, that application will not be approved. We are adding language to § 412.230(a)(5)(v) in this final rule to specify that an application for reclassification will not be approved under these circumstances.
Comment: One commenter supported our proposal to reclassify a hospital based on its FY 2002 approval unless the hospital notified the MGCRB otherwise by June 18, 2001. This commenter questioned whether or not hospitals would have this same option in future years. In other words, if a hospital successfully sought reclassification to a different area for FY 2003 and then withdrew that reclassification, would that hospital have the option to fall back on the FY 2002 reclassification, or would it then not be reclassified.
Response: We appreciate the commenter's support of our proposal on this issue. This was specifically put in place because the new 3-year reclassification policy was not enacted until well after the reclassification process for FY 2002 was underway. Therefore, some hospitals may have sought reclassification to a different area or for a different purpose than they did for FY 2001, and the option to carry forward a FY 2001 wage index reclassification for 3 years may have changed their decisions.
This policy applies in future years as well. For example, a hospital that successfully seeks reclassification for the wage index for FY 2004 to Area A, then successfully seeks reclassification for FY 2005 for the wage index to Area B, has the option to withdraw its FY 2005 decision, thereby reinstating its FY 2004 decision. However, if the hospital successfully withdraws its FY 2005 decision, the hospital cannot return to its FY 2005 decision without reapplying at a later date.
Comment: Several commenters expressed uncertainty about the timing of the extension of the wage index reclassification for 3 years. Some hospitals had successfully applied for FY 2001 as well as FY 2002 to the same area for the wage index, and it was not clear to these hospitals whether their wage index reclassifications were effective through FY 2003 or through FY 2004.
Response: As noted above, section 304(a) provides for 3-year wage index reclassifications effective with FY 2001 reclassifications. In the case of hospitals reclassified to the same area for both FY 2001 and FY 2002, because hospitals had already submitted their FY 2002 applications prior to enactment of Public Law 106-554, and the MGCRB had already issued its decision on these applications prior to publication of the May 4 proposed rule, we will consider FY 2002 to be the first year of the 3-year reclassification for these hospitals. Therefore, the reclassification period will extend through FY 2004. If a hospital was approved for FY 2001 for a wage index reclassification, but was unsuccessful in seeking a wage index reclassification for FY 2002, then its wage index reclassification would be effective for FY 2001, FY 2002, and FY 2003, and the hospital would have to reapply to seek reclassification for FY 2004.
Comment: One commenter supported our proposal that a hospital could cancel its withdrawal of an approved reclassification for the wage index in a future year in order to reinstate its original MGCRB approval.
Response: We appreciate the commenter's support of our proposal that hospitals reclassified for the wage index that then withdraw that approval have the ability to cancel the withdrawal, in effect reinstating the hospital's original reclassification approval for the wage index. We provided this option so that a hospital that later discovers that the withdrawal of its approved wage index reclassification was disadvantageous would have the ability to reinstate its MGCRB approval for the wage index for the remaining years in the 3-year term. However, a hospital is eligible to revert to its most recent MGCRB approval only.
In addition, the same process applies to cancellations of a withdrawal or termination as applies to requests for withdrawals and terminations. A hospital must request a cancellation of its withdrawal or termination within the 45-day period after the proposed rule is published, and that cancellation will become effective for the following Federal fiscal year.
Comment: Several commenters supported our proposal to extend the 3-year reclassification provision for the wage index to those hospitals that were reclassified for FY 2001 under section 152(b) of Public Law 106-113. While these hospitals did not successfully apply for reclassification through the MGCRB, they were effectively “reclassified” by this legislation, and the commenters believed that it would be correct to extend the 3-year wage index reclassification to this group of hospitals.
Response: We appreciate the commenters' support of our proposal. Section 152(b) of Public Law 106-113 required that the assignment of these hospitals to alternative geographic areas should be treated as if they were decisions of the MGCRB. As a result, these hospitals will be reclassified for the wage index to their designated areas for FY 2002 and FY 2003. They will be required to apply for reclassification to the MGCRB for FY 2004 if they wish to retain this reclassification for subsequent years.
Section 304(a) of Public Law 106-554 amended section 1886(d)(10)(D) of the Act by adding clause (vi) which provides that the MGCRB must use the average of the 3 most recent years of hourly wage data for the hospital when evaluating a hospital's request for reclassification. Specifically, the MGCRB must base its evaluation on an average of the average hourly wage for the most recent years for the hospital seeking reclassification and the area to which the hospital seeks to reclassify. This provision is effective for reclassifications for FY 2003 and subsequent years. (Section III.F. of this preamble discusses the development and application of the hospital's 3-year average hourly wage data (Table 2 in the Addendum to this final rule) that the MGCRB will use to evaluate hospitals' applications for reclassifications for FY 2003; and the MSA and statewide rural 3-year average hourly wage data (Tables 3A and 3B in the Addendum to this final rule) for hospital reclassification applications for FY 2003.)
In the May 4, 2001 proposed rule, we proposed to revise §§ 412.230(e)(2) and 412.232(d)(2) to incorporate the provisions of section 1886(d)(10)(D)(vi) of the Act as added by section 304(a) of Public Law 106-554. Specifically, we provided that, for redesignations effective beginning FY 2003, for hospital-specific data, the hospital must provide a 3-year average of its average hourly wages using data from our hospital wage survey used to construct Start Printed Page 39890the wage index in effect for prospective payment purposes. For data for other hospitals, we proposed to require hospitals to provide a 3-year average of the average hourly wage in the area in which the hospital is located and a 3-year average of the average hourly wage in the area to which the hospital seeks reclassification. The wage data would be taken from the CMS hospital wage survey used to construct the wage index for prospective payment purposes, as published in Tables 2, 3A, and 3B of this final rule (unless those data are subsequently changed by CMS). The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described in section III. of this final rule) across all 3 years, by the sum of the hours.
Comment: Several commenters responded positively to our proposal to use a 3-year average of the most recent 3 years of average hourly wages based on data from our hospital wage survey used to construct the wage index when evaluating a hospital's request for reclassification. Under the proposal, if data does not exist for all 3 years, the available data within the 3-year period will be used to construct the average.
While it was clear to these commenters that these data will be used to construct the average hourly wage for a hospital applying for reclassification, they noted it was not clear to them whether the 3-year average would also be used for the area in which that hospital is physically located as well as the area to which that hospital seeks reclassification.
Response: We appreciate the commenters' support of our proposal to calculate the 3-year average hourly wage based on the data available during the applicable 3-year period, even if a hospital does not have data in all 3 years.
As noted above, the MGCRB will evaluate applications using the 3-year average hourly wages for hospitals and geographic areas as published in Tables 2, 3A, and 3B of this final rule (unless those data are subsequently changed by CMS).
Comment: One commenter requested that in cases of a change in ownership, a hospital be permitted the option of excluding prior years' wage data submitted by a previous owner for the purpose of calculating the average of the average hourly wages in order to qualify for reclassification. As a result, the average of the average hourly wages would be based on current and prior year data submitted by the new owner only.
Response: We believe we should treat these cases in a manner consistent with how we treat hospitals whose ownership has changed for other Medicare payment purposes. That is, where a hospital has simply changed ownership and the new owners have acquired the assets and liabilities of the previous owners, all of the applicable wage data associated with that hospital are included in the calculation of its 3-year average hourly wage. On the other hand, in the case of a new hospital, where there is no legal obligation to the operations of a predecessor hospital, the wage data associated with the previous hospital's provider number would not be used in calculating the new hospital's 3-year average hourly wage.
As stated earlier, section 304(b) of Public Law 106-554 provides for a process under which an appropriate statewide entity may apply to have all the geographic areas in the State treated as a single geographic area for purposes of computing and applying the area wage index for reclassifications beginning in FY 2003.
Section 304 does not indicate the duration of the application of these statewide wage indexes. However, it should be noted that the statutory language does refer to these applications as reclassifications. In the May 4, 2001 proposed rule, we proposed that these statewide wage index applications be processed similar to MGCRB applications, with the same effective dates of the decisions and the withdrawal and termination process. Therefore, similar to wage index reclassification decisions under section 1886(d)(10)(D)(v) of the Act as added by section 304(a) of Public Law 106-554, the statewide wage index reclassification would be effective for a total of 3 years. The same deadlines and timetable applicable to MGCRB reclassification applications would apply for statewide wage index applications.
We proposed to establish a new § 412.235 to include the requirements for statewide wage indexes. We proposed to apply the following criteria to determine whether hospitals would be approved for a statewide geographic wage index reclassification (§ 412.235(a)):
There must be unanimous support for a statewide wage index among hospitals in the State in which the statewide wage index would be applied. We would require a signed affidavit on behalf of all the hospitals in the State of this support as part of the application for reclassification.
All hospitals in the State must apply through a signed single application for the statewide wage index in order for the application to be considered by the MGCRB. We believe this is necessary to ensure that every hospital in the State is included in the application, since the payment of every hospital would be affected by the statewide wage index.
There must be unanimous support for the termination or withdrawal of a statewide wage index among hospitals in the State in which the statewide wage index would be applied. We would require a signed affidavit for this agreement.
All hospitals in the State waive their rights to any wage index that they would otherwise receive absent the statewide wage index, including a wage index that any of the hospitals might have received through individual or group geographic reclassification under § 412.273(a).
An individual hospital within the State may receive a wage index that could be higher or lower under the statewide wage index reclassification in comparison to its wage index otherwise (§ 412.235(b)). Specifically, hospitals must be aware that there may be a reduction in the wage index as a result of participation on a statewide basis.
In addition, we proposed to consider statewide wage index applications under the same process we use for hospital reclassification applications, including the effective dates of the MGCRB decision and the withdrawal and termination process (§ 412.235(c)). We proposed that applications for the statewide wage index would be effective for 3 years beginning with discharges occurring on the first day (October 1) of the second Federal fiscal year following the Federal fiscal year in which the hospitals file a complete application unless all of the participating hospitals withdraw their application or terminate their approved statewide wage index reclassification earlier, as discussed below. Once approved by the MGCRB, an application for a statewide wage index can only be withdrawn or terminated as a result of a signed affidavit on behalf of all the hospitals in the State indicating their request that the statewide reclassification be withdrawn or terminated. A request for withdrawal or termination must be submitted within 45 days of the publication of the annual proposed rule for the inpatient hospital prospective payment system announcing the reclassification. New hospitals that open prior to the September 1 deadline for submitting an application for a statewide wage index, but after a group Start Printed Page 39891application has been submitted, would be required to agree to the statewide wage index in order for the group application to remain viable. New hospitals that open after the deadline for submitting an application would receive the statewide wage index. The agreement of new hospitals would also be required in order to withdraw or terminate a statewide wage index reclassification. The rules discussed under section IV.G.1.c. of this preamble for withdrawals of applications and terminations of approved 3-year wage index reclassification decisions would apply to decisions regarding statewide wage index reclassifications.
Comment: Several commenters believed that Washington, DC should be recognized as a State for purposes of this statewide wage index reclassification policy. However, they were concerned that, while such a recognition may benefit hospitals located in Washington, DC, it may not benefit hospitals that are currently located outside of Washington, DC but within the Washington, D.C.-MD-VA-WV MSA. As a result, while these commenters believed that Washington, DC should be recognized as a State for this purpose, they also requested guidance about how the remainder of the hospitals in the current MSA would be treated.
One commenter did not believe that Washington, DC should be considered a State for this purpose. However, this commenter also stated that, should we decide that Washington, DC could be considered a State for this purpose, we should configure the criteria such that none of the hospitals that are currently located in the Washington, D.C.-MD-VA-WV MSA would be harmed.
Response: Section 304(b) of Public Law 106-554 directs the Secretary to establish a process “under which an appropriate statewide entity may apply to have all the geographic areas in a State treated as a single geographic area for purposes of computing and applying the area wage index under section 1886(d)(3)(E) of [the Social Security] Act. * * *” Most States encompass multiple labor market areas (urban MSAs and rural areas) with differing wage indexes, and we believe that the intent of section 304(b) is to offer hospitals within a State the opportunity to eliminate the disparate wage indexes resulting from separate urban and rural labor market areas within the State. However, hospitals in Washington, DC are not subject to disparate wage indexes. Washington, DC is part of a larger labor market area where all the hospitals receive the wage index for that labor market area (subject to MGCRB reclassifications). Put another way, Washington, DC is already “treated as a single geographic area” for purposes of the hospital wage index.
If we treated Washington, DC as a separate distinct labor market area and applied the usual wage index methodology, Washington, DC hospitals might reap a significant windfall and the hospitals remaining in the MSA might be disadvantaged. Given the intended purpose of section 304(b), we believe that such results would be inappropriate. We believe that Congress did not intend for section 304(b) to address the type of situation presented by Washington, DC.
As indicated above, section 304(b) permits a State to be treated as a single geographic area “for purposes of computing and applying the area wage index under section 1886(d)(3)(E) of [the] Act.” Section 304(b) does not specify how to compute and apply the wage index for statewide geographic areas. Under section 1886(d)(3)(E) of the Act, the Secretary has broad authority to develop and apply the methodology for determining the wage index for labor market areas, and section 304(b) did not limit the agency's authority. Thus, even if Washington, DC is a State for purposes of section 304(b), the Secretary has broad authority under section 1886(d)(3)(E) to determine the wage index for all affected hospitals. Given the purpose of section 304, and to avoid conferring an inappropriate and unintended windfall (or disadvantage) to hospitals, we are providing (pursuant to our broad authority under section 1886(d)(3)(E) of the Act) that, even if Washington, DC is a State for purposes of section 304(b) of Public Law 106-554, the wage index applicable to the Washington, DC “statewide” geographic area would be the same wage index that would apply to the Washington, DC-MD-VA-WV MSA as a whole (which would be calculated by including Washington, DC hospitals, in accordance with all applicable rules).
Under section 1886(h) of the Act, Medicare pays hospitals for the direct costs of graduate medical education (GME). The payments are based in part on the number of residents trained by the hospital. Section 1886(h) of the Act, as amended by section 4623 of Public Law 105-33, caps the number of residents that hospitals may count for direct GME.
Section 1886(h)(2) of the Act, as amended by section 9202 of the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 (Public Law 99-272), and implemented in regulations at § 413.86(e), establishes a methodology for determining payments to hospitals for the costs of approved GME programs. Section 1886(h)(2) of the Act, as amended by COBRA, sets forth a payment methodology for the determination of a hospital-specific, base-period per resident amount (PRA) that is calculated by dividing a hospital's allowable costs of GME for a base period by its number of residents in the base period. The base period is, for most hospitals, the hospital's cost reporting period beginning in FY 1984 (that is, the period of October 1, 1983 through September 30, 1984). The PRA is multiplied by the number of FTE residents working in all areas of the hospital complex (or nonhospital sites, when applicable), and the hospital's Medicare share of total inpatient days to determine Medicare's direct GME payments. In addition, as specified in section 1886(h)(2)(D)(ii) of the Act, for cost reporting periods beginning on or after October 1, 1993, through September 30, 1995, each hospital's PRA for the previous cost reporting period is not updated for inflation for any FTE residents who are not either a primary care or an obstetrics and gynecology resident. As a result, hospitals with both primary care and obstetrics and gynecology residents and nonprimary care residents have two separate PRAs beginning in FY 1994: one for primary care and obstetrics and gynecology and one for nonprimary care.
Section 1886(h)(2) of the Act was further amended by section 311 of Public Law 106-113 to establish a methodology for the use of a national average PRA in computing direct GME payments for cost reporting periods beginning on or after October 1, 2000, and on or before September 30, 2005. Generally, section 1886(h)(2) of the Act establishes a “floor” and a “ceiling” based on a locality-adjusted, updated, weighted average PRA. Each hospital's PRA is compared to the floor and ceiling to determine whether its PRA should be revised. PRAs that are below the floor, that is, 70 percent of the locality-adjusted, updated, weighted average PRA, would be revised to equal 70 percent of the locality-adjusted, updated, weighted average PRA. PRAs that exceed the ceiling, that is, 140 percent of the locality-adjusted, updated, weighted average PRA, would, depending on the fiscal year, either be frozen and not increased for inflation, or increased by a reduced inflation factor. Start Printed Page 39892We implemented section 311 of Public Law 106-113 in the hospital inpatient prospective payment system final rule published on August 1, 2000 (65 FR 47090). In that final rule, we set forth the methodology for calculating the weighted average PRA and outlined the steps for determining whether a hospital's PRA would be revised.
Section 511 of Public Law 106-554 amended section 1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of the locality-adjusted national average PRA. In general, section 511 provides that, effective for cost reporting periods beginning on or after October 1, 2001, and before October 1, 2002, PRAs that are below 85 percent of the respective locality-adjusted national average PRA would be increased to equal 85 percent of that locality-adjusted national average PRA. Accordingly, we proposed to implement section 511 by revising § 413.86(e)(4)(ii)(C)(1) to incorporate this change and by outlining the methodology for determining whether a hospital's PRA(s) will be adjusted in FY 2002 relative to the increased floor of the locality-adjusted national average PRA.
In the August 1, 2000 final rule (65 FR 47091 and 47092), as implemented at § 413.86(e)(4), we determined, in accordance with section 311 of Public Law 106-113, that the weighted average PRA for cost reporting periods ending during FY 1997 is $68,464. We described the procedures for updating the weighted average PRA of $68,464 for inflation to FY 2001 and for adjusting this average for the locality of each individual hospital. We then outlined the steps for comparing each hospital's PRA(s) to the locality-adjusted national average PRA to determine if, for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2001, the PRAs should be revised to equal the 70-percent floor.
In accordance with section 511 of Public Law 106-554, in the May 4 proposed rule, we proposed that, for cost reporting periods beginning during FY 2002, the FY 2002 PRAs of hospitals that are below 85 percent of the respective locality-adjusted national average PRA for FY 2002 be increased to equal 85 percent of that locality-adjusted national average PRA. Specifically, to determine which PRAs (primary care and nonprimary care separately) for each hospital are below the 85-percent floor, each hospital's locality-adjusted national average PRA for FY 2002 is multiplied by 85 percent. This resulting number is then compared to each hospital's PRA that is updated for inflation to FY 2002. If the hospital's PRA would be less than 85 percent of the locality-adjusted national average PRA, the individual PRA is replaced with 85 percent of the locality-adjusted national average PRA for that cost reporting period, and in future years the new PRA would be updated for inflation by the Consumer Price Index for All Urban Consumers (CPI-U) as compiled by the Bureau of Labor Statistics.
There may be some hospitals with both primary care and nonprimary care PRAs that are below the floor, and both PRAs are, therefore, replaced with 85 percent of the locality-adjusted national average PRA. In these situations, the hospitals would receive a single PRA; a distinction between PRAs would no longer be made based on the different inflation adjustments (under § 413.86(e)(3)(ii)). On the other hand, hospitals may have primary care PRAs that are above the floor, and nonprimary care PRAs that are below the floor. In these situations, only the nonprimary care PRAs would be revised to equal 85 percent of the locality adjusted national average PRA, and the prior year primary care PRAs would be updated for inflation by the CPI-U. An example of application of this provision appeared in the preamble of the May 4, 2001 proposed rule (66 FR 33697).
We note that section 511 of Public Law 106-554 only affects hospitals with PRAs below the 85-percent floor, and does not affect hospitals with PRAs that are either between the floor and ceiling or exceed the ceiling. Thus, with the exception of the change in the floor as provided by section 511, the policy regarding the use of a national average PRA for making direct GME payments remains as implemented in the regulations at § 413.86(e)(4).
We proposed to amend § 413.86(e)(4)(ii)(C)(1) to add the rules implementing section 1886(h)(2)(D)(iii) of the Act as amended by section 511 of Public Law 106-554.
We also proposed to amend § 413.86(e)(5) regarding the determination of base year PRAs for new teaching hospitals for cost reporting periods beginning during FYs 2001 through 2005. In the August 1, 2000 final rule, we made a conforming change to § 413.86(e)(5) to account for situations in which hospitals do not have a 1984 base year PRA and establish a PRA in a cost reporting period after the 1984 base year. Existing § 413.86(e)(5)(iv) specifies that the new base year PRAs of such hospitals are subject to the regulations regarding the floor and the ceiling of the locality-adjusted national average PRA. Although the determination of new base year PRAs is subject to the national average methodology, it is not necessary to include this provision in the regulations. Therefore, we proposed to remove § 413.86(e)(5)(iv).
In the proposed rule, we clarified that, for purposes of calculating a base year PRA for a new teaching hospital, when calculating the weighted mean value of PRAs of hospitals located in the same geographic area or the weighted mean value of the PRAs in the hospital's census region (as defined in § 412.62(f)(1)(i)), the PRAs used in the weighted average calculation must not be less than the floors for cost reporting periods beginning during FY 2001 or FY 2002, or if they exceed the ceiling, they must either be frozen for FYs 2001 and 2002 or updated with the CPI-U minus 2 percent for FYs 2003 through 2005. In addition, existing § 413.86(e)(5) provides that the PRA for a new teaching hospital is based on the lower of the hospital's actual costs incurred in connection with the GME program or the weighted mean value of PRAs. If a hospital's actual costs of the GME program during its cost reporting period beginning during FY 2001 or FY 2002 are less than the floors, the hospital's PRA would not be based on the actual costs. Instead, it would be equal to 70 percent in FY 2001, or 85 percent during FY 2002, of the locality-adjusted national average PRA. The floor applies to hospitals with existing PRAs in FYs 2001 and 2002, or to hospitals that are establishing new base year PRAs in FYs 2001 and 2002. We proposed to clarify that if a hospital establishes a new base year PRA in a cost reporting period beginning after FY 2002, its PRA would not be increased to equal the floor if it is less than the floor. Similarly, the ceiling applies to hospitals with existing PRAS in FYs 2001 through 2005, or to hospitals that are establishing new base year PRAs in FYs 2001 through 2005.
Comment: One commenter believed that the provision to increase the PRA floor to 85 percent of the locality-adjusted national average will address many concerns about the fairness of GME payments. One commenter asked if the provisions of the proposed rule to increase PRAs that are less than 85 percent of the locality-adjusted national average PRA to equal 85 percent of the locality-adjusted national average PRA would provide relief to hospitals who do not have base year PRAs established in the 1984 base year and could not increase their PRAs because the appeal period has elapsed.Start Printed Page 39893
Response: Section 511 of the Public Law 106-554 amended section 1886(h)(2)(D)(iii) of the Act by increasing the floor to 85 percent of the locality adjusted national average PRA. Effective for cost reporting periods beginning on or after October 1, 2001 and before October 1, 2002, any PRAs that are below 85 percent of the respective locality-adjusted national average PRA would be increased to equal 85 percent of that locality-adjusted national average PRA. Accordingly, hospitals with PRAs (primary care and/or nonprimary care) that are less than 85 percent of the respective locality-adjusted national average PRA for the hospital's cost reporting period beginning on or after October 1, 2001 and before October 1, 2002, will have those PRAs increased to equal 85 percent of that locality-adjusted national average PRA. This provision sets the floor on per resident amounts for cost reporting periods beginning during FY 2002, regardless of the base year used to establish the hospital's PRA.
Comment: One commenter requested that we clarify the references in the preamble stating that the national average PRA methodology is applicable for “cost reporting periods beginning on or after October 1, 2000 and on or before September 30, 2005.” The commenter believed that the PRA changes authorized in the law were meant to be permanent, and therefore, did not understand the basis for the September 30, 2005 endpoint.
Response: The changes made to a hospital's PRA as a result of section 311 of Public Law 106-113 and section 511 of Public Law 106-554 are permanent. However, this new methodology for determining whether or not a hospital's PRA is revised, as described in the statute, is only effective for cost reporting periods beginning on or after October 1, 2000 and on or before September 30, 2005. For cost reporting periods beginning on or after October 1, 2005, a hospital's PRA, whether or not it was revised by the new methodology, is updated with the full CPI-U, using the procedures in place prior to October 1, 2000. If a hospital's PRAs are below the floors, they will be revised accordingly in FYs 2001 or 2002, or both. After FY 2002, that hospital's revised PRA will be updated for inflation as usual, that is, using the procedures in place for all PRAs prior to October 1, 2000. If a hospital's PRAs exceed the ceiling, the PRAs would be frozen in FYs 2001 and 2002, and updated with a reduced inflation factor in FYs 2003, 2004, and 2005. Thus, after September 30, 2005, although any changes made to a hospital's PRAs as a result of the new methodology would remain in place, the procedure for updating PRAs reverts back to the procedure in place prior to October 1, 2000, that is, updating for inflation with the full CPI-U.
Comment: One commenter requested that we publish in the final rule the CPI-U factors that must be used to update the 1997 national average PRA to the midpoint of a hospital's cost reporting period beginning in FY 2001.
Response: As the commenter requested, we are including below the CPI-U factors. For cost reporting periods beginning on or after October 1, 2000 and before October 1, 2001, the following update factors should be used when implementing section 311 of Public Law 106-113. Specific instructions for applying these factors can be found in the hospital inpatient prospective payment system final rule published on August 1, 2000 (65 FR 47091). (Refer to the bottom of the middle column and the right column on page 47091 for “Step 1: Update the weighted average PRA for inflation”.)
GME Update Factors for Midpoint of Periods Ending in FY 1997 to Cost Reporting Periods Beginning in FY 2001 Using the CPI (U)—All Items
Update weighted average PRA from:
To midpoint of cost reporting period beginning:
Use update factor of: \*\
October 1, 1996 October 1, 2000 1.11200
October 1, 1996 November 1, 2000 1.11389
October 1, 1996 December 1, 2000 1.11579
October 1, 1996 January 1, 2001 1.11800
October 1, 1996 February 1, 2001 1.12053
October 1, 1996 March 1, 2001 1.12307
October 1, 1996 April 1, 2001 1.12465
October 1, 1996 May 1, 2001 1.12528
October 1, 1996 June 1, 2001 1.12591
October 1, 1996 July 1, 2001 1.12780
October 1, 1996 August 1, 2001 1.13097
October 1, 1996 September 1, 2001 1.13414
* Source: Forecast by Standard and Poor's DRI; Historical Data through August 2000.
Section 1886(h)(4)(G)(iii) of the Act, as added by section 4623 of Public Law 106-33, provides that for the hospital's first cost reporting period beginning on or after October 1, 1997, the hospital's weighted FTE count for direct GME payment purposes equals the average of the weighted FTE count for that cost reporting period and the preceding cost reporting period. For cost reporting periods beginning on or after October 1, 1998, section 1886(h)(4)(G) of the Act requires that hospitals' direct medical education weighted FTE count for payment purposes equal the average of the actual weighted FTE count for the payment year cost reporting period and the preceding two cost reporting periods (rolling average). This provision phases in the associated reduction in payment over a 3-year period for hospitals that are reducing their number of residents.
In the August 29, 1997 final rule with comment period (62 FR 46004), we revised § 413.86(g)(5) accordingly, and outlined the methodology for determining a hospital's direct GME payment. Based on what we explained in the 1997 final rule, for cost reporting periods beginning on or after October 1, 1997, we would determine a hospital's direct GME payment as follows:
Step 1. Determine the average of the weighted FTE counts for the payment year cost reporting period and the prior two immediately preceding cost reporting periods (with exception of the hospital's first cost reporting period beginning on or after October 1, 1997, which will be based on the average of the weighted average for that cost Start Printed Page 39894reporting period and the immediately preceding cost reporting period).
Step 2. Determine the hospital's direct GME amount without regard to the FTE cap (before determining Medicare's share). That is, take the sum of (a) the product of the primary care PRA and the primary care weighted FTE count in the current payment year, and (b) the product of the nonprimary care PRA and the nonprimary care weighted FTE count in the current payment year.
Step 3. Divide the hospital's direct GME amount by the total number of FTE residents (including the effect of weighting factors) for the cost reporting period to determine the weighted average PRA (this amount reflects the FTE weighted average of the primary and nonprimary care PRAs) for the cost reporting period.
Step 4. Multiply the weighted average PRA for the cost reporting period by the 3-year average weighted count to determine the hospital's allowable direct GME costs. This product is then multiplied by the hospital's Medicare patient load for the cost reporting period to determine Medicare's direct GME payment to the hospital.
Steps 2 and 3 above describe the methodology for combining a hospital's primary care PRA and nonprimary care PRA to determine the hospital's single weighted average PRA for the payment year cost reporting period. (This step accounts for hospitals that were training residents in both primary care and nonprimary care residency programs in FYs 1994 and 1995, when, as described in § 413.86(e)(3)(ii), each hospital's PRA for the previous cost reporting period was not adjusted for any resident FTEs who were not either a primary care resident or an obstetrics and a gynecology resident. As a result, such hospitals have two PRAs for direct GME payment; one for primary care and obstetrics and gynecology residents, and one for all other, or nonprimary care, residents. Hospitals that train either only primary care (including obstetrics and gynecology) residents or only nonprimary care residents follow the methodology described above, with the exception of combining two PRAs. Step 4 then dictates that the resulting average PRA is multiplied by the 3-year rolling average, which, in turn, is multiplied by the hospital's Medicare patient load in the current year to determine Medicare's direct GME payment to the hospital for that cost reporting period.
In implementing this provision in the August 29, 1997 final rule with comment period, we believed that the methodology described above was appropriate because it was consistent with the methodology described under section 1886(h)(3)(B) of the Act. This section specifies that, in order to arrive at the average PRA, or “aggregate approved amount,” the Secretary must multiply a hospital's PRA by the “weighted average number of [FTE] residents * * * in the hospital's approved medical residency training programs in that period” (emphasis added).
We also believed the methodology outlined above and in the August 29, 1997 rule was appropriate because it was consistent with the intent of the statute that, after October 1, 1997, direct GME payments should be based on a rolling average. Specifically, section 4623 of Public Law 106-33 provides that, “For cost reporting periods beginning on or after October 1, 1997 * * * the total number of full-time equivalent residents for determining a hospital's graduate medical education payment shall equal the average of the actual full-time equivalent resident counts for the cost reporting period and the preceding two cost reporting periods' (emphasis added). Thus, while the statute does not include a specific methodology for computing the direct GME payments, it clearly indicates that the payment should be based on a 3-year average of the weighted number of residents, not the weighted number of residents in the current payment year cost reporting period.
As stated above, Congress provided that the direct GME payments should be made based on a 3-year average of the weighted number of residents in order to phase in the associated reduction in payment over a 3-year period for hospitals that are reducing the number of residents they are training. However, in steps 2 and 3 above, when combining a hospital's primary care PRA and nonprimary care PRA, we weight the respective PRAs by current year residents. This introduces the number of residents that a hospital is training in the current cost reporting period into the payment formula. A payment formula that incorporates the number of current year residents “dilutes” the effect of the rolling average as related to direct GME payments. After further consideration, we believe that, consistent with the statute, the formula should be based on rolling average counts of residents. We proposed an alternative methodology which would replace the current methodology in which the direct GME payment would be the sum of (a) the product of the primary care PRA and the primary care and obstetrics and gynecology rolling average, and (b) the product of the nonprimary care PRA and the nonprimary care rolling average. (This sum would then be multiplied by the Medicare patient load.) The new methodology would only be used for determining direct GME payments because there is no distinction between primary care and nonprimary care residents for IME payment purposes.
The new methodology is effective for cost reporting periods beginning on or after October 1, 2001. The methodology for determining a hospital's direct GME payment is as follows:
Step 1. Determine that the hospital's total unweighted FTE counts in the payment year cost reporting period and the prior two immediately preceding cost reporting periods for all residents in allopathic and osteopathic medicine do not exceed the hospital's FTE cap for these residents in accordance with § 413.86(g)(4). If the hospital's total unweighted FTE count in a cost reporting period exceeds its cap, the hospital's weighted FTE count, for primary care and obstetrics and gynecology residents and nonprimary care residents, respectively, will be reduced in the same proportion that the number of these FTE residents for that cost reporting period exceeds the unweighted FTE count in the cap. The proportional reduction is calculated for primary care and obstetrics and gynecology residents and nonprimary care residents separately in the following manner:
(FTE cap/unweighted total FTEs in the cost reporting period) × (weighted primary care and obstetrics and gynecology FTEs in the cost reporting period)
(FTE cap/unweighted total FTEs in the cost reporting period) × (weighted nonprimary care FTEs in the cost reporting period).
Add the two products to determine the hospital's reduced cap.
Step 2. Determine the 3-year average of the weighted FTE count for primary care and obstetrics and gynecology residents in the payment year cost reporting period and the two immediately preceding cost reporting periods. Determine the 3-year average of the weighted FTE count for nonprimary care residents in the payment year cost reporting period and the two immediately preceding cost reporting periods.
Step 3. Determine the product of the primary care PRA and the primary care and obstetrics and gynecology 3-year average from step 2. Determine the product of the nonprimary care PRA and the nonprimary care 3-year average from step 2.
Step 4. Sum the products of step 3.
Step 5. Multiply the sum from step 4 by the hospital's Medicare patient load Start Printed Page 39895for the cost reporting period to determine Medicare's direct GME payment to the hospital.
Existing § 413.86(g)(5) specifies that residents in new programs are excluded from the rolling average calculation for a period of years equal to the minimum accredited length for the type of program, and are added to the payment formula after applying the averaging rules. Accordingly, for hospitals that qualify for an adjustment to their FTE caps for residents training in new programs under § 413.86(g)(6), primary care and obstetrics and gynecology residents in new programs would be added to the quotient of the primary care and obstetrics and gynecology 3-year average, and nonprimary care residents in new programs would be added to the quotient of the nonprimary care 3-year average. The sums of the respective 3-year averages and new residents would then be multiplied by the respective PRAs.
The following example illustrates the determination of direct GME payment under the proposed rolling average methodology for an existing teaching hospital with no new programs:
Assume a hospital with a cost reporting period ending September 30, 1996 (beginning October 1, 1995) had 100 unweighted FTE residents and 90 weighted FTE residents. The hospital's FTE cap is 100 unweighted residents.
Step 1. In its cost reporting period beginning in FY 2000, it had 100 unweighted residents and 90 weighted residents (50 primary care and 40 nonprimary care).
The hospital had 90 unweighted residents and 85 weighted residents (50 primary care and 35 nonprimary care) for its cost reporting period beginning in FY 2001.
In its cost reporting period beginning in FY 2002, the hospital had 80 unweighted residents and 80 weighted residents (50 primary care and 30 nonprimary care).
Step 2. The 3-year average of weighted primary care and obstetrics and gynecology residents is (50 +50 + 50)/3 = 50. The 3-year average of weighted nonprimary care residents is (40 + 35 + 30)/3 = 35.
Step 3. Primary care: $80,000 PRA × 50 weighted primary care and obstetrics and gynecology FTEs = $4,000,000. Nonprimary care: $78,000 × 35 weighted nonprimary care FTEs = $2,730,000.
Step 4. $4,000,000 + $2,730,000 = $6,730,000.
Step 5. If the hospital's Medicare patient load for the payment cost reporting period is .20, Medicare's direct GME payment would be $6,730,000 × .20 = $1,346,000.
Whether the proposed methodology results in a payment difference for a hospital is dependent upon whether or not the number and mix (primary care and nonprimary care) of FTEs changes in a 3-year period. If the number and mix of FTEs does not change in a 3-year period, there would be no difference in a direct GME payment amount derived using the proposed methodology versus the existing methodology. For example, if a hospital has 90 weighted FTEs (50 primary care and 40 nonprimary care) in the current year and the 2 previous years (using the PRAs and the Medicare patient load from the example above), the payment amounts derived from the existing methodology and the proposed methodology would be equal.
If the number and mix of FTEs varies from year to year, there will be a difference in the results of the two methodologies. In some instances the existing methodology would result in a higher payment, and in other instances the proposed methodology would result in a higher payment. In the example above, the hospital has reduced its number of weighted residents by 5 FTEs in FYs 2001 and 2002. Calculating this hospital's direct GME payment amount using the existing methodology (using the PRAs and the Medicare patient load from the example) would result in a payment of $1,347,250, which is $1,250 more than $1,346,000, the amount calculated in the example using the proposed methodology.
In a scenario where a hospital makes larger reductions to the number of FTEs, the proposed methodology may be more beneficial. For example, using the PRAs and the Medicare patient load from the example above, assume a hospital has 90 weighted FTEs (50 primary care and 40 nonprimary care) in FY 2000, 85 weighted FTEs (50 primary care and 35 nonprimary care) in FY 2001, and 70 weighted FTEs (35 primary care and 35 nonprimary care) in FY 2002. If the proposed methodology is used, the payment amount of $1,292,050 would be calculated, which is $1,666 more than $1,290,386, the amount calculated if the existing methodology is used.
We proposed to revise § 413.86(g)(4) to specify that, effective for cost reporting periods beginning on or after October 1, 2001, if the hospital's total unweighted FTE count in a cost reporting period exceeds its cap, the hospital's weighted FTE count, for primary care and obstetrics and gynecology residents and nonprimary care residents, respectively, will be reduced in the same proportion that the number of these FTE residents for that cost reporting period exceeds the unweighted FTE count in the cap. We also proposed to revise § 413.86(g)(5) to specify that, effective for cost reporting periods beginning on or after October 1, 2001, the direct GME payment will be calculated using two separate rolling averages, one for primary care and obstetrics and gynecology residents and one for nonprimary care residents.
Comment: Two commenters asked whether or not the proposed new methodology for calculating direct GME payment using two separate rolling averages for primary care and nonprimary care residents is truly an “alternative,” or, if finalized, would it replace the present methodology.
Response: The proposed new methodology would replace the existing rolling average methodology effective for cost reporting periods beginning on or after October 1, 2001 (the effective date of this final rule). Hospitals training both primary care and nonprimary care residents would determine two separate rolling average counts; one for primary care and one for nonprimary residents.
Comment: One commenter stated: “although the new rolling average methodology is difficult and complex, its impact on GME programs is far from clear.” The commenter asked how much change in resident number and mix is necessary before this new methodology has an effect on payment, and stated that more examples would be helpful in determining this effect. The commenter also expressed hope that, if this change is finalized, we will revisit this issue after implementation and fully examine and analyze its impact on teaching program payment.
Response: As we explained in the proposed rule, whether the new methodology results in a payment difference for a hospital is dependent upon whether or not the ratio of primary care to nonprimary care FTEs changes in a 3-year period. If the ratio of the FTEs does not change over the 3-year period, there would be no difference in a direct GME payment amount derived using the new methodology versus the existing methodology. In particular, there would be an increase in direct GME payment under the revised methodology, where a hospital's proportion of primary care residents to nonprimary care residents over the last 3 years is higher than the hospital's proportion of primary care residents to nonprimary care residents in the current year. As this new rolling average methodology is implemented, we intend to evaluate hospitals' direct GME payments to further analyze the impact of using this methodology.
Comment: One commenter asked how many hospitals would still be “at risk” Start Printed Page 39896for changes in payment because they retain different primary care and nonprimary care PRAs, given the implementation of the 85 percent floor.
Response: As described in the impact section of this final rule in Appendix A, we estimated that, of 1,231 teaching hospitals included in the analysis, approximately 562 hospitals have PRAs that will be increased to equal 85 percent of the national average PRA. This leaves 669 hospitals with PRAs that exceed the 85 percent floor. However, not all of these hospitals will be using the new methodology because not all of them have both primary care and nonprimary care PRAs.
Comment: One commenter noted that, in order to implement the new rolling average methodology, significant changes must be made to Worksheet E, Part A, the worksheet on the Medicare cost report used for calculating a hospital's IME adjustment. The commenter also stated that past cost reports using the current cost reporting forms would have to be reopened.
Response: As we explained in the preamble to the proposed rule and above in this final rule, we have decided to institute a separate rolling average for primary care and nonprimary care residents due to an issue with respect to the current payment methodology for direct GME only. That is, when combining a hospital's primary care PRA and nonprimary care PRA on Worksheet E-3, Part IV of the Medicare cost report, we currently weight the respective PRAs by current year residents. As a result, although Congress provided that the direct GME payments should be made based on a 3-year rolling average count of weighted residents, the current methodology introduces the number of residents that a hospital is training in the current cost reporting period into the payment formula. A payment formula that incorporates the number of current year residents “dilutes” the effect of the rolling average as related to direct GME payments. However, in regard to the IME payments, we also noted that, although they are also based on a rolling average, no change in the existing methodology is needed because there is no distinction between primary care and nonprimary care residents for IME payment purposes. Therefore, while two separate rolling averages will be used for direct GME payments (one for primary care and one for nonprimary care), a single rolling average will continue to be used for IME payments under the existing methodology. We will make the necessary changes to the Medicare cost report on Worksheet E-3, Part IV, which is used for calculating a hospital's direct GME payment, to accommodate two separate rolling average calculations.
The commenter also stated that affected cost reports in which the current rolling average methodology was used would need to be reopened. However, the effective date of this change in the methodology is prospective, and will only affect cost reporting periods beginning on or after October 1, 2001. We will not be reopening past cost reports to change direct GME payment because of the new methodology.
Comment: One commenter indicated that the separation of the 3-year rolling average between primary care and nonprimary care FTEs will be difficult because the prior year FTEs were not separated into primary care and nonprimary care FTEs. The commenter asked how a provider could obtain the information from prior years if the same methodology was not used.
Response: We do not believe it will be difficult for a hospital to obtain the weighted FTE counts of its primary care and nonprimary care residents separately. This is because, in fact, although the rolling average was computed based on total residents, there are lines on Worksheet E-3, Part IV (lines 3.07 and 3.08) in which the current year weighted count of primary care and nonprimary care residents are reported separately. Therefore, the hospital and the fiscal intermediary can easily refer to these lines on prior year cost reports to determine a 3-year average for primary care and nonprimary care residents, respectively.
It has come to our attention that there appears to be some confusion in the provider community as to whether the time that residents spend performing research is countable for the purposes of direct and indirect GME reimbursement. Although we did not propose to make any policy changes in the May 4 proposed rule, we did reiterate our longstanding policy regarding time that residents spend in research and proposed to incorporate this policy in the IME regulations.
Section 413.86(f) specifies that, for the purposes of determining the total number of FTE residents for the direct GME payment, residents in an approved program working in all areas of the hospital complex may be counted. Accordingly, the time the residents spend performing research as part of an approved program anywhere in the hospital complex may be counted for direct GME payment purposes. If the requirements listed at §§ 413.86(f)(3) and (f)(4) are met, a hospital may also count the time residents spend doing research in nonhospital settings for direct GME payment.
For purposes of determining the IME payment, § 412.105(f)(1)(ii) specifies that the time residents spend training in parts of the hospital that are subject to the inpatient prospective payment system, in the outpatient departments, or (effective on or after October 1, 1997, in accordance with § 413.86(f)(3) or (f)(4), as applicable) in nonhospital settings, may be counted. Section 2405.3.F.2. of the Provider Reimbursement Manual (PRM) further states that a resident must not be counted for the IME adjustment if the resident is engaged exclusively in research. Resident time spent “exclusively” in research means that the research is not associated with the treatment or diagnosis of a particular patient of the hospital. Therefore, although the research component may be part of an approved program, the time that residents devote specifically to performing research that is not related to delivering patient care, whether it occurs in the hospital complex or in non-hospital settings, may not be counted for IME payment purposes. “Exclusively research” time is not allowable for IME purposes irrespective of whether the resident is engaged only in research or spends only part of his or her time on research. Accordingly, time spent exclusively in research over the course of a program year should be subtracted from the total FTE count for that year. For example, if a resident is required to spend 3 months in a particular program year engaged in research activities unrelated to delivering patient care, that amount of time should be subtracted from the total FTE count, whether or not the research time is fulfilled in one block of time, or is distributed throughout the training year.
We note that in order to count residents for both direct GME and IME payment purposes, the residents' training must be part of an approved program. This applies whether or not the residents are doing work that is clinical in nature. There are situations where residents have completed their residency program requirements but remain for an additional period of time to continue their training (that is, to conduct research or other activities) outside the context of a formally organized approved program. As we explained in the September 29, 1989 final rule (54 FR 40306), these residents are not countable for direct GME or IME Start Printed Page 39897reimbursement. Rather, patient care services provided by these residents should be paid as Part B services.
We proposed to amend § 412.105(f)(1)(iii) to add a paragraph (B) to incorporate language that reflects this policy.
We received several comments disagreeing with our clarification to longstanding policy on whether the time that residents spend performing research may be included in the FTE count for the purpose of determining direct and indirect GME reimbursement.
Comment: One commenter stated that the proposed revised IME regulations at § 412.105 do not mention any requirement that residents counted for purposes of the IME adjustment and assigned to a hospital's inpatient prospective payment system or outpatient area be involved in “patient care activities.” Instead, that requirement is only mentioned with reference to residents assigned to nonprovider settings. Therefore, the commenter believed that a patient care requirement in reference to counting residents in nonprovider settings implies the exclusion of the same requirement when counting residents in the hospital (specifically as it applies to counting research time for IME purposes).
Response: The clarification in the proposed rule addresses our longstanding interpretation of existing regulations and reflects longstanding general Medicare reimbursement principles. Under general Medicare reimbursement principles, as reflected in § 413.9, costs incurred by a hospital generally must be related to patient care in order to be reimbursed by Medicare.
The purpose of the IME payments is to address the additional costs that hospitals incur in treating patients. In our May 6, 1986 interim final rule (51 FR 16775), we stated: “Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals receive an additional payment for the indirect costs of medical education computed in the same manner as the adjustments for those costs under regulations in effect as of January 1, 1983. Under those regulations, we provided that the indirect costs of medical education incurred by teaching hospitals are the increased operating costs (that is, patient care costs) that are associated with approved intern and resident programs” (emphasis added). In addition, in our September 29, 1989 final rule (54 FR 40286), we specifically state: “As used in section 1886(d)(5)(B) of the Act, ‘indirect medical education' means those additional costs (that is, patient care costs) incurred by hospitals with graduate medical education programs. The indirect costs of medical education might, for example, include added costs resulting from an increased number of tests ordered by residents as compared to the number of tests normally ordered by more experienced physicians” (emphasis added).
Thus, payments for IME address the additional operating costs that teaching hospitals incur in furnishing patient care. Accordingly, consistent with the purpose of IME payments and general Medicare reimbursement principles, in determining the FTE count with respect to the IME adjustment, it has been our longstanding policy that we do not include residents to the extent that the residents are not involved in furnishing patient care but are instead engaged exclusively in research.
Comment: One commenter disagreed with our use of the Provider Reimbursement Manual (PRM), section 2405.3.F.2, in support of our policy on excluding residents from the IME count if the resident is “engaged exclusively in research.” The commenter stated that the reference to exclusion from the resident count for residents engaged “exclusively in research” must be read in the context of the Manual provision, and not in a regulatory vacuum. The commenter believed that PRM section 2405.3.F.2 is addressing situations outside of the traditional residency program—where the resident time at issue is not part of an approved medical education program. The commenter believed that the phrase “engaged exclusively in research” refers to persons who are research scientists and not engaged in research as part of a clinical residency program.
In addition, this commenter stated that our interpretation of the word “exclusively” in this context is not reasonable and is contrary to the clear meaning of the term. The commenter argued that our interpretation practically eliminates the word “exclusively,” effectively saying that a resident is “exclusively engaged in research” if that resident participates in any research at all.
Response: Section 2405.3.F.2 of the PRM (published in August 1988) was written to address “Questionable situations” for the IME FTE count. Indeed, in the introductory paragraph in this section we state: “It is recognized that situations arise in which it may be unclear whether an individual is counted as an intern or resident in an approved program for the purposes of the indirect medical education adjustment.” Thus, the point of section 2405.3.F.2 of the PRM was to clarify situations for counting resident FTEs in approved programs for IME purposes. As the commenter suggested, some of the situations listed under this section address situations where the resident FTE time at issue is not part of the approved medical education program (for example, that a resident must not be counted for the IME adjustment if “the individual's services in provider settings are payable as physician services (situations in which it is clear that the otherwise eligible resident is ‘moonlighting')”.) (Section 2405.3.F.2. of the PRM). However, this section in the PRM was written to clarify counting rules for IME purposes in various situations. In addition to clarifying situations where resident time is spent in an unapproved program, this section in the PRM certainly also clarifies the rules for determining resident time spent in an approved program—such as time the resident is “engaged exclusively in research” (as cited in the proposed rule) and that “any portion of the individual's salary is subject to reasonable compensation equivalency limits.” (Section 2405.3.F.2. of the PRM)
Therefore, we do not agree with the commenter that we have read this manual provision in a “regulatory vacuum”. The phrase “engaged exclusively in research” is not meant only to refer to persons who are research scientists and not engaged in research as part of an approved clinical residency program, since as explained above, there is nothing in the manual provision that limits the research provision to research performed outside of an approved program.
In the proposed rule, we stated that resident time spent “exclusively” in research “means that the research is not associated with the treatment or diagnosis of a particular patient of the hospital.” (66 FR 22700). The commenter argued that this interpretation of the word “exclusively” in the context of the manual provision is unreasonable and contrary to the clear meaning of the term, that under our policy, a resident would be “engaged exclusively in research” if that resident participates in any research at all. We do not agree.
Resident time spent “engaged exclusively in research” means time not associated with the care of a particular patient (see proposed § 412.105(f)(1)(iii)(B)); thus, any research time that is associated with the treatment or diagnosis of a particular hospital patient or, effective on or after October 1, 1997, of patients in nonhospital settings, that is, usual patient care, is countable for IME payment purposes. We note that this distinction between activities that are Start Printed Page 39898“usual patient care” and research activities is, again, longstanding Medicare policy. In April 1975, at section 500 of the PRM, we stated the principle that “Costs incurred for research purposes, over and above usual patient care, are not included as allowable costs.” Indeed, since the inception of Medicare, we have distinguished between activities that are “usual patient care” and activities that are outside this scope, such as research activities.
Comment: One commenter stated that “by its very nature as a regression analysis, or statistical measure, the IME formula is not intended to be dependent on ‘the treatment or diagnosis of a particular patient of the hospital.' ” Another commenter stated: “our understanding of the development of the adjustment is that statistical analyses showed that the use of an intern/resident-to-bed ratio (IRB) was (and continues to be) the best proxy for the patient care cost differences between teaching and non-teaching hospitals. Given that the IRB is only a proxy, the relevance of a requirement that residents themselves must be engaged in activities related to patient care in order for their training time to be counted in the IRB is unclear.”
Response: Generally, the statistical analyses used in the development of the statutory IME adjustment measured the differences between teaching and nonteaching hospitals with respect to the additional costs associated with patient care. Inpatient hospital care that involves the use of residents is costlier than inpatient hospital care that does not involve the use of residents. As the comments and the statute reflect, the hospital's ratio of interns and residents to beds is one factor in measuring the additional costs that a hospital incurs due to the use of residents in furnishing patient care. While a resident is engaged exclusively in research, the hospital is not incurring additional patient care costs due to that resident. Accordingly, we believe that the measure of additional patient care costs is more accurate if it excludes residents engaged exclusively in research.
Suppose, for example, that a teaching hospital has a total of 20 FTE residents training in prospective payment system sections of the hospital who are all involved in furnishing patient care. The amount of the IME payment to the hospital would reflect 20 FTE residents, reflecting the additional operating costs arising from the use of 20 FTE residents in furnishing patient care. Now suppose that the same hospital has the same 20 residents involved in furnishing patient care but it also has 4 additional FTE residents engaged exclusively in research. The 4 residents engaged exclusively in research do not contribute to higher operating costs and, therefore, as our longstanding policy reflects, we believe it is appropriate not to count them for purposes of the IME adjustment. Thus, in both situations, the hospital's FTE count for purposes of IME is 20. If we did make higher payments in the second situation, then the hospital would receive higher payments even though the hospital did not incur higher patient care costs.
Comment: One commenter stated that our regulations at § 413.86(e)(1)(i)(B) clearly allow research time to be counted for direct GME purposes. This commenter asserted that “it cannot be reasonably argued that research time should be counted differently for IME than direct GME based on a new, very specific definition of patient care that applies solely to IME”. Another commenter stated the proposed rule is “unduly burdensome” by requiring hospitals to maintain different counts for direct GME and IME based on research activity or rotations. A third commenter stated that there is an alternative to distinguishing between direct GME and IME as it relates to research—“lawyers, often when faced with conflicting sections of the law, attempt to reconcile a common policy out of these conflicts, rather than further complicating things. You could do the same here.”
Response: As we have stated above and in the proposed rule, the clarification we made concerning the counting of FTEs for research time related to the diagnosis and treatment of a particular patient for IME purposes is longstanding Medicare reimbursement policy. We were not proposing a change in Medicare policy.
We are not introducing unnecessary complexity to the direct and indirect medical education counts, since it has always been Medicare policy to require the hospital to distinguish between time spent by residents involved exclusively in research and time spent on patient care. Further, the IME and direct GME FTE counts have and will continue to differ for several reasons. Hospitals have always been able to count residents in all areas of the hospital complex for direct GME but cannot count residents working in units exempt from the prospective payment system for IME. In addition, each resident included in the hospital's direct GME FTE count is counted as 0.5 FTE if they have trained beyond the number of years required to become eligible in the specialty in which they first began training. These same residents are counted as 1.0 FTE in the hospital's IME FTE count. We reiterate that we are not making a change in policy, but merely clarifying our policy with respect to counting residents involved in GME.
With respect to research, our policies for direct GME payment are consistent with our policies for IME payment. In both contexts, we do not pay for the costs of time spent by residents engaged exclusively in research. In making payments for IME and direct GME for a given year, it is true that we treat research time differently for purposes of the IME FTE count and the direct GME FTE count, but, as explained below, this difference arises from the direct GME base year methodology and does not mean that we pay for research costs in the direct GME payment.
In the September 29, 1989 final rule implementing the direct GME base year payment methodology, we described the calculation of the per resident amounts (PRAs). Each hospital's PRA is determined by taking the hospital's total allowable graduate medical education costs (which do not include costs allocated to the nursery cost center, research, and other nonreimbursable cost centers) in a base year and dividing the costs by the number of FTE residents working in all areas of the hospital complex in the base year. (§ 413.86(e)(1)(i)) In the case of research and other nonreimbursable cost centers, costs were excluded from the PRA calculation because they were nonreimbursable in the base year, consistent with longstanding Medicare policy on Medicare cost reimbursement to teaching hospitals. Ideally, residents engaged exclusively in research would also have been excluded from the base year FTE count used in the PRA calculation. However, for a number of hospitals, the FTE count for the base year did include residents engaged exclusively in research because the 1984 base year information available when the PRAs were determined in 1990 did not distinguish between residents involved in furnishing patient care services and residents exclusively engaged in research.
In order to avoid disadvantaging these hospitals, in making direct GME payments for a given year, we have included and continue to include residents exclusively engaged in research in the direct GME FTE count both in the base year PRA calculation and in the FTE count in subsequent payment year calculations. Doing so “offsets” the effects of the inclusion of such residents in the direct GME base year FTE count (no such “offset” is necessary in the context of IME). However, because the costs were Start Printed Page 39899excluded in calculating the PRA, the end result is that the direct GME payment does not encompass the costs of residents engaged exclusively in research. Therefore, as with the IME payment, Medicare is not and has not been reimbursing teaching hospitals under direct GME for costs the hospital incurs associated with resident time spent in research unrelated to usual patient care.
Comment: One commenter stated that our policy on counting research time is well stated and clear. However, this commenter stated that there is much research that is done outside any funding source, but is an essential part of the resident's training. The commenter further stated that the hospital does assume these costs, and they are not part of the direct GME component, and so represent valid hospital expenditures due to the presence of residents.
Response: We certainly acknowledge that hospitals incur research costs associated with the training of interns and residents. We understand that many specialties require a research component to be completed as part of the specialties' board eligibility requirements. The question as far as IME payments are concerned is whether or not the research is associated with the diagnosis and treatment of a particular patient. As explained above, teaching hospitals receive Medicare IME payments to pay hospitals for Medicare's share of the additional costs these hospitals incur associated with patient care costs; if the research is not associated with usual patient care costs, then the resident research time is not reimbursable.
Comment: Two commenters stated that they are concerned that clarifications on the exclusion of resident FTEs from the IME payment for trainees engaged in activities that are purely research would be extended to include those individuals in an approved program that requires research activities at the same time as the delivery of patient care.
Response: As stated above, where the residents are engaged exclusively in research, it is appropriate to exclude that time from the IME payment calculation. However, consistent with longstanding policy, in the situation where residents are in an approved program participating in research activities that are associated with the diagnosis and treatment of a particular patient, we believe it is appropriate to include that time in the IME payment calculation.
In the July 30, 1999 hospital inpatient prospective payment system final rule (64 FR 41522), we indicated that we would allow a temporary adjustment to a hospital's FTE resident cap under limited circumstances and if certain criteria are met when a hospital assumes the training of additional residents because of another hospital's closure. We made this change because hospitals had indicated a reluctance to accept additional residents from a closed hospital without a temporary adjustment to their caps. When we proposed this change 2 years ago, we received several comments suggesting that we include lost accreditation of a program (that is, a program's closure) in the temporary adjustment policy. We explained in our response to these comments (64 FR 41522) that we did not believe it was appropriate to expand our policy to cover any acts other than a hospital's closure. We made this decision because, unless the hospital terminates its Medicare agreement, the hospital would retain its statutory FTE cap and could affiliate with other hospitals to enable the residents to finish their training.
It has come to our attention that, despite a hospital's ability to affiliate with other hospitals when it shuts down a residency program, some hospitals for various reasons do not affiliate before their programs close, particularly when the program closes abruptly towards the end of the program year (the deadline to submit Medicare affiliation agreements is July 1 of the upcoming program year). Therefore, in the May 4 proposed rule, we proposed that if a hospital that closes its residency training program agrees to temporarily reduce its FTE cap, another hospital(s) may receive a temporary adjustment to its FTE cap to reflect residents added because of the closure of the former hospital's residency training program. For purposes of this policy on closed programs, we proposed to define “closure of a hospital residency training program” as when the hospital ceases to offer training for residents in a particular approved medical residency training program (proposed § 413.86(g)(8)(i)(B)). The methodology for adjusting the caps for the “receiving hospital” and the “hospital that closed its program” is described below.
a. Receiving hospital. We proposed that a hospital(s) may receive a temporary adjustment to its (or their) FTE cap to reflect residents added because of the closure of another hospital's residency training program if—
The hospital is training additional residents from the residency training program of a hospital that closed its program; and
No later that 60 days after the hospital begins to train the residents, the hospital submits to its fiscal intermediary a request for a temporary adjustment to its FTE cap, documents that the hospital is eligible for this temporary adjustment by identifying the residents who have come from another hospital's closed program and have caused the hospital to exceed its cap, specifies the length of time the adjustment is needed, and submits to its fiscal intermediary a copy of the FTE cap reduction statement by the hospital closing the program, as specified in paragraph (g)(8)(iii)(B)(2).
In general, the proposed temporary adjustment criteria are reflective of the temporary adjustment criteria for taking on the training of displaced residents from closed hospitals. We note that we proposed that more than one hospital would be eligible to apply for the temporary adjustment, because residents from one closed program may go to different hospitals, or they may finish their training at more than one hospital. We also noted that only to the extent a hospital would exceed its FTE cap by training displaced residents would it be eligible for the temporary adjustment.
Finally, we proposed that hospitals that meet the proposed criteria would be eligible to receive temporary adjustments (for cost reporting periods beginning on or after October 1, 2001, for direct GME and with discharges beginning on or after October 1, 2001 for IME) for training the displaced residents from programs that closed even before the effective date of this policy. We mentioned this because hospitals may have closed programs in the recent past and the residents from the closed programs may not have completed their training as of the effective date of this policy. For instance, if a 5-year residency program, such as surgery, closed on July 1, 1997, the 5th program year residents may still be training during this residency year (2001). We proposed that if both the receiving hospital(s) and the hospital that closed the program in this example follow the criteria described in this preamble, the receiving hospital may receive a temporary adjustment to its FTE cap for 9 months (October 1, 2001 through June 30, 2002) to accommodate the 5th year surgery residents. However, we noted that hospitals would not be eligible to receive a temporary adjustment for Start Printed Page 39900training the residents until the effective date of this rule (that is, October 1, 2001).
b. Hospital that closed its program(s). We proposed that a hospital that agrees to train residents who have been displaced by the closure of another hospital's program may receive a temporary FTE cap adjustment only if the hospital with the closed program(s)—
Temporarily reduces its FTE cap by the number of FTE residents in each program year training in the program at the time of the program s closure. The yearly reduction would be determined by deducting the number of those residents who would have been training in the program year during each year had the program not closed; and
No later than 60 days after the residents who were in the closed program begin training at another hospital, submits to its fiscal intermediary a statement signed and dated by its representative that specifies that it agrees to the temporary reduction in its FTE cap to allow the hospital training the displaced residents to obtain a temporary adjustment to its cap; identifies the residents who were training at the time of the program's closure; identifies the hospitals to which the residents are transferring once the program closes; and specifies the reduction for the applicable program years.
Unlike the closed hospital policy at § 413.86(g)(8), we proposed under this closed program policy (which we proposed to amend § 413.86(g)(8) to include), that in order for the receiving hospital(s) to qualify for a temporary adjustment to its FTE cap, the hospitals that are closing their programs would need to reduce their FTE cap for the duration of time the displaced residents would need to finish their training. We proposed this change because, as explained below, the hospital that closes the program still has the FTE slots in its cap, even if the hospital chooses not to fill the slots with residents. We believe it is inappropriate to allow an increase to the receiving hospital's cap without an attendant temporary decrease to the cap of the hospital with the closed program, even if the increase is only temporary. We noted that even under the proposed closed program policy, the hospital that closes its program may choose instead to affiliate with another hospital by July 1 of the next residency year so that the residents can more easily finish their training.
We proposed that the cap reduction for the hospital with the closed program would be based on the number of FTE residents in each program year who were in the program at the program's closure, and who began training at another hospital, rather than the count of residents each year at the hospital(s) receiving the temporary adjustment(s). We believe it would be too burdensome administratively to require the hospital closing the program to keep track of the status of the residents when they are training at other hospitals. For instance, Joe Smith, a resident who is a PGY 1 when Hospital X closes its pathology residency program, may then finish his training at Hospital Y. The resident trains for one year at Hospital Y as a PGY 2, but decides to drop out of the program before finishing. It would be burdensome to require Hospital X to keep track of Joe Smith's status while he is training at Hospital Y for purposes of the reduction in Hospital X's cap. Therefore, we proposed to “freeze” the basis for the reduction of the FTE cap of the hospital that closed the program based on the count and status of the residents when the hospital closes the program.
Example: Hospital A, which has a direct GME FTE cap of 20 FTEs and an IME FTE cap of 18 FTEs, is experiencing financial difficulties and decides to close down its internal medicine residency training program effective June 30, 2002. As of June 30, 2002, Hospital A is training 2 PGY 1s, 4 PGY 2s, and 6 PGY 3s in its internal medicine program. Hospitals B, C, and D take on the training of the displaced residents. These hospitals are eligible to receive temporary adjustments to their FTE caps if they follow the proposed criteria stated above. In order for Hospitals B, C, and D to receive the temporary adjustments, however, Hospital A must agree to reduce its FTE cap. According to the proposed criteria stated above, Hospital A's reduction would be:
Direct GME FTE cap: 14 FTEs, (20 FTEs cap—2 PGY 2s-4 PGY 3s)
IME FTE cap: 12 FTEs (18 FTEs-2 PGY 2s-4 PGY 3s)
We note that no downward adjustment for the 6 PGY 3s for either cap is necessary since these residents will have completed their training in that program by the July 1, 2000 through June 30, 2003 program year.
Direct GME FTE cap: 18 FTEs (20 FTEs cap—2 PGY 3s)
IME FTE cap: 16 FTEs (18 FTEs cap—2 PGY 3s)
Direct GME FTE cap: 20 FTEs
IME FTE cap: 18 FTEs
We also proposed to revise § 412.105(f)(1)(ix) to make the provision relating to the adjustment to FTE caps to reflect residents affected by closure of hospitals' medical residency training programs applicable to determining the IME payment.
Comment: Several commenters commended us for extending payment of IME and direct GME to situations of program closure, explaining that this change will help stabilize the GME system and ensure that residents can continue their training without imposing financial hardship on the institutions that accept them into their programs. One commenter also noted that the tradeoff in the FTE resident cap between a hospital closing its residency program and the hospital receiving the displaced residents seems reasonable. Another commenter stated that while the proposed rule more than adequately described the requirements and procedures for allowing a hospital to receive a temporary adjustment to its FTE caps to reflect residents added because of the closure of another hospital's program, the receiving hospital is penalized because the 3-year rolling average applies to these residents. The commenter noted that, in the first and second year, the receiving hospital will be paid one third and two thirds of the costs of these displaced FTE residents because of the rolling average, although the receiving hospital is paying for these FTE residents at full cost. The commenter suggested that a temporary exception should be granted to receiving hospitals from the 3-year rolling average in the same manner as residents in new programs under § 413.86(g)(5) are excluded from the rolling average. The commenter also asked that temporary relief should be granted in the IME adjustment with regard to the application of the resident-to-bed ratio cap, wherein the relief from this cap should be an adjustment to the prior year's resident FTEs equal to the increase in the current year's FTEs which is attributable to the transferred residents.
Response: We understand the commenter's concern regarding the inclusion of the resident FTEs displaced by the closure of another hospital's program in the receiving hospital's rolling average count of residents, for both direct GME and IME purposes. In addition, we believe that a similar concern also exists in regard to the inclusion of residents in the receiving hospital's rolling average calculation for residents displaced by the closure of another hospital. Therefore, we are revising proposed § 412.105(f)(1)(v) for IME and adding a paragraph (vi) to proposed § 413.86(g)(5) for direct GME to specify that FTE residents that are displaced by the closure of either another hospital or another hospital's program are added after the calculation of the rolling average for the receiving Start Printed Page 39901hospital for the duration of time that those displaced FTE residents are training at the receiving hospital.
In regard to providing temporary relief to the receiving hospital's IME resident-to-bed ratio cap for the displaced residents, while we understand the commenter's concern about this issue as well, at this time we have decided not to allow the exclusion of these displaced residents in applying the resident-to-bed ratio cap. Under existing IME policy, the receiving hospital may be held to a lower cap in the first year of training the displaced residents. However, the receiving hospital may benefit from the higher cap in the year following the final year of the displaced residents' training. Effective in the first year that the receiving hospital takes on the displaced residents, it will be capped by the prior year's lower resident-to-bed ratio because the displaced residents will not be included in the prior year FTE count. However, an increase in the current year's ratio will establish a higher cap for the following year. Furthermore, in the last year that the receiving hospital is training the displaced residents, a higher cap will be established for the following year in which all the displaced residents will have left the hospital since they have completed their training. Therefore, we believe it is unnecessary to exclude displaced residents in applying the resident-to-bed ratio cap. While we are not making any changes to address this issue at this time, we will consider suggestions for possible changes in the future, if warranted.
Comment: One commenter stated that it is unclear at what rate the payments for IME and direct GME will be made for the hospital receiving the displaced residents. The commenter asked if Medicare would pay that hospital at the same rate that the hospital with the closed program was paid for its residents, or would the receiving hospital receive Medicare payment at the same rate it currently is paid.
Response: The receiving hospital will receive payment for the displaced residents using its own rates—that is, the same rates as those used for residents in its own programs. The receiving hospital will use its own bed count for IME payment purposes, and its own PRA and Medicare patient load for direct GME payment purposes.
Comment: One commenter stated that, although the commenter supports the proposal for allowing temporary adjustments for residents coming from a closed program, the commenter believed that a mechanism should be established to “permanently preserve resident positions, as opposed to individual residents,” so long as there is no increase in the total number of FTE residents for which Medicare payment is made.
Response: In proposing § 413.86(g)(8)(iii), which allows a hospital to receive a temporary adjustment to its FTE caps to reflect residents added because of the closure of another hospital's program, we have attempted to make these regulations consistent with the existing regulations at § 413.86(g)(8). These existing regulations allow a hospital to receive a temporary adjustment to its FTE caps to reflect residents added because of the closure of another hospital. Therefore, because the regulations only allow for a temporary cap adjustment in situations involving hospital closure, we believe that it is appropriate to only allow for a temporary adjustment in situations involving program closure, as well.
We have discovered a technical error in the regulations at § 405.2468(f) regarding payment to federally qualified health centers (FQHCs) and rural health centers (RHCs) for the costs of graduate medical education. Specifically, § 405.2468(f)(6)(ii)(D) provides that “The costs associated with activities described in § 413.85(d) of this chapter” are not allowable graduate medical education costs. We recently amended § 413.85 in a final rule (66 FR 3358, January 12, 2001) regarding Medicare pass-through payment for approved nursing and allied health education programs. However, we inadvertently did not make a conforming change to § 405.2468(f)(6)(ii)(D). Section 405.2468(f)(6)(ii)(D) should read “The costs associated with activities described in § 413.85(h) of this chapter.” We proposed to revise § 405.2468(f)(6)(ii)(D) to reflect this change.
The following provisions were included in the August 1, 2000 interim final rule with comment period. We are presenting a discussion of these provisions here in order to respond to the public comments received on the provisions and to finalize the rule.
Section 1886(h) of the Act, as revised by Public Law 105-33, caps the number of residents a hospital may count for direct GME and IME. In general, the total number of residents in the fields of allopathic or osteopathic medicine in a hospital may not exceed the number of such FTE residents in the hospital with respect to the hospital's most recent cost reporting period ending on or before December 31, 1996. In the regulations we published on August 29, 1997 (62 FR 46003), May 12, 1998 (63 FR 26327), July 31, 1998 (63 FR 40986), and July 30, 1999 (64 FR 41517), we established special rules for adjusting the FTE resident caps for indirect and direct GME for new medical residency programs. Public Law 106-113 further revised sections 1886(d) and 1886(h) of the Act to allow a hospital's caps to be adjusted if certain additional criteria are met.
The limit that was placed on the number of residents that a hospital may count for purposes of direct GME and IME is based on the number of residents in the hospital's most recent cost reporting period ending on or before December 31, 1996. In the situation where a primary care resident was previously training in a hospital's residency program, but was on an approved leave of absence during the hospital's most recent cost reporting period ending on or before December 31, 1996, the hospital's FTE cap may be lower than it would have been had the resident not been on an approved leave of absence. Section 407(a) of Public Law 106-113 amended section 1886(h)(4)(F) of the Act to direct the Secretary to count an individual for purposes of determining a hospital's FTE cap, to the extent that the individual would have been counted as a primary care resident for purposes of the FTE cap but for the fact that the individual was on maternity or disability leave or a similar approved leave of absence.
The statute allows a hospital to receive an adjustment for those residents to its individual FTE cap of up to three additional FTE residents. We provided that, in order for a hospital to receive this adjustment, the leave of absence must have been approved by the residency program director to allow the residents to be absent from the program and return to the program after the absence. We required that no later than 6 months after the date of publication of this interim final rule, the hospital must submit a request to the fiscal intermediary for an adjustment to its FTE cap and must provide contemporaneous documentation of the approval of the leave of absence by the residency program director, specific to Start Printed Page 39902each additional resident that is to be counted for purposes of the adjustment. For example, a letter to the resident by the residency program director before the resident takes the leave would be sufficient documentation of prior approval of the leave of absence.
Under section 407(a)(3) of Public Law 106-113, this provision is effective for direct GME FTE counts with cost reporting periods beginning on or after November 29, 1999, and for IME FTE counts, with discharges occurring in cost reporting periods beginning on or after November 29, 1999.
We added §§ 412.105(f)(1)(xi) and 413.86(g)(9) to our regulations to incorporate the provisions of section 407(a) of Public Law 106-113.
We received one comment concerning section 407(a)(1) of Public Law 106-113, as implemented at §§ 412.105(f)(1)(xi) and 413.86(g)(9), concerning the counting of primary care residents in certain approved leaves of absence in base-year FTE counts.
Comment: One commenter asked us to consider allowing hospitals to count FTE residents for residents who had been training in an approved residency program at a hospital but then left the hospital during the 1996 base-year and never returned. The commenter stated that the FTE slot in which the “abandoning” resident vacated sometime in 1996 was filled by another resident in 1997 and thereafter, but the hospital has never received any direct or indirect GME payment for this FTE slot.
Response: Section 407(a) of Public Law 106-113 amended section 1886(h)(4)(F) of the Act to direct the Secretary to count an individual for purposes of determining a hospital's FTE cap to the extent that the individual would have been counted as a primary care resident for purposes of the FTE cap but for the fact that the individual “was on maternity or disability leave or a similar approved leave of absence.” We believe that this provision was not intended to apply to residents who leave the program in the base-year and never return. The statutory language is quite clear that in order for a hospital to count residents in this provision, the resident must have been on an “approved leave of absence.” A “leave of absence” necessarily translates to a resident being away and then returning to the hospital at which the resident had been training.
Public Law 105-33 included several provisions with the intent of encouraging physician training and practice in rural areas. Section 1886(h)(4)(H)(i) of the Act, as added by section 4623 of Public Law 105-33, directed the Secretary, in promulgating rules for the purpose of the FTE cap, to give special consideration to facilities that meet the needs of underserved rural areas. Consistent with the intent of this provision, section 407(b) of Public Law 106-113 provides a 30-percent expansion of a rural hospital's direct and indirect FTE count for purposes of establishing the hospital's individual FTE cap. Specifically, section 407(b) provided that, effective for direct GME with cost reporting periods beginning on or after April 1, 2000, and for IME, with discharges occurring on or after April 1, 2000, the FTE count may equal 130 percent of the number of unweighted residents the rural hospital counted in its most recent cost reporting period ending on or before December 31, 1996.
For example, if a hospital located in a rural area had 10 unweighted FTEs for its count for both direct GME and IME in its most recent cost reporting period ending on or before December 31, 1996, under this new provision the hospital would have a FTE cap of 13 unweighted FTEs, instead of 10 unweighted FTEs, because the hospital is located in a rural area. The revised FTE cap is equal to 130 percent of the number of unweighted residents in its most recent cost reporting period ending on or before December 31, 1996. The rural hospital's new FTE cap, effective April 1, 2000, is now 13 FTEs. However, if a hospital located in a rural area had zero unweighted FTEs for its count for both direct GME and IME in its most recent cost reporting period ending on or before December 31, 1996, under this new provision, this hospital would receive no adjustment to its FTE cap (130 percent of zero is zero FTEs).
We incorporated the provision of section 407(b) of Public Law 106-113 in §§ 412.105(f)(1)(iv) and 413.86(g)(4). We did not receive any comments on this provision.
In order to encourage the training of physicians in rural areas, section 407(c) of Public Law 106-113 amended section 1886(h)(4)(H) of the Act to add a provision that in the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in a rural area or has an accredited training program with an integrated rural track, an adjustment may be made to the hospital's cap on the number of residents. For direct GME, the amendment applies to payments to hospitals for cost reporting periods beginning on or after April 1, 2000; for IME, the amendment applies to discharges occurring on or after April l, 2000.
Section 407(c) of Public Law 106-113 did not define “rural tracks” or an “integrated rural track,” nor are these terms defined elsewhere in the Social Security Act or in any applicable Federal regulations. Currently, there are a number of accredited residency programs, particularly 3-year primary care residency programs, in which residents train for 1 year of the program at an urban hospital and are then rotated for training for the other 2 years of the 3-year program to a rural facility. These separately accredited “rural track” programs are identified by the Accreditation Council of Graduate Medical Education (ACGME) as “1-2” rural track programs. Accordingly, we implemented section 407(c) to address these “1-2” programs. In addition, we implemented section 407(c) to account for other programs that are not “1-2” programs but which include rural training portions.
As stated above, since there is no existing definition of “rural track” or “integrated rural track,” we defined at § 413.86(b) a “rural track” and an “integrated rural track” as an approved medical residency training program established by an urban hospital in which residents train for a portion of the program at the urban hospital and then rotate for a portion of the program to a rural hospital(s) or to a rural nonhospital site(s). We noted that “rural track” and “integrated rural track,” for purposes of this definition, are synonymous.
We amended § 413.86 to add paragraph (g)(11) (and amended § 412.105 to add paragraph (f)(1)(x)) to specify that, for direct GME, for cost reporting periods beginning on or after April 1, 2000, (or, for IME, for discharges occurring on or after April 1, 2000), an urban hospital that establishes a new residency program, or has an existing residency program, with a rural track (or an integrated rural track) may include in its FTE count residents in those rural tracks, in addition to the residents subject to the FTE cap at § 413.86(g)(4). An urban hospital may count the residents in the rural track up to a “rural track FTE limitation” for that Start Printed Page 39903hospital. We defined this rural track FTE limitation at § 413.86(b) as the maximum number of residents training in a rural track residency program that an urban hospital may include in its FTE count, that is in addition to the number of FTE residents already included in the hospital's FTE cap.
Generally, the rural track policy is divided into two categories: Rural track programs in which residents are rotated to a rural area for at least two-thirds of the duration of the program; and rural track programs in which residents are rotated to a rural area for less than two-thirds of the duration of the program. These two categories are then subdivided according to where the residents are training in the rural area; the residents may be trained in a rural hospital or the residents may be trained in a rural nonhospital site. To account for rural track residency programs with rural rotations that have program lengths greater than or less than 3 years, or that are not “1-2” programs, we specified “two-thirds of the length of the program,” instead of “2 out of 3 program years,” as a qualification to count FTEs in the rural track.
In the interim final rule with comment period, we specified that urban hospitals that wish to count FTE residents in rural tracks, up to a rural track FTE limitation, must comply with the conditions discussed below:
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(i) that if an urban hospital rotates residents in the rural track program to a rural hospital(s) for at least two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count for the time the rural track residents spend at the urban hospital. The urban hospital may include in its FTE count those residents in the rural track training at the urban hospital, not to exceed its rural track FTE limitation, determined as follows:
For the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents training in the rural track at the urban hospital.
Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of: (1) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the urban hospital or the rural hospital(s) and are designated at the beginning of their training to be rotated to the rural hospital(s) for at least two-thirds of the duration of the program; and (2) the number of years those residents are training at the urban hospital.
We utilized the term “designated” at § 413.86(g)(11)(i) (as well as at §§ 413.86(g)(11)(ii) and (iv)) to refer to the calculation of the rural track FTE limitation. “Designated” means that the residents must actually have enrolled in that rural track program to rotate for a portion of the rural track program to a rural area (either rural hospital(s) or rural nonhospital site(s)). To be counted as an FTE in this first scenario, these enrolled residents must actually rotate for at least two-thirds of the duration of the program to a rural hospital(s). If a resident, at the beginning of his or her training, intends to train in the rural area for at least two-thirds of the duration of the program, but ultimately never does so, this resident would be proportionately excluded from the urban hospital's rural track FTE limitation.
We noted that if the residents in the rural track are rotating to a rural hospital(s), the rural hospital(s) may be eligible to count the residents as part of its FTE count. If the rural track residency program is a new residency program as specified in redesignated § 413.86(g)(12), the rural hospital may be eligible to receive an FTE cap adjustment for those residents training in the rural track for the time those residents are training at the rural hospital(s), in accordance with the provisions of existing § 413.86(g)(6)(iii). If the rural track residency program is an existing residency program, a rural hospital may be eligible to count the FTE residents training in the rural track at the rural hospital(s), in accordance with the provisions of § 413.86(g)(4), as amended in the interim final rule with comment period to implement section 407(b)(1) of Public Law 106-113.
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(ii) that if an urban hospital rotates residents in the rural track program to a rural nonhospital site(s) for at least two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count, subject to the requirements under existing § 413.86(f)(4). The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
For the first 3 years of the rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents training in the rural track at the urban hospital and the rural nonhospital site.
Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of: (1) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the urban hospital and are designated at the beginning of their training to be rotated to a rural nonhospital site(s) for at least two-thirds of the duration of the program and the rural nonhospital site(s); and,(2) the number of years in which the residents are expected to complete each program based on the minimum accredited length for the type of program.
We note that we specified at § 413.86(g)(11)(ii) that an urban hospital may include in its FTE count those residents in the rural track rotating to a rural nonhospital site, subject to the requirements under existing § 413.86(f)(4). Section 413.86(f)(4) provides, in part, that a hospital that incurs “all or substantially all” of the costs of training residents in a nonhospital site may include those residents in determining the number of FTE residents (not to exceed the FTE cap) for that hospital. Under this rural track policy, where the urban hospital rotates residents for at least two-thirds of the residency program to a rural nonhospital site, the urban hospital would be eligible to include in its FTE count residents training in the rural track up to its rural track FTE limitation, but the urban hospital must still reimburse the rural nonhospital site for the costs of training those residents, as specified under § 413.86(f)(4). In the August 1, 2000 interim final rule with comment period (66 FR 47034), we included an example of application of this policy.
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(iii) that if an urban hospital rotates residents in the rural track program to a rural hospital(s) for periods of time that are less than two-thirds of the duration of the program, the urban hospital may not include those residents in its FTE count, nor may the urban hospital include those residents as part of its rural track FTE Start Printed Page 39904limitation. However, we noted that, in this scenario, if the rural track residency program is a new residency program as specified in redesignated § 413.86(g)(12), the rural hospital may be eligible to receive an FTE cap adjustment for those residents training in the rural track, in accordance with the provisions of existing § 413.86(g)(6)(iii). If the rural track residency program is an existing residency program, a rural hospital may count the FTE residents training in the rural track at the rural hospital(s), in accordance with the provisions of § 413.86(g)(4), as amended, to incorporate the provisions of section 407(b)(1) of Public Law 106-113.
We are not permitting an urban hospital to count the time of residents training at the urban hospital in a rural track rotating to a rural hospital(s) for less than two-thirds the duration of the program (either as part of the urban hospital's FTE count or as part of its rural track FTE limitation), because to do so would inappropriately allow the urban hospital to circumvent the FTE caps by creating a new program with minimal training in a rural track. However, in this situation, like the other three provisions that concern the training of residents in rural areas, we indicated that we will allow Medicare payment for the rural portion of the training to the rural hospital.
In the August 1, 2000 interim final rule with comment period, we specified at § 413.86(g)(11)(iv) that if an urban hospital rotates residents in the rural track program to a rural nonhospital site(s) for periods of time that are less than two-thirds of the duration of the program, the urban hospital may include those residents in its FTE count, subject to the requirements under existing § 413.86(f)(4). The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
For the first 3 years of the rural track's existence, the rural track FTE limitation for the urban hospital will be the actual number of FTE residents training in the rural track at the rural nonhospital site.
Beginning with the fourth year of the rural track's existence, the rural track FTE limitation is equal to the product of: (a) The highest number of residents in any program year who, during the third year of the rural track's existence, are training in the rural track at the rural nonhospital site(s); and (b) the length of time in which the residents are being trained at the rural nonhospital site(s).
We noted that, in this situation, an urban hospital would not be able to count the FTE for the rural track resident while the resident is training at the urban hospital. The rural track FTE count and the rural track FTE limitation for the urban hospital would be limited to account for the residents training at the rural nonhospital site.
As in the second scenario at § 413.86(g)(11)(ii), we specified at § 413.86(g)(11)(iv) that an urban hospital may include in its FTE count those residents in the rural track rotating to a rural nonhospital site, subject to the requirements under § 413.86(f)(4). Under the rural track policy, where the urban hospital rotates residents for less than two-thirds of the residency program to a rural nonhospital site, the urban hospital would be eligible to include in its FTE count residents training in the rural track up to its rural track FTE limitation, but the urban hospital must still reimburse the rural nonhospital site for the costs of training those residents, as specified under § 413.86(f)(4).
We noted that, in this last scenario, we are allowing the urban hospital to receive a rural track FTE limitation even in situations where it is rotating residents to a rural area for a minimal period of time (less than two-thirds the duration of the program). However, we believe that this last scenario can be distinguished from the third scenario in which the urban hospital is again rotating residents to a rural area for a minimal portion of the program but to a rural hospital instead of a rural nonhospital site. In the third scenario, we allow Medicare payment to go to the rural hospital for the portion of the urban hospital program that involves rural training (but not to the urban hospital, if the rural hospital is receiving an FTE cap adjustment for that training). However, in the last scenario, we allow the urban hospital to include the rural track residents in its FTE count (and as part of its rural track FTE limitation), based on how long it rotates the residents to the rural nonhospital site (and also incurs all or substantially all of the training costs). We do not believe that the urban hospital can circumvent its FTE cap in this last scenario because it will only count the rural track residents based on the portion of training in the rural nonhospital site. In the interim final rule with comment period (66 FR 47035), we included an example of the last scenario.
In the August 1, 2000 interim final rule with comment period, we specified that all urban hospitals that wish to count FTE residents in rural tracks, not to exceed their respective rural track FTE limitations, must also comply with each of the following conditions, as stated at §§ 413.86(g)(11)(v) and (vi):
A hospital may not include in its FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap (if the rural track program was in existence during the hospital's most recent cost reporting period ending on or before FY 1996).
A hospital must base its count of residents in a rural track on written contemporaneous documentation that each resident enrolled in a rural track program at the urban hospital intends to rotate for a portion of the residency program to a rural area. For example, written contemporaneous documentation might be a letter of intent signed and dated by the rural track residency program director and the resident at the time of the resident's entrance into the rural track program as a PGY 1.
All residents who are included by the hospital as part of its FTE count (not to exceed its rural track FTE limitation) must ultimately train in the rural area.
If we find that residents who are included by the urban hospital as part of its FTE count did not actually complete the training in the rural area, we will reopen the urban hospital's cost report within the 3-year reopening period (as specified in § 405.1885) and adjust the hospital's Medicare GME payments (and, where applicable, the hospital's rural track FTE limitation).
We received several comments regarding the provisions of section 407 of Public Law 106-113 implemented in the August 1, 2000 interim final rule with comment period.
Comment: One commenter cited studies that found that more than half of residents with as little as 3 months of rural training became rural physicians, and, therefore, to best serve the intent of the legislation and significantly increase the number of rural physicians, we should fully fund FTEs with less than two-thirds total training in rural areas.
Response: Section 1886(h)(4)(H)(iv) of the Act, as added by section 407(c) of Public Law 106-113, provides for adjustments to the FTE cap “[i]n the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in a[] Start Printed Page 39905rural area * * *.” Thus, in order for a hospital to receive an adjustment under this provision, the training program must be separately accredited. The ACGME has established criteria to separately accredit programs that involve training in rural areas; under these criteria, a training program may be separately accredited if residents in the program train for at least 2 years of the 3-year program at a rural facility. Currently, the ACGME does not separately accredit a program as a rural track program or a program in a rural area unless it meets this “1-2” condition. We make an adjustment to the FTE cap under the rural track provision only if a program is separately accredited, and in order to be separately accredited, the program must meet ACGME's “1-2” criteria. We are amending the regulations at § 413.86 by adding paragraph (g)(11) to reflect this policy .
Furthermore, we believe that incorporating the ACGME's criteria reasonably identifies the situations in which an adjustment to the FTE cap under the rural track provision is warranted. We believe that it is important to limit adjustments under this provision to situations in which residents receive a significant amount of training in rural areas. While we certainly agree that post-residency physician retention in rural areas is important, we believe that it is also important to prevent hospitals from receiving adjustments to the FTE cap in situations when an adjustment is not warranted. We believe that, if an urban hospital could receive an adjustment to its FTE cap by providing only a nominal amount of training in a rural area, then hospitals might be able to inappropriately circumvent the FTE caps. Thus, our policy reflects the requirements of the statute as well as a balancing of considerations (permitting adjustments for hospitals that establish programs that provide a significant amount of training in rural areas, and preventing adjustments for hospitals that do not warrant an adjustment).
Comment: One commenter noted that, for cost reporting periods beginning on or after April 1, 2000, section 407 of Public Law 106-113 allows rural hospitals to increase their FTE resident caps by 30 percent and urban hospitals with rural training tracks to count those residents in rural tracks. The commenter had two concerns: (1) What happens to rural track programs that were in existence between January 1, 1997 and April 1, 2000; and (2) if the intent of the rural track provision is to encourage training in rural areas, then rural track programs in existence between January 1, 1997 and April 1, 2000 should also be permitted to expand by 30 percent.
Response: Section 1886(h)(4)(F) of the Act, as added by section 407(b) of Public Law 106-113, and as implemented at §§ 413.86(g)(4) and 412.105(f)(1)(iv), provides for a 30-percent expansion to a rural hospital's direct and indirect FTE counts for purposes of establishing the hospital's individual FTE cap. Section 407(c) provides for an adjustment to the FTE cap of urban hospitals for training residents in rural areas. Section 407(b) clearly only applies to rural hospitals, and not to urban hospitals, regardless of whether or not the urban hospitals train residents in rural areas. Therefore, while the general intent of the provisions at section 407 is to encourage training in rural areas, only those rural hospitals that have a FTE resident cap based on the count of residents in the hospital's cost reporting period ending on or before December 31, 1996, may qualify for a 30-percent increase to that FTE cap under the amendments made by section 407(b).
To address the commenter's uncertainty concerning what happens to rural track programs that were in existence between January 1, 1997 and April 1, 2000, we point to our language at §§ 413.86(g)(11) and 412.105(f)(1)(x) which states that for cost reporting periods beginning on or after April 1, 2000, “an urban hospital that establishes a new residency program, or has an existing residency program, with a rural track (or an integrated rural track) may include in its FTE count residents in those tracks * * *” (emphasis added). Thus, urban hospitals with rural tracks that were in existence between January 1, 1997 and April 1, 2000, and continue to be in existence after April 1, 2000, may be eligible for Medicare payment under this provision. We note that urban hospitals with rural tracks that were established before January 1, 1997, and continued to exist after April 1, 2000, may be eligible for payment under this rural track provision, as well.
We note that we have received questions from the provider industry regarding the application of the rural track FTE limitation and rural track FTE count to hospitals with rural track programs that have already been in existence before April 1, 2000. Generally, the methodology at § 413.86(g)(11) states that the actual count of residents for the first 3 years of the rural track's existence is to be used as the hospital's rural track FTE limitation, and beginning with the fourth year, the rural track FTE limitation is determined based on the number of residents training in the rural track in the third year of the program's existence. However, if a rural track program has been in existence for at least 3 years prior to April 1, 2000, the provision regarding using the actual count of residents in the first 3 years of the program would not apply. Rather, for such a program, the rural track FTE limitation would take effect immediately on April 1, 2000. The limitation would be based on the highest number of residents in any program year training in the rural track in the third year of the program, depending on the amount of time the residents spent in the rural area, subject to the regulations at § 413.85(g)(11)(i) through (iv). It would be the responsibility of the hospital to provide the necessary information regarding the third year of the program to the fiscal intermediary. For example, if the third year of the rural track's existence is July 1, 1997 to June 30, 1998, the rural track FTE limitation would be based on the highest number of residents in any program year in 1997-1998 training year. The urban hospital may begin to count the additional FTEs up to its rural track FTE limitation in its cost reporting period beginning on or after April 1, 2000 for direct GME, and for discharges occurring on or after April 1, 2000 for IME.
Comment: One commenter noted that the interim final rule with comment period states that “all residents that are included by the hospital as part of its FTE count must ultimately train in the rural area.” The commenter expressed concern that we are requiring hospitals to designate specific individuals, rather than FTEs, and that basing payment on individuals rather than FTEs would set a poor precedent. The commenter further stated that, while specific individuals may not remain in a program, hospitals should be permitted to fill these slots with FTEs and receive payment.
Response: The commenter is concerned with the provision at § 413.86(g)(11)(v)(C), which states that all residents that are included by the hospital as part of its FTE count under this provision must ultimately train in the rural area. As the commenter correctly assesses, this particular provision would link the rural track policy to specific individual residents, rather than FTEs. We made this link to individuals rather than FTEs because we believe the additional provision at § 413.86(g)(11)(v)(C) (as well as the provision at §§ 413.86(g)(11)(v)(B)) was necessary in order to ensure that urban hospitals did not count additional FTE Start Printed Page 39906residents who did not actually rotate at any time to a rural area.
However, we understand the commenter's concern about permitting hospitals to fill slots with FTEs that are open because individuals did not remain in the program. We agree that where a hospital fills a vacated FTE slot in a rural 1-2 program with another resident, it would be consistent with the intent of the rural track provision to allow the urban hospital to count the time of the resident who left the training program. Accordingly, we are amending the regulations at § 413.86(g)(11)(v)(C) to allow for the counting of the resident's time at the urban hospital where, for example, a resident who just completed her PGY1 year at the urban hospital decides to drop out of the program, and then the urban hospital fills the vacated FTE slot with another PGY2 resident who then continues and completes the rural portion of the rural track program. We note that we would not allow for the counting of the time at the urban hospital for the first year of training for that resident who left the program where the urban hospital fills the vacated FTE slot with another PGY1 resident who first begins to train in the urban hospital, since, in effect, this would result in double counting one FTE at the urban hospital without the required amount of training occurring in the rural area.
Comment: One commenter expressed concern with the provision at § 413.86(g)(11)(v)(A) that states “an urban hospital may not include in its rural track FTE limitation or FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap.” The commenter stated that this provision fails to account for the fact that many hospitals may have “backed out” residents training time in rural sites from their base year FTE cost reports. The commenter stated further that this provision may be interpreted by cost report accountants to mean that appeals to include FTEs that were excluded by Public Law 105-33 are prohibited.
Response: We believe the commenter is confusing the provision at § 413.86(g)(11)(v)(A), that an urban hospital may not include in its rural track FTE limitation or rural track FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap, and the policy contained in section 4623 of Public Law 105-33, as implemented at §§ 412.105(f)(1)(iv) and 413.86(g)(4), which places a limit on the count of residents, or hospitals' FTE caps. The intent of the provision at § 413.86(g)(11)(v)(A) is to encourage more residency training in rural areas by providing for Medicare payment to an urban hospital for FTE residents who are training in a rural area and are not already included as part of the hospital's FTE cap. Whether or not there are many hospitals that have “backed out” resident training time in rural sites from their base year FTE cost reports is irrelevant to this rural track requirement. The possible mistaken exclusion of the count of resident FTEs spent in rural settings is an issue relevant to the determination of a hospital's initial FTE cap as provided for at §§ 412.105(f)(1)(iv) and 413.86(g)(4). The rural track requirement at § 413.86(g)(11)(v)(A) was not intended to provide for adjustments to reflect FTEs that were excluded from the FTE cap.
With regard to rural training, generally, and the determination of a hospital's FTE cap under §§ 412.105(f)(1)(iv) and 413.86(g)(4), a FTE resident should not have been included in the hospital's FTE cap to the extent that, in that cost reporting year, the resident was rotating to another rural hospital, or if the resident was rotating to a rural nonhospital to which the urban hospital was not paying all or substantially all of the costs of training (see § 413.86(f)(3)).
To clarify the intent of the requirement that “an urban hospital may not include in its rural track FTE limitation or FTE count residents who are training in a rural track residency program that were already included as part of the hospital's FTE cap,” we are providing the following example:
Assume there are 10 unweighted FTE residents training at an urban Hospital A in the hospital's most recent cost reporting period ending on or before December 31, 1996, thereby establishing Hospital A's FTE cap at 10.
In July 2002, Hospital A starts a rural training track program. In addition to devoting 2 out of its 10 FTE slots to the rural track, Hospital A recruits an additional 2 FTEs to participate in the rural track, for a total of 12 FTEs to be trained in that cost reporting year.
These 4 FTEs will complete 1 year of training at Hospital A and 2 years of training at a rural nonhospital site. This type of program is modeled after the scenario outlined at § 413.86(g)(11)(ii), where the urban hospital may include in its FTE count the FTEs in the rural track at the urban hospital and at the rural nonhospital site. (Hospital A is complying with the requirements at § 413.86(f)(4) regarding the counting of residents in nonhospital sites).
However, when calculating the rural track FTE limitation in the fourth year of the rural track's existence, Hospital A may not include in its rural track FTE limitation those FTEs that were already included as part of the hospital's initial FTE cap. Two of the hospital's four FTEs training in the rural track were already included in the hospital's FTE cap. Therefore, beginning July 2002, only two FTEs may be included to determine the hospital's rural track FTE limitation, as well as its rural track FTE count. Since it is the two FTEs that Hospital A added when it started the rural track that have caused the hospital to exceed its FTE cap, only two FTEs may be counted above the FTE cap for the hospital's rural track FTE count and limitation. However, we note that the other two FTEs training in the rural track that were not included as part of the hospital's rural FTE count and limitation because they had already been included as part of the hospital's FTE cap, may still be counted by the hospital in its general FTE count, according to §§ 412.105(f) and 413.86(f).
Comment: One commenter requested that, since rural hospitals often do not have the resources or infrastructure to claim their GME costs on a Medicare cost report, we should revise the regulations to allow urban hospitals to claim the resident FTEs training at the rural hospitals, as long as the urban hospitals are providing “adequate funding” to the rural hospital, similar to our Medicare policy on nonhospital settings.
Response: In regard to the request to allow urban hospitals to claim the FTEs training in rural hospitals, while we understand that it is not uncommon for urban hospitals to incur the costs of training residents in rural hospitals because the rural hospitals cannot incur the costs themselves, there is longstanding policy that prohibits one hospital from claiming the training time of FTEs training at another hospital. First, section 1886(h)(4)(B) of the Act states that the rules governing the direct GME computation of count of the number of FTE residents “shall take into account individuals who serve as residents for only a portion of a period with a hospital or simultaneously with more than one hospital.” Accordingly, the September 4, 1990 Federal Register (55 FR 36065) states that “* * * the other hospital is required to include the portion of time the resident spent at its facility in its FTE count consistent with § 413.86(f).” Further, the regulations at § 413.86(f)(2) state that “No individual may be counted as more than one FTE * * *. [I]f a resident spends time in more than one hospital * * * the Start Printed Page 39907resident counts as partial FTE based on the proportion of time worked at the hospital to the total time worked * * *.” Therefore, even though the urban hospital incurs the training costs and the rural hospital does not claim the FTEs for Medicare direct GME and IME payment purposes, the urban hospital is precluded from claiming any FTEs training at the rural hospital (or any other hospital, for that matter). The commenter is correct in stating that a hospital may count the time residents spend in nonhospital settings if they comply with the criteria at § 413.86(f)(4). However, this regulation implements statutory provisions (sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act), which specifically provide for Medicare direct GME and IME payment to be made to hospitals for training residents in nonhospital settings.
Comment: One commenter objected to the policy in the interim final rule with comment period that the terms “rural track” and “integrated rural track” are synonymous. The commenter (a hospital) believed that we have the authority to develop a new definition for “integrated rural track” based on our interpretations of congressional intent, and we should not wait for further clarification from Congress at the expense of the commenter's particular allopathic family practice residency program. The commenter described this program as one in which the residents train in the rural setting for approximately 7 months out of a 3-year program, and for the remainder of the program when the residents spend training in the urban setting, the residents treat rural patients. The commenter proposed the following new definition for integrated rural track: “Accredited Training Program with an Integrated Rural Track—refers to an accredited program that provides at least 6 months of training at a rural location in addition to 2 years of rural training at an urban location. The 6 months of rural training should be conducted as part of all 3 years of training. The program should also establish a continuity of care with patients in a rural area for at least one program year.”
Response: When we implemented this provision on August 1, 2000, we did so based on discussions with the Accreditation Council for Graduate Medical Education (ACGME), which accredits rural track programs. The ACGME specifically identifies and separately accredits programs with 1 year of training in an urban hospital and 2 years of training in a rural facility as “rural tracks.” However, the ACGME explained that it did not have a separate definition of “integrated rural track” and, in particular, did not separately classify programs with portions of rural training of less than 2 years as “integrated rural tracks”. In response to questions raised on this provision, we have followed up with the ACGME to confirm whether a definition of, or criteria for identifying programs with, “integrated rural tracks” had been established. We were informed that the term “integrated rural track” is not, and never was, a term that is used by the ACGME in accrediting its programs. Other than the 1-2 programs that specifically incorporate 2 years of rural training, the ACGME does not grant unique accreditation to programs with a rural focus, nor do any of the other accreditation organizations listed at § 415.152.
In addition, we do not believe it is administratively feasible for us to review documentation and confirm that the training at the urban hospital, as suggested by the commenter, is rural in nature, based on the patient load treated by the residents at the urban hospital. We currently do not have a way of tying patient data to the residents that treat them. Accordingly, for purposes of this policy, until we believe we can appropriately categorize and define rural tracks and integrated rural tracks separately, we will continue to define these terms synonymously. We remain open to adopting another definition of a separately accredited training program, and we welcome suggestions for definitions that would be administratively feasible to apply.
Comment: One commenter suggested that we add a fifth scenario to those already described at § 413.86(g)(11). The commenter proposed the following regulation text:
Rotating Residents of an Accredited Training Program with an Integrated Rural Track to a Rural Nonhospital Site—If an urban hospital rotates residents in an accredited training program with an integrated rural track to a rural nonhospital site throughout all 3 years of training, the urban hospital may include those residents in its FTE count, subject to the requirements under existing § 413.86(g)(4). The urban hospital may include in its FTE count those residents in the rural track, not to exceed its rural track FTE limitation, determined as follows:
(A) For the first 3 years of the integrated rural track's existence, the rural track FTE limitation for each urban hospital will be the actual number of FTE residents training in the rural track at the urban hospital and the rural nonhospital site.
(B) Beginning with the fourth year of the integrated rural track's existence, the rural track FTE limitation is equal to the product of:
(1) The highest number of residents in any program year who, during the third year of the integrated rural track's existence, are training in the integrated rural track at the urban hospital and are designated at the beginning of their training to be rotated to a rural nonhospital site throughout all 3 years of training, and
(2) The number of years in which the residents are expected to complete each program based on the minimum accredited length for the type of program.
(C) This would apply to accredited training programs with integrated rural tracks that were in existence prior to 1997.
The commenter explained that this language is designed to address the unique program at the commenter's hospital, and it also is date sensitive so that newer programs would be required to comply with the existing criteria in the existing regulations.
Response: We have concerns about the commenter's proposal. First, the commenter assumes a separate definition of “integrated rural track,” which, as explained above, we currently do not have. Even if we were to adopt such a change in policy, the cut-off date of 1997 in paragraph (C) of the commenter's proposed changes seems arbitrary; there is nothing in the statute that would serve as a basis to simply grandfather existing “integrated rural track” programs and not provide for new ones post-1997. Accordingly, we are not adopting such a change in our rural track policy as the one described by the commenter.
Comment: One commenter thought that if a hospital's rural track program has been in existence since 1993, then the 4th program year is 1997. The commenter explained that when the FTE cap went into effect, the hospital was capped at 15 FTEs. The hospital subsequently added another three residents at its own expense. The commenter stated that it interprets § 413.86(g)(11)(v)(A) to mean that the hospital would only be able to count the additional three FTE residents for the rural track count. The commenter urged us to reconsider this language as it relates to hospitals with only one residency program, because the commenter was unsure whether or not all the residents in the program count toward the rural track FTE count. The commenter believed that for hospitals with only one residency program that existed prior to 1996, all rural track residents included in the original hospital FTE cap should be counted toward the rural FTE count.
Response: The commenter correctly interprets the intent of the regulation at § 413.86(g)(11)(v)(A), which states that only those FTEs in the rural track that were not already counted as part of the Start Printed Page 39908hospital's FTE cap may be considered when calculating the hospital's rural track FTE limitation and count. In the scenario the commenter outlined above, if the first program year of the rural track program began on July 1, 1993, then the fourth program year would begin on July 1, 1996, not in 1997. Because 15 FTEs were already included in the hospital's FTE cap, assuming the urban hospital qualifies to count the FTEs, only 3 out of the 18 FTE residents training in the program may be considered in determining the hospital's rural track FTE limitation and counts (the specific rural FTE limitation and count are dependent upon which scenario the hospital's program fits under § 413.86(g)(11)).
We do not believe it is necessary to revise this policy for hospitals whose only GME program is the rural track program that was in existence prior to 1996, as the commenter suggested. Hospitals that had rural track programs in existence in 1996 were able to count those residents training at the urban hospital at that time as part of their initial FTE caps. Our existing policy on rural tracks at § 413.86(g)(11) provides additional assistance to these hospitals by allowing them to count separately in their rural track FTE limitations, FTE residents not included in the FTE cap but participating in a rural track.
Accordingly, we are adopting the provisions in the August 1, 2000 interim final rule with comment period implementing section 407(c) of Public Law 106-113 as final.
In addition, we are making a technical correction. The regulations at § 413.86(g)(6) currently state, “If a hospital established a new medical residency training program as defined in paragraph (g)(9) of this section * * *.” When we revised the regulations at § 413.86(g)(9) to redesignate the paragraph as § 413.86(g)(12) in the August 1, interim final rule with comment period, we inadvertently did not make a corresponding revision at § 413.86(g)(6). Therefore, we are revising § 413.86(g)(6) to read “If a hospital established a new medical residency training program as defined in paragraph (g)(12) of this section * * *” We are making the same revision to the regulations for IME at § 412.105(f)(vii).
Section 407(d) of Public Law 106-113 addressed the situation where residents were training in a residency training program at a Veterans Affairs (VA) hospital and then were transferred on or after January 1, 1997, and before July 31, 1998, to a non-VA hospital because the program in which the residents were training would lose its accreditation by the ACGME if the residents continued to train at the VA hospital. In this situation, the non-VA hospital may receive a temporary adjustment to its FTE cap to reflect those residents who were transferred to the non-VA hospital for the duration that those transferred residents were training at the non-VA hospital. In the August 1, 2000 interim final rule with comment period, we specified that, in order to receive this adjustment, the non-VA hospital must submit a request to its fiscal intermediary for a temporary adjustment to its FTE cap, document that the hospital is eligible for this temporary adjustment by identifying the residents who have come from the VA hospital, and specify the length of time the adjustment is needed.
We noted that section 407(d) of Public Law 106-113 only refers to programs that would lose their accreditation by the ACGME. This provision does not apply to accreditation by the American Osteopathy Association (AOA), the American Podiatry Association (APA), or the American Dental Association (ADA).
Under section 407(d)(3) of Public Law 106-113, this policy is effective as if included in the enactment of Public Law 105-33, that is, for direct GME, with cost reporting periods beginning on or after October 1, 1997, and for IME, discharges occurring on or after October 1, 1997. If a hospital is owed payments as a result of this provision, payments must be made immediately.
We added §§ 412.105(f)(1)(xii) and 413.86(g)(10) to incorporate the provisions of section 407(d) of Public Law 106-113.
We did not receive any comments on this provision and are adopting it as final.
Generally, section 1886(h)(5)(F) of the Act defines the term “initial residency period” to mean the “period of board eligibility.” The period of board eligibility is defined in section 1886(h)(5)(G) of the Act as the period recognized by ACGME as specified in the Graduate Medical Education Directory which is published by the American Medical Association. The initial residency period limitation was designed to limit full Medicare payment for direct GME to the time required to train in a single specialty. Therefore, the initial residency period is determined based on the minimum time required for a resident to become board eligible in a specialty and the published periods included in the Graduate Medical Education Directory. During the initial residency period, the residents are weighted at 1.0 FTE for purposes of Medicare payment. Residents seeking additional specialty or subspecialty training are weighted at 0.5 FTE.
In order to become board eligible in child neurology, residents must complete training in more than one specialty. Thus, for example, before the effective date of section 312 of Public Law 106-113, if a resident enrolled in a child neurology residency program by first completing 2 years of training in pediatrics (which is associated with a 3-year initial residency period), followed by 3 years of training in child neurology, the resident would be limited by the initial residency period of pediatrics. Section 312 of Public Law 106-113 amended section 1886(h)(5) of the Act by adding at the end a clause (v) which states that “in the case of a resident enrolled in a child neurology residency training program, the period of board eligibility and the initial residency period shall be the period of board eligibility for pediatrics plus 2 years.” (The initial residency period for pediatrics is currently 3 years). The policy under section 312(b) of Public Law 106-113 applies to future child neurology residents and to child neurology residents who have already begun their training (for whom an initial residency period was already established). However, it does not apply to residents who have completed their child neurology training before July 1, 2000.
In the August 1, 2000 interim final rule with comment period, we revised § 413.86(g)(1) to reflect that, effective on or after July 1, 2000, for residency programs that began before, on, or after Start Printed Page 39909November 29, 1999, the period of board eligibility and the initial residency period for child neurology is now the period of board eligibility for pediatrics plus 2 years. We noted that the initial residency period is the same for all child neurology residents, regardless of whether or not the resident completes the first year of training in pediatrics or neurology.
In the August 1, 2000 interim final rule with comment period, we indicated that it had come to our attention that the first sentence of the then existing § 413.86(g)(1) contains a technical error. The first sentence of this paragraph reads “For purposes of this section, an initial residency period is the number of years necessary to satisfy the minimum requirements for certification in a specialty or subspecialty, plus one year.” This section of the regulation was revised as a result of section 13563(b) of Public Law 103-66, and was effective only until June 30, 1995. Generally, effective July 1, 1995, an initial residency period is defined as the minimum number of years required for board eligibility. Therefore, we revised the first sentence of paragraph (g)(1) of § 413.86 accordingly. The remainder of paragraph (g)(1) of § 413.86 was unchanged.
Under sections 1861(v) and 1886(a) of the Act, hospitals that operate approved nursing or allied health education programs may be eligible for the reimbursement of their reasonable costs of operating such programs. Section 1886(h) of the Act establishes the methodology for determining payments to hospitals for the direct costs of GME programs. Section 1886(h) of the Act, as implemented in regulations at 42 CFR 413.86, specifies that Medicare payments for direct costs of GME are based on a prospectively determined per resident amount (PRA). The PRA is multiplied by the number of full-time equivalent residents working in all areas of the hospital complex (and nonhospital sites, where applicable), and the product is then multiplied by the hospital's Medicare share of total inpatient days to determine Medicare's direct GME payment.
Section 1886(h)(3)(D) of the Act, as added by section 4624 of Public Law 105-33, provides a 5-year phase-in of payments to teaching hospitals for direct costs of GME associated with services to Medicare+Choice (managed care) enrollees for portions of cost reporting periods occurring on or after January 1, 1998. The amount of payment for direct GME is calculated by (1) multiplying the aggregate approved amount (that is, the product of the PRA and the number of FTE residents working in all areas of the hospital (and nonhospital sites, if applicable)), by the ratio of the number of inpatient bed days that are attributable to Medicare+Choice enrollees to total inpatient bed days, and (2) multiplying the result by an applicable percentage.
The applicable percentages are 20 percent for portions of cost reporting periods occurring in calendar year 1998, 40 percent in calendar year 1999, 60 percent in calendar year 2000, 80 percent in calendar year 2001, and 100 percent in calendar year 2002 and subsequent years. (Section 1886(d)(11) of the Act, as added by section 4622 of Public Law 105-33, provides a 5-year phase-in of payments to teaching hospitals for IME associated with services to Medicare+Choice enrollees for portions of cost reporting periods occurring on or after January 1, 1998, as well. However, the Medicare+Choice IME payments are irrelevant for the purposes of this section of the interim final rule with comment period, because although section 541 of Public Law 106-113 affects the payments for Medicare+Choice direct GME, it in no way affects the payments for Medicare+Choice IME.)
Section 541 of Public Law 106-113 further amended section 1886 of the Act by adding subsection (l) and amending section 1886(h)(3)(D) to provide for additional payments to hospitals for nursing and allied health education programs associated with services to Medicare+Choice enrollees. Hospitals that operate approved nursing or allied health education programs, as defined under the regulations at 42 CFR 413.85, and receive Medicare reasonable cost reimbursement for these programs, would receive additional payments. This provision is effective for portions of cost reporting periods occurring in a calendar year, beginning with calendar year 2000.
Section 1886(l) of the Act, as added by section 541 of Public Law 106-113, specifies the methodology to be used to calculate these additional payments and places a limitation, that is, $60 million, on the total amount that is projected to be expended in any calendar year. We refer to the total amount of $60 million or less as the payment “pool.” We emphasize that we use the term “pool” solely for ease of reference; the term reflects an estimated dollar figure, a number that is plugged into a formula to calculate the amount of additional payments. The term “pool” does not refer to a discrete fund of money that is set aside in order to make the additional payments (thus, for example, if the estimated “pool” is $50 million, we use the number $50 million to calculate the amount of additional payments, but this does not mean that we set aside $50 million in a separate fund from which we make the additional payments). The total amount of additional payments is based on the ratio of estimated total direct GME payments for Medicare+Choice enrollees to estimated total Medicare direct GME payments, multiplied by the total Medicare nursing and allied health education payments. Under section 541 of Public Law 106-113, a hospital would receive its share of these additional payments in proportion to the amount of Medicare nursing and allied health education payments received in the cost reporting period that ended in the fiscal year that is 2 years prior to the current calendar year, to the total amount of nursing and allied health payments made to all hospitals in that cost reporting period. Section 541(b) of Public Law 106-113 amended section 1886(h)(3) of the Act to provide that direct GME payments for Medicare+Choice utilization will be reduced to account for the additional payments that are made for nursing and allied health education programs under the provisions of section 1886(l) of the Act.
In the August 1, 2000 interim final rule with comment period, we implemented section 541 by establishing regulations at 42 CFR 413.87 to incorporate the provisions of section 1886(l) of the Act. We specified the rules for a hospital's eligibility to receive the additional payment under section 1886(l), the requirements for determining the additional payment to each eligible hospital, and the methodologies for calculating each additional payment and for calculating the payment “pool.” The preamble language regarding § 413.87 can be found in the August 1, 2000 interim final rule with comment period (65 FR 47036 through 47039).
We also made a conforming change to §§ 413.86(d)(4) through (d)(6) to account Start Printed Page 39910for the revised methodology in determining a hospital's Medicare+Choice direct GME payments.
Public Law 106-554 further amended section 1886(l)(2)(C) of the Act. Specifically, section 512 of Public Law 106-554 changed the formula for determining the additional amounts to be paid to hospitals for Medicare+Choice nursing and allied health costs. Under Public Law 106-113, as described above, the additional payment amount was determined based on the proportion of each individual hospital's nursing and allied health education payments to total nursing and allied health education payments made across all hospitals. This formula does not account for a hospital's specific Medicare+Choice utilization. Section 512 of Public Law 106-554 revised this payment formula to specifically account for each hospital's Medicare+Choice utilization. Accordingly, we made conforming changes at § 413.87 to reflect this change. The changes are effective for portions of cost reporting periods occurring on or after January 1, 2001. We refer the reader to the preamble of the June 13 interim final rule with comment period for a detailed description of the revised methodology for calculating the additional payments (66 FR 32178).
We revised § 413.87 to incorporate the provisions of section 512 of Public Law 106-554.
In the June 13, 2001 interim final rule with comment period, we indicated that it had come to our attention that the regulations at § 413.86(d)(4) and § 413.87(d) contained errors. The regulations at § 413.86(d)(4) had read, “Effective for cost reporting periods beginning on or after January 1, 2000, the product derived from step three is reduced in accordance with the provisions of § 413.87(f).” Consistent with the statutory effective date and to clarify the intent of the reference to § 413.87(f), we revised § 413.86(d)(4) to state that, “Effective for portions of cost reporting periods occurring on or after January 1, 2000, the product derived from step three is reduced by a percentage equal to the ratio of the Medicare+Choice nursing and allied health payment “pool” for the current calendar year as described at § 413.87(f), to the projected total Medicare+Choice direct GME payments made to all hospitals for the current calendar year.” We also made a conforming change to § 413.87(d), which had read, “Subject to the provisions of paragraph (f) of this section * * *.” Instead, we revised this language to state, “Subject to the provisions of § 413.86(d)(4) * * *.”
Section 4451 of Public Law 105-33 required that allowable bad debt reimbursement for hospitals be reduced by 25 percent for cost reporting periods beginning during FY 1998, by 40 percent for cost reporting periods beginning during FY 1999, and by 45 percent for cost reporting periods beginning during a subsequent fiscal year.
In the June 13, 2001 interim final rule with comment period (66 FR 32183), we implemented section 541 of Public Law 106-554. Section 541 amended section 1861(v)(1)(T) of the Act, thereby modifying the reduction in payment for Medicare beneficiary bad debt for hospitals made by section 4451 of Public Law 105-33. Specifically, this provision reduced the amount of bad debts otherwise treated as allowable reductions in revenue, attributable to the deductibles and coinsurance amounts, by 30 percent for cost reporting periods beginning during FY 2001 and later. Therefore, for cost reporting periods beginning during the year 2001 and later, hospital bad debt amounts otherwise allowable will be reimbursed at 70 percent of the total allowable amount. In the June 13 interim final rule with comment period, we revised § 413.80 to implement this change.
We did not receive any comments on this provision and, therefore, are adopting the proposed revision to § 413.80 as final.
Federal fiscal year (FY) 2001 is the last year of the 10-year transition period established to phase in the prospective payment system for hospital capital-related costs. For the readers' benefit, we are providing a summary of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital-related payments to hospitals, and the policy for providing exceptions payments during the transition period.
Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services “in accordance with a prospective payment system established by the Secretary.” Under the statute, the Secretary has broad authority in establishing and implementing the capital prospective payment system. We initially implemented the capital prospective payment system in the August 30, 1991 final rule (56 FR 43409), in which we established a 10-year transition period to change the payment methodology for Medicare inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate).
The 10-year transition period established to phase-in the prospective payment system for capital-related costs is effective for cost reporting periods beginning on or after October 1, 1991 (FY 1992) and before October 1, 2001 (FY 2002). Beginning in FY 2001, the last year of the 10-year transition period for the prospective payment system for hospital capital-related costs, capital prospective payment system payments are based solely on the Federal rate for the vast majority of hospitals. Since FY 2001 is the final year of the capital transition period, we will no longer determine a hospital-specific rate for FY 2002 in section III. of the Addendum of this final rule. For cost reporting periods beginning on or after October 1, 2001, payment for capital-related costs for all hospitals, except those defined as new hospitals under § 412.324(b), will be determined based solely on the capital standard Federal rate.
Generally, during the transition period, inpatient capital-related costs are paid on a per discharge basis, and the amount of payment depends on the relationship between the hospital-specific rate and the Federal rate during the hospital's base year. A hospital with a base year hospital-specific rate lower than the Federal rate is paid under the fully prospective payment methodology during the transition period. This method is based on a dynamic blend percentage of the hospital's hospital-specific rate and the applicable Federal rate for each year during the transition period. A hospital with a base period hospital-specific rate greater than the Federal rate is paid under the hold-harmless payment methodology during the transition period.
During the transition period, a hospital paid under the hold-harmless payment methodology receives the higher of (1) a blended payment of 85 percent of reasonable cost for old capital plus an amount for new capital based on Start Printed Page 39911a portion of the Federal rate; or (2) a payment based on 100 percent of the adjusted Federal rate. The amount recognized as old capital is generally limited to the allowable Medicare capital-related costs that were in use for patient care as of December 31, 1990. Under limited circumstances, capital-related costs for assets obligated as of December 31, 1990, but put in use for patient care after December 31, 1990, also may be recognized as old capital if certain conditions were met. These costs are known as obligated capital costs. New capital costs are generally defined as allowable Medicare capital-related costs for assets put in use for patient care after December 31, 1990.
Hospitals that are defined as “new” for the purposes of capital payments during the transition period (see § 412.300(b)) will continue to be paid according to the applicable payment methodology outlined in § 412.324. During the transition period, new hospitals are exempt from the prospective payment system for capital-related costs for their first 2 years of operation and are paid 85 percent of their reasonable capital-related costs during that period. The hospital's first 12-month cost reporting period (or combination of cost reporting periods covering at least 12 months), beginning at least 1 year after the hospital accepts its first patient, serves as the hospital's base period. Those base year costs qualify as old capital and are used to establish its hospital-specific rate used to determine its payment methodology under the capital prospective payment system. Effective with the third year of operation and through the remainder of the transition period, the hospital will be paid under either the fully prospective methodology or the hold-harmless methodology. If the fully prospective methodology is applicable, the hospital is paid using the appropriate transition blend of its hospital-specific rate and the Federal rate for that fiscal year until the conclusion of the transition period, at which time the hospital will be paid based on 100 percent of the Federal rate. If the hold-harmless methodology is applicable, the hospital will receive hold-harmless payment for assets in use during the base period for 8 years, which may extend beyond the 10-year transition period.
The basic methodology for determining capital prospective payments based on the Federal rate is set forth in § 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows:
(Standard Federal Rate) × (DRG Weight) × (GAF) × (Large Urban Add-on, if applicable) × (COLA Adjustment for Hospitals Located in Alaska and Hawaii) × (1 + DSH Adjustment Factor + IME Adjustment Factor)
Hospitals may also receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments.
In accordance with section 1886(d)(9)(A) of the Act, under the prospective payment system for inpatient operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. However, effective October 1, 1997, under amendments to the Act enacted by section 4406 of Public Law 105-33, operating payments to hospitals in Puerto Rico are based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges on or after October 1, 1997, we compute capital payments to hospitals in Puerto Rico based on a blend of 50 percent of the Puerto Rico rate and 50 percent of the Federal rate as specified in the regulations at § 412.374. For capital-related costs, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs.
In the August 30, 1991 final rule (56 FR 43409), we established a capital exceptions policy, which provided for exceptions payments during the transition period (§ 412.348). Section 412.348 provides that during the transition period, a hospital may receive additional payment under the exceptions process when its regular payments are less than a minimum percentage, established by class of hospital, of the hospital's reasonable capital-related costs. The amount of the exceptions payment is the difference between the hospital's minimum payment level and the payments the hospital would have received under the capital prospective payment system in the absence of an exceptions payment. The comparison is made on a cumulative basis for all cost reporting periods during which the hospital has been subject to the capital prospective payment transition rules. The minimum payment percentages throughout the transition period for regular capital exceptions payments by class of hospitals are:
For sole community hospitals, 90 percent;
For urban hospitals with at least 100 beds that have a disproportionate share patient percentage of at least 20.2 percent or that received more than 30 percent of their net inpatient care revenues from State or local governments for indigent care, 80 percent;
For all other hospitals, 70 percent of the hospital's reasonable inpatient capital-related costs.
The provision for “regular” exceptions payments expires at the end of the transition period, that is, for cost reporting periods beginning after September 30, 2001. Capital prospective payment system payments are no longer adjusted to reflect regular exceptions payments at § 412.348 after that date. Accordingly, for cost reporting periods beginning on or after October 1, 2001, all hospitals other than those defined as “new” under § 412.324(b) will receive only the per discharge payment based on the Federal rate for capital costs (plus any applicable DSH or IME and outlier adjustments) unless a hospital qualifies for a special exceptions payment under § 412.348(g).
In the August 30, 1991 final rule (56 FR 43409), we established a capital exceptions policy at § 412.348, which provided for regular exception payments during the transition period. In the September 1, 1994 final rule (59 FR 45385), we added the special exceptions process, describing it as “* * * narrowly defined, focusing on a small group of hospitals who found themselves in a disadvantaged position. The target hospitals were those who had an immediate and imperative need to begin major renovations or replacements just after the beginning of the capital prospective payment system. These hospitals would not be eligible for protection under the old capital and obligated capital provisions, and would not have been allowed any time to accrue excess capital prospective payments to fund these projects.”
Under the special exceptions provisions at § 412.348(g), an additional payment may be made through the 10th year beyond the end of the capital Start Printed Page 39912prospective payment system transition period for eligible hospitals that meet (1) a project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test; and (2) a project size requirement as described at § 412.348(g)(5). Eligible hospitals include sole community hospitals, urban hospitals with at least 100 beds that have a disproportionate share patient percentage of at least 20.2 percent, and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent.
When we established the special exceptions process, we selected the hospital's cost reporting period beginning before October 1, 2001, as the project completion date in order to limit cost-based exceptions payments to a period of not more than 10 years beyond the end of the 10-year transition to the fully Federal capital prospective payment system. Therefore, hospitals are eligible to receive special exceptions payments for the 10 years after the cost reporting year in which they complete their project. Generally, if a project is completed in the hospital cost reporting period ending September 29, 2002, exceptions payments would continue through September 29, 2012. In addition, we believe that, for projects completed after the deadline, hospitals would have had the opportunity to reserve their prior years' capital prospective payment system payments for financing projects. We note that the August 1, 2000 final rule (65 FR 47095) incorrectly stated that special exceptions payments could extend through September 30, 2011; the date should have been September 29, 2012.
For each cost reporting period, the amount of the special exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital payment system to the cumulative minimum payment levels applicable to the hospital for each cost reporting period subject to the prospective payment system. This comparison is offset or reduced by (1) any amount by which the hospital's cumulative payments exceed its cumulative minimum payments under the regular exceptions process for all cost reporting periods during which the hospital has been subject to the capital prospective payment system; and (2) any amount by which the hospital's current year Medicare inpatient operating and capital prospective payment system payments (excluding 75 percent of its operating DSH payments) exceed its Medicare inpatient operating and capital costs (or its Medicare inpatient margin). During the capital prospective payment system transition period, the minimum payment level under the regular exceptions process varied by class of hospital as set forth in § 412.348(c) and described in section V.A. of this preamble. After the transition period and for the duration of the special exceptions provision, the minimum payment level is 70 percent as set forth in § 412.348(g)(6).
As we indicated in the July 30, 1999 final rule (64 FR 41526), we have little information about the number of hospitals that may qualify for special exceptions payments or the projected dollar amount of special exception payments, because no hospitals are currently being paid under the special exceptions process. Until FY 2002, the special exceptions provision pays either the same as the regular exceptions process or less for high DSH and sole community hospitals. In accordance with § 412.348(g)(7), a qualifying hospital may receive additional payments for up to 10 years from the year in which it completes a project that meets the project need and project size requirements of the special exception provision in §§ 412.348(g)(2) through (g)(5). Because a qualifying project under the special exceptions provision at § 412.348(g) must be completed (put into use for patient care) by the end of the hospital's last cost reporting period beginning before the end of the transition period (September 30, 2001), a hospital may receive special exception payments for 10 years through September 30, 2012. For example, an eligible hospital that completes a qualifying project in October 1993 (FY 1994) will be eligible to receive special exception payments up through FY 2003 (September 30, 2003).
In order to assist our fiscal intermediaries in determining the end of the 10-year period in which an eligible hospital will no longer be entitled to receive special exception payments, in the May 4, 2001 proposed rule, we proposed to add a new § 412.348(g)(9) to require that hospitals eligible for special exception payments under § 412.348(g) submit documentation to the intermediary indicating the completion date of their project (the date the project was put in use for patient care) that meets the project need and project size requirements outlined in §§ 412.348(g)(2) through (g)(5). We proposed that, in order for an eligible hospital to receive special exception payments, this documentation would have to be submitted in writing to the intermediary by the later of October 1, 2001, or within 3 months of the end of the hospital's last cost reporting period beginning before October 1, 2001, during which a qualifying project was completed. For example, if a hospital completed a qualifying project in March 1995, it would be required to submit documentation to the intermediary by October 1, 2001. If a hospital with a 12-month cost reporting period beginning on July 1 completed a qualifying project in November 2001, it would be required to submit documentation to the intermediary no later than September 30, 2002, which is 3 months after the end of its 12-month cost reporting period that began on July 1, 2001.
We did not receive any comments on our proposed revision to § 412.348 to add paragraph (g)(9). Accordingly, we are adopting the proposed revision as final without change.
Section 412.348(h) limits the estimated aggregate amount of exceptions payments under both the regular exceptions and special exceptions process to no more than 10 percent of the total estimated capital prospective payment system payments in a given fiscal year. Consistent with the requirements for regular exceptions at § 412.348(c), in the May 4, 2001 proposed rule, we proposed that if we estimate that special exception payments would exceed 10 percent of total capital prospective payment system payments for a given fiscal year, we will adjust the minimum payment level of 70 percent by one percentage point increments until the estimated payments are within the 10-percent limit. For example, we could set the minimum payment level at 69 percent to ensure that estimated aggregate special exceptions payments do not exceed 10 percent of estimated total capital prospective payment system payments. If the estimate of aggregate special exceptions payments were still projected to exceed 10 percent of total capital prospective payment system payments, we would continue reducing the minimum payment level by one percentage point increments until the requirements in § 412.348(h) were satisfied. We proposed to revise § 412.348(g)(6) accordingly to reflect this policy.
We received no comments on this proposed change. Thus, we are revising § 412.348(g)(6) accordingly.
Section 412.308(c)(3) requires that the standard capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of additional payments for both regular exceptions and special exceptions under § 412.348 Start Printed Page 39913relative to total capital prospective payment system payments. In estimating the proportion of regular exceptions payments to total capital prospective payment system payments during the transition period, we used the model originally developed for determining budget neutrality (described in Appendix B of this final rule) to determine the exception adjustment factor, which was applied to both the Federal and hospital-specific rates. In the May 4, 2001 proposed rule, we described our proposed methodology for determining the special exceptions adjustment used in establishing the Federal capital rate as follows:
Under the special exceptions provision specified at § 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share patient percentage of at least 20.2 percent or qualify for DSH payments under § 412.106(c)(2), and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. An eligible hospital may receive special exception payments if it meets (1) a project need requirement as described at § 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test; (2) an age of assets test as described at § 412.348(g)(3); and (3) a project size requirement as described at § 412.348(g)(5).
In order to determine the estimated proportion of special exceptions payments to total capital payments, we attempted to identify the universe of eligible hospitals that may potentially qualify for special exception payments. First, we identified hospitals that met the eligibility requirements at § 412.348(g)(1). Then we determined each hospital's average fixed asset age in the earliest available cost report starting in FY 1992 and later. For each of those hospitals, we calculated the average fixed asset age by dividing the accumulated depreciation by the current year's depreciation. In accordance with § 412.348(g)(3), a hospital must have an average age of buildings and fixed assets above the 75th percentile of all hospitals in the first year of capital prospective payment system. In the September 1, 1994 final rule (59 FR 45385), we stated that, based on the June 1994 update of the cost report files in HCRIS, the 75th percentile for buildings and fixed assets for FY 1992 was 16.4 years. However, we noted that we would make a final determination of that value on the basis of more complete cost report information at a later date. In the August 29, 1997 final rule (62 FR 46012), based on the December 1996 update of HCRIS and the removal of outliers, we finalized the 75th percentile for buildings and fixed assets for FY 1992 as 15.4 years. Thus, for the proposed rule, we eliminated any hospitals from the potential universe of hospitals that may qualify for special exception payments if its average age of fixed assets did not exceed 15.4 years.
For the hospitals remaining in the potential universe, we proposed to estimate the project-size by using the fixed capital acquisitions shown on Worksheet A7 from the following HCRIS cost reports updated through December 2000.
PPS Year
Cost reports periods beginning in . . .
IX FY 1992
X FY 1993
XI FY 1994
XII FY 1995
XIII FY 1996
XIV FY 1997
XV FY 1998
XVI FY 1999
Because the project phase-in may overlap 2 cost reporting years, we proposed to add together the fixed acquisitions from sequential pairs of cost reports to determine project size. Under § 412.348(g)(5), the project-size must meet the following requirements: (1) $200 million; or (2) 100 percent of its operating cost during the first 12-month cost reporting period beginning on or after October 1, 1991. We proposed to calculate the operating costs from the earliest available cost report starting in FY 1992 and later by subtracting inpatient capital costs from inpatient costs (for all payers). We proposed not to subtract the direct medical education costs as those costs are not available on every update of the HCRIS minimum data set. If the hospital met the project size requirement, we assumed that it also met the project need requirements at § 412.348(g)(2) and the excess capacity test for urban hospitals at § 412.348(g)(4).
Because we estimate that so few hospitals will qualify for special exceptions, projecting costs, payments, and margins would result in high statistical variance. Consequently, we modeled the effects of special exceptions using historical data based on hospitals' actual cost experiences. If we determined that a hospital may qualify for special exceptions, we modeled special exceptions payments from the project start date through the last available cost report (FY 1999). For purposes of modeling, we used the cost and payment data on the cost reports from HCRIS assuming that special exceptions would begin at the start of the qualifying project. In other words, when modeling costs and payment data we proposed to ignore any regular exception payments that these hospitals may otherwise have received as if there had not been regular exceptions during the transition period. In projecting an eligible hospital's special exception payments, we applied the 70-percent minimum payment level, the cumulative comparison of current year capital prospective payment system payments and costs, and the cumulative operating margin offset (excluding 75 percent of operating DSH payments).
Because hospitals may receive regular exceptions payments up through the end of their last cost reporting period beginning before October 1, 2001, hospitals with cost reporting periods beginning on a day other than October 1 will continue to receive regular exception payments until the end of their FY 2002 cost reporting period. Therefore, these hospitals will only receive special exception payments for the remainder of Federal FY 2002. Consequently, the special exceptions payments made in FY 2002 will be less than for subsequent years since they are only being paid a special exception payment for a portion of FY 2002.
Based on more recent data and HCRIS cost reports updated through March 2001, our modeling of special exception payments produced the following results:Start Printed Page 39914
Cost report
Number of hospitals eligible for special exceptions
Special exceptions as a fraction of capital payments to all hospitals
Special exceptions as a fraction of capital payments to all hospitals weighted by portion of FY 2002 for which special exceptions are paid
PPS IX
PPS X
PPS XI 3
PPS XII 6 0.0001 0.0001
PPS XIII 7 0.0001 0.0000
PPS XIV 14 0.0002 0.0001
PPX XV 17 0.0009 0.0002
PPS XVI 23 0.0009 0.0007
Currently, the PPS XVI cost reports in HCRIS are incomplete because there is a 2-year lag time between the end of a hospital's cost reporting period and the submission and processing of the cost reports for HCRIS. In particular, we have not received all the cost reports for hospitals whose cost reporting periods begin in July. We expect that more hospitals may qualify for special exceptions once data from later HCRIS updates are available. In addition, hospitals still have two more cost reporting periods (PPS XVII and PPS XVIII) to complete their projects in order to be eligible for special exceptions.
In the May 4, 2001 proposed rule (66 FR 22705), we estimated that about 30 additional hospitals could qualify for special exceptions. Based on more recent data, we still estimate that about 30 additional hospitals could qualify for special exceptions. Thus, we project that special exception payments as a fraction of capital payments to all hospitals is approximately 0.0025. However, after weighting this amount to account for the FY 2002 phase-in of special exception payments, we project that this factor is approximately 0.0012. These projections have not changed since the publication of the May 4, 2001 proposed rule (66 FR 22706). We received no comments on our proposed methodology for determining the special exceptions adjustment used in establishing the capital Federal rate. Because special exceptions are budget neutral, we will offset the Federal capital rate by 0.12 percent for special exceptions for FY 2002. Therefore, the final special exceptions adjustment factor is equal to 0.9988 (1-0.0012) to account for special exception payments in FY 2002.
In the June 13, 2001 interim final rule with comment period, we implemented section 301(b) of Public Law 106-554 (66 FR 32176). Section 301(b) provides for a special rule for payment for the operating standardized amounts for hospitals other than SCHs for FY 2001. For discharges occurring on or after April 1, 2001, and before October 1, 2001, the update to the operating standardized amounts for hospitals other than SCHs is equal to the market basket percentage increase plus 1.1 percentage points. This provision amends the prior statutory 1.1 percent reduction to the update to the FY 2001 operating standardized amounts for hospitals other than SCHs as provided by section 4401(a)(1) of Public Law 105-33 and 406 of Public Law 106-113.
Section 1886(d)(3)(B) of the Act directs the Secretary to adjust the inpatient operating national standardized amounts to account for the estimated proportion of operating DRG payments made to payments in outlier cases. Accordingly, as a result of this change to the update to the operating standardized amounts for discharges occurring on or after April 1, 2001 and before October 1, 2001, we revised the fixed-loss outlier threshold. The regulations at § 412.312(c) establish a unified outlier methodology for inpatient operating and inpatient capital-related costs, which utilizes a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital prospective payment system payments.
Because operating DRG payments increased as a result of implementing section 301 of Public Law 106-554, the fixed-loss outlier threshold decreased, which resulted in an increase in estimated outlier payments. Thus, the capital national outlier adjustment factor was revised. Since the revision to the fixed-loss outlier threshold also affected total capital payments, the exceptions adjustment factor was also revised in order to maintain budget neutrality. The exceptions adjustment factor is determined based on an estimate of the ratio of exception payments to total capital payments. The GAF/DRG budget neutrality factor was also revised. We discuss the impact of changes to the rates and payments under the capital prospective payment system that result from implementation of section 301 of Public Law 106-554 in further detail in the Addendum of this final rule.
We did not receive any comments on the revised FY 2001 capital Federal rate for discharges occurring on or after April 1, 2001 and before October 1, 2001 as a result of implementing section 301(b) of Public Law 106-554.
Section 1886(b)(3) of the Act (as amended by section 4414 of Public Law 105-33) established caps on the target amounts for certain existing hospitals and units excluded from the prospective payment system for cost reporting periods beginning on or after October 1, 1997 through September 30, 2002. The caps on the target amounts apply to the following three classes of excluded hospitals: psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals.
In addition, section 4416 of Public Law 105-33 limited payments for Start Printed Page 39915psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals that first received payments on or after October 1, 1997. Payment for these hospitals and units is limited to the lesser of the hospital's operating costs per case or 110 percent of the national median of target amounts for the same class of hospitals for cost reporting periods ending during FY 1996, updated and adjusted for differences in area wage levels.
A discussion of how the caps on the target amounts and the payment limitation were calculated can be found in the August 29, 1997 final rule with comment period (62 FR 46018); the May 12, 1998 final rule (63 FR 26344); the July 31, 1998 final rule (63 FR 41000), and the July 30, 1999 final rule (64 FR 41529). For purposes of calculating the caps for existing facilities, the statute required the Secretary to estimate the national 75th percentile of the target amounts for each class of hospital (psychiatric, rehabilitation, or long-term care) for cost reporting periods ending during FY 1996 without adjusting for differences in area wage levels. Under section 1886(b)(3)(H)(iii) of the Act, the resulting amounts are updated by the market basket percentage to the applicable fiscal year.
Section 121 of Public Law 106-113 amended section 1886(b)(3)(H) of the Act to also provide for an appropriate wage adjustment to the caps on the target amounts for existing psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals, effective for cost reporting periods beginning on or after October 1, 1999, through September 30, 2002. On August 1, 2000, we published an interim final rule with comment period that implemented this provision for cost reporting periods beginning on or after October 1, 1999 and before October 1, 2000 (65 FR 47026) and a final rule that implemented this provision for cost reporting periods beginning on or after October 1, 2000 (65 FR 47054). This final rule addresses the wage adjustment to the caps and payment limitations for cost reporting periods beginning on or after October 1, 2001 as proposed in the May 4, 2001 proposed rule.
For purposes of calculating the caps, section 1886(b)(3)(H)(ii) of the Act requires the Secretary to first “estimate the 75th percentile of the target amounts for such hospitals within such class for cost reporting periods ending during fiscal year 1996.” Furthermore, section 1886(b)(3)(H)(iii), as added by Public Law 106
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Know Thy Opponent: Gonzaga Bulldogs
12/05/2008 11:30 am in
Instead of our usual ‘let’s try to piece together what we know about our opponent writeup’ normally found in this here space, we’ve reached out to The Kennel Report, an unofficial, student run blog about Gonzaga, to get the scoop on IU’s next opponent. Our email exchange begins…Now.
Inside the Hall: One of the fascinating things about Gonzaga is how they’ve been able to keep Mark Few in Spokane despite obvious interest from other programs. Two-part question: 1. How has Gonzaga been able to hold on to Few? and 2. Why has Few resisted the temptation to jump ship? Was he scared off by the Dan Monson epic fail at Minnesota?
The Kennel Report: The decision by Mark Few to remain in Spokane despite overtures from programs like Indiana, Kentucky, and Stanford has been the key to Gonzaga sustaining this great run. Here is a story that took place today that I think might hold the answer to your question. After class this morning, I had some time to kill so I went to the student center on campus. After waiting in line to get something to eat I went and sat on a couch to pass the time before my next class. Sitting directly across from me was none other than Mark Few. He was reading the local newspaper and enjoying a cup of tea. For the 10-15 minutes he was there, nobody bothered him, asked for his autograph, or tried to explain why running a 2-3 defense would help the team. I don’t think the constant questioning and demand for time that the head coach at schools like Indiana or Kentucky has to deal with is appealing to Mark Few in anyway.
As you mentioned, the experience of Dan Monson also has had some sort of impact. I think Few learned that money doesn’t buy happiness or experience. Could he make more money at another school? Of course he could, but the pressure and expectations that he would have to deal with ruins the appeal of more dollar signs.
ITH: The three Zags getting the most attention seem to be Josh Heytvelt, Austin Daye and Micah Downs. Which of these three guys is the most indispensable and why?
TKR: This is a great question, and one that is very difficult to answer. Each one of the guys you mentioned brings so much to the table, and of course Gonzaga also has Jeremy Pargo, who is one of the top PG’s in the country. Of the group you mentioned, Heytvelt would have to be considered the most indispensable. While this team has Ira Brown and Robert Sacre to provide depth in the frontcourt, neither of the two mentioned can take over a game like Josh can. A great example of this is the Maryland game in the Old Spice Classic, when Josh scored 22 points and grabbed nine rebounds. We have no other player with his size and strength who is capable of dominating a game like that. Austin is certainly one of the more talented scorers in the country, but his game is more perimeter based. When Josh is healthy and focused, he can be one of the top post players in the country.
ITH: Gonzaga was a mid-major before it was cool to be a mid-major. Do those around the program still consider the program as a part of this group or have they moved beyond that status?
TKR: At this point, Gonzaga is a high major program that plays in a mid-major conference. There are two main events that made this transition happen. The first was the building of the McCarthey Athletic Center, which is the home gym for the Zags. The MAC is arguably one of the top five gyms on the West Coast, and also has one of the best game atmospheres of any gym in the country. The building of this gym elevated the type of player Gonzaga could recruit. Having this type of facility has allowed Gonzaga to recruit against some of the top programs in the nation.
The other reason that Gonzaga has been elevated to a high-major program is recruiting. The best example of this would be the class of 2007, which featured Austin Daye, Steven Gray, Rob Sacre, and Ira Brown. Austin was the first five-star recruit to ever sign with Gonzaga out of high school, and Steven and Rob were both consensus top 100 recruits. This class ended up ranked in the top 15 in the country. The class of 2008 also features three top 150 recruits in Meech Goodson, Grant Gibbs, and Andy Poling. These are the type of recruiting classes that high-major programs are able to bring in on a consistent basis.
ITH: Every team has an unsung hero or a player who holds things together. Who’s that guy for the Zags?
TKR: Lets go with Goodson for this one. His stats wont blow away anyone (3.8 pts, 1.8 assists), but his impact in the game is noticeable. Last season, when Jeremy Pargo would go to the bench, the team would fall apart. With Meech available this season, the team doesn’t miss a step when Pargo goes to the bench. Meech also brings tremendous toughness to a program that has been categorized as “soft” and “finesse”. Meech’s brother is Mike Goodson, who plays football at Texas A&M, and Meech brings that football toughness to the basketball court. He has really proven to be the type of player who can change the perception of the Gonzaga program.
ITH: Finish these two sentences. A successful season for Gonzaga would be…
TKR: A National Championship. Besides North Carolina, we really believe that we have the top team in the country. In terms of depth, athleticism, and talent, Gonzaga matches up the best with North Carolina.
ITH: A disappointing season for Gonzaga would be…
TKR: Anything short of the Final Four. This team has been building for the past two seasons for this year. With Pargo returning for his senior season, and Heytvelt being fully healthy, this has to be the season for Gonzaga to break through and make the Final Four.
Filed to: Gonzaga Bulldogs, Mark Few
Taskmaster75
Gonzaga seems very similar to what Memphis was last year. They had three core players in Rose, Roberts, and (drawing a blank for his name…whatever the F/C's name is…ahhh Dorsey). They also seemed to have title aspirations that several people thought would come true, not including me of course. Im very skeptical of any team in a mid major competing for a national championship, simply because of how little they are tested in the bulk of the season (conference play). I personally think they will make it to the elite 8 and fall to a #2 seeded team, but that's just my opinion.
Ben_M
This season is going to trun me into an alcoholic.
so we are probably looking at losing by 50…somebody throw some magic mushrooms in Hetyvelt's luggage
I think this could be our worst whoopin of the year………
MikeinNC
This one definitely has the potential to get ugly. I haven't been able to watch a lot of our games this year, but it struck me against Wake Forest that it will be tough to run an uptempo, running offense with Moore at point, he is just not quick enough plus we don't have the size to rebound strongly and get out fast on the break. I wonder if we would be better off trying to slow the tempo down and run a more deliberate offense against teams like Gonzaga. It might fail, but you know we can't run with them, so what do you have to lose?
On live blogs, the Internet, and people who just don’t get it
A sneak peak at Lucas Oil Stadium’s basketball setup
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Kenyan Elections: A Sense of Cautious Optimism
Two weeks after Kenyans took to the polls to elect their new president on March 4th, 2013, IPI hosted a policy forum that assessed the outcome of the elections in Kenya. Panelists considered the mechanisms of the electoral process, the 2010 Kenyan constitution, and the implications of the International Criminal Court (ICC) indictment of Uhuru Kenyatta, who won the majority vote. With so much uncertainty following the disputed 2007 elections, which entailed widespread violence, the 2013 elections were seen as relatively peaceful. Nonetheless, challenges remain and the outcome of the elections will set the tone for Kenya’s internal security and international standing.
Dr. Ozonnia Ojielo, Coordinator for Conflict Prevention and Recovery at the Bureau for Crisis at the United Nations Development Programme (UNDP), discussed the violence prevention mechanisms that were put in place before the elections. In February, he had visited Kenya for two weeks, on an invitation by the government, to look at the preparations and provide advice to the national authority.
From his perspective, at the local, grassroots level, there was greater engagement in violence prevention among civil society and community groups. However, at the national level, he explained that there were no mechanisms in engagement in a higher context, among the political actors, and this was also a gap in the 2007 elections.
Despite the gap, however, the election process was still an improvement from 2007. “There has been a lot of time and resources committed to building the capacity of the electoral commission,” Dr. Ozonnia said. Opinion polls in the country rated the electoral commission as the most trusted in Kenya, although with 33,000 police stations, thousands of polling officers and six elections in one day, it was a logistical challenge, he remarked.
With enhanced security arrangements and reforms in the judiciary that enacted regulations and designated special courts for election disputes, there was greater confidence among Kenyans in the election process, he said, underscoring that the transparent process it conducted was significant.
Reflecting on the lessons learned from the new elections, he highlighted the importance of national capacities for conflict prevention and management. Within the country, there was distrust of external mediation and intervention so it was important that the election process was lead by Kenyans themselves, Dr. Ozonnia said.
“The idea of national standing capacity is not an ad-hoc but something we need to do systematically and build the capacity early on,” he remarked.
In regards to the 2010 Kenyan constitution, E.J. Hogendoorn, Deputy Director of the Africa program at the International Crisis Group, discussed the challenges to the process of devolution, a new idea that was presented in the constitution.
Even though the voting period has finished and the campaigns have ended, Mr. Hogendoorn said that Kenya is not out of the woods yet.
In his view, a significant challenge in the reform process will be “the implementation of the 2010 constitution and in particular, the efforts to devolve government in Kenya.”
Traditionally, Kenya has been a centralized presidential state, one of the sources of chronic conflict and instability in the country, he said. Drafters of constitutions decided to create 48 new counties with their own governors and local assemblies, giving those counties significant fiscal responsibilities.
“How exactly that devolution process will occur and how far it will go remains a question for the Kenyan people and for all these new politicians, and we argue could be a very significant source of conflict, both at the local and national level, as communities in counties themselves compete for the resources that these new institutions control,” Mr. Hogendoorn remarked. He argued that the international community needs to keep a close eye on the events in Kenya for the foreseeable future, especially for the next 2-3 years when the devolutionary process takes hold.
Citing a World Bank report which said, “A rushed transition could set up counties to fail, by giving them responsibilities before they have the capacity to carry them out,” he said that a rushed devolution could undermine the reform process in general.
Mr. Hogendoorn concluded by highlighting the budgetary implications of the devolution process, which poses strains on the government’s fiscal controls to stabilize the macroeconomic environment in the country.
Peter Gastrow, Senior Adviser at the International Peace Institute, discussed the implications of the ICC’s indictment of several presidential candidates on the election, addressing the contradiction between the Kenyan people’s support of the ICC and their intentions to support the indicted candidates.
Citing a December 2010 public opinion poll, Mr. Gastrow said that 85% of Kenyans were in favor of the ICC trying those who bore the greatest responsibility for the violence in 2007. However, once the names of the suspects were announced, support dropped to 60%. In October 2012, a Gallup poll found that while 70% of Kenyans supported the ICC, a majority of the voters still intended to support an indicted candidate, he remarked.
“Maybe in hindsight–with all the wisdom one has in hindsight–that should have been looked at very carefully, that tension between support the ICC but don’t touch my candidate, that type of attitude,” he said.
Mr. Gastrow went on to highlight the statements made by the Western powers on the ICC indictments, many of which said they will have limited to no contact with the ICC indictees. “[These statements] would be perceived as self-righteous, arrogant and condescending by many Kenyans, and that’s what happened,” he said, arguing that Uhuru Kenyatta used the vibe to whip up support.
Mr. Gastrow also noted the post-election responses. “None of the responses [from the Western powers] referred directly to the victory of Uhuru Kenyatta. They all congratulated the Kenyan people,” he said. China, however, congratulated Kenyatta for winning the elections, saying it was looking forward for close cooperation with the country. “A very different vibe and very different approach,” he added.
Turning back to the ICC, Mr. Gastrow said, “The political elite [in Kenya] are strongly against the ICC. They see it as a threat, I think, partially because it threatens political and criminal impunity. It potentially threatens their interests.”
“If it was not for the significant support which now exist for the Supreme Court and the judiciary in Kenya, one would be very pessimistic,” he continued. “That is one of the very few factors which for me suggest that Kenya is a country with a future. The judiciary has broad support and the public has trust in it and once institutions start having broad support and trust, I think developing countries are on their way to success, which I hope Kenya will be.”
The event was chaired by John Hirsch, Senior Advisor at the International Peace Institute.
Download the meeting brief
Why Kenyans Voted For ICC-Indicted Candidates
Watch event:
Governance, State-Society Relations
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It is already too late, but we still have time
By Gene Quinn
“If you want to see the effects of not having clear title just go to Cuba, where you see there hasn’t been anything built in the private sector since 1959,” Lauder explained.
Judge Kathleen O’Malley (CAFC) and David Kappos, at the Newseum, April 10, 2018. Panel discussion “The Great Patent Debate Continues”, with Chief Judge Paul Michel (ret.), Gary Lauder, Jamie Simpson.
Earlier this morning the annual LeadershIP symposium was held at the Newseum in Washington, DC. Moderating the first panel was Judge Kathleen O’Malley of the United States Court of Appeals for the Federal Circuit.
“It is surprising that we continue to make the same mistakes that we have made over the last several hundred years,” said Judge O’Malley as she opened the panel, which included Chief Judge Paul Michel (CAFC, ret.), David Kappos (former Director of the USPTO), venture capitalist Gary Lauder, Managing Director of Lauder Partners, and Jamie Simpson, USPTO Detailee to the Senate Judiciary Committee for Senate Christopher Coons.
Judge O’Malley would go on to explain that throughout history the swing of the pendulum that is the U.S. patent system has swung from over emphasis on patent quality, to then allowing too much to be patented, only to repeat all over again.
“The point of the patent system is to incentivize investors, as much as it is to incentivize inventors,” explained Judge Michel. “The tilt of the pendulum has shifted dramatically.” Explaining that investment capital is truly mobile and on a global level today, “if the incentives are better in China that is where the money will go.” Michel also explained the undeniable reality that those with money are also only interested in a return on investment, which means that if there are better options for return in movies or other investment vehicles that is where focus will shift.
He is right. It is hardly surprising that investors have shifted away from paradigm shifting innovations that required proprietary protections (i.e., patents).
“Every light on the panel is blinking red,” Michel explained, as he talked about the U.S. falling out of the top 10 patent jurisdictions in the world, and the double to triple invalidation rate at the Patent Trial and Appeal Board when compared with federal district court, which suggests the procedures and processes of the PTAB are flawed.
Michel also went on to discuss the “double whammy” of the “vague, inconsistent, irrational standards of the Alice/Mayo standard.” Michel pointed out that there are potentially many thousands of patents that exist “under a cloud” because of the Alice/Mayo standard, and that uncertainty is not helpful for business. Again, Michel is absolutely correct.
Gary Lauder (L) and Chief Judge Paul Michel (CAFC ret.)
Michel went on to mention that he has reason to know that some attorneys are advising defendants who know they are infringing patents that the time to money for patent owners is now at least doubled from four years to about eight years, and defendants can string along patent owners. “Many in Congress continues to believe the problem in the industry is trolls, it is not.”
“The biggest problem is the patent that doesn’t get issued,” Kappos explained. “The patient that doesn’t get cured… The pendulum has definitely swung too far…. Quality just isn’t about not issuing patents that shouldn’t be issued, but quickly issuing patents that should be issued.”
Historically the philosophy discussed by Kappos was the rationale by leaders of the Patent Office. More damage is done by burying deserving innovations and denying patents than by making a mistake here and there and issuing a patent that shouldn’t be issued. That philosophy has not been in favor for much of the last 15+ years.
“The truth is most entrepreneurs to don’t realize how useless the patents they have are,” Lauder said. “My hope is we can fix things before they realize how hopeless things are.”
“Most of the technologies relating to human health sciences have been hit most hard,” Michel said. “And if you look at it from the size of companies the small companies have been hit unusually hard. And startups are the canary in the coal mine… In 2014, more startups died than were formed for the first time in American history.” Startups are more important than more established companies because they are responsible for job growth, the more likely to create disruptive innovation. According to Michel, a rationale policy would be to advantage startups and small companies, not to strangle them.
Judge O’Malley would go on to ask Lauder, the resident venture capitalist on the panel, “is there less funding for life sciences startups because of [patent eligibility concerns]?”
“Most definitely,” Lauder explained. “Medical diagnostic companies, as well as companies developing new drugs… I do investments in that field and it is a problem.”
“If companies were to lobby to allow for more polluting most people would think that is unethical,” Lauder explained. But there are people lobbying to make it more difficult for companies to come up with cures that allow for the creation of cures that save lives, which Lauder says he finds “equally unethical.” Lauder hopes that others start to look at the problem in the same way. That would indeed be a big step forward.
As the conversation moved toward discussing the PTAB and PTAB rules and procedures, O’Malley, explained that the statute and rules seem to be geared toward allowing for amendments to allow for the fixing of patents that shouldn’t have issued quite as broadly, and to getting rid of those patents that couldn’t be saved. “But the emphasis seems to be on getting rid of as many patents as possible,” O’Malley said.
“I thought I gave them a pretty good road map in Aqua Products, but that portion didn’t get a majority,” O’Malley said, to laughter in the audience.
As the discussion turned to Oil States, and property rights, Lauder talked about the importance of property rights for investors, and how a decision that says the wrong things or goes the wrong directions could go the wrong way could be “devastating.”
To end the discussion, about what we do and when the industry must respond, Lauder gave one of his characteristically brilliant, pithy quotes: “It is already too late, but we still have time.” He explained that the best time to fix a problem is yesterday, but since we didn’t do that we need to do it immediately before any more damage is done.
From a venue in sight of the Capitol building one can only hope the message from the panel will reach those with decision making capacity. While those who are skeptical certainly have reason to be doubtful, there is an optimism behind the scenes and a hope that has not existed in recent years. Where that leads and how soon is anyone’s guess.
Gene Quinn is a Patent Attorney and Editor and President & CEO ofIPWatchdog, Inc.. Gene founded IPWatchdog.com in 1999. Gene is also a principal lecturer in the PLI Patent Bar Review Course and Of Counsel to the law firm of Berenato & White, LLC. Gene’s specialty is in the area of strategic patent consulting, patent application drafting and patent prosecution. He consults with attorneys facing peculiar procedural issues at the Patent Office, advises investors and executives on patent law changes and pending litigation matters, and works with start-up businesses throughout the United States and around the world, primarily dealing with software and computer related innovations. Gene is admitted to practice law in New Hampshire, is a Registered Patent Attorney and is also admitted to practice before the United States Court of Appeals for the Federal Circuit. CLICK HERE to send Gene a message.
Tags:Chief Judge Michel, David Kappos, Gary Lauder, Jamie Simpson, Judge Kathleen O'Malley, LeadershIP, life sciences, patent, patent eligibility, patent eligible, patent system, patentable, patentable subject matter, patents, US Patent System
Posted In:IP News, IPWatchdog Articles
Night Writer April 10, 2018 11:03 am
>>“I thought I gave them a pretty good road map in Aqua Products, but that portion didn’t get a majority,” O’Malley said, to laughter in the audience.
O’Malley was the last judge to be appointed that wasn’t selected by Google.
But still she is not a very good judge to have on the CAFC. She had no patent experience prior to he appointment and no science background. Frankly, I think she is intelligent, honest, and well-meaning, but she is not qualified and doesn’t understand at a meaningful level the issues.
All the judges appointed after her are abysmal and were chosen to burn the system down. ( I think Chen was a surprise as he was very anti-patent before the appointment but flipped.)
Anon April 10, 2018 12:13 pm
Night Writer,
Recently, I had the benefit of conversing in some detail with a Washington insider, an attorney with a long and detailed history of interacting with the United States Court of Appeals for the Federal Circuit.
He had many interesting stories about several of the current Judges of the CAFC.
Part of our discussion centered around a reflection that Judge O’Malley does appear to have an earnest wish to properly apply the law and to have the CAFC meet its original mandate of bringing stability to patent law at the appeals court level.
However, what each of us surmised was that the body that which is the CAFC will not hew to such reason or efforts.
That group is – and will remain for the foreseeable future – out of control.
Try as may, the efforts of such as Judge O’Malley (and even more so, Judge Newman), will not suffice on their own due in no small part to the LACK of actual leadership from Judge Prost, and the egos of other judges, who refuse to adhere to anything but their own view of what patent law should be.
This is why in no small part that when I discuss my idea that Congress should engage in its Constitutional power of jurisdiction stripping of the non-original jurisdiction of patent appeals from the Supreme Court (to take back its statutory power and prevent law writing from the Bench – and yet maintain the holding of Marbury – which is for Article III review, and NOT Supreme Court review); that a NEW Article III court be established.
This existing one is tainted with the repeated Supreme Court beatdowns and just does not have the right constituents.
Curious April 10, 2018 12:38 pm
I don’t worry too much about the technical backgrounds of the CAFC. Certainly, it would be nice. However, I am far, far, more concerned about whether his/her guiding principle is “patents are the solution” versus “patents are the problem.”
The CAFC is supposed to give deference to findings of fact, which is where most of the “technical” stuff lies. Personally, I would rather that they be solid on the law and not try to invent ways to get around the law so as to arrive at a conclusion (i.e., the patent is invalid) that they predetermined before even reading the briefs.
The Alice/Mayo test is one big pile of poo. The tests are meaningless before just about any patent these days can pass either test (i.e., the test for patent eligible subject matter or patent ineligible subject matter). It now just comes down to who are the sitting on the panel in the Federal Circuit that determines whether your patent survives or not.
We’ve gone from statutory law to judge-made law to judges are the law.
angry dude April 10, 2018 1:31 pm
The doc said ‘to the morgue’, to the morgue it is!
Tesia Thomas April 10, 2018 1:33 pm
“The truth is most entrepreneurs to don’t realize how useless the patents they have are.”
Yes. And most people think everyone else’s patents are useless.
So, it’s a weird thing where my patents are valuable and yours are useless by the same rules.
PTAB doesn’t make weak patents weaker and strong patents stronger, it makes ALL patents WEAK. No one has strong IP.
Night Writer April 10, 2018 1:36 pm
@3 Curious: some good points, but I think the technical background does matter. I think that many of the non-technical judges just have no frame of reference by which to judge the facts or the invention. They are simply lost and the facts always come into play and are not simply given deference to the dist. ct.
>>We’ve gone from statutory law to judge-made law to judges are the law.
I think it went from judges (kings/queens) are the law, to judge-made law, to statutory law, to judge-made law, to judges are the law. Pretty darn sad.
American Cowboy April 10, 2018 1:42 pm
“More damage is done by burying deserving innovations and denying patents than by making a mistake here and there and issuing a patent that shouldn’t be issued.” Amen to that.
Invalidating a patent by spending hundreds of thousands of dollars to find some obscure reference with a teaching that those of ordinary skill in the art were not aware of before the patent issued, or even after the patent issued, strikes me as an injustice. The reference was only found because some defendant obstinately preferred to spend the money searching and litigating rather than designing around or paying a royalty.
Even if what the patentee has done amounts to “re-inventing” what was taught in the obscure reference, hasn’t she done a service to the public by publicizing what she invented?
If we are not going to go that far, at least stop the vilifying of inventors and those associated with them.
I think there are a lot of patent attorneys who spent many years understanding science and technology and find it offensive that people like Obama will appoint people with no science background.
Reality is that many cases depend on the underlying facts and need someone that can apply their science knowledge to understand what is going on. Plus, this is the one court in the country where a judge should have a science background.
(Probably more offensive that Obama ceded his authority to pick the appointment to Google for selection of anti-patent judicial activists.)
I also think that people just don’t appreciate what a profound difference it makes to have people trained in science. The current 101 tests are just outrageous. They seem to hearken back to the medieval thinking of spirits where our thinking was not performed by our brains but by our spirit in the spirit world. Etc.
The other thing is that those who know technology/science know that the steps of progress are often small. The ignorant think in terms of movies where a sole inventor makes an enormous leap by themselves. It goes on and on.
@Night Writer, 9
“The other thing is that those who know technology/science know that the steps of progress are often small. The ignorant think in terms of movies where a sole inventor makes an enormous leap by themselves.”
It’s both but neither are less of innovations than the other. The patent system should encourage both.
But, as in Josh Malone’s case, incumbents will PTAB and kill the patents of paradigm shifts.
Ternary April 10, 2018 2:04 pm
In one of my cases it was determined by a Primary Examiner, supervised by a panel of no less than two Supervisory Examiners, that a device with inputs to receive a signal and an output to provide a signal, is not a physical device. No arguments were provided why. All in support of a 101 rejection (without a 112, 102 or 103 rejection). The allegation was literally that “the claimed invention is not a physical device.” This is a situation wherein one would expect the SPE to ask the PE, “Are you sure about this argument? In my old textbooks, these were all very much physical devices. Perhaps you should rephrase.” It renders the PTO examination process and quality control an utter and complete farce. To have to rely on the PTAB or the Courts to correct it does not make an inventor feel any better about it. Frankly, I do not see Judge O’Malley correcting this.
The process is shamelessly riddled with unsupported rejections, technical nonsense and ignored rebuttals, adding to an unaffordable bill for independent inventors and generating patents that are susceptible to post-issuance invalidation, making them basically worthless.
I used to believe that the above occurrences were incidents. But I am starting to see this as a systematic flaw of the PTO and the system, induced by a bunker mindset/policy that no longer appears to know what its mission is, receiving incomplete and technically undefined guidance from the Courts and Congress and no longer embarrassed by producing technical nonsense. Having Judges and Justices (even well meaning ones) with no technical background does not help. They are just cementing in concrete a system that is hopelessly flawed. I am starting to believe that it is too late to salvage the system, at least too late for independent inventors.
Josh Malone April 10, 2018 2:06 pm
@American Cowboy – your spidey sense is correct, but I suggest phrasing it a little differently. We should all stand firmly for the provisions of §102 of the Patent Act, that only “new” inventions are patentable. Even if the reference is obscure and difficult to find, or even hidden – no one other than the original inventor is entitled to the exclusionary rights.
The problem is when obscure and hidden references are used to determine an invention is “obvious” under §103. KSR, hypothetical POSITA, prima facie showings are all esoteric legal fictions that bring in prior art to prove obviousness. The concepts of new and non-obvious must be kept distinct. If POSITA is effectively an encyclopedia and a computer that can run billions of permutations of all of the prior art in the field and analogous fields, then everything is obvious. But that is not the law, that is the result of paying lawyers and experts millions of dollars to use these tricks to argue that what the inventor discovered “would have been obvious”.
Josh Malone@12
Correct,
Obviousness MUST be determined by the PTO right at the get-go, without going back 10 years later to reassess it using all possible combinations of multiple “prior-art” references
Everything is obvious to everybody in hindsight, especially 10-20 years after patent is published and granted
PTO-Indentured April 10, 2018 3:05 pm
RE “patents are the problem” or not… @3
While philosophizing up to Q2 2018′–whether or not “patents are the problem”–since at least ‘AIA 2012’, the United States PTO eco-system of has figuratively been a ‘Rome burning’.
One benchmark alone should have sufficed to put an end to such philosophizing, and to instead make immediate course corrections:
The USPTO ranked #1 worldwide, pre-AIA,
The USPTO ranked 12th worldwide by Q2 2018 (and probably still in a nosedive).
This is NOT a matter of “Patents are the problem” rather, THOUSANDS of U.S. “Patents made defenseless/invalidated, therefore valueless/worthless–by
CBM challenges
serial IPRs
venues favorable / most proximate to defendants
a near extinction of licensed exclusivity and injunction rights…
Fanning to new heights, an efficient infringment addiction and epidemic.
All exacerbated by an AIA implemented intentional double-standard, whereby: the PTO sells you a property issued and deemed valid according to a first standard, then allows such validity to be challenged (knowingly) under a significantly easier-to-invalidate second standard, shown since 2012, to always render more of THEIR ‘issued properties’ invalid, defenseless and worthless than not (i.e., always a majority of THEIR patents not able to stand up to THEIR own easier-to-defeat challenges).
Seemingly then, for years (now), turning a blind eye, and rendering zero empathy not only to the demise of our/their own U.S. patent system, but also to the THOUSANDS of patentees who watched their properties get extinguished by the PTO always-lose-more-than-win system, and in a good deal of such cases additionally get hit with a requirement to pay all attorneys fees.
Final note: Good laws, are just laws.
No more philosophizing, ‘judge’ the AIA train wreck, and its injustice, for what it is, and let’s get back to the good laws ASAP that pre-AIA had ensured the #1 ranking of our U.S. patent sytem.
>Everything is obvious to everybody in hindsight, especially 10-20 years after patent is published and granted
that is the other thing about having non-science and non-patent people appointed to the CAFC. They have spent zero time thinking about hindsight reasoning.
Brian Pangrle April 10, 2018 4:23 pm
Ternary@11
I’ve seen it too. I venture to guess that the application is in AU 2800. AU 2800 has some examiners that are science deniers, much like another federal agency.
I had a junior examiner ask me the other day, in a rather sarcastic tone: “Why do you keep saying ‘preponderance of the evidence'”? Standards for fact finding, I guess not too important anymore.
Brian @16. It is just so exhausting and causes me “prosecution fatigue.” You get no reasonable response to any rebuttals, just the same standard crap lifted from a standard response.
I wish it was limited to junior Examiners. It is not. It seems nobody cares. Go fight it out before the PTAB or the Courts, but leave me alone, they seem to think. Perhaps the Examiners are also suffering from prosecution fatigue. The fun has completely gone out of it.
Brian Pangrle April 10, 2018 11:38 pm
Ternary@17, I remember chatting with Mr. Stoll, saying 101 “policy” would burn decades of goodwill. Reminds me of a Schwarzenegger movie where Arnold emerges from the smoke while others are engulfed in chaos, shooting at each other, expending their resources. Arnold navigates flawlessly because he created the chaos. Those that created the 101 chaos are certainly pleased.
Ternary April 11, 2018 9:47 am
Basically, the plan was to make it harder for independent inventors and small entities to fundamentally threaten incumbent companies. One event that accelerated the unhappiness of established industries with the “power of patents” was the NTP v. RIM case. Thus AIA was easily achieved, despite well argued opposition. There was never a single convincing argument for the positive effects of AIA. Yes, international harmonization was an argument. Why the heck would we care about harmonization with other lower rated patent systems? Let them harmonize with us. Have we seen one single instance wherein our economy has benefited from this harmonization? Absolutely not. In fact, our patent system, once the golden standard, is now at its lowest rating. Harmonization indeed.
I believe the ensuing chaos was unintended and was achieved by having KSR and Alice in the toxic mix of AIA. The intention was to “merely” create a costly patent system more like the European one, wherein the participants are limited to mainly large institutions and companies, shutting out the lifeblood of the US economy: small start-ups and independent inventors. That part of the Mission has been accomplished!
One point made above bears repeating. Having judges or the PTO look at new obvious arguments 10-15 years after the invention is fraught with hindsight reasoning. (This is another problem of appointing judges with no experience with patents and science.)
I’ve been around a long time. I’ve seen many things go from being incredibly difficult for people to understand to being put in the introductory course.
Tiburon April 11, 2018 11:37 am
It is ridiculous to suggest that the U.S. is #12 in innovation. If the stats you’re looking at say that then may I suggest you consider carefully what you’re looking at because the majority of innovative software and online services being created today still originate in the USA.
Give your heads a shake, Rome is not burning, the U.S. software and hardware industry is thriving. Startups are being created more than ever and investment into those startups is correspondingly up.
Ternary April 11, 2018 12:27 pm
Tiburon @21:
“We are at an inflection point with respect to the patent system itself. As a nation, we cannot continue down the same path if we want to maintain our global economic leadership. And we will not continue down the same path,” Iancu explained.
Tiburon April 11, 2018 1:02 pm
Ternary – the inflection point is behind us (2011, AIA, etc). It’s legacy shows us that while innovation incentives may have changed (less about patents, more about open collaboration and data), it has continued to thrive. U.S. is not #12 but rather remains #1, look around you.
Tiburon @23
In a capitalistic society incentive for “real innovation” (by “real” I mean R&D with the emphasis on R) is money and money only (used to be enabled by working patent system)
You can call open source software “innovation” all you want but
for the most part it’s just a replication of someone else’s original ideas and efforts
or just plainly insignificant for progress – e.g. no one really cares how many open source media players are out there – what really matters is the math used for encoding/decoding audio and video files
Anon April 11, 2018 2:36 pm
Tiburon,
Your comments do not accord with reality.
Tiburon. An inflection point (if you remember from calculus) is a point on a curve where the first derivative is 0. You may not know if a curve just inflects and continues or if you have reached an extremum. AIA/KSR/Alice are all part of a patent deteriorating trend and it will be very difficult to turn that trend around.
While I am all for collaboration and collaborative R&D, history shows that original ideas come from individuals and pretty much from obstinate/persistent/unconventional individuals. Groups accept new ideas mostly after substantial struggle. In fact, so-called collaborative groups are often organized to suppress unconventional ideas. Many of current “collaborative” research ideas are more of the same and are intended to not fall behind competitors, not to develop pioneering technology.
I see very few incentives nowadays for independent inventors to develop their inventions. Proponents of institutional R&D have declared many times that the time of the individual inventor has passed and have been active in removing incentives to help realizing their prediction.
@21 Tiburon Give your heads a shake, Rome is not burning, the U.S. software and hardware industry is thriving. Startups are being created more than ever and investment into those startups is correspondingly up.
The problem is that we do need to quantify the health of innovation in the USA. Wild statements can be made with no evidence.
One thing that is a good sign that the patent system is failing the innovation engine is that big corporations are hording money and not spending it on R&D. That indicates they aren’t afraid of competition and are instead setting up task forces to quickly take whatever innovation may be generated by start-ups.
Another thing to think about is that not one country has built an innovation engine without patents.
So maybe we can have a good innovation engine without patents, but it is a theoretical construct that has never been achieved.
Night Writer @ 27:
My statements are not wild and unsubstantiated.
Where are all the unemployed software and hardware engineers, programmers, and the like? Where are the recent grads in those programs not being snapped up?
I’ll answer for you: there are none. The industry is thriving like never before – yet according to this site, patents have never been more dead and useless. So how do you explain the juxtaposition and contradiction?
Ternary @ 26:
The origin of the incentives have changed but as evidenced by the industry thriving, the innovation continues.
angry dude @ 24:
When all you have is a hammer then everything looks like a nail.
Patents are hammers, but there are more tools in the shed.
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Fears of performing arts crackdown after Moscow theatre raided
Concerns as arts director’s home searched in inquiry into suspected theft of state funds
Thu, May 25, 2017, 16:41 Updated: Thu, May 25, 2017, 16:46
Isabel Gorst in Moscow
Journalists gather outside the Gogol Centre theatre in Moscow after it was raided by police. Photograph: Vasily Maximov/AFP/Getty Images
Twin police raids on one of Moscow’s most respected theatres and the home of its artistic director this week have sparked fears of an official crackdown on the Russian performing arts.
Russian actors appealed to President Vladimir Putin to intervene after law enforcers targeted Kirill Serebrennikov, the arts director of the Gogol Centre in a criminal case involving the alleged theft of millions of rubles of state funds.
Many observers believe that Mr Serebrennikov, who is renowned for his innovative work in the cinema and theatre, is being punished by the authorities for criticising Kremlin policies and refusing to bow to creeping state censorship of the arts.
Masked police and secret service agents swarmed into the Gogol Centre without explanation on Tuesday corralling theatre staff into a rehearsal hall and confiscating their mobile phones.
A few kilometres away police were already rifling through the apartment of Mr Serebrennikov in a six-hour search that ended when the director, complaining of being “shocked and bewildered” was taken away by law enforcers for questioning.
A large crowd gathered outside the the Gogol Centre on Tuesday evening to show their support for the theatre as actors, in a show of defiance, decided to go ahead with the planned evening performance.
Russia’s Investigative Committee said the police raids were linked to an investigation of the suspected theft of 200 million roubles (€3.16 million) awarded by the city government to Seventh Studio, an experimental drama group founded by Mr Serebrennikov in 2012.
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Police have arrested two suspects including the former general director and the chief accountant of Seventh Studio. Mr Serebrennikov, who was released on Tuesday evening after signing a gagging order agreeing not to reveal details of the investigation, is being regarded as a witness in the case.
Mr Putin’s press secretary, Dmitry Peskov, urged reporters not to politicise the raids on the Gogol Centre, saying the Kremlin had no hand in the matter.
That prompted Vladimir Urin, the head of the Bolshoi Theatre, to lead a group of directors and actors writing to Mr Putin to demand a fair and objective investigation of the Seventh Studio case.
Yevgeny Mironov, the artistic director at Moscow’s Theatre of Nations, took matters a step further when he was invited to the Kremlin to receive an award for his work on Thursday. As the champagne was flowing after the ceremony, Mr Mironov accosted the Russian president demanding to know why law enforcers had taken such extreme measures against Mr Serebrennikov.
Appointed as artistic director of the Gogol Centre in 2012, Mr Serebrennikov brought a new vigour to one of Moscow’s most respected yet slightly stuffy theatrical institutions with cutting edge, provocative productions.
But Mr Serebrennikov has made enemies along the way. Fiercely patriotic pro-Kremlin groups detected amorality and slander in his work and loathed the Gogol Centre’s bold interpretations of Russian classical literature.
Offended
Mr Serebrennikov’s film The Student, tracing the story of a troubled schoolboy who becomes a religious fanatic, won a prize at the Cannes Film Festival last year, but offended some Russian Christian Orthodox believers.
Then there were arguments with Vladimir Medinsky, the highly conservative Russian cultural minister, who considers state funding for art that conflicts with traditional values a waste of taxpayers’ money. Mr Medinsky’s declared policy “to water only the useful flowers,” was seen at the Gogol Centre as state censorship in disguise.
Many political commentators believe it will not be long before Mr Serebrennikov loses his job at the Gogol Centre and the theatre that flags itself as “a place of freedom” on its website, will become a symbol of latent official repression of the arts.
“Minister of culture Medinsky has been trying to replace Serebrennikov with someone else for a long time,” Stanislav Belkovsky, a Russian political commentator, wrote on the Open Russia website this week. “We’ll soon find out who that is.”
The authorities’ attack on Mr Serebrennikov is part of an alarming trend in Russia where the “theatre is becoming one of the main battlegrounds between the state and national cultural institutions,” Svobodnoe Slovo (Free Speech) a Russian literary rights group warned this week.
“All of the theatre directors who have experienced repressive measures are known for their social and political criticism.”
Dmitry Peskov
Kirill Serebrennikov
Stanislav Belkovsky
Vladimir Medinsky
Vladimir Urin
Yevgeny Mironov
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Intelligence sources vouch for author of Russia-Trump dossier
Ex-MI6 officer Christopher Steele a ‘highly-regarded professional’
Thu, Jan 12, 2017, 15:55 Updated: Thu, Jan 12, 2017, 15:58
Nick Hopkins, Luke Harding
Speaking in Trump Tower, New York, US President-elect has accused opponents of releasing 'fake news' about him
President-elect Donald Trump at a news conference in the lobby of Trump Tower in New York on Wednesday. Photograph: Evan Vucci/AP
A journalist rings the bell of the building housing the offices of business consultants Orbis Business Intelligence Ltd in central London on Thursday. Photograph: Daniel Leal-Olivas/AFP/Getty Images
His denials – at least some of them – were emphatic, even by the standards that Donald Trump has come to be judged by. The dossier, he said, was a confection of lies; he compared it to Nazi propaganda; it was fake news spread by sick people.
At his press briefing on Wednesday, the president-elect effectively dared the world’s media to scrutinise the 35 pages of claims, before throwing down a challenge – where’s the proof? Nobody had any. Case closed.
But in the rush to trample all over the dossier and its contents, one key question remained. Why had America’s intelligence agencies felt it necessary to provide a compendium of the claims to Barack Obama and Trump himself?
And the answer to that lies in the credibility of its apparent author, the ex-MI6 officer Christopher Steele, the quality of the sources he has and the quality of the people who were prepared to vouch for him.
In both respects, the 53-year-old was in credit. Former colleagues of Steele describe him as “very credible” – a sober, cautious and meticulous professional with a formidable track record.
One former foreign office official who has known Steele for 25 years and considers him a friend, said: “The idea his work is fake or a cowboy operation is false, completely untrue. Chris is an experienced and highly regarded professional. He’s not the sort of person who will simply pass on gossip.
“If he puts something in a report, he believes there’s sufficient credibility in it for it to be worth considering. Chris is a very straight guy. He could not have survived in the job he was in if he had been prone to flights of fancy or doing things in an ill-considered way.”
That is the way the CIA and the FBI, not to mention the British government, regarded him, too. It’s not hard to see why.
An Oxford graduate, Steele was one of the Secret Intelligence Service’s (MI6’s) more eminent Russia specialists. The Guardian understands he focused on Soviet affairs after joining the agency, and spent two years living in Moscow in the early 1990s.
This was a period when Russia, and the breakup of the eastern bloc, was still the prime focus for Britain’s intelligence agencies and a successful spell in the region was a good way to get on.
By all accounts, that’s exactly what Steele did.
And his interest in Russia did not diminish as he continued to rise up the ranks, which at the time included his friend and contemporary Alex Younger – now head of MI6.
Over a career that spanned more than 20 years, Steele did a series of different roles, but always appeared to be drawn back to Russia; he was, sources say, head of MI6’s Russia desk. When the agency was plunged into panic stations over the poisoning of its agent Alexander Litvinenko in 2006, the then chief, Sir John Scarlett, needed a trusted senior officer to plot a way through the minefield ahead – so he turned to Steele.
It was Steele, sources say, who correctly and quickly realised Litvinenko’s death was a Russian state “hit”.
As good as he was, Steele was unlikely to get the top MI6 job, perhaps because his specialisms were not a priority in that period – Russian espionage was taking a back seat to Islamic terrorist and non-state threats.
And, of course, there was money to be made in the private sector – lots of it, particularly in the last two years. He decided to quit the service in 2009.
As the Russian president, Vladimir Putin, exerted influence in all kinds of spheres, so Steele’s background made him hot property indeed. Though he could not travel to Russia, Steele appears to have kept up his contacts and made new ones, using old-school techniques: going out, meeting people, shaking hands, making friends – and paying for information.
With his partner Chris Burrows, he set up the London-based company Orbis Business Intelligence, which was busy and expanding. Their operation would have been a good choice for anyone trying to gather intelligence about Russia and Trump.
It is unlikely that Steele would have had direct contact with the unnamed Kremlin officials who allegedly gave sensitive information on the president-elect. In fact, it’s believed the former spy hasn’t been able to visit Russia for more than 20 years.
Rather, Steele would have tapped up his network of sources deep inside the country, some of them dating from his time there, others cultivated later, British officials suggested.
In turn, these individuals will have had sources of their own. Steele would likely have subcontracted some of his Trump investigation to trusted intermediaries in Moscow, who will have reported back to him via secure channels.
This method of intelligence collection may explain the odd language anomaly in the Trump dossier that emerged into the public eye late on Tuesday.
In a September briefing note, Steele mentions the Alpha-Group, a reference to the consortium headed by the powerful oligarch Mikhail Fridman. The more usual English spelling is Alfa.
Almost certainly, a native Russian speaker wrote the original material, correctly transliterating the Russian “f” as “ph”. It was Steele’s job to collate, evaluate and verify this material before passing it to his American client Fusion GPS, a Washington-based political research firm.
The company had been hired originally by one of Trump’s early Republican opponents before the contract was taken up by senior Democrats.
The foreign office official who spoke to the Guardian on Thursday acknowledged that the Steele dossier isn’t perfect. But he pointed out that intelligence reports always come with “gradations of veracity” and include phrases such as “a high degree of probability”.
“You aren’t dealing with a binary world where you can say this is true and this isn’t,” the official said.
He added: “The strongest reason for giving this report credence is that intelligence professionals in the US take it seriously. They were sufficiently persuaded by the author’s track record to find the contents worth passing to the president and president-elect.”
The CIA and FBI will have taken various factors into consideration before deciding it had credibility. They include Trump’s public comments during the campaign, when he urged Russia to hack Hillary Clinton’s emails. The agencies may also have classified intercept material provided by the National Security Agency and Britain’s GCHQ.
They must, equally, have considered whether some of the claims in the report might have been part of an elaborate Russian disinformation exercise.
“This is unlikely. The dossier is multi-dimensional, involving many different people, and many moving parts,” the official suggested.
Steele’s personal views on Russia are unlikely to be very different from those of his former employers. Or from a former UK ambassador to Moscow, who is understood to have passed the dossier to the Republican senator John McCain, who in turn passed it to the FBI.
SIS has been privately warning that Putin, unchallenged by the west, has grown in confidence and, of course, that the Kremlin has targeted Trump. It would be odd if they hadn’t. The consensus among British securocrats is that “Putin is a wolf . . . and he preys on the weakest sheep”.
But intelligence is not evidence, and Steele would have known, better than anyone, that the information he was gathering was not fact, and could be wrong. In the smoke and mirrors world of counter-espionage, there are few certainties.
Those caveats do not appear on the documents – but it’s what Steele warns any prospective new clients.
Whether he could have imagined that a summary of his work would be used in the way it has is a moot point; Steele did not go to ground in the weeks before Christmas as different US media outlets tried to stand up some of the claims against Trump. He was in London, thinking about where to take Orbis next, eating his favourite tapas and pottering around Victoria, where his newly refurbished office is based.
From Moscow’s perspective, the report’s publication can hardly be counted a success. As a former KGB agent, Putin understands the first rule of intelligence: that special operations should remain secret.
“In the world in which Putin operates, if people can see the strings you’ve failed,” the foreign office official said. “The Russians will be asking: “How the hell did it get out?”
The spotlight is certainly not something Steele was looking for. He is mainly distrustful of the media – he chooses who to speak to, having been let down, so he has confided to friends, by reporters working for a Sunday newspaper.
After a career in MI6, anonymity is something he has prized. He once asked a journalist if he had ever heard of him. The reporter’s reply was a decisive: “No.” Steele was relieved. “That’s the way I like it.”
Now that his cover has been blown, his next steps are uncertain. The fact that Steele is a British citizen, and an outed former MI6 officer, makes him relatively secure from any act of Russian revenge. At the moment, the situation may look bleak for Steele; he’s in hiding, apparently fearful for his life. But things can change.
“This will eventually blow over,” Steele’s friend said. “What you are left with is a effective marketing campaign. He’s a very sober guy but he also has a sense of humour.”
– Guardian
Alex Younger
Chris Burrows
Christopher Steele
John Scarlett
Mikhail Fridman
Secret Intelligence Service
London(GB)
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Nicolas Roeg: the director who took the familiar and made it strange
November 24, 2018, 17:34
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Cergol Sets Record Straight at League of Women Voters Debate
Greenlawn -- Huntington Councilwoman Joan Cergol used the occasion of the annual League of Women Voters Meet the Candidates debate October 22 to set the record straight on where she stands on issues and to highlight the clear differences between herself and her Republican opponent.
Among the starkest distinctions were in the areas of the proposed 2019 Town budget and the need for diversity on the Town Board. Councilwoman Cergol noted that she opposes the administration’s submitted budget because it increases taxes and raises fees, including a general property tax hike, a proposed 50 percent hike in rates in the Dix Hills Water District and the imposition of mooring fees for Town residents who own boats. In contrast, Republican James Leonick said he had been too busy campaigning to look at the budget.
Councilwoman Cergol noted that women represent 51 percent of the population and that she is the only woman on the five-member board. If she were unsuccessful in her election bid, the Town Board would be all male. Leonick said he “did not see an issue” with a Town Board that’s composition did not attempt to represent any of the Town’s many diverse components – gender, race and ethnic background.
Councilwoman Cergol also cited her experience in both the private sector and Town government and how she had obtained $20 million in grants for community revitalization, much of that for Huntington Station. She spoke of the need to create additional business opportunities and affordable housing for the area, in fulfilling the desires community members expressed in meetings over the past decade. Leonick suggested what the community really wanted for revitalization was brighter street lights on New York Avenue.
In response to questions from the audience, Councilwoman Cergol noted that she is committed to protecting Huntington’s history and historic structures and cited her vote against a proposed development at the historic Platt’s Tavern site on Main Street and Park Avenue in Huntington Village.
Asked about her vision for Huntington Village 10 years from now, she spoke of reacting to the changing retail environment and the possibility of turning parking lots into green spaces if car use declines, as some have forecast. A key to Huntington’s future, she noted, is creating jobs and affordable housing.
When asked about the LIPA tax certiorari suit, Councilwoman Cergol spoke of the need to be unified in its opposition and to continue working with the Northport-East Northport School District in seeking a resolution. “It needs NOT to be a political issue,” she said. Leonick’s main point was that he needed to “educate people in the Town” about the existence of the suit and its ramifications.
But perhaps the greatest difference came in response to a question about independence. Leonick noted that he was part of the Republican team. As Councilwoman Cergol noted, “I don’t wear my political affiliation on my sleeve. I am an independent, not part of a team. Being part of a team suggests a rubber stamp. I refuse to deal in absolutes. I evaluate every matter and make decisions based on their merits, not on a political view or party-line vote.”
Councilwoman Cergol, who was named to the seat in December after spending 17 years in government and 18 in the private sector, is running on the Democratic, Independence, Working Families and Women’s Equality lines
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Nat Turner: A Troublesome Property
Nat Turner's slave rebellion is a watershed event in America's long and troubled history of slavery and racial conflict. NAT TURNER: A TROUBLESOME PROPERTY tells the story of that violent confrontation and of the ways that story has been continuously re-told during the years since 1831. It is a film about a critical moment in American history and of the multiple ways in which that moment has since been remembered. Nat Turner was a "troublesome property" for his master and he has remained a "troublesome property" for the historians, novelists, dramatists, artists and many others who have struggled to understand him.
A unique collaboration between MacArthur Genius Award feature director Charles Burnett, acclaimed historian of slavery Kenneth S. Greenberg and award-winning documentary producer Frank Christopher.
"This film about the historic figure Nat Turner is magnificent. It is required viewing by all who are deeply concerned about the nature of race relations in America." - Cornel West, Princeton University
"Brilliant work. The myth and reality of this slave rebel are both explored in an unblinking and historically informed way. And most tellingly, this film unravels the enduring dilemma of knowing and representing this most vexing aspect of American history - revolutionary violence by slaves seeking their own freedom. Finally, the elusive Nat Turner story, and the multiple ways of representing it, has been captured in this stunning and original film." - David W. Blight, Yale University
"Both public and academic library collections, alike, will be enhanced by this film, which is highly recommended." - Educational Media Reviews Online
Frank Christopher, Kenneth Greenberg
Nat Turner's Rebellion
Part of the Series: Up From Slavery
This part of the series presents the reaction by individuals and parties to the continued use of slave labor
Slavery in the United States After the Revolution
This segment of the series talks of the changes in slavery in the newly-created United States and the
Abolition from the North Grows
This segment of the series speaks about the efforts by Northern Abolitionists to eliminate slavery prior to the Civil War.
Aftermath of the Civil War and New "Freedom"
This section of the series looks at the conclusion of the War Between the States and the effects of the outcome for slaves, slave owners and the entire country.
The Abolitionists Part 1
Episode 1 of American Experience: The Abolitionists
Shared beliefs about slavery bring together Angelina Grimke, the daughter of a Charleston plantation family, who moves north and becomes a public speaker against slavery; Frederick Douglass, a young slave who becomes hopeful when he hears about the abolitionists; William Lloyd Garrison, who founds the newspaper The Liberator, a powerful…
Douglass escapes slavery, eventually joining Garrison in the anti-slavery movement. Threatened with capture by his former owner, Douglass flees to England, returning to the U.S. in 1847. He launches his own anti-slavery paper. John Brown meets with Douglass, revealing his radical plan to raise an army, attack plantations and free…
The battle between pro-slavery and free-soil contingents rises to fever pitch. During his raid on Harpers Ferry, John Brown is captured, then executed, becoming a martyr for the cause. Abraham Lincoln is elected president in 1860. Southern states secede, war breaks out and the conflict unexpectedly drags on. On New…
American Experience: The Abolitionists
Vividly bringing to life the epic struggles of the men and women who fought to end slavery, THE ABOLITIONISTS tells the intertwined stories of Frederick Douglass, William Lloyd Garrison, Angelina Grimke, Harriet Beecher Stowe and John Brown. Fighting body and soul, they led the most important civil rights crusade in…
The Age of Slavery - 1780-1860
Part of the Series: The African Americans
What made cotton so desirable? In the 1790s Americas oldest crops, like tobacco, were depleting farmland and dropping in value. At the same time, the textile industry in Great Britain was exploding, creating enormous international demand for cotton clothing. Eli Whitney's invention of the cotton gin, which easily separated cotton…
The Jackson Years: Toward Civil War
Part of the Series: Shaping of the American Nation Collection
The forceful personality of Old Hickory (Andrew Jackson) dominates this investigation of the major events of his presidential administration -- South Carolina's threat of succession, Nat Turner's rebellion, and John Quincy Adams' struggle to debate the question of slavery -- all as America marches toward civil war. "A textbook made…
A Slave's Story - Running a Thousand Miles to Freedom
Based on a slave narrative by William and Ellen Craft. This dramatization of the Crafts' escape from slavery in 1848 follows their perilous journey from the Deep South to Philadelphia--where, on free soil, they were still to experience racial discrimination. "Excellent for exposing racial stereotypes."--History Teacher. An LCA release. Honored…
Emancipation Road: 1625-1863 - The Shadows of Slavery
Part of the Series: Emancipation Road
This first episode takes a look into the history of slavery in the United States, from the beginnings of the Atlantic slave trade to the Civil War.
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Teen hit by car making good progress
Updated: 5:05 PM CDT Aug 31, 2012
A Des Moines teen who was hit by a vehicle near Roosevelt High School in Des Moines more than a week ago is making progress to recover.The crash was reported near Polk Boulevard and Harwood Drive about 2:57 p.m. a couple blocks south of the school.Police said two cars were headed south on Polk Boulevard when 14-year-old Matthew Gardner tried to cross street. The first car stopped and waived Gardner across.The second car driven by Xavier Williams, of West Des Moines, went around the first car and hit Gardner, police said.Gardner has serious head injuries, but family said he's making pretty good progress. They are constantly at his side encouraging him to fight on.He is out of a medically induced coma and starting to communicate, but his family knows it will be a long journey.They said it's too early to tell how he's going to progress, but they have high hopes.If you'd like to help Gardner and his family you can make donations to the Matthew Gardner fund at any metro Des Moines area U.S. Bank location.
A Des Moines teen who was hit by a vehicle near Roosevelt High School in Des Moines more than a week ago is making progress to recover.
The crash was reported near Polk Boulevard and Harwood Drive about 2:57 p.m. a couple blocks south of the school.
Police said two cars were headed south on Polk Boulevard when 14-year-old Matthew Gardner tried to cross street. The first car stopped and waived Gardner across.
The second car driven by Xavier Williams, of West Des Moines, went around the first car and hit Gardner, police said.
Gardner has serious head injuries, but family said he's making pretty good progress. They are constantly at his side encouraging him to fight on.
He is out of a medically induced coma and starting to communicate, but his family knows it will be a long journey.
They said it's too early to tell how he's going to progress, but they have high hopes.
If you'd like to help Gardner and his family you can make donations to the Matthew Gardner fund at any metro Des Moines area U.S. Bank location.
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Mark de Clive-Lowe, London
Jazz Cafe, London
http://www.mdcl.tv/tour/
Musical polymath Mark de Clive-Lowe seems an impossibility at first sight - juggling piano, synths, live sampling and beat making all on-the-fly, brought to life with a casual ease that’s mind-boggling. The Japanese-New Zealander was raised primarily in New Zealand where he learnt piano from a young age developing an avid passion for jazz through his father’s record collection. In high school, he fell in love with Native Tongues hip hop and early UK jungle – laying the foundation for what was to come next…
During his hugely formative decade at the epicenter of London’s underground music scene, MdCL helped evolve broken beat alongside some of the UK’s most forward-thinking trailblazers, establishing himself as a new voice in progressive electronic music and leading global tastemaker DJ Gilles Peterson to designate him “the main behind a million great tunes”. Since 2008, MdCL has called Los Angeles, California home where his acclaimed club night CHURCH has taken his signature sound of technology and beat-infused jazz mash-up from coast to coast and around the globe. Equal parts pianist, composer and live production wizard, MdCL’s sets are a treat for the listeners, the dancers, the progressives and the purists alike - as he casually erases the lines between genres and eras.
Whether he’s remixing classic Blue Note Records in real time, on stage joined by the likes of Kamasi Washington, Nia Andrews or Eric Harland, improvising solo piano or creating live soundtracks to classic film material, MdCL is an artist in constant evolution, reaching for that next level. He has performed with Harvey Mason, Miguel Atwood-Ferguson, Dwight Trible and Jean Grae; remixed Shirley Horn, Hiatus Kaiyote, Mantombi Matotiyana and Jerry Goldsmith; and recorded as producer and collaborator with artists all over the planet. Having contributed to over 300 releases, to call MdCL prolific is something of an understatement.
MdCL has featured at festivals including Montreal Jazz, North Sea Jazz, Uberjazz, Tokyo Crossover Jazz Festival, Montreux Jazz Atlanta and is an established performer globally from South Africa to Japan and across the US and Europe.
Attend Contact
Friday, 17 March 2017, 07:00 PM - Friday, 17 March 2017, 11:00 PM
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News and Photo Submission
Kelowna Contests
Arts & Entertainment News
Kelowna Home and Garden
World News posted Sep 9, 2018 @ 08:00pm by Stephanie Hilash
NYC train station reopens nearly 17 years after 9/11
The WTC Cortlandt subway station in New York City closed down after it was destroyed on 9/11.
Today, it reopened for the first time in nearly 17 years.
The new WTC Cortlandt station on the 1 line is now open to the public. It’s fully accessible, has fewer columns for easier customer flow, and is also air-tempered to keep you cooler on hot days. pic.twitter.com/A5DaiBb06w
— NYCT Subway (@NYCTSubway) September 8, 2018
According to the NYCT Subway, the station is fully accessible, has fewer columns to ensure better customer flow and is air-tempered.
The station has also become the home to a number of art installations and mosaics including a piece that features woven text from the U.S. Declaration of Independence and the 1948 United Nations Universal Declaration of Human Rights.
The name of the station references its location within the World Trade Centre site as well as its legacy under Cortlandt Street.
This $181 million upgrade is now fully accessible to the public.
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ΑρχικήINFORMATIONTHE HISTORY OF THE HIV/AIDS EPIDEMIC
24 August 2017 5 July 2018 Kentrozois Press
1920 - 1980: The origin and initial spread of HIV
All available scientific data suggest that HIV originates from a family of viruses that infect the immune system of the primates (Simian Immunodeficiency Virus / SIV). The ancestral viral strain is hypothesized to have been first transferred to humans around the 1920s in Central Africa (today’s Democratic Republic of the Congo), probably during chimpanzee hunt.
Various factors, such as the conditions of extreme poverty and the rapid urbanization of many African countries, as well as the large migration movements during the 50s and 60s, contributed to the spread of HIV around the globe during the decades that followed.
Research on the origins of HIV began in the mid-’80s, almost simultaneously with the discovery that the cause of AIDS, that yet incomprehensible illness that was spreading around the world (see What is AIDS?), is this previously unknown virus (see What is HIV?). The discovery of HIV raised many hopes in the medical community, which, until then, was simply viewing a constantly increasing number of people, mainly young, rapidly led to premature death, without understanding why and without being able to provide any actual help. Since the cause of AIDS became known, it was just a matter of time, as many believed, for the virus to be further examined, its mechanisms to become understood, and finally a way of treatment to be discovered, as it had actually occurred with many other viral diseases in the past. Research on the origin of HIV was, from the beginning, an important part of this effort.
Researchers soon focused their attention on the region of Central Africa, where the AIDS epidemic had already spread largely during the 1960s and 1970s, as it was finally realized, as well as on a group of viruses that infect apes (monkeys, chimpanzees etc.). This particular virus family, known as SIV (Simian Immunodeficiency Virus), has many genetic similarities to HIV and may cause to some of these animals a syndrome similar to AIDS. The basic assumption was that one of the SIV strains had been somehow transferred to humans and eventually developed, after a series of mutations and adaptations, to the current HIV [1]. Besides, this is something that often occurs in nature, especially among related animal species.
The first indication in favor of the above case was the discovery of a second virus, in 1986, which also caused AIDS to people in West Africa [2]. In the same year, the two AIDS viruses were named as they are currently known, so that they can be distinguished from each other: HIV-1 and HIV-2. Surprisingly, HIV-2 differed largely genetically from HIV-1, but was similar to a SIV virus type, that caused immune deficiency to macaques, a monkey species living in Africa. In the next few years, more than 40 virus types of SIV were discovered in various species of primates in Sub-Saharan Africa. Some of them were genetically similar to HIV-1, some to HIV-2, but all of them seemed to belong to the same genetic family tree. The genetic and genealogical connection of all these viruses indicated that both HIV-1 and HIV-2 were the evolutionary product from a series of transitions and adaptations of these precursor viruses of the SIV family, from species to species and, finally, to humans [3,4].
Indeed, through an exhausting process of collection and genetic analysis of virus samples from the SIV family, that lasted for more than a decade, later studies provided strong evidence that the most immediate ancestor of HIV-1 is the SIVcpz strain, which was discovered in chimpanzees of Central Africa [5], while the HIV-2 ancestor is the SIVsmm strain , which was discovered in the sooty mangabey monkeys [6] (see Figure 1). Somehow, at some point, these strains were passed from these animals on to humans and then followed their own evolutionary course in their new host. From the two HIV types, HIV-1 is by far the most studied one, as HIV-2 is less contagious and found almost exclusively in West Africa. The following text refers only to HIV-1.
Figure 1. The origin of HIV-1 and HIV-2 viruses (source: Sharp & Hahn (2011). Origins of HIV and the AIDS Pandemic)
After the formulation of its genealogical tree, the next step in the research on HIV origin was to trace the path it followed into the human population and to determine the time and place, where the HIV precursor virus first transferred from chimpanzees to humans. This opportunity is offered by modern methods of epidemiological, genetic and molecular biology, by studying the mutations that – in the case of HIV – occur at a steady rate.
Thus, all the available data indicate that the first transmission to humans occurred between 1910 and 1930 in the wider Kinshasa region, the capital of the current Democratic Republic of Congo, a Belgian colony until 1960 [4]. According to the most widely accepted theory, the transmission occurred during chimpanzee hunting, a practice that is still common among peasant groups of Central Africa. It is assumed that an injured hunter probably came in contact with the blood of a killed animal and then transferred the virus to his community through sexual intercourse. This should have happened not once, but several times and the human immune system should have managed in most cases to cope with the new virus. However, since the virus had the opportunity, even for a limited amount of time, to multiply within the body of its new hosts, it went through mutations, some of which helped it adapt to the environment of the human body and manage to escape the human immune system [7].
Figure 2. All available data indicate that the first transfer of the HIV precursor virus (SIVcpz) to humans occurred around 1920 in the Kinshasa region, the capital of the current Democratic Republic of Congo, a Belgian colony until 1960
Figure 3. It is assumed that the HIV precursor virus first transferred to humans during chimpanzee hunting, a practice common among peasants in Central Africa
In the following decades, the spread of HIV to the African population remained relatively limited, as the human communities were small, scattered and disconnected from each other. Things changed during the 1960s, with the departure of colonial powers and the independence of African countries. The conditions of extreme poverty, due to the long-standing colonial exploitation, led to an increasing concentration of the population in large urban centers, as well as many women to prostitution. A common practice that contributed to the spread of the virus was the massive vaccinations with reusable needles. The first AIDS-confirmed death (based on a preserved blood sample) occurred in 1959 to a man, resident in the town of Leopoldville (renamed Kinshasa in 1966), which was back then capital of the Belgian colony of Congo [8]. As it was discovered several years later, AIDS had already appeared during the 1960s and 1970s in a large part of the population, male and female, in countries of Central and West Africa.
Figure 4. The capital of the Belgian Congo, Leopoldville (today’s Kinshasa), in the late ’20s
Figure 5. Kinshasa, Democratic Republic of Congo, 1960s: Central African societies that have been in decline for decades were led to sudden urbanization, after the collapse of the colonial powers, which significantly contributed to the spread of HIV
It certainly makes no impression that these first AIDS epidemics in Africa went unnoticed by the developed world. During the 1970s, however, HIV continues to spread silently from Africa to the rest of the world, especially to the United States, following the large migration flows that took place at that time. It would take about a decade for the first US citizens infected by the virus, to start experiencing the symptoms of a new, unexplained and fatal illness, which was named AIDS a few years later (see below 1981-1994: From inaction to massive panic).
1981 - 1994: From inaction to massive panic
Since the first years of the AIDS epidemic in the US, HIV has been strongly associated with male homosexuality, drug abuse and ‘deviant’ behavior in general. In this way, HIV/AIDS was primarily understood a lot more in moral terms rather than in terms of medical science.
The initial indifference or even contempt for HIV/AIDS, as a disease that exclusively affects certain minorities, gave way to terror and mass hysteria during the mid-80s, after the deaths of well-known figures of the American society, which escalated the stigmatization and social exclusion of people living with HIV/AIDS.
In 1983, it was discovered that AIDS is caused by a retrovirus, which in 1986 was named HIV. In 1985, the first screening test for HIV was made available (ELISA). The initial expectations for prompt development of an effective treatment strategy for HIV infection soon proved to be far too optimistic, as the complex mechanisms of HIV were becoming more fully understood.
The action of massive social movements, since the late 80s and on, contributed to a significantly increased funding of research programmes for HIV/AIDS treatment and accelerated progress in this field.
Until 1995, AIDS remained synonymous to death, as no treatment prospect had been shown to have any lasting and beneficial effect. Globally, it was estimated that, by 1995, about 20 million people were infected by HIV and 6.4 million people had already died of AIDS.
If the first part of the HIV/AIDS history is more closely linked to the countries of Central Africa (see above 1920 – 1980: The origin and initial spread of HIV), the second one focuses primarily on the United States, the country that became the centre of major sociopolitical and scientific developments, which largely determined the attitude towards the HIV/AIDS epidemic in the following years.
2.1. The first inexplicable incidents
In the early months of 1981, an unexplained increase in the incidence of some particularly unusual diseases was observed in the hospitals of Los Angeles, San Francisco and New York, in young and previously healthy people, such as pneumonia from carinii pneumonocystis, a serious respiratory infection and Kaposi sarcoma, a viral form of skin cancer. The problem was that these specific diseases are extremely rare and typically occur only in patients that suffer heavy immunosuppression. Indeed, it was soon discovered that the common feature between all these people was the almost complete absence of T4 helper lymphocytes in their blood, that is, the severe deficiency of their immune system (see How does HIV affect the immune system?). However, there was no obvious explanation for why this was happening.
In June 1981, the US Center for Disease Control and Prevention (CDC), realizing that the situation was unprecedented and needing to attract the attention of doctors and encourage the reporting of similar incidents in hospitals across the country, published in its weekly edition ‘Morbidity and Mortality Weekly Report’ a clinical description of the 5 first patients (see Figure 6) [9]. It was the first official scientific publication on the syndrome which, about a year later, would be named AIDS. By the end of the year, the recorded incidents were 270. With their immune system destroyed, these patients were essentially surrendered to a series of exhausting illnesses, having no therapeutic potential. Most of them died within a few months.
Figure 6. The first scientific report on the syndrome, which, a year later, would be named AIDS (http://www.cdc.gov/mmwr/preview/mmwrhtml/june_5.htm)
2.2. The association of AIDS with male homosexuality
What initially caught the attention of the American medical community was the fact that the vast majority of these incidents concerned young gay men with a distinctive social profile: particularly active sexually for about a decade, frequent partner changes and frequent use of recreational drugs. Besides, most reports came from large urban cities such as New York, Los Angeles and San Francisco, where the echo of the 1960s radical movements was still strong and where, due to the relative tolerance towards homosexuality, the biggest part of the young gay population of the country was gathered. On the contrary, the attitude of the rest, essentially puritanical and conservative, American society regarding homosexuality was clearly negative and gay men were a stigmatized and widely marginalized social group [10].
It was, therefore, reasonable for the largest part of the American society, scientific or non-scientific, to believe that the new illness is somehow connected or caused by the unacceptable sexual behavior and the habits of homosexual men. Initially, the use of poppers, a group of inhaled drugs particularly popular among gay men, was accused. Another suggested explanation was the ‘overloading of the immune system’, according to which the frequent appearance of sexually transmitted diseases among gay men eventually caused the exhaustion and collapse of the immune system [11]. Of course, there were also religious explanations, according to which, AIDS was just one (welcome for many) punitive intervention of god towards those who disobeyed his laws.
Thus, from the very beginning, the HIV/AIDS history was associated with male homosexuality, sexual liberty and, in more general terms, “deviant” sexual behavior. In this way, HIV and AIDS became understood based more on ethical terms rather than on medical science [10,12,13]. This has been in many ways critical, when it comes to how the epidemic was dealt with in the US and other Western countries in the years to come and, to a large extent, still to this day (also see “High risk groups” or the origins of stigma).
Figure 7. Greenwich Village, New York: the most important centre of the American gay community in the 1980s and the district that suffered the biggest blow in the early years of the HIV/AIDS epidemic [11]
2.3. From contempt to mass hysteria
Early on, indications existed that AIDS does not only concern gay men, but the whole population. In 1981, there had already been reports of transmission of this yet inexplicable illness to women through heterosexual sexual intercourse in the US, in many European countries and mainly in Africa. In addition, after November 1981, starting from the district of Bronx in New York, a constantly increasing number of new AIDS diagnoses was discovered among people that made injecting drug use. However, the group of people that experienced the greatest impact, already after 1982, was people that regularly received blood transfusions (mainly patients with hemophilia, a hereditary disorder of blood clotting). In the next few years, almost 50% of hemophiliac patients were infected by HIV.
Figure 8. Bronx, New York: After homosexual men, intravenous drug users, mainly African-Americans, were the second group of the US population to suffer from HIV/AIDS
However, the government and most of the American society, as well as the scientific community, continued to view AIDS exclusively as a problem regarding homosexual men and drug addicts, that is, marginalized population groups that were faced with indifference and contempt. In addition, the HIV/AIDS epidemic emerged after a period of intense action of movements that supported the human rights of minority groups, such as homosexuals and African-Americans, which back then fueled the deep conflict and polarization of the American society (see “High risk groups” or the origins of stigma). As a result, the expression of sympathy or interest for AIDS patients could easily be viewed as support for the gay community and the respective activist movements, which was deterrent for most of the political and scientific world [12].
It is, therefore, not surprising that the attitude towards AIDS patients, during the early years of the epidemic, was characterized by indifference and even hostility. Prior to the introduction of the term “AIDS”, in August 1982, the majority of people referred to the new syndrome with contempt, using degrading terms such as GRID (Gay-related immune deficiency, sounding similar to greed), Gay Cancer or Gay Plague. Public figures, especially from the super-conservative religious world, welcomed the divine intervention that would finally clear society from the moral perversion brought by homosexuals. In congresses of the Republican Party slogans had appeared, such as “AIDS is killing all the right people”. Besides, the appearance of the HIV/AIDS epidemic in the US coincides with the presidency of the conservative republican Ronald Reagan as the 40th president of the US (1981-1989). During all the years of the Reagan presidency and although deaths from AIDS doubled each year, the HIV/AIDS epidemic was largely ignored and no significant measure was taken that could prevent or deal with the problem, while the relevant research was firmly undermined [10,12,13].
The event that shook the untroubled, until then, American society and brought AIDS to the forefront was the death of the Hollywood movie star Rock Hudson on October 2, 1985. It was the first death of a well-known and especially popular person from AIDS, who though did not belong to the marginalized groups of homosexual men or drug addicts.
Figure 9. Actor Rock Hudson at the peak of his popularity (left) and in his last public appearance (right), three months before he died of AIDS
Rock Hudson’s death made American citizens realize that AIDS concerns everyone. Unfortunately, this realization, combined with the ignorance regarding the ways of HIV transmission and non-transmission, as well as the constraint of the medical community triggered an extensive feeling of terror and mass hysteria, fueled also by public statements of political figures.
Figure 10. In 1985 American society was captured by intense horror and mass hysteria for AIDS
US President Ronald Reagan was asked at a press conference in September 1985, one of his very few public positions on the issue, if he would allow his children to attend a school where students with HIV/AIDS would also be attending, in view of parents’ complaints and cases of expulsion of HIV-positive hemophiliac students from schools, which had taken place at that time. The answer was the following (summarized): “Science has not yet provided specific answers as to whether daily contact is safe. Until this happens, I understand the reactions of the parents” [12]
Figure 11. US President Ronald Reagan at a press conference in 1985 justifies the parents’ fears for their children, which attend school together with HIV positive students
The cases of expulsion of students with hemophilia that have been identified as HIV-positive, after transfusion of infected blood, are indicative of the fear and panic that prevailed. Typical is the case of the Ray family in Florida in 1986 with three children, all of whom had hemophilia, who were banned from entering the school, after being diagnosed with HIV. When the children went back to school next year, after legal decision, their home was completely burnt and the family was forced to leave the city. However, more publicity was given to the legal conflict between the student Ryan White and the administration of his school in Kokomo Indiana and the hostility he faced from a big part of the local community. In the following years, Ryan White, with the public support of well-known artists and other public figures, became one of the first individuals-symbols of the fight against discrimination towards people with HIV/AIDS. He died in 1990, at the age of 19.
Figure 12. Ryan White (1971-1990), one of the first individuals-symbols of the fight against discrimination towards people living with HIV/AIDS
2.4. Το HIV/AIDS στην Ελλάδα
In Greece, during this period of time, the image of the HIV/AIDS epidemic spread and approach is similar. The first AIDS-related death was recorded in 1983 and afterwards the HIV/AIDS incidence, as in most countries around the world, was constantly increasing until 1998 [14]. During these first years, AIDS was ignored in Greece, too, as an exclusive disease of homosexuals and drug addicts and deaths of popular figures were necessary, such as the death of the fashion designer Vasilis Kourkoumelis (Billy Bo) and the gallery owner Alexandros Iolas in 1987, in order for it to become a public topic. The ignorance about the nature of the disease and the ways of HIV transmission, the constraint of the medical community regarding the new disease and the intimidating public commentary, created an atmosphere of intense terror among a large portion of the population and caused irrational reactions, which had painful consequences for the social life of people already living with HIV in Greece [15]. Typical examples are the terrifying TV messages of the 1990s, which aimed at raising social awareness through the cultivation of fear, taking place in macabre settings such as cemeteries, morgues and dark and filthy sandlots, presenting HIV/AIDS (and essentially people living with HIV/AIDS) in the form of Death, a gravestone, a used syringe or a time-bomb (Figure 13).
Figure 13. Depiction of HIV/AIDS in the media until mid-1990s
2.5. Developments in the scientific field
Back to the scientific field, the first major achievement came from the Pasteur Institute in Paris and the research team headed by Nobel Prize winner Luc Montagnier. In May 1983, French researchers published the discovery of a new retrovirus, which was suspected for causing AIDS [16]. Figure 14 illustrates the first ever depiction of HIV through an electron microscope.
Figure 14. The first depiction of HIV by Luc Montagnier’s research team at the Pasteur Institute
About a year later, the research team headed by American biologist Robert Gallo confirmed at the National Cancer Institute in the US that this new retrovirus, which was in 1986 given the name HIV, is indeed the infectious agent that causes AIDS. The same team also created the first HIV blood test (ELISA), which became available in the market in 1985 (see Testing for HIV).
Figure 15. Luc Montagnier (Pasteur Institute, France) and Robert Gallo (National Cancer Institute, US)
The announcement of the discovery that HIV is responsible for AIDS was received with great enthusiasm by the medical and scientific community of the US and the rest of the world. At the momentous press conference on April 23, 1984, where Robert Gallo announced the discovery of the cause of AIDS, the US Health Minister, Margaret Heckler, expressed the view that, within the next two years, the first ready-to-test vaccine against HIV/AIDS would be available.
Figure 16. Shot from the momentous press conference of the Health Minister, Margaret Heckler, and the researcher Robert Gallo on April 23, 1984, where the discovery of HTLV-III (later HIV), the AIDS-causing virus, was announced
This statement may today seem overly optimistic or even naive, but at that time it actually reflected the scientists’ expectations. Besides, in the not very distant past, many viral diseases had been treated through the manufacturing of vaccines, once the infectious agent was discovered. However, as it was proved after extensive research in the years to come, HIV is in many ways a unique (and in a close scientific viewpoint, extraordinary) virus, mainly because it is characterized by a series of complex mechanisms that allow it to go unnoticed by the human immune system. No other virus has been the subject of such long and systematic study. And yet, to this day, more than thirty years after its discovery, there is no way of treatment (although significant progress has taken place in recent years).
Immediately after the discovery of HIV, an additional property of the virus was understood, which terrified the scientific community and the rest of the world: HIV infection goes through a long asymptomatic period, before it develops into AIDS. Until then, scientists believed that, from the moment a person is infected by HIV, he/she will, within a short period of time, show the first symptoms of AIDS. However, it was proved that this time period can be much longer: from a few years to more than a decade (see Stages of HIV infection). In this time, during which (as it was initially believed) the virus remains latent (something like a sleep mode), the HIV-positive person does not show any special symptoms and, therefore, there is no way to know that he/she is HIV-positive, unless having a specialized blood test done. During this time, the virus can, of course, be accidentally transmitted to other people. Thus, it was realized that the number of people that had contracted HIV was actually much larger than the number of those diagnosed with AIDS [12].
In 1985, the first test for the existence of antibodies against HIV in the blood (ELISA) was introduced in the market and in 1987 the more reliable Western Blot examination (see Testing for HIV), which confirmed the fears of scientists. The epidemic escalated from a scale of a few thousand to a scale of a few million cases. It was estimated that in early 1981, when the first AIDS cases had been observed, 250,000 people had already been infected by HIV. At the end of 1987, the World Health Organization estimated that 5 to 10 million people were living with HIV worldwide [17].
2.6. Social movements and change of attitude
The end of 1986 found the US counting 24,806 deaths and 31,741 people under medical surveillance for AIDS complications, while it was estimated that one million American citizens were infected by HIV. At this point, the action of massive and radical collective organizations, which supported people that lived with HIV/AIDS, was of utmost importance. The most significant of them was the ACT UP organization, founded in 1987, which brought together the biggest part of associations that supported people with HIV/AIDS, as well as a relatively big part of the progressive artistic and political world. Through massive activist action, ACT UP put great pressure on the Reagan administration, criticizing its passive attitude, and later on that of G.H.W. Bush, asking for the increase of funding for relevant research, the widespread availability of medication still in experimental state, as well as the cost reduction of the medication that was allowed in the market. The progress in HIV/AIDS treatment that followed the next years and the access of all people living with HIV/AIDS in the US to antiretroviral drugs is largely due to the action of ACT UP [10,12,13].
Figure 17. Washington DC, 1988: ACT UP organizes one of the biggest mass demonstrations in the US history, occupying the Food & Drug Administration (FDA)
One of the medicinal substances tested under laboratory conditions already since 1985, zidovudine (known as azidothymidine or AZT) was found in successive clinical trials to significantly limit the immune system’s deterioration caused by the illness, by preventing the action of the viral enzyme ‘reverse transcriptase’ (see HIV life circle and the action of antiretroviral drugs). In March 1987, the US Food and Drug Administration (FDA) permitted, through exceptionally rapid procedures, the disposal of AZT by the company Burroughs Wellcome, under the trade name Retrovir. Six years after the epidemic had started, AZT was the first drug that seemed to fight the virus effectively and, as anticipated, created enormous expectations that treatment of HIV/AIDS was finally possible.
Figure 18. Retrovir (AZT), the first medicinal product that raised hopes concerning the HIV/AIDS treatment, was soon proved as only temporarily effective
However, it was soon discovered that the beneficial effect of AZT was limited and temporary. For reasons that were not yet understood, many patients, on average after a 9-month period of showing spectacular improvement, were seeing the virus rebounding, their health deteriorating and the drug becoming no longer effective (see HIV resistance to antiretroviral drugs and HAART). This was also proved for a series of other substances with similar action, which were tested in the following years, such as zalcitabine (ddC), didanosine (ddl) and stavudine (d4T) [18]. HIV seemed to be able to overcome any drug used against it. Until 1994, the only tangible progress made in the medical field concerned the treatment of many of the opportunistic infections that AIDS patients had to face, prolonging the lives of many, being though a temporary solution. Nothing seemed to be able to stop the action of the virus itself.
However, during these years, peoples’ attitude in most of the countries affected by HIV/AIDS had already begun to change. As the numbers of the epidemic increased, societies went from the initial indifference to panic and from panic to anguished mobilization, in the hope of finding ways to treat HIV and limit its spread. The numbers were so high that HIV/AIDS started being perceived as a global threat, rather than a disease of marginalized population groups. In 1994, AIDS became the first cause of death for people between the age of 25-44 in the US, with a total of 491,763 people diagnosed with HIV/AIDS since the start of the epidemic, 294,515 of which had lost their lives. Globally, by the end of 1995 it was estimated that almost 20 million people lived with HIV/AIDS and an estimated number of 6.4 million people (1.4 of which were children) had died of AIDS [19]. In addition, the intense pressure that was put on political leaderships from various parts of society, activist organizations, the scientific community, artists and other public figures, resulted in a large increase of funding for HIV/AIDS research, the fruit of which soon became visible.
1995 and after: the era of HAART
1995 was the year when HAART (combinational antiretroviral treatment) was established as the treatment of choice for HIV/AIDS, which had an extraordinary beneficial effect on the health and life expectancy of people living with HIV. Since then, new classes of antiretroviral drugs have been developed, increasing treatment choices even more. Within a few years, HIV infection was turned into a chronic but non-fatal and manageable disease.
Large scale studies have repeatedly shown that it is quite unlikely for people that live with HIV and systematically receive antiretroviral treatment to pass on the virus to other people. HAART is nowadays considered one of the most important means of HIV prevention.
New challenges have arisen in the HAART era, which mainly have to do with its high cost and problems of availability to developing countries, the management of its possible side-effects and the need for strict adherence to its administration instructions. At the same time, the search for a cure for HIV infection is continued.
The year 1995 is in many ways a turning point in HIV/AIDS history. It is the time when the previously misinterpreted, as it turned out, HIV action mechanism becomes more comprehensible, new groups of antiretroviral drugs are created and, for the first time, the therapeutic potential of the so-called “combinational” therapy is shown. The years that followed 1995, an unprecedented advance has been made regarding the treatment of HIV infection, which changed forever the lives of people that live with HIV. However, the rest of the history of the HIV/AIDS pandemic shows that scientific progress is only a part of the effort to address the situation. The effectiveness of scientific achievements can only be limited, if not accompanied with political will and planning to implement them.
3.1. The founding and evolution of HAART
The person that maybe contributed the most to HIV research in this time period is the physician and researcher David Ho, head of one of the most important HIV/AIDS research teams at Aaron Diamond AIDS Research Center in the US. Through a series of pioneering laboratory studies, David Ho’s team showed that the understanding of HIV activity, as it was so far perceived by the scientific community, was incorrect in terms of a critical detail [12,20,21]. Until 1994, scientists believed that HIV, from the moment it infects a person, remains dormant for a long period of time (up to more than a decade) and then, for reasons that no one could understand, starts multiplying rapidly, weakening the immune system and eventually leading to AIDS. What David Ho’s research team revealed was that HIV never remains dormant. From the very first days of infection, HIV is in constant battle with the human immune system and manages to multiply at enormous rates (see How does HIV affect the immune system?). As it multiplies, HIV is constantly mutating, which allows it to adapt and develop resistance to the drugs used against it, essentially rendering them ineffective (see HIV resistance to antiretroviral drugs and HAART). This is the reason why any medical substance tested until then could only have a temporary therapeutic effect. Therefore, and this was the main conclusion of Ho’s research team, it is necessary for the virus to be faced as soon as possible and in every possible way simultaneously, with the use of drug combinations. It is much harder for HIV to simultaneously develop resistance to two drugs, rather than to each of them separately. The distinctive statement of David Ho, which was soon embraced by the entire medical community, was “hit early, hit hard“.
In autumn 1995, the preliminary results of two major clinical trials were announced, the Delta [22] and the ACTG 175 [23] studies. Both studies indicated that combination treatment, the parallel administration of two reverse transcriptase inhibitors, is clearly more effective than monotherapy, the administration of a single reverse transcriptase inhibitor, in terms of delaying the development of drug resistance and the progress of HIV infection to AIDS and in terms of reducing morality rates (see What is antiretroviral treatment? & HIV life circle and the action of antiretroviral drugs). This was the first of a series of exceptional achievements in the treatment approach of HIV infection that followed in the years to come. In the same year, clinical trials on a new group of antiretroviral drugs, protease inhibitors (e.g. saquinavir, ritonavir, indinavir) had begun. These drugs were manufactured in laboratories of large pharmaceutical companies, aiming at the inhibition of the viral enzyme ‘protease’, thus providing an additional way of suppressing the virus’s reproduction. However, their clinical utility was still uncertain.
The effectiveness of the combination of these two drug groups (a protease inhibitor and two reverse transcriptase inhibitors) became fully visible at the 11th World AIDS Conference in July 1996 in Vancouver, Canada, where a series of impressive relevant clinic discoveries were presented: the combination of three active substances makes HIV drug resistance almost impossible. This particular conference became almost festive and was presented even by the daily news [12]. It was then that the terms “Triple Cocktail” and “HAART” (Highly Active Anti-Retroviral Therapy) became popular. In 1996, Time Magazine declared David Ho person of the year, recognizing his great contribution to the apparent radical change in treatment prospects of people living with HIV.
Figure 19. The research work of David Ho and his team drastically changed the therapeutic approach to HIV/AIDS and at the same time the lives of millions of people
In June 1996, a third group of antiretroviral drugs, non-nucleoside reverse transcriptase inhibitors (e.g. nevirapine) also became available, further increasing treatment options. HAART soon became the treatment of choice for HIV/AIDS patients in the US and in Europe, leading to a dramatic improvement of their health. Until 1998, the occurrence of AIDS in Europe for people with HIV was limited from 30.7% to 2.5% [24]. In the following years, new types of drugs have been added to the HIV arsenal, such as the fusion inhibitor enfuvirtide in 2003, the integrase inhibitor raltegravir and the CCR5 receptor antagonist maraviroc in 2007. Today, doctors have a variety of drugs available, so the reduction and maintenance of the viral load to an undetectable level (see Important medical tests) for most people with HIV/AIDS is becoming more and more possible [18].
Another important step was the use of antiretroviral therapy as means of preventing new HIV transmissions. As indicated by a series of large-scale studies, the systematic use of HAART and the stabilization of the viral load to an undetectable level reduces (up to 96%) the probability of HIV transmission to heterosexual couples. [25]. This probably applies also to male homosexual couples, as indicated by the preliminary results of the ongoing PARTNER study (final results are expected in 2017) [26]. Since 2015, the World Health Organization recommends that all people living with HIV should receive antiretroviral treatment upon diagnosis for the protection of both individual and public health [27].
For some years now, in several countries, including Greece, some antiretroviral drugs are used as prophylactic means after a possible exposure to HIV (see Post-exposure prophylaxis (PEP)). If someone thinks that he/she has somehow been exposed to the virus, it is possible for him/her to avoid infection by addressing the respective hospital department (timely, within 72 hours at most) and receiving antiretroviral therapy. Finally, on 22 August 2016, the relevant European Commission approved the availability of the regimen Truvada in all 28 EU member states, as prophylactic means before a possible HIV exposure [http://www.aidsactioneurope.org/en/news/european-commission-approves-prep]. In this way, population groups that are most likely to be exposed to HIV (e.g. people who make injecting drug use, sex workers) are now able to receive prophylactic antiretroviral treatment, reducing thus dramatically the likelihood of HIV infection. Several EU countries have already adopted this measure and Greece is also expected to do so.
3.2. New challenges and the era of HAART
Progress made during this relatively short period of time in HIV and AIDS treatment is impressive. It is hard to find a similar example in the whole history of medical science. HIV/AIDS, a disease that within a few years became pandemic as the main cause of death among young people around the world, had finally turned into a chronic, but non-fatal and treatable disease. However, during the HAART era, the scientific community and the global community of people living with HIV/AIDS, although able to be more optimistic about the future, still have to face a new set of critical issues. Apart from the difficulties that were soon found to come with antiretroviral therapy, such as possible side effects and the necessity for strict adherence to their use instructions, the big bet was (and still is) the disposal of this high-cost medication to developing countries, the economy of which cannot bear this great expense and many of which lack the necessary infrastructure, in order to support such a long-term treatment. As it was realized, there is a great distance between the treatment availability and the implementation of this treatment. It is a distance practically measured in economic terms.
3.2.1. Treatment duration and compliance
During the early years of HAART disposal in developed countries, many researchers expected that, since antiretroviral therapy completely prevents HIV reproduction and as human body tissues are renewed at a relatively steady pace (the old cells die and are replaced by new), after a period of systematic use of antiretroviral therapy, the virus should be effectively eliminated from the human body, as all affected cells will have been replaced by new and healthy ones. Although this reasoning seems well founded, it was proved to be in fact false. All studies examining what happens when antiretroviral therapy stops after diverse periods of continuous use, have found that HIV rapidly rebounds. This happens because, as proved by later studies, HIV infects not only mature and active immune cells, but also immature and latent ones which remain in this inactive state for many years (see How does HIV affects the immune system?). These cells, when latent (as the virus does not multiply within them), cannot be identified and cured by the immune system and antiretroviral drugs have no effect on them. This hidden “reservoir”, as it is called, created by HIV is a major problem when antiretroviral treatment is discontinued, as the immature cells mature and become active, allowing the virus to start multiplying again. Identifying and eliminating this hidden backup of the virus is the main objective of modern HIV research and, although significant steps have been made, it has not yet become possible [28].
Therefore, antiretroviral therapy, at least in its current form, is not a definite HIV treatment. It suppresses the virus’s multiplication and prevents harm to the immune system, but cannot eliminate it completely. Apart from this, antiretroviral therapy is necessarily a lifelong treatment. Active substances of antiretroviral drugs must be steadily kept at a sufficient level in the human body, so that the activity of the virus can be suppressed. Finally, the efficiency of antiretroviral treatment requires the strict compliance of people that receive it with its use instructions. In the early years, this meant that people with HIV/AIDS had to receive daily for the rest of their life up to 20 pills at strictly regular intervals, which in practice caused many difficulties. However, in the years after, drugs combining two or three active substances became available and, thus, today antiretroviral therapy, in most cases, now involves 1 or 2 pills per day. Again, however, these should be received for a lifetime on a daily basis and at strictly defined intervals (see Proper use of antiretroviral treatment). Otherwise, HIV will immediately start replicating with the additional risk of drug-resistant strain development (see HIV resistance to antiretroviral drugs and HAART).
3.2.2. Possible side effects of antiretroviral treatment
The second issue regarding antiretroviral therapy is its possible short-term, mid-term and long-term side effects. As for the short-term side effects, the first antiretroviral drugs were especially toxic to most people receiving them, causing a wide range of side effects during the first period of use. Today, things have changed. The action of modern antiretroviral drugs is much more selective and, thus, they have much less short-term side effects, which in most cases fade within a few weeks.
As for the mid-term side effects, as early as 1997-8, several people who received antiretroviral treatment began to notice changes in their body, such as fat deposition in the abdomen, chest and neck and a respective fat loss from the face, hands and legs. This condition, known as lipodystrophy, has not yet become fully understood. However, it is now known to be caused by specific and relatively old drugs (mainly stavudine and zidovudine), which are generally avoided. The frequency of lipodystrophy is currently very low. Other side effects caused by long-term antiretroviral medication are related to bone density disorders, cardiovascular and metabolic diseases as well as disorders of the kidneys and liver. For this reason people receiving antiretroviral treatment are subjected to regular medical check-ups and, if any of the above side effects appears, treatment is accordingly modified (see Possible side effects of antiretroviral treatment). For the same reason, HIV treatment is not restricted to receiving antiretroviral drugs, but also involves generally adopting a healthy lifestyle (e.g. regular exercise, proper nutrition, avoidance of bad health habits).
Lastly, the understanding we have today about the possible long-term side effects of antiretroviral treatment is in fact limited, since HAART has only been in use for about 20 years. The long-term effects of these drugs on the bones, heart, kidneys and other body organs in a group of people, a big part of which is now approaching an old age, are not easy to foresee.
3.2.3. Availability of antiretroviral treatment in developing countries
The third and most important challenge the scientific community and the global society have to face is the disposal of antiretroviral therapy in many countries with weak economy that are unable to cope with the huge cost. The good news from the 11th World AIDS Conference in Canada in 1996, apart from the long anticipated hope they brought to people living with HIV/AIDS in the US and Europe, have also demonstrated the huge difference between the so-called developed and developing world [12]. Twenty million Africans were estimated to have been infected with HIV by 1996, while new epidemics had occurred in countries such as Brazil, India Vietnam, China and several states of the former Soviet Union [19]. Although treatment was now theoretically possible, availability for citizens of these countries who needed it, presupposed both the political will to recognize, on the one hand, the HIV/AIDS problem and to offer a significant part of their budget in order to acquire it and, on the other hand, the willingness of large pharmaceutical companies to reduce its cost, which, as they argued, would greatly limit their ability to fund further research for new and more effective ways of treatment.
In the years that followed, many efforts have been made in this direction in many countries, both by organized civil movements and by institutional factors. The resistance was significant and the reasons were not always purely economic. HIV/AIDS, from its beginning, has been a disease deeply linked to moral issues and largely affected by political activity, precisely because it has been associated with minority groups and unacceptable aspects of human behavior (e.g. drug use) and sexuality (e.g. homosexuality). For reasons that will not be discussed here, open discussion about these issues always provoke feelings of uneasiness or disapproval to a large part of the population, so many political leaders preferred to ignore the HIV/AIDS epidemic or avoided dealing with it by timely taking drastic measures (the most representative case is that of South Africa). Typical is the resistance of many countries, including the US, concerning the implementation of HIV/AIDS prevention programs through the promotion of condom use, unprejudiced sex education and syringe exchange, despite the experience of other countries, which managed to significantly reduce transmission rates through such actions.
Concerning the economic aspect of the issue, in 2000, UNAIDS chaired by Kofi Annan, negotiated with the major pharmaceutical companies and achieved a drastic reduction in the cost of certain antiretroviral drugs disposal in developing countries. In the following years, the UN spent large sums of money, in order for HIV/AIDS to be addressed in these countries, most of which were used for making antiretroviral drugs available. A major development has also been the possibility of generic medication manufacturing by smaller domestic pharmaceutical companies (Doha Declaration, 2001).
According to the most recent available data by UNAIDS [29], the number of people receiving antiretroviral treatment worldwide has increased from less than one million in 2000 to almost 7.5 million in 2010 and 17 million in 2015, while the expected target for 2020 is 30 million (see Table 1). It is also estimated that 43-50% of people with HIV/AIDS worldwide receive antiretroviral treatment. The lowest percentages are found in the Middle East and North Africa (12-24%), Eastern Europe and Central Asia (19-22%), while the highest are found in countries of Western and Central Europe and North America (56-68%).
Table 1. Number of HIV-positive people receiving ART worldwide (source: UNAIDS, 2016 [29])
4.1. Global epidemiological data
According to the latest epidemiological reports by the World Health Organization (WHO) and the United Nations (UNAIDS) [29], it is estimated that by the end of 2016, around 36.7 million people were living with HIV worldwide, 17.8 million (48.5%) of whom are women (above 15 years old) and 2.1 million (5.7%) children under the age of 15. In 2016, it is estimated that 1,800,000 new HIV transmissions have been noticed, 160,000 (8.9%) of which occurred in children, while 1,000,000 million people died of AIDS complications, 120,000 (12%) of which were children under the age of 15. From the beginning of the epidemic until today, more than 70 million people have been infected with HIV and about 35 million have died of AIDS.
Table 2. The HIV/AIDS epidemic in 2016 (global data) (source: UNAIDS, 2017 [29])
Table 3 presents quantitative data on the total number of people living with HIV, new HIV transmissions and AIDS-related deaths in wider geographic areas of the world during the year 2016.
Table 3. 2016 data on the HIV/AIDS epidemic in wider areas of the world (source: UNAIDS, 2017 [29])
4.2. Epidemiological data for EU countries
The most recent epidemiological report by the European Centre for Disease Prevention and Control (ECDC) covers the period from 2006 to the end 2015 [31]. According to it, in 2015, 29,747 people were diagnosed for the first time with HIV in the 31 countries of the European Union. A higher incidence of HIV infection is observed in Estonia, Latvia and Malta and a lower one in Slovakia, Slovenia and the Czech Republic (see Table 6).
The average incidence of HIV infection in the EU is estimated at 6.3 per 100,000 people and remains fairly stable in the 2006-2015 period. The average male/female ratio is 3.3 to 1 (incidence 9.1/100,000 in men and 2.6/100,000 in women). A higher incidence is observed in the 25-29 age group (14.8/100,000), while 10.8% of new diagnoses concern young people aged between 15-24.
Regarding the route of HIV transmission, 42% of cases are related to male homosexual intercourse, 32% to heterosexual intercourse, 4.2% to injecting drug use and 0.8% to vertical transmission from mother to child (in 20% of cases the way of transmission is unknown).
In addition, by 2015, 3,754 people had been diagnosed with AIDS (incidence: 0.8 per 100,000 people) and 991 people died of AIDS complications. Over the last decade (2006-2015), the number of AIDS-related deaths is constantly decreasing (see Table 7). Since the appearance of the HIV/AIDS epidemic from the early 1980s and until 2015, 592,056 people in total have been diagnosed with HIV in the EU, 349,491 have developed AIDS and 187,506 have died of AIDS complications.
Table 6. Incidence (per 100,000 people) of HIV infection in EU countries (2011-2015) (source: ECDC/WHO [31])
Estonia 27.5 23.8 24.6 22.1 20.6
Latvia 14.4 16.6 16.8 17.3 19.8
Malta 5.1 7.2 8.5 9.4 14.2
Ireland 7.2 7.6 7.5 7.8 10.5
Luxembourg 10.9 11.1 11.4 12.6 10.1
Portugal 15.9 15.2 14.0 8.8 9.5
Great Britain 9.8 9.8 9.4 9.5 9.4
Cyprus 6.4 6.7 6.2 6.5 9.4
Belgium 10.8 11.1 10.1 9.3 8.9
Spain 10.6 9.9 8.3 7.2 7.4
Greece 8.6 10.3 7.9 6.5 6.4
France 8.3 8.7 8.4 6.6 5.9
Italy 6.6 7.0 6.4 6.1 5.7
Lithuania 5.4 5.3 6.0 4.8 5.4
Denmark 4.8 3.6 4.2 4.5 4.9
Netherlands 6.9 6.3 6.0 4.9 4.7
Sweden 4.2 4.0 3.7 3.6 4.6
Germany 3.3 3.6 4.0 4.4 4.5
Norway 5.5 4.9 4.6 5.2 4.3
Romania 3.9 4.3 4.5 4.0 3.8
Iceland 7.2 5.9 3.4 3.4 3.6
Finland 3.2 2.9 2.9 3.3 3.2
Bulgaria 2.7 2.1 2.7 3.4 3.1
Austria 3.9 3.9 3.1 2.8 3.1
Croatia 1.8 1.7 2.0 2.2 2.8
Poland 2.9 2.9 2.9 2.8 2.7
Hungary 1.6 2.2 2.4 2.7 2.7
Czech Republic 1.5 2.0 2.2 2.2 2.5
Slovenia 2.7 2.2 2.1 2.4 2.3
Slovakia 0.9 0.9 1.5 1.6 1.6
Liechtenstein 2.8 0 0 2.7 0
Table 7. New diagnoses of HIV infection and AIDS-related deaths in the EU (2006-2015) (source: ECDC & WHO)
4.3. Epidemiological data for Greece
The latest epidemiological surveillance data published by the Hellenic Center for Disease Control and Prevention (HCDCP) covers the time period from 1984, the year when the reporting of HIV cases became mandatory, until the end of 2017 [14].
According to this, in Greece, between 1984 and by the end of 2017, 16,669 people (82.8% men, 16.9% women) were diagnosed as HIV-positive. Out of these, 4,094 (83.6% men, 16.4% women) have developed AIDS at least once in their life (24.6% of the total HIV diagnoses) and 2,745 people (86.1% men, 13.7% women) died of AIDS complications (16.5% of the total HIV diagnoses and 67.1% of the total AIDS diagnoses).
As for the route of transmission, regarding the reported incidents (in 16.2% of the incidents the mode of transmission has not been determined), 57.8% of these cases (48.4% out of the total, with defined or non-defined transmission route) are related to male homosexual intercourse and 13.6% (11.5% out of the total) to injecting drug use. Out of the 3,584 people that were infected with HIV through heterosexual intercourse, 1,914 (53.5%) were women and 1,666 (46.5%) men.
Fewer are the cases of transmission through blood transfusion (0.6% out of the total) or blood products (1.4% out of the total) and mostly relate to the first years of the epidemic. For over 10 years, no case of transmission through blood transfusion or blood products has been reported. Finally, few are the cases of transmission from a pregnant HIV-positive mother to the fetus or infant (0.4% out of the total) which are reported in recent years (1-2 on average per year).
In terms of ethnicity, out of the total amount of people diagnosed with HIV, from 1984 to the end of 2017, 81.7% are of Greek ethnicity and 18.3% of non-Greek ethnicity. 64.6% of the non-Greek people diagnosed with HIV are men and 35.2% women, while in 42.2% of these cases transmission is associated with heterosexual intercourse, in 21.1% with male homosexual intercourse and 16.5% with injecting drug users.
In 2017, 628 people (83.1% men, 16.9% women) were diagnosed with HIV for the first time, 112 (75.9% men, 24.1% women) developed AIDS and 90 (86.1% men, 18.9% women) died of AIDS complications [14]. HIV was mostly common among people between 30-39 years (35.8% of all cases), while 7.7% of the diagnoses concerned young people of 15-24 years (48 cases). It should be noted that in 2017, 1 case of vertical transmission was recorded, while the increasing trend of new HIV diagnoses among people of 40+ years of age, observed since 2012, is continuing (27.9% of total new diagnoses in 2012 but 45.2% in 2017).
Observing the evolution of the HIV epidemic in Greece (see Table 8), a more or less steady increase of new HIV diagnoses is noticed from 1981 to 1998, followed by a relative stabilization at 400-600 annual diagnoses in the next decade. From 2010 to 2012 a dramatic increase in new incidents was observed concerning people that made injecting use of psychoactive substances, which seems to be limited in the next three years. AIDS diagnoses and deaths due to AIDS complications have significantly declined since 1996 and, with the exception of the 2012-13 increase, remain relatively steady over the past 15 years.
Table 8. Time evolution of HIV infection in Greece (1981-2017) [14]
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Mocroft, A., Katlama, C., Johnson, A.M., et al. AIDS across Europe, 1994-98: the EuroSIDA study. Lancet, 356(9226), 291-6.
Anglemyer, A., Rutherford, G.W., Egger, M., & Siegfried, N. (2011). Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database for Systematic Reviews, 5, CD009153.
Rodger, A.J., Cambiano, V., Bruun, T., et al. (2016). Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. Journal of the American Medical Association, 316(2), 171-81.
World Health Organization (2015). Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva: WHO Press.
Siliciano, J.D., Kajdas, J., Finzi, D., et al. (2003). Long-term follow-up studies confirm the stability of the latent reservoir for HIV-1 in resting CD4+ T cells. Nature Medicine, 9(6), 727-8.
UNAIDS (2017). UNAIDS data 2017. Geneva: UNAIDS.
UNAIDS (2016). Global AIDS update 2016. Geneva: UNAIDS.
European Centre for Disease Prevention and Control, & WHO Regional Office for Europe (2016). HIV/AIDS surveillance in Europe 2015. Stockholm: ECDC.
With the kind support of:
Positive Counseling Brochures
“Take the first step for your protection”
HIV PREVENTION PROGRAM FOR SENIOR HIGH SCHOOL STUDENTS
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Tech giants commit to end spread of terrorist content online
France Online Extremism
Five of the world’s largest tech companies have agreed to introduce new measures to their businesses to help eliminate violent and terrorist content from the internet.
Amazon, Facebook, Google, Microsoft and Twitter have agreed on a nine-point plan of action following a meeting with world leaders and tech firms in Paris named the Christchurch Call to Action.
Prime Minister Theresa May meets New Zealand Prime Minister Jacinda Ardern ahead of the forum (Thibault Camus/AP)
The meeting, hosted by French president Emmanuel Macron and New Zealand Prime Minister Jacinda Ardern, was in response to the terror attack on mosques in Christchurch in March, in which 51 people were killed.
The attack was live streamed online and widely shared.
We’re leading the world in tackling online harms, but it’s not enough for us to act alone.
Today I’ll be calling on governments and tech companies to address this issue on a global scale.#ChristchurchCall pic.twitter.com/LgTM3P4QSH
— Theresa May (@theresa_may) May 15, 2019
Prime Minister Theresa May was among the world leaders at the meeting.
However, the White House said on Wednesday that the US will not be backing the plans.
They said in a statement: “The United States stands with the international community in condemning terrorist and violent extremist content online in the strongest terms.
“While the United States is not currently in a position to join the endorsement, we continue to support the overall goals reflected in the Call.”
In a joint statement, the tech companies said they would each take individual steps to improve their policies on violent content, as well as increase collaboration in order to fight the spread of such content.
“The terrorist attacks in Christchurch, New Zealand, in March were a horrifying tragedy. And so it is right that we come together, resolute in our commitment to ensure we are doing all we can to fight the hatred and extremism that lead to terrorist violence,” the statement said.
“The Christchurch Call announced today expands on the Global Internet Forum to Counter Terrorism (GIFCT), and builds on our other initiatives with government and civil society to prevent the dissemination of terrorist and violent extremist content.
“Additionally, we are sharing concrete steps we will take that address the abuse of technology to spread terrorist content, including continued investment in technology that improves our capability to detect and remove this content from our services, updates to our individual terms of use, and more transparency for content policies and removals.
“Terrorism and violent extremism are complex societal problems that require an all-of-society response. For our part, the commitments we are making today will further strengthen the partnership that governments, society and the technology industry must have to address this threat.”
The five companies have each agreed to individually update their terms of use to expressly prohibit the distribution of such content, as well as establishing new tools to make it easier for users to report violent content.
The agreement also includes pledges to invest in new technology to better find and remove inappropriate posts, as well introduce new checks on livestreams and publish regular transparency reports.
Collaboratively, the five firms have said they will for the first time work together on crisis protocols, establishing with governments and other organisations a protocol for responding to active terror events.
The companies have also committed to increase the amount of shared technology development taking place in the industry, as well as offering more education for users on how to report and respond to such content.
Just landed in Paris, with a busy few days ahead. First, the Christchurch Call to Action meeting, where world leaders & social media companies will meet to take action against violence & hate online. Then, I’ll speak at @VivaTech about restoring trust in the digital world.
— Justin Trudeau (@JustinTrudeau) May 15, 2019
Former deputy prime minister Sir Nick Clegg, who is now Facebook’s head of global affairs, attended the summit, along with Canadian prime minister Justin Trudeau, European Commission president Jean-Claude Juncker and Twitter chief executive Jack Dorsey.
The Government recently published a White Paper around online harms which called for a statutory duty of care to be introduced for internet firms, which would be enforced by a new independent regulator.
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NationalNational
Report details sexual abuse by more than 300 priests in Pennsylvania's Catholic Church
<p>General view of Epiphany Catholic Church and Consol Energy Center on February 22, 2011 in Pittsburgh, Pennsylvania.</p>
A new grand jury report says that internal documents from six Catholic dioceses in Pennsylvania show that more than 300 "predator priests" have been credibly accused of sexually abusing more than 1,000 child victims.
"We believe that the real number of children whose records were lost or who were afraid ever to come forward is in the thousands," the grand jury report says.
"Priests were raping little boys and girls, and the men of God who were responsible for them not only did nothing; they hid it all. For decades. Monsignors, auxiliary bishops, bishops, archbishops, cardinals have mostly been protected; many, including some named in this report, have been promoted. Until that changes, we think it is too early to close the book on the Catholic Church sex scandal."
The lengthy report , released Tuesday afternoon, investigates clergy sexual abuse in six dioceses dating back to 1947. Pennsylvania's two other dioceses, Philadelphia and Altoona-Johnstown, were the subjects of earlier grand jury reports, which found similarly damaging information about clergy and bishops in those dioceses.
"There have been other reports about child sex abuse within the Catholic Church. But never on this scale," the grand jurors wrote in Tuesday's report.
"For many of us, those earlier stories happened someplace else, someplace away. Now we know the truth: it happened everywhere."
The grand jurors said that "almost every instance of abuse we found is too old to be prosecuted." But charges have been filed against two priests, one in Erie diocese and another in Greensburg diocese, who have been accused of abusing minors.
"We learned of these abusers directly from their dioceses -- which we hope is a sign that the church is finally changing its ways," the grand jurors said. "And there may be more indictments in the future; investigation continues."
Molestations and rapes
At times, the lengthy catalog of clergy sexual abuses in the report is difficult to read. As the grand jurors note, priests and other Catholic leaders victimized boys and girls, teens and pre-pubescent children.
Some victims were plied with alcohol and groped or molested, the report says. Others were orally, vaginally or anally raped, according to the grand jurors.
"But all of them were brushed aside, in every part of the state, by church leaders who preferred to protect the abusers and their institution above all."
Among the more egregious cases, the grand jury reports that:
• In the Greensburg diocese, a priest impregnated a 17-year-old, forged a pastor's signature on a marriage certificate and divorced the girl months later. According to the grand jury, the priest was allowed to stay in ministry by finding a "benevolent bishop."
• Another priest in Greensburg groomed middle-school students for sex, according to the grand jury, by telling them that Mary had to "bite off the cord" and "lick" Jesus clean after the Nativity.
• In Harrisburg, a priest abused five sisters from the same family and collected samples of their urine, pubic hair and menstrual blood.
• In Pittsburgh, church officials said that a 15-year-old boy "pursued" and "literally seduced" a priest. A church report later acknowledged that the priest had admitted to "sado-masochistic" activities with several boys.
• In the Allentown diocese, a priest admitted sexually molesting a boy and pleaded for help, according to documents, but was left in ministry for several more years.
'Grave failings'
The grand jury's searing report comes as the Catholic Church, including Pope Francis, is struggling to contain a sexual abuse scandal rapidly consuming the church on several continents.
In Australia, a bishop has been found guilty of covering up sexual abuse. In Chile, the Pope was forced to recant his dismissal of an abuse scandal involving a prominent priest and bishops accused of covering up his crimes.
And in the United States, a prominent archbishop was removed from the powerful College of Cardinals following reports that he had molested a teenage altar boy and several others while he was rising through the church's ranks. Meanwhile, bishops in Boston and Nebraska are investigating possible cases of sexual abuse in Catholic seminaries.
For weeks, though, many Catholics in the United States had been warily waiting for the Pennsylvania grand jury's report, especially as bishops in the state began publicly releasing the names of accused clergy in an apparent attempt to preempt some of the report's findings.
In a statement on Monday before the report was published, Cardinal Donald Wuerl, the former Bishop of Pittsburgh who now heads the Archdiocese of Washington, said the report "will be a reminder of the grave failings that the church must acknowledge and for which it must seek forgiveness."
"We are now in the midst of a new era where our communal bonds of trust are once again being tested by the sin of abuse."
Delays in publication
Court action had delayed the report's publication. A number of individuals named in the report claimed that its findings were false or misleading, that they were denied due process of law and that its release would impair their reputations.
On July 27, the Pennsylvania Supreme Court ordered the grand jury report to be released by 2 p.m. August 14 with redactions in sections where litigation was ongoing.
State Attorney General Josh Shapiro had written to Pope Francis on July 25, requesting that the Pontiff direct church leaders to stop "efforts to silence the survivors."
"A comprehensive investigation by the Office of Attorney General found widespread sexual abuse of children and a systematic coverup by leaders of the Catholic Church," Shapiro said in his letter. "Last month I planned to release the findings of our investigation. As I prepared to do so, anonymous petitioners implicated in this report went to court to stop me and silence the victims ..."
Shapiro later issued a statement welcoming the state Supreme Court's decision to allow the report's release.
"Our fear throughout this process has been that the entire grand jury report would be shelved and victims' truth would be silenced," Shapiro said. "Today's order ensures that will not be the case -- the redacted report on widespread sexual abuse and cover up within the Catholic Church will be released."
"I will continue to fight to ensure every single victim is heard and every priest, bishop and church official is held accountable for their abhorrent conduct. No one victim's truth is any less important than another and no one's criminal conduct any less loathsome."
Harrisburg abuse list
On August 1, the leader of one of the largest Roman Catholic dioceses in Pennsylvania released a list identifying 71 priests, deacons and seminarians accused of "substantiated" sexual misconduct over the past seven decades.
Bishop Ronald Gainer of the Harrisburg Diocese also issued an apology on behalf of the religious community.
"That conduct has left a legacy of pain and sorrow that is still being felt," he wrote. "I apologize for these actions."
While most men on the Harrisburg list are accused of sexually abusing children, others were investigated for inappropriate behavior, such as kissing or inappropriately communicating with a minor, Gainer wrote. Others were accused of viewing or possessing child pornography.
The list did not say how the diocese handled most of the accusations and did not give the men's current whereabouts, though a few cases that were forwarded to civil authorities were more detailed.
Archbishop's resignation
A long series of abuse allegations have rocked the world's 1.2 billion Catholics since the scope of systemic abuse and cover-ups began emerging in 2002.
In July, Pope Francis accepted the resignation of Archbishop Theodore McCarrick from the College of Cardinals, one of the church's most powerful bodies, amid allegations of molestation and sexual misconduct. McCarrick, 88, had been a popular and politically influential leader in Washington. He maintained his innocence in June against some claims and has been unavailable to comment on others.
The sexual abuse accusations against McCarrick reveal a "grievous moral failure" within the Catholic Church, the president of the US Conference of Catholic Bishops said July 31.
"Our Church is suffering from a crisis of sexual morality," Daniel DiNardo said. "The way forward must involve learning from past sins."
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Datebook: Art about play, colorful yarn paintings, shows of abstraction and boogeymen
“Desert Fun,” 2015, by Tom Wheeler — part of “Play: Open Call 2016,” is at the L.A. Municipal Art Gallery.
(Tom Wheeler / LAMAG )
By Carolina A. MirandaStaff Writer
An open-call biennial gathers Los Angeles artists exploring playful themes. A museum showcases bright yarn paintings by an early innovator. And a downtown gallery takes on the boogeyman. Plus: A doc about Boyle Heights, happenings on the border and a live staging of the “Call Your Girlfriend” podcast. Here are seven openings and events to check out in the coming week:
“Play: Open Call 2016,” at the L.A. Municipal Art Gallery. A community-based biennial riffs on the notion of “play” — featuring works of painting, photography, collage and more by 300 L.A. artists. Opens Sunday and runs through Sept. 18. 4800 Hollywood Blvd., Hollywood, lamag.org.
"Untitled," José Benítez Sánchez, 2005, is one of numerous yarn paintings on view at the Fowler Museum.
(José Benítez Sánchez / Fowler Museum at UCLA )
“The Spun Universe: Wixárika (Huichol) Yarn Paintings,” at the Fowler Museum. A new show at the Fowler gathers the brightly woven yarn paintings of Wixárika artist Ramón Medina Silva, known for his elaborate compositions depicting astral figures, holy plants and important ritual objects, all crafted with brilliant threads. Opens Sunday and runs through Dec. 4. UCLA, 308 Charles E. Young Drive N., Westwood, Los Angeles, fowler.ucla.edu.
“Omul Negru,” at Nicodim. A summer group show stocked with a mind-bending assortment of artists — Mike Kelley, Genesis Breyer P-Orridge, Sheree Rose, Sterling Ruby, Richard Serra and many others — takes on the idea of the boogeyman (that’d be the “omul negru” of the title). Sounds like the perfect exhibition for Election 2016. Through Aug. 20. 571 S. Anderson St., Suite 2, Boyle Heights, nicodimgallery.com.
A pair of untitled abstractions from a show by Sigrid Sandström is seen at Anat Ebgi in Culver City.
(Sigrid Sandstrรถm / Anat Egbi )
Sigrid Sandström, “Other Places,” at Anat Egbi. A series of new works by the Swedish painter takes abstraction to an intimate scale with a series of small, portrait-sized canvases that play with form and color. Through Aug. 27. 2660 S. La Cienega Blvd., Culver City, anatebgi.com.
“Ambos,” at the U.S./Mexico International Border. Tanya Aguiñiga, a Tijuana-born, L.A.-based artist, has organized a series of happenings and events at the international border — from image projections to a hyper-local pirate radio station run out of a station wagon. Events will take place at the Mercado de Artesanías, the craft market situated between the regular lanes and the medical pass lanes on the Tijuana side of the border. See the website for a calendar of events and the Google Map coordinates for exact location. San Ysidro Port of Entry, International Border, Tijuana, Mexico, ambosproject.com.
A screening of “East LA Interchange,” at Skid Row History Museum & Archive. The 2015 documentary looks at the forces that have shaped the Boyle Heights we know today: from successive waves of immigration to the construction of the freeways, which split the neighborhood into pieces. 7 p.m. Friday. 440 S. Broadway, downtown Los Angeles, lapovertydept.org.
“Call Your Girlfriend Live,” at the Theatre at the Ace Hotel. Ann Friedman and Aminatou Sow of the funny and feministy podcast “Call Your Girlfriend” are hosting a live show in Los Angeles next week with special guests Stephanie Beatriz of the Fox comedy “Brooklyn Nine-Nine,” Caroline Goldfarb of the podcast “This Week Had Me Like” (she also runs the popular Instagram account “Official Sean Penn”) and Lindsey Weber of the podcast “Who? Weekly.” Should be good, clean lady fun. OK, maybe not so clean. 8 p.m. Aug. 18; tickets $30. Theatre at the Ace Hotel, 929 S. Broadway, downtown Los Angeles, acehotel.com.
"Barbara, Moscow, Russia," 2002 by Deanna Templeton, is from the artist's exhibition at Little Big Man Gallery.
(Deanna Templeton / Little Big Man Gallery )
Deanna Templeton, “What She Said,” at Little Big Man Gallery. The Huntington Beach photographer has a one-woman show that explores the nature of moody female adolescence — gathering works that show images of teens looking both demure and defiant. Says Templeton in her exhibition statement: “I see my own struggles, disappointments and bravery in these girls.” Through Saturday. 1427 E. 4th St., Unit 2, downtown Los Angeles, littlebigmangallery.com.
Carl Berg, “With a Little Help From My Friends,” at the Torrance Art Museum. A series of prints created by the artist showcases abstract music and lyrics from the favorite albums of his family and friends. Also on view is “Grafforists,” an exhibition that gathers works by artists preoccupied with the most elemental types of mark-making. Through Saturday. 3320 Civic Center Drive, Torrance, torranceartmuseum.com.
“Routine Pleasures,” at the MAK Center. Michael Ned Holte, who served as curator on the last Made in L.A. biennial at the Hammer, has put together a group show that focuses on artists who value focus and process over producing shiny objets — “termite” art as opposed to “white elephant” art. This includes works from L.A. artists such as Harry Dodge, ceramists Magdalena Suarez Frimkess and Michael Frimkess, sound artist Steve Roden and others. Just the antidote to overheated art market shows. Through Sunday. Schindler House, 835 N. Kings Road, West Hollywood, makcenter.org.
Tim Youd, “100 Novels,” at Los Angeles Contemporary Exhibitions. As part of this long-running project, Youd retypes novels by famous authors in locations connected to the works — using the same typewriters employed by the writers. At LACE, he retyped John Rechy’s infamous hustling novel “City of Night” on an Underwood Model S (the typewriter Rechy rented to write his book), followed by “Numbers,” which he completed at the entrance to Griffith Park. Youd also makes related sculptures and paintings that tie in with these performances. The sculptures will be on view at LACE through Sunday. 6522 Hollywood Blvd., Hollywood, welcometolace.org.
“Current: LA Water,” in locations around Los Angeles. The city’s new public art biennial features installations around the city by more than a dozen artists focusing on the theme of water. This includes a new film by Kerry Tribe, sculptural fountains by Edgar Arceneaux, a garden by Mel Chin and an installation by Teresa Margolles, which employs water used to wash sites of violent crimes. There also are plenty of events, including film screenings, musical performances and family-friendly workshops. Through Monday. See the website for location and event information, currentla.org.
ONGOING EXHIBITIONS
"Sunday Prayer," 2015, by Rosemarie Trockel, is part of a show of women artists at Sprüth Magers in Los Angeles.
(Spr端th Magers )
“Eau de Cologne,” at Sprüth Magers. The gallery has gathered works by five artists key to its development — Jenny Holzer, Rosemarie Trockel, Louise Lawler, Cindy Sherman and Barbara Kruger — all of whom subtly address women’s roles in very different ways. The pieces on view date to the 1970s, when many of these figures first began to achieve artistic renown. Through Aug. 20. 5900 Wilshire Blvd., Mid-Wilshire, spruethmagers.com.
“Me, Myself, I,” at China Art Objects. A group exhibition, featuring works by artists such as Moyra Davey, LaToya Ruby Frazier and Sean Landers, look at the idea of self in art — be it through literal self-portraiture or works that capture the stream of consciousness of the mind. Through Aug. 20. 6086 Comey Ave., Culver City, chinaartobjects.com.
“Cabinet of Curiosities,” at Union Station. The train station’s Grand Waiting Room will be turned into a gallery with a series of installations designed to be viewed through peepholes — a contemporary take on the cabinet of curiosities. Participating artists include Tanya Brodsky, David DiMichele, Ashley Hagen, Noel Korten, Keith Lord, Cecilia Miniucchi and Andre Yi. Through Aug. 20. 800 N. Alameda St., downtown Los Angeles, facebook.com.
“Mertzbau: An Exhibition by Joe Sola featuring Albert Mertz,” at Tif Sigfrids. In a show that reads like a turducken of conceptualism, L.A. artist Joe Sola pays tribute to German artist Kurt Schwitters (known for transforming his family home into an all-encompassing architectural installation known as the “Merzbau”) through the lens of Danish artist Albert Merz, who was influenced by Schwitters’ Dadaist leanings. To achieve this, Sola has created his own architecturally-minded construction — out of 419 salvaged wooden chairs. Through Aug. 20. 1507 Wilcox Ave., Hollywood, tifsigfrids.com.
Shio Kusaka, at Blum & Poe. In her second solo show at the gallery, the Los Angeles ceramic artist is presenting a new body of work inspired by existing forms — from beach balls to porcelain animals — all presented on a single pedestal 100 feet in length. Also on view is a new exhibition of the work of Françoise Grossen, the Swiss artist known for her textile and fiber works (who recently has come to the attention of Los Angeles at Hauser Wirth & Schimmel’s debut exhibition, “Revolution in the Making: Abstract Sculpture by Women.” Through Aug. 20. 2727 S. La Cienega Blvd., Culver City, blumandpoe.com.
“Division: Reflections and Shadows,” with Los de Abajo Printmaking Collective with guest artists, at SPARC. Organized by curator Marietta Bernstorff, this exhibition consists of a series of new works by the L.A.-based collective, along with pieces by friends and colleagues, that push the genre while exploring the nature of borders, both physical and imagined. Through Aug. 20. 685 Venice Blvd., Venice, sparcinla.org.
“Sam Maloof Woodworker: Life/Art/Legacy,” at the Maloof Foundation. The foundation is celebrating the centennial of the birth of the renowned Southern California woodworker, whose elegant objects and furnishings are in the collections of the Metropolitan Museum of Art, the L.A. County Museum of Art and the Smithsonian. The exhibition will feature more than 60 objects from throughout the artist’s life, including furnishings, drawings, photographs and other ephemera. The show is part of a year’s worth of events that will celebrate Maloof’s life and work. Through Aug. 27. 5131 Carnelian St., Alta Loma, malooffoundation.org.
“Teen Choice,” at C. Nichols Project. A summer group show featuring work by various artists, including painter Zak Smith, video artist Stanya Kahn and collagist Bjorn Copeland, riffs on that in-between state of adolescence and all the conflict and desire that entails. Through Aug. 27. 12613 1/2 Venice Blvd., Mar Vista, cnicholsproject.com.
“Southland: A Group Exhibition Inspired by the Greater Los Angeles Area,” at Charlie James Gallery. Organized by artist and curator Patrick Martinez, this group exhibition takes Southern California as its point of inspiration. Martinez gathers works by a range of figures — including Gregory Bojorquez, Sandow Birk, Mario Ybarra Jr. and Kenturah Davis — that in some way depict or deal with different aspects of the city’s landscape. Through Aug. 27. 969 Chung King Road, Chinatown, Los Angeles, cjamesgallery.com.
Deanna Thompson, at Kayne Griffin Corcoran. The California painter has a posthumous exhibition (she died last year) that brings together images of isolated desert homesteads and paintings of cars. They are simple works that emanate a vibrating intensity. Through Aug. 27. 1201 S. La Brea Ave., Mid-Wilshire, Los Angeles, kaynegriffincorcoran.com.
An installation view of Kenzi Shiokava's works is seen at the Hammer Museum's "Made in L.A." biennial.
(Brian Forrest / Hammer Museum )
“Made in L.A. 2016: a, the, though, only,” at the Hammer Museum. The third iteration of the Hammer’s SoCal-focused biennial keeps things wondrously minimal, featuring thoughtful exhibits by only 26 artists that jumps between art-making styles, ideas and generations — from the powerful totemic wood sculptures of Kenzi Shiokava to the bright, graphic paintings of Huguette Caland to the humorous research-based installation of Daniel R. Small. The show is a testament to the notion that, in Los Angeles, many ideas can bubble to the surface at once. Through Aug. 28. 10899 Wilshire Blvd., Westwood, Los Angeles, hammer.ucla.edu.
“In Focus: Electric!” at the Getty Museum. Electricity: It powers your home, it powers your work and it powers the phone on which you are likely reading this post. This photographic exhibition at the Getty gathers historic images that showcase the allure of light and power. Through Aug. 28. 1200 Getty Center Drive, Brentwood, Los Angeles, getty.edu.
“Art of the Austronesians: The Legacy of Indo-Pacific Voyaging,” at Fowler Museum. A look at the legacy of Austronesian-speaking peoples gathers art and artifacts from the Philippines, Indonesia and other points in the South Pacific. This includes nearly 200 works, from wood sculptures to ceremonial textiles to canoe prow ornaments. Through Aug. 28. 308 Charles E. Young Drive N., Westwood, fowler.ucla.edu.
“Duchamp to Pop,” at the Norton Simon Museum. Drawing mostly from the Norton Simon’s permanent collection, this exhibition looks at the influence Duchamp likely had on generations of artists, from assemblagists to pop painters — figures who have appropriated elements of the everyday world and transformed them into art. Through Aug. 29. 411 W. Colorado Blvd., Pasadena, nortonsimon.org.
“Maiden L.A.,” in locations around Los Angeles. A month-long series of happenings around the county will feature talks, exhibitions, digital projects and open studios. This includes a peephole cinema in Chinatown, sculpture inspired by surrealist fistfights, a scent-blending workshop, and even a workshop about painting on black velvet. Through Aug. 31. Locations around Los Angeles, maiden.la.
“Closing Celebratory Show,” at Rosamund Felsen Gallery. On the Los Angeles gallery scene since 1978, Rosamund Felsen is bidding farewell to her space with this group exhibition featuring works from her stable of gallery artists — which includes figures such as painters Karen Carson and Steven Hull and sculptors Jacci Den Hartog and Tim Ebner — among countless others. On view through the summer. 1923 S. Santa Fe Ave., downtown Los Angeles, rosamundfelsen.com.
Veronika Kellndorfer, “Tropical Modernism: Lina Bo Bardi,” at Christopher Grimes Gallery. The German artist explores the work of Brazilian Modernist architect Lina Bo Bardi — among other influential Brazilian designers — in works that place silkscreened photographic images onto reflective glass paneling. The focus, ultimately, is on unusual pairings — of the architecture and Brazil’s riotous plant life. Through Sept. 2. 916 Colorado Ave., Santa Monica, cgrimes.com.
Betty Tompkins' show at Gavlak includes 1,000 paintings she created after asking people to email terms describing women.
(Jeff McLane / Betty Tompkins and Gavlak Gallery )
Betty Tompkins, “Sex Works/WOMEN Words: 1000 Words, Phrases and Stories,” at Gavlak. Known for paintings that take graphic images of pornography and give them a distinctly feminist cast, Tompkins has taken on the ways in which women are referred to in our society. An installation of 1,000 paintings features words that describe women — from “babe” to “sis” to “hot tomato” to others that remain unprintable. The show also includes works from her various series devoted to sex and sexuality. Expect up-close views of various body parts. Through Sept. 3. 1034 N. Highland Ave., Hollywood, gavlakgallery.com.
TMR as Hub: Páramo, at the Mistake Room. As part of its TMR as Hub series, the Mistake Room is showcasing the works of other cultural platforms — from galleries to artist-run spaces to schools. For this iteration, they are featuring the work of the Mexican collective Gabinete Homo-Extraterrestre (Gabinete H-E) in collaboration with the Guadalajara gallery Páramo. For this, their first Los Angeles exhibition, Gabinete has produced a body of new work that riffs on a symbolic exhumation of their past projects. Through Sept. 3. 1811 E. 20th St., downtown Los Angeles, tmr.la.
“Revolution in the Making: Abstract Sculpture by Women, 1947-2016,” at Hauser Wirth & Schimmel. The debut exhibition at the city’s newest gallery tackles more than half a century of sculpture by women, featuring key works by important international figures (Louise Bourgeois, Lee Bontecou) and key California artists (Ruth Asawa, Clare Falkenstein). Pieces range from the ethereal (Lygia Pape’s golden threads) to downright hilarious (Lara Schnitger’s lacy/cat/fur assemblage sculptures). Altogether, the show offers an alternative to the narrative of the macho man postwar painting scene that has so dominated the story of 20th century art. Through Sept. 4. 901 E. Third St., Los Angeles, hauserwirthschimmel.com.
“Gronk’s Theater of Paint,” at the Craft and Folk Art Museum. The Los Angeles artist Gronk (born Glugio Nicandro) is widely known for his career as a painter, conceptual artist and for his work with the inventive 1970s collective Asco. He is also a longtime set designer, one who has built and painted elaborate sets for performances, plays and avant-garde operas, including works by the celebrated director Peter Sellars. This exhibition that tracks a long-running practice that melds art and architecture with the theatrical. Through Sept. 4. 5814 Wilshire Blvd., Mid-Wilshire, Los Angeles, cafam.org.
“Ed Ruscha: Books & Co.,” at Gagosian Gallery. For their summer group show, the gallery is gathering historic artist books by Ed Ruscha (think: the seminal “Every Building on the Sunset Strip”) and exhibiting them with a range of book and book-inspired works by other artists, such as Amy Park’s ambitious paintings project that renders Ruscha’s famous work as a series of watercolors, as well as other pieces that bear Ruscha’s influence in less direct ways, such as Jennifer Dalton’s exhaustive catalogue of potentially hazardous environmental sites in Brooklyn. Through Sept. 9. 456 N. Camden Drive, Beverly Hills, gagosian.com.
“Phantom Limb,” at Shulamit Nazarian. A group exhibition features the work of five artists whose work treads the line between the figurative and the abstract, including the wild collaged canvases of Trenton Doyle Hancock and the paintings of Scott Anderson, whose abstracted figures and landscapes manage to nod to art history even while feeling totally sci-fi. Through Sept. 9. 17 N. Venice Blvd., Venice, shulamitnazarian.com.
A detail from Ken Price's "Barren Rock," from 2006.
(Matthew Marks Gallery )
Ken Price, “Drawings,” at Matthew Marks Gallery. The gallery is displaying more than 40 drawings from the estate of the artist, one of the largest West Coast presentations of the famous ceramicist’s work on paper. He produced often whimsical and otherworldly renditions of mundane objects, as well as sketches for possible sculptures. The exhibition will also feature a small selection of the three-dimensional works. Through Sept. 10. 1062 N. Orange Grove Ave., West Hollywood, matthewmarks.com.
“Claire Falkenstein: Beyond Sculpture,” at the Pasadena Museum of California Art. The 20th century California artist, whose name has is circulating once again after being included in the debut exhibition at Hauser Wirth & Schimmel, is now the subject of her own retrospective, tracking her entire career, from the 1930s to the ‘90s. (She passed away in 1997.) The artist, who worked in San Francisco and Los Angeles — as well as Paris — produced prints and murals, among other works, but she is best known for her sculpture: in particular, her often gritty assemblages made out of wire studded with chunks of glass. Through Sept. 11. 490 E. Union St., Pasadena, pmcaonline.org.
Danielle Abrams, “Quadroon,” at the Grand Central Art Center. A reference to someone who is one-quarter black, the term “quadroon” gets at the absolutist ways in which race is viewed in the United States. (Someone who is part black is regarded simply as black.) Abrams is part Jewish and part African American, and in this video installation, she picks apart the myriad elements — beyond simple ethnicity and race — that come together to make up any one person’s identity. Through Sept. 11. 125 N. Broadway, Santa Ana, grandcentralcenter.com.
Hito Steyerl: Factory of the Sun, at the Museum of Contemporary Art. A video installation by the German artist takes the viewer into a dystopia where the movements of workers are harvested to create artificial sunshine. The piece, which debuted at the Venice Biennale in 2015, is a mash-up of contemporary communication, told as video game, news report documentary film and Internet video. Through Sept. 12. MOCA, 250 S. Grand Ave., Los Angeles, moca.org.
Alex Da Corte, “A Season in He’ll,” at Art + Practice. An exhibition by the New Jersey-born conceptual artist includes a series of works inspired by French poet Arthur Rimbaud’s influential prose poem, “A Season in Hell,” which explores topics of morality, desire and death. In video and in sculptural installations — works that employ banal consumer goods and pop cultural tropes — Da Corte takes on these topics and others, touching on issues of identity, alienation and instability. Through Sept. 17. 4339 Leimert Blvd., Leimert Park, Los Angeles, hammer.ucla.edu and artandpractice.org.
Tanya Aguiñiga, Loie Hollowell and Lenore Tawney, “3 Women,” at the Landing. A three-woman show — inspired by the Robert Altman movie of the same name — serves as a cross-generational gathering of works that blur the line between craft and fine art. These are represented by the weavings of Tawney, a contemporary of painter Agnes Martin; Hollowell, who paints pulsing abstractions inspired by the female form; and Aguiñiga, who uses modern and traditional weaving techniques to create wild biomorphic forms. Through Sept. 17. 5118 Jefferson Blvd., West Adams, thelandinggallery.com.
“Reflections on the Self,” at the California African American Museum. Drawn from the museum’s permanent collection, this wide-ranging exhibition looks at the representation of the self, examining the idealized and mythicized ways that artists have portrayed pop and cultural icons, from Malcolm X to Thelonious Monk to a New Orleans grand marshal. Also on view at the museum is “Oh Snap! West Coast Hip Hop Photography,” which will feature an array of hip-hop artists who came up in the ’90s, such as Ice Cube, Tupac Shakur and others. Through Sept. 18. 600 State Drive, Exposition Park, Los Angeles, caamuseum.org.
“In the Cut,” at Gallery Luisotti. A group show curated by Michael Peña explores the myriad meanings of the phrase “in the cut” — from the idea of a wound to places that are remote, either physically or psychologically. The show brings together photography by Sam Contis, Whitney Hubbs, Lisa Ohlweiler and Cindy Bernard, depicting secluded desert spaces, nudist camps and a Riverside ranch, among other spaces. Through Sept. 24. An artist’s reception will be held at 6 p.m. Aug. 13. Bergamot Station, 2525 Michigan Ave., Building A2, Santa Monica, galleryluisotti.com.
Fast Forward: The Architecture of William F. Cody, at the Architecture and Design Museum. A new exhibition looks at the career of one of Palm Springs’ most notable Modernist architects — known for a range of designs (some quite flamboyant) that included homes, condominiums, commercial centers and the temple-like El Dorado Country Club for a clientele that included Frank Sinatra, Walt Disney and Bing Crosby. Through Sept. 25. 900 E. Fourth St., downtown Los Angeles, aplusd.org.
Kenyatta A.C. Hinkle and Tyler Matthew Oyer, “Exploring The Nowannago: Kentifrican Modes of Resistance,” at Grand Central Art Center. A combination of performance and video piece, “Exploring the Nowannago” is part of Hinkle’s long-running exploration of the ways in which black female bodies are commoditized and exoticized. Also on display is Jesse Kees’ sound installation featuring a series of pieces drawn from the artist’s experience working in Santa Ana. Through Oct. 16. 125 N. Broadway, Santa Ana, grandcentralartcenter.com.
Francis Bacon's "Triptych August 1972" shows disquieting figures trapped within flat, blank, geometric voids and caged in a wide, golden frame, a Bacon signature.
(Getty Museum )
“London Calling,” at the Getty Museum. Drawn primarily from the collection of the Tate in London, this exhibition brings together six of the leading British painters of the 20th century, figures who resisted trends toward abstraction to focus on the figure, revolutionizing the act of painting in the process. Through Nov. 13. 1200 Getty Center Drive, Brentwood, Los Angeles, getty.edu.
“Guillermo del Toro: At Home With Monsters,” at the Los Angeles County Museum of Art. The filmmaker’s work — which includes movies such as “Pan’s Labyrinth,” “Hellboy” and “Pacific Rim” — all play with notions of the fantastical. This exhibition looks at the director’s artistic process, including plenty of drawings and maquettes, along with the objects that inspire him (including some truly odd and macabre works from LACMA’s permanent collection). These are presented in a series of thematic rooms that explore magic, occultism, death and monsters. A totally wild ride. Through Nov. 27. 5905 Wilshire Blvd., Mid-Wilshire, Los Angeles, lacma.org.
Marcos Ramirez ERRE and David Taylor, “Delimitations: A Survey of the 1821 United States-Mexico Border,” at the Museum of Contemporary Art San Diego. In 2014, Ramirez and Taylor set out on a more than 3,000-mile journey to mark the 1821 border between the U.S. and Mexico, which took them to unlikely places such as Medicine Bow, Wyo., and Dodge City, Kan. This exhibition presents photography and other documentation from that journey, one that looks at the fragile nature of political borders. Also on view will be the wild urban architecture-inspired sculptures of L.A. artist Ruben Ochoa — rising like monsters from the gallery floor. A pair of shows not to miss. Through Nov. 27. Jacobs Building, 1100 Kettner Blvd., downtown San Diego, mcasd.org.
“American Mosaic: Picturing Modern Art Through the Eye of Duncan Phillips,” at the Orange County Museum of Art. In the early 20th century, at a time when many U.S. moguls were focusing on amassing European masters, banking and steel scion Duncan Phillips focused his collecting efforts on American art, acquiring canvases by now venerated painters such as Thomas Eakins, Marsden Hartley, Winslow Homer, Georgia O’Keeffe and Helen Frankenthaler. This exhibition brings together more than five dozen works from his collection. Through Dec. 4. 850 San Clemente Drive, Newport Beach, ocma.net.
“MOLAA at Twenty: 1996-2016,” at the Museum of Latin American Art. The Museum of Latin American Art in Long Beach is celebrating two decades in existence with a show that draws from the museum’s permanent collection of more than 1,600 objects. These include works by renowned Modernists Joaqun Torres-Garca and Wifredo Lam, Argentine conceptualist Len Ferrari as well as contemporary figures such as Alexandre Arrechea and Patssi Valdez. Through Jan. 1. 628 Alamitos Ave., Long Beach, molaa.org.
“Senses of Time: Video and Film-Based Works of Africa,” at the Los Angeles County Museum of Art. For one of its long-term installations, the museum has gathered works of video or film by contemporary African artists that explore the body and the looping nature of time. This includes pieces by figures such as Yinka Shonibare, Sammy Baloji, Berni Searle, Moatax Nasr and Theo Eshetu. Through Jan. 2. 5905 Wilshire Blvd., Mid-Wilshire, lacma.org.
“Non Fiction” at the Underground Museum. An emotionally charged exhibition curated by the late Noah Davis, in collaboration with the Museum of Contemporary Art Los Angeles brings together works that explore issues of race and violence. This includes important works from MOCA’s permanent collection by artists such as Robert Gober, Kara Walker, Henry Taylor and David Hammons. Through March. 3508 W. Washington Blvd., Arlington Heights, Los Angeles, theunderground-museum.org.
“Islamic Art Now: Part 2” at the Los Angeles County Museum of Art. Contemporary works from LACMA’s permanent collection by 20 artists who live in or have roots in the Middle East look at questions of society, gender and identity. Runs indefinitely. 5905 Wilshire Blvd., Mid-Wilshire, lacma.org.
Find me on Twitter @cmonstah.
Carolina A. Miranda
Carolina A. Miranda is a Los Angeles Times staff writer covering a wide gamut of culture, including visual art, architecture and film, not to mention performance art cabaret divas.
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Donald Trump continues to praise Planned Parenthood’s “very good work”
By Calvin Freiburger | February 27, 2016 , 07:19am
Days after pledging to sign a bill completely defunding Planned Parenthood as president, Republican presidential candidate Donald Trump is once again sending mixed messages on the abortion giant.
On Sunday’s “Meet the Press,” Chuck Todd asked Trump, who first waffled on the subject in August, “Democrats will say that money they give to Planned Parenthood does not go to abortions, that the money they give to Planned Parenthood only goes to other women’s health including mammograms and things like that. If you knew the government money were only going to that, would you support funding Planned Parenthood?”
Trump first responded (emphasis added):
Yeah, if it didn’t have to do with abortions. Look, I understand it. I have many, many friends who, women who understand Planned Parenthood, better than you and I will ever understand it. And they do some very good work, cervical cancer, lots of women’s issue, women’s health issues are taken care of. I know one of the candidates, I won’t mention names, said we’re not gonna spend that kind of money on women’s health issues. I am.
Trump was referring to August comments by former Florida Governor Jeb Bush, who dropped out of the race Saturday night, saying “I’m not sure we need a half a billion dollars for women’s health issues” over the course of discussing Planned Parenthood’s federal funding. Trump said at the time that Bush “owes women an apology,” assuring voters that by contrast, “I will be so good to women.” Bush clarified that he was not referring to general health subsidies, but to “the hard-to-fathom $500 million in federal funding that goes to Planned Parenthood — an organization that was callously participating in the unthinkable practice of selling fetal organs.”
On Sunday, Trump continued:
Planned Parenthood does a lot of good, does a really good job on a lot of different areas, but not on abortion. So I am not gonna fund it if it’s doing the abortion. I am not gonna fund it. Now they say it’s three percent, and it’s four percent, some people say it’s sixty percent. I don’t believe it’s sixty percent, by the way, I think it’s probably a much lower number. But Planned Parenthood does some very good work. But I would defund as long as they’re doing abortions.
Despite Planned Parenthood’s claim that abortions comprise just 3% of its business, the truth is that Planned Parenthood receives roughly a third of its clinic revenue, and over 10% of its overall revenue, from the procedure. In addition, Planned Parenthood’s breast exams, pap tests, and prenatal services have been declining while their abortion business has increased over the past several years.
Trump’s remarks—which ostensibly endorse complete defunding yet suggest openness to Planned Parenthood’s argument that their subsidies are sufficiently partitioned from their abortion services (despite fungibility)—come days after he threatened to sue GOP competitor Sen. Ted Cruz for an ad arguing pro-lifers cannot trust him.
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Published 20 Jun 18
Maddison: Leicester City's New Signing In Pictures
After James Maddison joined Leicester City, we take a look at the 21-year-old's career so far in pictures...
James Maddison joined Coventry City's youth team in 2013 and made his senior debut in August 2014, at the age of 17, during a 2-1 Carabao Cup defeat by Cardiff City.
Maddison quickly established himself as an exciting English talent, scoring a number of impressive goals from set-plays.
After scoring four goals in 24 games for the Sky Blues, Maddison earned a move to Norwich, but moved back on loan to Ricoh Arena in 2016.
The Coventry-born forward made another 11 appearances for his hometown club before a loan move north of the border.
Once again becoming a fans' favourite quickly, Maddison settled into the Scottish top flight swiftly.
His relationship with the fans was aided significantly by scoring a 90th minute winner against Rangers in September.
Maddison returned to Carrow Road the following summer, making his long-awaited debut in a 3-1 win over Preston North End.
The 2017/18 season was becoming a breakthrough campaign for Maddison as the Sky Bet Championship took notice.
Daniel Farke, the Norwich boss, entrusted Maddison with 42 starts for Norwich.
Appearances against Arsenal and Chelsea in the Carabao Cup further enhanced Maddison's reputation.
A Man of the Match display against rivals Ipswich continued to build a bond between the Norwich supporters and Maddison.
An England Under-21s debut came in November against Ukraine and he played against them again in March - alongside Demarai Gray and Ben Chilwell.
In total, Maddison scored 15 goals and registered eight assists for Norwich, enough to warrant a place in the PFA Championship Team of the Year.
After joining the Club in June, Maddison becomes Leicester City's seventh current England international at senior or youth level.
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A Guide to the Agency Workers Regulations The Agency Workers Regulations 2010 (AWR) came into force on 1 October 2011. They apply to those workers who are supplied by a temporary work agency to work temporarily for and under the supervision and direction of a hirer. All temporary agency workers...
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Home > News > Industrial News > Full of black technology! Take.....
Full of black technology! Take a step to light 35 LED lights
Author:Innolite
The University of Wisconsin-Madison official website recently announced that Wang Xudong, an associate professor of materials at the school, led his team to develop a cheap and simple method to convert the footsteps on the floor into usable electrical energy, thereby transforming the floor. Become a more "green" product. Related research is published in the journal Nano Energy.
The new method uses a common and often discarded material - wood pulp. Wood pulp mainly contains nanofibers composed of wood fibers and is a common component in flooring. These nanofibers are chemically treated to produce an electrical current when combined with untreated nanofibers.
china COB GU10 LED Spotlights suppliers
New materials turn walking power into electrical energy
“The chemically treated nanofiber layer and the untreated nanofiber layer are encapsulated in the cardboard. The two layers of nanofibers have different electrical properties, and the electrons flow from one layer to the other to form Current. The cardboard containing two layers of nano-wood pulp fiber can be integrated into the wooden floor through high-pressure technology.” Wang Xudong said in an interview with the Science and Technology Daily that this technology can be easily integrated into any kind of wooden floor on the market. in.
When two layers of nanofibers are integrated into the floor, they can generate electricity, illuminate the lighting in the house or be used to charge the battery. Wood pulp is extremely cheap, rich in source, recyclable and biodegradable. The wood flooring combined with the new technology will be as affordable as ordinary flooring. There have been reports of materials that use walking to generate electricity, but those materials often use ceramics and metals at relatively high cost.
Wang Xudong said that in addition to the low price, they studied the service life and efficiency of energy collected by nano-wood pulp fibers through experiments. Preliminary tests have shown that new materials can be used millions of times. “We can't translate this number into years to measure the life of the floor, but with proper design modifications, the new material will certainly exceed the floor life.”
The test also proved that 35 LED bulbs can be illuminated at the same time for every step of the electricity generated on the floor containing this new material.
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Roadside energy harvesting technology is sought after
Over the years, the Wang Xudong team has been studying the technology of generating electricity using vibration, testing various materials, and optimizing related technologies called “triboelectric nano-power generation equipment”. The static electricity generated by clothes is a kind of frictional electrification. Many wearable electronic devices use this frictional electrification to obtain electric energy. Wood pulp nanofibers have once again expanded the range of sources that utilize existing mechanical energy.
The research breakthrough of the Wang Xudong team is the latest achievement in the field of green energy research, the roadside energy harvesting technology. “The roadside energy harvesting technology only needs to consider where there is enough energy to collect and use. As long as there is crowd activity, you can consider collecting it.” Wang Xudong said, “One idea is to develop wearable equipment. Another way of thinking is Collecting equipment that is densely populated by local people, such as the floor technology we developed this time.” Gymnasiums, shopping centers, etc., where there are many people, and crowded aisles, installing floors that integrate this new energy harvesting technology can produce considerable Big power. The nanofiber function unit for collecting energy is less than one millimeter thick, so it is possible to implant several layers of such functional units to increase the amount of power generation, and the floor is not significantly thickened after implantation.
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The future is a powerful complement to solar energy
Roadside energy harvesting technology is more competitive than solar energy in some respects. It does not depend on weather conditions, so many researchers believe that it will occupy an important position in the development of renewable energy alternatives to fossil fuels.
But Alistair Sparer, a researcher at the University of New South Wales in Australia, believes that, like existing power generation floors, new materials have no advantage over other green energy sources. “If you want green energy to achieve social benefits, you should look for solar or wind energy. Although new materials are innovative in their ideas, they may not be meaningful.”
Wang Xudong retorted this, the new material is a powerful complement to solar energy. “Our philosophy is to transform the energy that is wasted in life into usable electrical energy. It has the advantage that solar energy cannot be compared, such as underground that can't be exposed to sunlight, or buildings with insufficient sunlight.”
Wang Xudong has applied to the university to set up a new material power generation prototype on campus for publicity and education. They will also continue to optimize their performance.
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More Obituaries for PATRICIA POHLMANN
PATRICIA MOLL POHLMANN
POHLMANN PATRICIA MOLL
Age 83, died peacefully, surrounded by family members, at Providence Point in Pittsburgh, PA, on March 30, 2019. Born in Chicago on January 30, 1936, the daughter of the late Eugene and Helen Moll, she grew up in Indianapolis, Indiana. Growing up, Pat was an outstanding swimmer in major competitions across the country including the U.S. Olympic Trials. She graduated from Indiana University in 1958 and was a member of Kappa Kappa Gamma sorority. Pat lived in Darien, CT for many years and was an important member of the community. She was a grade school teacher and then had a very successful career as a realtor. She was an active member of the Noroton Presbyterian Church and was co-founder of both Wheeler Real Estate (now Halstead) and the Darien YMCA nursery school, both of which continue to thrive today. After marrying her late husband, William Pohlmann, Pat moved to Pittsburgh and became a passionate world traveler, visiting as many foreign destinations as time would permit, as well as her children in Connecticut, California and Florida. While in Pittsburgh she was an involved member of the Southminster Presbyterian Church and PEO and an avid fan of Pittsburgh sports teams. Pat was an incredible woman who spread light, kindness and love to everyone she met and who loved and fiercely protected her family. She is survived by her sister, Gail Pebworth of Crawfordsville, IN; as well as her son, Peter Wells of Newbury Park, CA; her daughter, Lynne Murphy of Wallingford, CT; stepsons, Steve Pohlmann of St. Petersburgh, FL, Jeffery Pohlmann of San Diego, CA; and six grandchildren. She was predeceased by her husband, William Pohlmann; and her grandson, Patrick Wells Murphy. In lieu of flowers, the family requests that donations be made to the (), or Southminster Presbyterian Church, Mt. Lebanon, PA. A service honoring Pat's life and legacy will be held at Southminster Church this summer.
Published in Pittsburgh Post-Gazette on Apr. 6, 2019
"My sincere condolences to the Pohlmann family for your..."
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"Sorry for your family's loss. In the days ahead, may you..."
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24 hours a day/ 7 days a week 1-800-970-3050
Tennyson, TX Cremation Services
What to Expect from Cremation Services in Tennyson, TX
The staff members of Funeral Services Provider will guide your family in creating a meaningful ceremony to honor the life and memory of a loved one. A ceremony can be anything you wish it to be: simple or elaborate, traditional or unique. No matter how it`s tailored, such a ceremony is an important step in recovering from loss.
In this time of sorrow there are decisions to be made; and to honor your loved one you will want to choose what is best. Cremation is an excellent choice. We will guide you through all the processes that are in involved in cremation services. We are family owned with two decades of experience in providing assistance with funeral services and comfort to those who have lost those dear to them.
Burial benefits are available for spouses & dependents buried in a national cemetery include burial with the Veteran, perpetual care, and the spouse or dependents name and date of birth and death will be inscribed on the Veteran`s headstone, at no cost to the family.
A one time payment is payable to the surviving spouse if he or she was living with the beneficiary at the time of death, or in the case that he or she had been living apart, was eligible for Social Security benefits on the beneficiary’s earnings record for the month of death.
Scattering at Sea
The popularity of scattering at sea is steadily growing as people look to the organic nature of the ocean to help them bring closure to the loss of a loved one. Scattering at sea combines a sense of finality and a new beginning. It returns us to nature and the origin of our being.
Cremation services in Tennyson, TX completely understand how you will be devastated by the loss of a loved one and will need help and assistance in arranging a cremation.
One of the main reasons that people regularly choose a cremation over a burial is linked to the cremation costs in Tennyson, TX. The final bill for cremating a person is usually far lower than the cost of arranging a burial because you do not have to pay for the land, its preparation and then the long-term upkeep.
Across all of America cremations are rapidly increasing as the most popular choice of interment and it is predicted that over 50% of people will choose cremation within the next 20 years or so. An exact and full price list will be passed to the person organizing the cremation so that you fully understand all of the cremation costs in Tennyson, TX.
Why Do People Choose Cremation in Tennyson, TX?
When you have experienced standing around a graveside as the body is lowered into the earth, it is an experience that many prefer to forget. The very different, and less dramatic experience of attending a cremation, focuses more on the person who has died rather than the events organized by Tennyson, TX cremation services.
As families grow, many people are moving long distances away with many people choosing to live abroad. This means that less people are available to tend a grave area. By choosing a cremation, the ashes can be spread and no-one is required to keep fresh flowers in a particular area to maintain a memory.
Some religions will only accept a cremation as the only option for interment and this will be explained by cremation services in Tennyson, TX. In the past, other religions would not accept a cremation as an alternative, but in modern times, the majority of religions are completely accepting of the cremation method being used.
Were you to cast a survey, you would find that modern cemeteries are regarded as extremely sterile and lacking of great character and if you live in a colder area, a grave is a difficult place to visit because of the weather, especially the snow and even more so in a northern state. This explains why many people look at the Tennyson, TX cremation costs and choose it as their best option
For extreme forward thinkers, they don't wish their DNA to be available in the future and once the ashes have been scattered, the opportunity will disappeared forever.
What Happens During the Cremation?
In the majority of states, you can care for the deceased at your own home, but the majority of people will prefer that cremation services in Tennyson, TX will undertake the facility.
Tennyson, TX cremation services will explain that the body of the deceased is placed into a container which can be a coffin or casket, but a simple and suitable container is all that the law requires. At the crematorium, the employees will remove jewelry and medical devices, like pacemakers, to reduce the safety hazards for the cremation process. An efficient tagging system is used so that the individual can always be properly identified.
The individual will be cremated in the furnace at temperatures between 1400?F and 2000?F during the course of 2 to 3 hours, when the body will be reduced completely to fine powder, mostly a grey color. These are the ashes that are then returned to the nominated person as part of the cremation costs in Tennyson, TX.
Planning a Fitting Memorial Service
A memorial service can take place immediately after a cremation or days or weeks later at a time that is convenient for all family members to be able to attend. Many people will find that a memorial service is extremely therapeutic because people have the opportunity to stand up and speak about the life and loves of the person who has died at this in turn, personalizes the service.
All of the options related to the memorial service will be carefully discussed with Tennyson, TX cremation services.
How Will I Receive the Ashes?
The Tennyson, TX cremation costs will detail whether the crematorium will be supplying a standard urn to return the ashes to you or whether you have opted to purchase a model for display which you may decide to use for a number of years.
The individual is always cremated alone, so you can rest assured that the ashes being returned to you are always correct and all of the procedures will be explained in detail by Tennyson, TX cremation services.
Religious Questions in Tennyson, TX
Some religious groups will require for a cremation to be completed inside 24 hours after the death of the person. This will be arranged by the funeral director and included within the Tennyson, TX cremation costs, once all of the legal documentation is complete.
Where the individual was particularly religious, the funeral director will liaise with the appropriate clergy and a funeral service may be conducted within the proper church or in the private chapel at the crematorium. This chapel may also be used where a non-religious funeral service is required and equally, the service may be held elsewhere.
There are so many things that you need to think about after someone has died so you should not be worried about leaning heavily on the skills and experience offered by Tennyson, TX cremation services.
Someone will get back to you within one business day.
How We’ve Helped Other Families
I just wanted to say thanks for the beautiful memorial service. It was so personal and dignified (just how my husband would have wanted). Thank you for helping me celebrate such a wonderful life with such honor.
– Kelly Watson
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We accept payments with Visa, MasterCard and Discover Card
Copyright © 2018 Legacy Funeral Services. All rights reserved.
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Lenexa City Council Calendar
Joe Karlin: Ward 1
Steve Lemons: Ward 1
Thomas R. Nolte: Ward 2
Bill Nicks: Ward 2
Dan Roh: Ward 3
Corey Hunt: Ward 3
Andy Huckaba: Ward 4
Mandy Stuke: Ward 4
City of Lenexa » Government » Lenexa City Council » Corey Hunt: Ward 3
Corey Hunt was elected to serve as a Ward 3 council member in 2017.
Hunt and his wife, Amy, grew up in the area, graduating from Shawnee Mission Northwest. They have an adult son.
Following high school, Corey enlisted in the U.S. Navy and was trained as a Search & Rescue (SAR) swimmer/helicopter crew chief, deploying all over the world, where he gained more than 5,000 helicopter flight hours. As a Senior Chief Petty Officer, Hunt held many leadership positions with significant background in aviation operations, combat search and rescue tactics, and personnel management. Hunt is a combat veteran and served in Desert Storm, Operation Iraqi Freedom and Iraqi Freedom-Philippines.
After he retired from the Navy in 2010 serving 23 years, Hunt moved his family back home to Kansas City. He currently serves as a Learning & Development Program Manager for Netsmart, a Johnson County-based healthcare software company that focuses on behavioral health, human services, senior care and care at home services.
Hunt earned his Bachelor of Science degree in management from Park University and a Master of Science degree in Operations Management from the University of Arkansas while on active duty. He recently completed a Master of Science degree in Instructional Design & Technology from Emporia State University.
He enjoys running and is a half-Ironman finisher.
Community involvement:
VFW member, Lenexa Post 7397
Selected / graduated Navy Senior Enlisted Academy (2005)
Navy Master Training Specialist
Communications Chair person, Veterans Affinity Group, DST Systems
Adjunct professor, Emporia State University
Certified running coach, Road Runners Club of America
13112 W. 91st St.
17101 W. 87th St. Pkwy.
chunt@lenexa.com
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B-Movies Podcast: Alex Garland on Ex Machina, Dredd 2 and 3
by William Bibbiani Apr 6th, 2015
Are you ready for a very special bonus episode of The B-Movies Podcast? We sure as hell hope so, because we’ve got writer/director Alex Garland on hand for an in-depth interview about his critically acclaimed new sci-fi thriller Ex Machina, in which future Star Wars: Episode VII co-stars Oscar Isaac and Domhnall Gleeson are trying to prove whether a sophisticated new artificial intelligence named Ava (Alicia Vikander, Seventh Son) has achieved true consciousness.
Alex Garland is no stranger to science-fiction, having written the screenplays for Dredd, Sunshine, and Never Let Me Go, and in Ex Machina he explores a number of serious issues. B-Movies Podcast host William Bibbiani grills him on the ethics behind artificial intelligence and some of the more far out conceits of Ex Machina, like using search engines to develop an artificial human consciousness and whether or not the film warrants the many comparison’s being made to Mary Shelley’s Frankenstein. And for hardcore film nerds, they also get into a serious debate about auteur theory, which Garland considers a serious matter now that he’s in the director’s chair.
Subscribe to The B-Movies Podcast on iTunes
Download this episode (right click and save)
But for Dredd fans, the real scorcher is Alex Garland’s revelations about Dredd 2 and Dredd 3. Although Garland says that the future of the Dredd series is uncertain, he does reveal that “it was the hope” that there would be at least two more movies, and he also reveals the plan was their storylines. And yes, Judge Death was in the cards…
Check Out: The B-Movies Podcast #216: Fast and Furious Retrospective
“We were thinking that’s where we’d end up,” Alex Garland reveals on The B-Movies Podcast. “You know, Dredd has different incarnations. He’s been going for a long time, and as the comic books have gone on they’ve got more serious, in a way, and less jokey. There’s a fantastic story that John Wagner wrote called Origins, that takes Dredd out into this desert area that surrounds Mega-City One, and speaks of the origins of the law system of the city and also the origins of Dredd himself. It’s a really beautiful, elegant sort of bit of storytelling.”
“The idea was roughly to do that on a sequel and then end up with Judge Death, because Judge Death is a sort of logical extension of Dredd in some respects. And the other thing about him that’s a bit weird is he’s kind of semi-supernatural, sort of supernatural, and you need to get there in stages. I think it would have been a weird thing to parachute straight into that world.”
“But even saying it now makes me feel a bit self-conscious because it seems so presumptuous to think in those terms before you’ve even released a film and know how it gets [received]. But that’s what we used to sit around and talk about and try and say, ‘Wouldn’t it be cool if…?'”
It would have been cool indeed. Listen to the full interview in The B-Movies Podcast Presents: Alex Garland for more insights from the filmmaker, follow the show on Twitter at @BMoviesPodcast and follow your hosts at @WilliamBibbiani and @WitneySeibold. And don’t forget to subscribe to our show for free on iTunes for weekly movie news, reviews, commentary tracks, exclusive interviews and – of course – whatnot.
William Bibbiani is the editor of CraveOnline’s Film Channel and the host of The B-Movies Podcast and The Blue Movies Podcast. Follow him on Twitter at @WilliamBibbiani.
action moviesAlex GarlandDreddDredd 3DEx MachinaJudge Dreddsci-fi moviessuperhero moviesThe B-Movies Podcast
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Coventry Lake (7)
A beautiful lake setting……..
www.marionbell.com/coventry-lake-7
John had found one of the students on a lonely back road. The young man James Burton was in real dire straits, and needed medical attention right away. John had gone and checked out a cabin for vacationers, who had heard strange noises outside after dark.
John had a busy day and night in the past day and a half. The search party was ready for another day of searching for student, Amanda Pitt. Amanda had gone missing while at a bush party, and was not seen again. This day was going to be tough, but joyous in another way. John let the teams know that he had come across a young man he presumed was James Burton. The teams were elated and the good news made all the members of the search teams smile, and cheer. John sent out his officers with the heat sensor guns, and had them scan the area. The teams were told to walk in a spread out formation, and never be alone. Stick together, was the message John made very clear, and told the searchers that this thing could make them a casualty at anytime or anywhere during the search. Everyone was equipped with a gun, a knife, and rations for the day. They all carried back packs with first aid items, a full water bladder to drink, and flares to light up the night if they found the student. Everyone had walkie talkies to keep in touch. With full orders understood, the teams were on their way. Slowly they searched the bush covered forest floor for any signs that was left behind by the student. An hour into their search and one of the officers, rang John and told him he found a shoe, and it was a girls shoe that was torn and bloody. John made his way to the site and bagged the shoe as evidence. John called his men to gather at his location, and they would concentrate their search in the direction where the shoe was found. The officers with the heat sensor guns scanned the area to make sure it was safe. The search had shifted from straight north, to the north-west section of the forest. The teams spread out and began to move forward.
Compass for direction………
Tirelessly the teams moved forward, as lunch time aproached. John told the teams their break to eat would be an hour. John added that they be watchful of their surroundings, and to stick together. The forest was full of noises that were unknown to most of the searches. The snapping of branches made the team agitated as they sat in the shadows of the forest. A few of the members of the team had seen a wolf. It paused only to look at them, and ran quickly away. The forest was not only a creepy place, but a place of beauty as well. John put out a message that had everyone on their feet, and ready to continue their search. As everyone trudged ahead John was called again. This time the find was bigger. A find that made the men wonder what they were up against. John made his way down the line, and there on the ground was a part of a leg from the knee down. Devin was there and when he saw the body part, he dumped his stomach contents on the ground. The leg had been there for a few days, and looked like it could have come from an older adult male. The foot looked like it had been chewed on by something, and just tossed away. The day would be running out of light soon, and John had that bad feeling in his stomach again. What was it this time? Devin and John moved forward with the teams. The air became thick with the smell of stale water. The kind a person would find in a pool that had not been cleaned in along time. A voice came loud and clear on John’s walkie talkie. “Sir the thing is heading our way as we speak.” John replied. “Circle the teams, weapons ready to fire.” The officers made their moves, and everyone was ready to fire on command. John raised his gun and fired his pistol into the air. The shots rang out through the forest, and then there was dead silence.
Pistol being fired to ward off danger….
There was danger coming right in same direction as the teams where. John fired his pistol into the air, and all went silent. “Can you see it?” John yelled over the walkie talkies. “No sir… But I can smell it… It’s really close.” His officer said. John could hear the sound of a gun going off. Was everyone okay, and did they hit whatever the thing was? “John.” A voice said. “Yes.” John replied. ” We short at the ground in front of the beast, and it took off going as fast as it could go.” The officer said. “Did you see it up close… And what did it look like?” John asked as he moved in the direction of the other team. “I seen it in the shadows.. John… and it’s huge.” The officer yelled. “Can you see it at all?” John barked back. “I’m coming up on you… Don’t shoot.” John yelled into the walkie talkie. John came into sight, and made his way over to his officer. “Where was it… Show me.” John asked. Together John and Devin went over to the area where the officer had seen it, and they searched for any tracks. There was one foot print, but it could not have come from the creature. It was way too small, and was not a fresh print. There was a bit of hair that was left on a branch of the tree, and it was course, brownish colored, and thick. John bagged the hair, and would take it to the office later, to have it tested. Devin wondered if the creature could be a Kodiak bear. But bears that size had never been recorded anywhere in the world. The officer gave a description of the creature, and Devin was very puzzled.
Kodiak Bears…..
John thought that maybe Devin was on the right track, but a bear that size would have been noisy and not quiet like this creature was. Sure they smelled bad too, but… John needed to look into this bear and see if there was any sightings in their area. Devin said he would look as well, later that evening. The evening was setting in pretty fast and the teams started to head for their vehicles. This day was done, and it was time for sleep. The next day would start real early. Devin hoped that tomorrow would bring them the student, Amanda Pitt. He hoped she would be alive as well. John didn’t have the same feeling after finding the torn bloody shoe. Then the half of a male leg with the foot chewed up. John knew in his heart that this search would not being ending well.
Join me tomorrow as we follow John and Devin deeper into the forest, with their teams…… 🙂
Hello everyone: Monday was the birth of Harry and Megan’s child. Their new addition to their family was a beautiful boy, that was delivered at home. There was no royal media attention, just a quiet birth at their home. “I wish the new parents all the happiness that a child will bring.” “And Welcome to Parenthood.” Speaking of the birth of a child. Today we are going to have a new grand-baby born. He will arrive around eight A.M. in the morning, via. cesarean section. His first name will be Parker. It is the first child to be born to Mark and Tiffany. I am both excited and happy, and can’t wait till the call comes that says we can meet him for the first time. Yesterday was a nice day with temperatures around twenty-one. Some rain started much later in the day, and will help the grass stay green. I must be going to wait for the call. Take care of those you love, and be kind to yourself…. I will see you of the flip side….. 🙂 🙂
I would like to thank all my followers, readers, and visitors who come read my stories each day.. And thanks to all the good photographers for their wonderful pictures I’ve added to my blog…. 🙂
MAGS. Thanks for being here each day…… 🙂
Author BellmPosted on May 7, 2019 Categories animals, attack, blood, burgers, challenges, choices, clues, discovery, family, fellas, foot prints, forest, hunting, knowledge, lake, loved ones, media, miracle, mystery, news, parents, people, Photographs, praying, questions, running, scary places, searching, shadows, suspence, talking, thinking, time, tragedy, trees, walking
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Quantum Jumps Between Tensor Products?
For this audience, I think it's best that I start by explaining the quantum formalism I propose, even though the formalism has been chosen solely to match the ontology. I will assume familiarity with the basics of quantum mechanics, including superposition, entanglement, and the fact that we only ever see one outcome, even though the wavefunction describes many.
Suppose we have three qubits, allegedly in a state like |011> + |101> + |110>. In a many-worlds interpretation, we suppose that all three components are equally real. In a one-world interpretation, we normally assume that reality is just one of the three, e.g. |011>, which can be expanded as |0> x |1> x |1>: the first qubit is actually in the 0 state, the second and third qubits in the 1 state.
However, we may, with just as much mathematical validity, express the original state as {|01>+|10>}|1> + |110>. If we look at that first term, how many things are present in it? If the defining property of a thing is that it has a state of its own, then we only have two things, and not three, because two of our qubits are entangled and don't have independent states. It is logically possible to have a one-world interpretation according to which there are two things actually there - one with quite a few degrees of freedom, in the state |01>+|10>, and the other in the much simpler state |1> (and with |110> being unreal, an artefact of the Schrodinger formalism, as must be all the unreal "branches" and "worlds" according to any single-world interpretation).
And there you have it. This is, in its essence, the quantum formalism or quantum interpretation I want to use, as a neo-monadologist. At any time, the universe consists of a number of entities whose formal states inhabit Hilbert spaces of various dimension (thus |01>+|10> comes from a four-dimensional Hilbert space, while |1> comes from a two-dimensional Hilbert space), and the true dynamics consists of repeatedly jumping from one such set of entity-states to another set of entity-states. Models like this exist in the physics literature (see especially Figure 1; you may think of the points as qubits, and the ovals around them as indicating potential entanglement). For those who think in terms of "collapse interpretations", this may be regarded as a "partial collapse theory" in which most things, at any given time, are completely disentangled; actually realized entanglements are relatively local and transient. However, from the monadological perspective, we want to get away from the idea of entanglement, somewhat. We don't want to think of this as a world in which there are two entangled qubits and one un-entangled qubit, but rather a world in which there is one monad with four degrees of freedom, and another monad with two degrees of freedom. (The degrees of freedom correspond to the number of complex amplitudes required to specify the quantum state.)
The Actual Ontology of the Self and Its Relationship to the Formalism
I've said that the self, the entity which you are and which is experiencing what you experience, is to be formally represented by one of these tensor factors; like |01>+|10>, though much much bigger. But I've also said that this is still just formalism; I'm not saying that the actual state of the self consists of a vector in a Hilbert space or a big set of complex numbers. So what is the actual state of the self, and how does it relate to the mathematics?
The actual nature of the self I take to be at least partly revealed by phenomenology. You are, when awake, experiencing sensations; and you are experiencing them as something - there is a conceptual element to experience. Thoughts and emotions also, I think, conform somewhat to this dual description; there is an aspect of veridical awareness, and an aspect of conceptual projection. If we adopt Husserl's quasi-Cartesian method of investigating consciousness - neither believing in that which is not definitely there, nor outright rejecting any of the stream of suppositions which make up the conceptual side of experience - we find that a specific consciousness, whatever else may be true about it, is partly characterized by this stream of double-sided states: on one side, the "data", the "raw sensations" and even "raw thoughts"; on the other side, the "interpretation", all the things which are posited to be true about the data.
Husserl says all this much better than I do, and says much more as well, and he has a precise technical vocabulary in which to say it. As phenomenology, what I just wrote is crude and elementary. But I do want to point out one thing, which is that there is a phenomenology of thought and not just a phenomenology of sensation. Because sensations are so noticeable, philosophers of consciousness generally accept that they are there, and that a description of consciousness must include sensations; but there is a tendency (not universal) to regard thought, cognition, as unconscious. I see this as just footdragging on the part of materialist philosophers who have at length been compelled to admit that colors, et cetera, are there, somewhere; if you were setting out to describe your experience without ontological prejudice, of course you would say something about what you think and not just what you sense, and you would say that you have at least partial awareness of what you're thinking.
But this poses a minor ontological challenge. So long as the ontology of consciousness is restricted to sensation, you can get away with saying that the contents of consciousness consist of a visual sensory field in a certain state, an auditory sensory field in another state, and so on through all the senses, and then all of these integrated in a unitary spatiotemporal meta-perception. A thought, however, is a rather different thing; it is something like a consciously apprehended conceptual structure. There are at least two ontological challenges here: what is a "conceptual structure", and how does it unite with raw sensory data to produce an interpreted experience, such as an experience of seeing an apple? The philosophers who limit consciousness to raw sensation alone don't face these problems; they can describe concepts and thinking in a purely computational and unconscious fashion. However, in reality there clearly is such a thing as conceptual phenomenology (or else we wouldn't talk about beliefs and thoughts and awareness of them), and the actual ontology of the self must reflect this.
A crude way to proceed here, which I introduce more as a suggestion than as the answer, is to distinguish between presence and interpretation as aspects of consciousness. It's almost just terminology; but it's terminology constructed to resemble the reality. So, we say there is a self, whatever that is; everything "raw" is "present" to that self; and everything with a conceptual element is some raw presence that is being "interpreted". And since interpretations are themselves processes occurring within the self, logically they are themselves potentially present to it; and their presence may itself be conceptually interpreted. Thus we have the possibility of iteratively more complex "higher-order thoughts", thoughts about thoughts.
Enough with the poetics for a moment. Is there a natural formalism for talking about such an entity? It would seem to require a conjunction of qualitative continua and sentential structure. For example, a standard way of talking about the raw visual field specifies hue, saturation, and intensity at every point in that field. But we also want to be able to say that a particular substructure within that field is being "seen as a square" or even "seen as an apple". We might build up these complex concepts square or apple combinatorially from a set of primitive concepts; and then we need a further notation to say that raw sensory structure X is currently being experienced as a Y. I emphasize again that I am not talking about the computation whereby input X is processed or categorized as a Y, but the conscious experience of interpreting sensation X as an object Y. It can be a slippery idea to hold onto, but I maintain that the situation is analogous to how it was with sensation. You can't say that a particular shade of red is really some colorless physical entity; you have to turn it around and say that the entity in your theory, which hitherto you only knew formally and mathematically, is actually a shade of red. And similarly, we are going to have to say that certain states and certain transitions of state, which we only knew formally and computationally, are actually conceptually interpreted perceptions, reflectively driven thought processes, and so forth.
Returning to the second part of the question with which we started - how does the actual ontology of the self relate to the quantum mathematics - I have supposed that there is a mapping (maybe not 1-to-1, we may be overlooking other aspects of the self) from states of the self to descriptions of those states in a hybrid qualitative/sentential formalism. The implication is that there is a further mapping from this intermediate formalism into the quantum formalism of Hilbert spaces. This isn't actually so amazing. One way to do it is to have a separate basis state for each state in the intermediate formalism - so the basis states are formally labelled by the qualitative/sentential structures - and to also postulate that superpositions of these basis states never actually show up (as we would be unable to interpret them as states of consciousness). But there may be more subtle ways to do it which take advantage of more of the structure of Hilbert space.
What About Unconscious Matter?
If I continue to use this terminology of "monads" to describe the entities whose quantum states, tensored together, form the formal state of the universe from moment to moment, then my basic supposition is that conscious minds, e.g. as known from within to adult humans, correspond to monads with very many degrees of freedom, and that these are causally surrounded by (and interact with) many lesser monads in simpler, unconscious states. I'm not saying that complexity causes consciousness, but rather that conscious states, on account of having a minimum internal structure of a certain complexity, cannot be found in (say) a two-qubit monad, and that these simple monads make up the vast majority of them in nature.
In fact, this might be an apt moment to say something about the relationship between these "monads" and the elementary particles in terms of which physics is normally described. I think of this in terms of string theory; not to be dogmatic about it, but it just concretely illustrates a way of thinking. There is a formulation of string theory in which everything is made up of entangled "D0-branes". An individual D0-brane, as I understand it, has just one scalar internal degree of freedom. A particular spatial geometry can be formed by a quantum condensate of D0-branes, and particles in that geometry are themselves individual D0-branes or are lesser condensates (e.g. a string would be, I suppose, a 1-dimensional D0-brane condensate). Living matter is made up of electrons and quarks; but these are themselves just D0-brane composites. So here we have the answer. The D0-branes are the fundamental degrees of freedom - the qubits of nature, so to speak - and their entanglements and disentanglements define the boundaries of the monads.
Abrupt Conclusion
This is obviously more of a research program than a theory. About a dozen separate instances of handwaving need to be turned into concrete propositions before it has produced an actual theory. The section on how to talk about the actual nature of consciousness without implicitly falling back into the habit of treating the formalism as the reality may seem especially slippery and mystical; but in the end I think it's just another problem we have to face and solve. However, the point of this article is not to carry out the research program, but just to suggest what I'm actually on about. It will be interesting to see how much sense people are able to extract from it.
P.S. I will get around to responding to comments from the previous article soon.
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Aide to Sen. Kamala Harris Resigns for Sexual Harassment
Larry Wallace frequently asked assistant to crawl under his desk to change the paper in his printer…
Kamala Harris/IMAGE: PBS via YouTube
(Alexei Koseff, The Sacramento Bee) A longtime top staff member of U.S. Sen. Kamala Harris resigned Wednesday after The Sacramento Bee inquired about a $400,000 harassment and retaliation settlement resulting from his time working for Harris at the California Department of Justice.
Larry Wallace, who served as the director of the Division of Law Enforcement under Harris when she was state attorney general, was accused by his former executive assistant in December 2016 of “gender harassment” and other demeaning behavior, including frequently asking her to crawl under his desk to change the paper in his printer.
By the time the lawsuit against the department settled less than five months later, in May 2017, Wallace had transitioned to work for the newly elected senator as a senior adviser in her Sacramento office.
“We were unaware of this issue and take accusations of harassment extremely seriously. This evening, Mr. Wallace offered his resignation to the senator and she accepted it,” Harris spokeswoman Lily Adams wrote in an email.
Wallace did not return a call to his office seeking comment.
In her lawsuit against the Department of Justice, Danielle Hartley said she was recruited to be Wallace’s assistant during a 2011 restructuring of the Division of Law Enforcement. Wallace, a former Oakland police detective who previously worked under Harris when she was the district attorney of San Francisco, had been appointed director earlier that year.
During an unspecified period, the lawsuit states, “Hartley had concerns she was being harassed and demeaned due to her gender.”
According to the lawsuit, Wallace placed his printer on the floor underneath his desk and ordered Hartley to replace the paper or ink on a daily basis. When she asked to move the printer to another location so she would not have to crawl under desk in dresses and skirts, the lawsuit states, Wallace refused. Wallace frequently asked Hartley to put paper in the printer while he was sitting at his desk or in front of other male executives from the division, according to the lawsuit.
Hartley also complained in the lawsuit that Wallace took away her “meaningful tasks” and put her in charge of running personal errands instead, including booking flights for Wallace’s children and washing and performing maintenance on his car. When she would return from these assignments, the lawsuit states, “co-workers would make hostile comments to her including, ‘Are you walking the walk of shame?’”
According to the lawsuit, Hartley eventually informed her supervisor, Shannon Patterson, of the harassment and asked for help. “Hartley observed Patterson enter Wallace’s office and met with him behind closed doors,” the lawsuit states, but after that, she began to experience retaliation.
The lawsuit describes that Hartley was “set up to fail,” micromanaged by Patterson, investigated by internal affairs on a “fabricated charge” for which she was never informed of the outcome, and “told she should quit her job and seek employment elsewhere.”
Patterson did not return a message requesting comment.
Two days before Christmas 2014, the lawsuit states, Hartley was involuntarily transferred to another bureau within the state Department of Justice. She then began to search for a job outside the department, according to the lawsuit, but she was ultimately unsuccessful because the “stress from all of the harassment” took a toll on her physical and mental health.
Twice, the lawsuit states, Hartley took a state exam for a new classification and scored a 95, but she was not considered either time for the promotion.
Hartley said in the lawsuit that she began suffering from panic attacks and depression, and that in March 2016, she developed a pinched nerve in her arm that required surgery. She had the surgery in September, according to the lawsuit, around which time she also filed a complaint with the Department of Fair Employment and Housing. When she sued two months later, Hartley was still out on medical leave because the Department of Justice has “chosen to not accommodate her.”
Through her attorney, Hartley declined to comment on the case.
In an answer to the lawsuit filed a month later, the department denied “generally and specifically each and every allegation contained in the Complaint.”
California Attorney General Xavier Becerra/Photo by Knight Foundation (CC)
Attorney General Xavier Becerra, who by then had been appointed to succeed Harris, and two of this deputies said the department took “reasonable steps to prevent and correct workplace harassment” by instituting procedures for harassment and training Harley on the policy.
Hartley “unreasonably failed to utilize the procedures during the period of time, and after, the alleged harassment or discrimination was occurring,” Becerra wrote. “Had Plaintiff taken reasonable effort to utilize these procedures Plaintiff’s alleged harm, injury or damages would have been avoided, in whole or in part.”
But on May 16, 2017, the department settled with Hartley for $400,000. It continued to deny her claims.
As part of the settlement, Hartley resigned her position and agreed not to seek employment with the Department of Justice again. She also agreed to a nondisclosure clause, forbidding her from discussing the settlement amount or alerting the media to the agreement.
Amanda Renteria, who worked as Becerra’s chief of operations before mounting a bid for California governor earlier this year, signed off on the settlement.
She said Wednesday that she did not remember the details of the case, which was a holdover from before she arrived at the department in March 2017. She did not know whether Wallace’s departure to work on Harris’ Senate staff had anything to do with the lawsuit.
“Most folks that were connected to Harris went with Harris,” Renteria said.
©2018 The Sacramento Bee (Sacramento, Calif.). Distributed by Tribune Content Agency, LLC.
Tags: California, Kamala Harris, sexual harassment, US Senate, Xavier Becerra
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What does Let It Die mean?
Foo Fighters: Let It Die Meaning
Tagged: Death [suggest]
Let It Die Lyrics
Play "Let It Die"
Heart of gold but it lost its pride
Beautiful veins and bloodshot eyes
I've seen your face in another light
Why'd you have to go and let it die?
In too deep and out...
SexxyJ692
Ok, so there's a picture perfect relationship to person A and apparently not to the other(person B). Person B decides to end it and the person A didn't do anything to stop it and now it is too late to do anything about it "In too deep and out of time." This has been killing person A so much that they stay up all night thinking about Person B "Beautiful veins and bloodshot eyes" Now person A wonders if Person B thinks of them as person A does "Do you ever think of me?" and out of sarcasm person A then says "You're so considerate."
It's hard to explain because the song is pretty much self explanatory but I did my best
Kurt was a good guess but what about when Taylor hawkins overdosed and almost died? That explains the eyes and the veins and all the rest same as Kurt
Aug 15th, 2014 8:54pm report
The best songs are written to have multiple interpretations. For Dave it could be about Kurt/Courtney or a general break up to anyone. It's for the listener to determine. If we knew for sure the meaning at its geniuses it could ruin it for many listeners. That's why the book is better than the movie. The movie spells out the directors imagination thus eliminating the viewers.
Nov 17th, 2009 11:30am report
Dave Grohl has said of the song: "It's a song that's written about feeling helpless to someone else's demise. I've seen people lose it all to drugs and heartbreak and death. It's happened more than once in my life, but the one that's most noted is Kurt. And there are a lot of people that I've been angry with in my life, but the one that's most noted is Courtney. So it's pretty obvious to me that those correlations are gonna pop up every now and again." (thanks, Ian - Lakeville, MA)
Time may not be the variable that allows one to "get it out of one's system" when one has lost a loved one. My mother lost her fight with cancer in 1992 from cancer and every day I feel her loss and the sadness that my toddler children will never know their grandmother. I miss Kurt and I didn't even know him.
Nov 15th, 2009 11:15pm report
Look guys not every single Foo Fighters song is about Kurt its almost 15 years later I think he's got all the sadness out of his system.
hey! this is the same dude who wrote that 5 star "anonomys" int. I AM 12 YEARS OLD.
ps: the only reason im saying this is because to everyone who agreed with me. i just want to let you know that i thank you
THIS SONG IS ABOUT KURT!!!!!!
cluez:
1.heart of gold but it lost it's pride(kurt was a good guy, but before he died he had alot of things going on in his life)
2.bloodshot eyes(that speaks for itself)
3. ive seen youre face in another light(dave remembering him)
4. why'd you have to go and let it die(when kurt died, dave lost his best friend)
5. in too deep and out of time(kurt had so many things happening at one time he took his life)
6.simple man and his blushing bride(kurt and his wife)
7.did you ever think of me(dave asking if kurt thought about how he would make his fans and friends feel when he died
I don't care what Dave Grohl says. there are way too many clues leading to kurt cobain. I think that Dave wants to keep it private and that's why he isn't saying if it is.
I believe that this song is about kurt because of clues given in the song. "simple man(kurt cobain),blushing bride(kurt's wife)";"bloodshot eyes(kurt had very eerie eyes),to see what i'm talking about, watch Nirvana's unplugged during the song "where did you sleep last night" after he screams "where".
I may be wrong, but that is what I believe.
Dave said himslf it's about a friend who had everything and he's just throwing it all away but not about kurt
Dave Grohl is not dead and it is about someone letting a relationship die.
Dec 14th, 2008 12:28am report
naw man, in an interview dave grohl was asked if it was about kurt and he said that he knew as soon as he started writing the song that people would think its about kurt but its just about a relationship going down the drain, ect.
This song is about Dave Grohl's animosity towards Courtney Love. He feels she was a great contributor to his death. But I love that he left the lyrics kind of open ended. One could easily say this is a break up song and one side of the party is cursing the other for ending a beautiful relationship.
I'm pretty sure that Dave Grohl said it was about the death of Kurt Cobain. The "beautiful veins and blood-shot eyes" part could be a reference to Kurt's heroin abuse.
More Foo Fighters song meanings »
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Wait, wait – it’s Ben Folds Five!
Oct 3rd, 2012
This weekend, Ben Folds Five becomes part of one of public radio’s most popular shows as Ben joins Peter Sagal, fellow North Carolinian Carl Kasell and the panel on Wait Wait, Don’t Tell Me.
Wait Wait is a weekly light-hearted news quiz program in which a panel of columnists, satirists and commentators discuss the week’s serious and strange events in a nutty way that will have you laughing. It’s recorded each week in front of a live audience, usually at the Chase Auditorium in Chicago, though they go on tour a couple times a year. Listeners call in (1-888-WAIT-WAIT) to play games like the Listener Limerick Challenge, where they have to complete a series of limericks about the news, or Bluff the Listener, where the caller has to figure out which of three offbeat news stories is the real one.
The most popular segment, though, is called Not My Job, where a celebrity guest (more…)
Help Ben pick the tunes on BBC’s “Now Playing”
Ben will be the guest on Tom Robinson’s Now Playing show on BBC Radio 6 Music Sunday, September 23, a popular British radio programme in which guest artists help choose the songs to be played during the two-hour 6-8pm block. (That translates to 1pm in the US Eastern time zone.) As Ben sits in, he’ll be watching the hashtag #BenFolds56Music on Twitter for fan suggestions. No worries – if you’re not in the UK you can listen online.
Ben on Bob Edwards Weekend
Ben will be one of the guests on the syndicated radio show Bob Edwards Weekend this weekend (November 6-7). The veteran public radio host discusses Lonely Avenue and other topics with Ben. The program can be heard in a variety of ways: local public radio stations (times vary by station), Sirius/XM Radio at 7AM Eastern time on Saturday, and online via iTunes podcast.
WNYC stop on New York publicity swing
Ben and Nick are making several appearances in and around New York City this week, which included the Housing Works benefit show on Oct. 12. Today (Oct. 13) they appeared on public radio WNYC’s Soundcheck program with John Schaefer. Also as we previously reported, tomorrow night (Oct 14) Ben and Nick will appear on NBC’s Late Night with Jimmy Fallon, along with the road band (drummer Sam Smith, new bassist Ryan Leeman, and tambo guy Chad Chapin).
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"So an in my rookie year it was a big learning experience," Drake continued. "Because at the end of the day I just wasn't mentally prepared to handle the work load. As if I was out there being an every-day starter. Which I take personally. Because I'm supposed to put myself in the position to help this team win games. And I came up short my rookie year. And as the second year went on I got a lot more special teams opportunities and that gave me a lot more opportunities. Once I got the ball in my hand it was just natural again."
Was it ever.
Drake was the league's leading rusher over the season's last five weeks, going for 444 yards and averaging 4.9 yards per pop.
Kenyan Drake, Miami Dolphins RB, talks to the media about the teams resilience after they defeated the New England Patriots at hard Rock Stadium.
But he sheepishly admitted Tuesday that this often-repeated stat is a bit misleading. Kareem Hunt and Todd Gurley, the league's top two gainers in 2017, had one combined carry in Week 17, as their respective teams were assured playoff spots and elected to protect their best players.
Still, Drake's work that final month speaks for itself — and helped validate the Dolphins' decision to trade Ajayi midway through yet another tumultuous season. Ajayi and Adam Gase were just a bad fit.
Expect none of that drama with Gore, who has one-tenth of Ajayi's ego despite building 10 times the resume.
Assuming he stays healthy, Gore should pass Curtis Martin for fourth on the league's all-time rushing list by Week 3. Gore, who turned 35 earlier this month, has 14,026 career rushing yards, just 75 fewer than Martin.
Drake on Thursday spoke in near-reverential terms about his new teammate, who broke into the league when Drake was just a grade-schooler.
Frank Gore, Miami Dolphins running back, talks to the South Florida media after joining the team. He spoke of the value of playing where his family lives and helping the Fins win.
"He works out like he's a first-year, second-year guy," Drake said. "Comes in with that same attitude. I feel like if I could have just half the success that he's had, that would be a win in my book. Because he's definitely the epitome of longevity in this league."
Gore is not here as a glorified coach, however. The Dolphins believe he can still play at a high level, and expect him to. But sure, they also hope he can be an example for Drake in a way that Ajyai and Arian Foster never were.
"I'm a fun-loving type of person," Drake said. "I love this game of football. I wouldn't want to be anywhere else in the world, other than down here playing football. And I love to win. That's why I went to Alabama. Because I love to win. And I love to be a competitor. Gase brought me here because he knows I'm a competitor. And he knows at the end of the day I have ability to make big plays in big games. But once I leave this field. I love the game. But I'm a human being at the end of the [day]."
Miami Dolphins strength emerges from most troubled area on the team
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Miami Dolphins running back Kenyan Drake speaks with reporters after Tuesday's practice. Charles Trainor Jr. ctrainor@miamiherald.com
By Adam H. Beasley
Dolphins assistant head coach Jim Caldwell has taken a leave of absence to address an undisclosed health issue and will serve as a consultant to the team for the 2019 season.
‘He’s got his life.’ Outpouring of support for Dolphins player who lost arm in crash
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Battle of Manzikert
International Military Forums > Military History Forums > Older and Ancient Military History
Topic: Battle of Manzikert
(1071), battle in which the Byzantines under the emperor Romanus IV Diogenes were defeated by the Seljuq Turks led by the sultan Alp-Arslan. It was followed by Seljuq conquest of most of Anatolia and marked the beginning of the end for the Byzantine Empire as a militarily viable state.
Spurred by Seljuq raids and incursions into Byzantine-ruled Anatolia, Romanus assembled a large army to reestablish the security of the Byzantine Empire’s eastern frontier there. In the spring of 1071 he led this army into parts of Turkish-held Armenia, entering Armenia along the southern branch of the Upper Euphrates River. Near the town of Manzikert (present Malazgirt, Tur.), he divided his army, which was composed of mercenaries that included a contingent of Turkmen, sending some ahead to secure the fortress of Akhlât on nearby Lake Van and taking others with him into Manzikert. Learning of the Byzantine foray into his territory, Alp-Arslan hastened to Manzikert, where he confronted the emperor’s army.
Romanus abandoned Manzikert in an attempt to reunite his forces with the group besieging Akhlât. Trapped in a valley on the Akhlât road, he neglected to send out scouts to assess the enemy’s position, and the Turks fell upon him. Romanus fought valiantly and might have won if his position had not been weakened by treachery within his ranks; his Turkmen troops went over to the enemy the night before the battle, and one of his generals, Andronicus Ducas, perceiving that the cause was lost, fled with his men. The Byzantine army was destroyed, and Romanus was taken prisoner.
If I had to go to past and witness an ancient war, it'd be this one. A real history maker, along with conquering Constantinople (1453) and ending the Byzantine / Holy Roman Empire.
The Battle of Horseshoe Bend 1814
How Technology Won Sadr City Battle
Battle of Persia
The Battle of Latakia.
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Have your say on town centres’ future
Local residents are being urged to help guide the future of Bearsden, Bishopbriggs and Milngavie town centres.
East Dunbartonshire Council is preparing strategies for each of the town centres and wants to hear from businesses and residents on key issues, as
well as opportunities for improvement.
The focus is initially on Bearsden, Bishopbriggs and Milngavie as Kirkintilloch has an ongoing Masterplan.
The strategies tie in with the Proposed Local Development Plan - currently
under a Scottish Government review which is expected to be completed soon - and the council’s forthcoming Economic Development
Strategy.
People are being invited to have their say via an online survey at www.surveymonkey.co.uk/r/MMBCKCF before Friday, October 21.
Councillor Alan Moir, Convener of Development and Regeneration, said, “The aim is to set out a positive, long-term vision for each town centre and
specific future actions.
“This will provide a reference point for new development proposals and give our town centres the best chance to thrive and prosper in the long term.
“It is essential that the people who live and work in the respective town centres, as well as those that regularly visit them, have an early
opportunity to get involved.
“Local communities, and businesses in particular, are best placed to work with us to address the key issues facing each town centre, and to help
identify opportunities for improvement and enhancement.
“I would urge everyone with an interest in Bearsden, Bishopbriggs and Milngavie town centres to complete the online survey, which aims to gain
feedback on their strengths, weaknesses and key requirements.
“The council will also be engaging directly with town centre partners and other relevant groups, as part of the preparation of each strategy.”
The Economic Development Strategy (EDS) aims to expand the local economy and encourage investment by supporting businesses, town centres and the
tourism industry.
Initial consultation on the new EDS took place in the spring - seeking views on the various attractions and assets in the area, and what people
want from the East Dunbartonshire economy.
The council says “relevant outcomes” will be reflected in the Town Centre Strategies.
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Olson strong for Tribe in spring debut
Bradley scratched; Martin returns; Lindor continues to progress
By Mandy Bell @MandyBell02
GOODYEAR, Ariz. -- When it comes to their bullpen, the Indians aren’t worried about the number of righties and lefties. They just want guys who can get outs. Tyler Olson did exactly that in his first Spring Training appearance of the year.
In Sunday’s 12-3 loss to the D-backs at Goodyear Ballpark, Olson was one of the bright spots for the Tribe, striking out the side in his one inning on the mound.
”On a day when we didn’t get a lot of guys out, he did really well,” Indians manager Terry Francona said. “Changed angles, even to the right-handers.”
In 2017, Olson didn't allow a run in his 30 appearances (20 innings) and notched 18 strikeouts. Last year, the left-hander faced more challenges, logging a 4.94 ERA in 43 games with a 1.39 WHIP and battling a left latissimus dorsi strain, which is a muscle that goes from the upper back into the side of the body.
”He’s a guy that a couple years ago, he came and kind of really pitched well for us,” Francona said. "Last year, there were ups and downs, some of it physically, but when he’s healthy, he can pitch.”
The Indians have a lot of arms to choose from in camp and few open spots on the 25-man roster, so Olson will need to stay healthy and consistent on the mound to earn his place in the Tribe’s bullpen in 2019.
”Just [told him] to be himself,” Francona said. “We told him we’re not worried about how many left-handers we carry because one, [closer Brad] Hand pitches at the end of the game anyway, but we just want guys that can get outs.”
Bradley scratched
Francona said first baseman Bobby Bradley landed awkwardly on his shoulder when he dove for a ball in Saturday’s game against the Reds. He was originally penciled in the Indians’ lineup as the designated hitter on Sunday, but he was scratched for precautionary reasons.
”Again, second day of Spring Training,” Francona said. “We’ll give him a couple days just to make sure he’s OK.”
Martin returns
In his first game since his battle with a life-threatening bacterial infection in August, Leonys Martin went 0-for-2 and started in center field. In his first at-bat, he grounded out to second base. He was robbed of a hit on a diving catch by D-backs left fielder Tim Locastro to end the second inning.
”I think he’s enjoying playing baseball right now,” Francona said. “I think he’s in a good place, but we’ll keep an eye on him."
For everyone asking to see Leonys Martin’s first at-bat: pic.twitter.com/t2wP4r8R70
— Mandy Bell (@MandyBell02) February 24, 2019
Lindor update
Although there hasn’t been much of a change in Francisco Lindor’s rehab process, Francona said that the shortstop has started doing some distance walking on the anti-gravity treadmill that displaces some of his weight.
”That’s where he’s progressed to,” Francona said. “He’s doing a little bit of strength work. He’s progressing really well. Those are the things he’s doing, other than contrast and those things in the training room.”
Daniel Johnson, the Indians' No. 22 prospect per MLB Pipeline, and Oscar Mercado (No. 19) had impressive showings at the plate on Sunday. Johnson got the Indians on the board with an RBI double to right-center field in the third inning, and Mercado went 2-for-3, hitting a two-run homer in the ninth.
”We get to see the young guys these first 10 days, two weeks more than [any other time] because that’s when they’re going to play,” Francona said. “It’s fun to watch. [Ernie] Clement, [Mark] Mathias, Daniel Johnson, we seem to have a good, young group that seems like they appreciate their playing time, so they are going to get some.”
The Indians host the Rangers on Monday at 3:05 p.m. ET at Goodyear Ballpark. Cleveland right-hander Trevor Bauer is slated to make his first start of the spring. Lefty Mike Minor will get the start for Texas.
Mandy Bell covers the Indians for MLB.com. Follow her on Twitter at @MandyBell02.
Tyler Olson
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MULTIPLICITY 2017: Jon Turk on Adventuring and the Consciousness Revolution
Jon Turk received his Ph.D. in chemistry in 1971, but abandoned academics to spend a life adventuring. His circumnavigation of Ellesmere Island with Erik Boomer was nominated in 2012 by National Geographic as one of the Top Ten Adventures of the Year.
Jon’s world-view was transformed by Moolynaut, a 96-year-old Siberian shaman. This journey is chronicled in Jon’s book, The Raven’s Gift. Jon’s newest book, Crocodiles and Ice: A Journey into Deep Wild represents “a continuing exploration of a consciousness revolution based on a deep, reciprocal communication with the earth.” As Jon believes, “beyond the wondrous and seductive opulence of our oil-soaked, Internet-crazed, consumer-oriented society, there lies a glorious and sustainable lifestyle that is based on deep wild as a foundation of solace, sanity, compassion, and hope.”
Join Jon Turk at MULTIPLICITY, this Sunday at the World Ski & Snowboard Festival.
Welcome to MULTIPLICITY.
I’m honoured to be here. There’s a great group of people speaking, and I’m very excited to meet them, listen to them, speak with them and drink a beer with them.
Give us a hint of what your presentation will be about.
It will be centered on the Ellesmere circumnavigation Eric Boomer and I did in 2011. We were nominated as the Top 10 Adventure of the Year by National Geographic. It was a big trip up in the polar arctic. But I’ve been to a million of these things, and given a million talks, and this is not a trip log. About 20 years ago, when I was on an adventure on the east coast of Russia, up in northeastern Siberia, I ran into an old shaman woman, a 96-year-old Koryak shaman, and then spent five years in this old village with this woman, trying to follow through with her wisdoms. Everything else I’ve done since then, has been re-framed in terms this shamatic vision of the Koryak people. So we go to Ellesmere, and we get tired and hungry and strung out and frostbitten, but I try to see it through the old woman’s eyes. Which, then leads me, following the Ellesmere trip, to a bike ride across the Himalayan plateau to the birthplace of the Dalai Lama, again trying to formulate not just what’s happening to Jon Turk—which is unimportant to say the least—but what our relationship as individuals in society is to nature, and how that’s important.
I read in your synopsis the term “consciousness revolution.” Can you elaborate what that means to you?
Well, I could elaborate for a whole book or two. The aboriginal people, they’ve done a lot of bad things. A lot of warfare and cannibalism and so forth, and we have to keep that in mind. But at the same time, they lived in a close relationship with the planet—a holistic relationship with their tribes and the planet. And it wasn’t until we got into the agricultural revolution, and the industrial revolution, that we received a different focus. And it concentrated on a lot of accumulating stuff—money and stuff. So the consciousness revolution—and I picked that term carefully, because I didn’t want to use the term spiritual—is really retraining our minds to think in a more aboriginal way, a more holistic way, seeing ourselves as part of our tribe, as part of our planet. This isn’t new stuff; I’m not the first to say this. A million people are saying this. Look, Donald Trump isn’t working for the world. That isn’t sustainable. So what is the consciousness revolution? To put it broadly, it’s based on a deep reciprocal relationship with the earth. And that’s what my story telling is trying to emphasize.
“An adventure story is nothing if it doesn’t take us to some greater meaning or greater understanding of ourselves.”
Being a journalist intertwining this consciousness revolution into your stories, how do you see adventure journalism today? Are we seeing enough deeper meaning tied into adventure stories, or is it more the author’s means self promotion? I guess you could call it “selfie” journalism?
Well, a lot of adventurers have taken a similar journey to mine. In any genre, there’s good stuff and not so good stuff. So I’m not going to criticize a whole genre. An adventure story is nothing if it doesn’t take us to some greater meaning or greater understanding of ourselves. In any literature, is just an excuse, just a vehicle, to take us to a greater understanding of ourselves. So if you have a good romance novel, or mystery novel, or good adventure story or bad adventure story—in any writing genre, the literature will have long-term value only if it takes us somewhere greater than the immediate story.
Why do you think Nat Geo nominated your trip to Ellesmere as a Top 10?
Well, you’re asking me to toot my own horn. But what we set out to do it travel 1,500 nautical miles in 100 days. That’s a half-marathon a day, for three and a half months. And you’re not in running shoes and shorts. Heavy boots, skis, carrying a 100-150 kilo sled over some of the harshest terrain on earth. It’s a horizontal Everest. And you’ve got all kinds of problems with ice. A little past the middle of that expedition, we went through what I believe is the most chaotic and dangerous environment in the arctic.
Sounds mental.
What you’ve got is Northeast Ellesmere and Northwest Greenland pinching together into a straight that’s 12 nautical miles in diameter, and you have an entire polar ocean of congested, driving, two-metre thick ice being pulled with the winds and currents into this 12-nautical-mile hourglass. So there’s tremendous power there. When we entered this zone, it was just at breakup, so the polar icecap, which during the winter is frozen and not moving, is now cracked and fractured and moving and being dragged southward into this bottleneck. Just a tremendous amount of compression, power and chaos. So at times you could go out for 15 minutes or half an hour when the ice is relaxed a little bit. And we were doing that, making about a mile a day, playing this cat and mouse game. We were walking across, and jumping from floe to floe, and also paddling, and sometimes we would wait till high tide would come in and walk in two-meter wide, knee-deep water, pulling the kayaks. But then you have a section of about 15 miles of vertical cliffs on shore, where if you go out, you have to make the entire 15 miles before the ice closes in again or you’re dead. And that’s the crux. So I think why national Geographic honoured us, is it was a hard trip, and it involved a lot of exposure. You can’t say no chance of rescue, because this it the 21st century. But rescue would be extremely difficult. No place to land airplanes, too far away for a helicopter to fly without fuel depots. Really difficult to extract somebody from there. And very little in the way of food drops. And in the middle of this, you have this most powerful environment.
“I realized I have to put my money where my mouth is. I wanted to see if I could really tickle the dragon’s tail of this power, relying on the old woman’s wisdom.”
So, I’ve gotta ask…Why? I mean, you were what, 65? That much exposure, that much danger, what motivated you?
There’re too many answers to that. One is, I’ve spent a lot of time in the arctic. I did a much easier trip with my wife a long time ago, 1843 or something like that. We had done 600 miles in 60 days. And during that time, I kept thinking, the real trip is to go around Ellesmere. And I was much younger then, and thought that it couldn’t be done, and so did a lot of other people in the Arctic exploration game. You just couldn’t do it in a single season. And then I’d taken that five years out on this spiritual journey, and I’ve gotta say the physical journeys were much easier. So now, I’m 65 years old and figured I’ve got one last shot. And I’ve been going around the country, bivying up in my pickup truck, living in the concrete jungle, and talking about power, the power of the aboriginal people. And suddenly I realized I have to put my money where my mouth is. I wanted to see if I could really tickle the dragon’s tail of this power, relying on the old woman’s wisdom.
What is it that attracted you to become an adventurer? You were an academic, published the first environmental science textbook, so where was the shift?
I think it started in my DNA when I was born. The question is not where did it come from. That’s easy. The struggle was to question all the direction and expectations of a society and ask, who am I really, who really is inside me that makes me happy? And follow that. But yeah, 65 was along time ago. I’m 71 now. I just can’t imagine not linking in an active outdoor environment on a daily basis.
That leads me to a question that I would personally like to know. You write books, and spend a lot of time indoors, behind a screen. How do you balance that office time with your lust for being outdoors?
Well, I love to write. That creative process is not disconnected. The game, of course, is to get outdoors as much as possible. But when I’m sitting in front of the computer writing, that creative process is intensely joyful for me.
I guess you’re not writing ad copy, so that helps.
Yeah, the textbooks were a really great gig. I would write them for a period of time, and then have big blocks of time to go on expeditions. It’s also the kind of thing that there’s a deadline six months out, so if there’s a powder day, you put on the skis and go skiing, and nobody knows the difference.
Except when you’re two days before deadline, and put too many powder days in.
Yeah, that happens. The man catches up to you, whether you like it or not.
“Adventuring isn’t like playing in the NF; it’s not an all-or-nothing, and if you don’t make it, you’re cut from the team. Adventuring is something where you can modify your expectations, and still go out there for a long, long time.”
OK, you did this Ellesmere adventure at 65. What are your thoughts on aging and adventuring? I look at my dad, or where I’m going to be at 65, and it’s not doing that.
About pushing on into the future, is that the questions? I don’t have the power that I had, and I don’t have the reserves of strength that I had. For me to go on the Ellesmere trip right now, I would die. I couldn’t make it. In the last six years, I’ve lost enough that I couldn’t make it again. But adventuring isn’t like playing in the NF; it’s not an all-or-nothing, and if you don’t make it, you’re cut from the team. Adventuring is something where you can modify your expectations, and still go out there for a long, long time. So my wife and I are going to Kenya with some biologists to work on a lion study. I’m going to spend a lot more time sitting behind a spotting scope, and not trying to make a lot of miles in a day. But the spirit of the journey is very similar.
Jon Turk and Eric Boomer.
Out of all your adventures, do you have a favourite?
No. I mean, I’ve been really fortunate in having a lot of really cool adventures. And there are moments in every one of them that I will carry to my grave. And the companions that I’ve traveled with—part of being an adventurer is the people you are with. So if I was to compare Misha, the person I paddled from Japan to Alaska with, versus Boomer, whom I did Ellesmere with, to say which one I like best? I can’t say that. They are both very dear and very different people.
OK, my last question: What do you hope the audience takes away from your presentation?
I hope they will go away with a knowledge that that their own personal relationships with the planet will empower them. And their own journeys into ecstasy and passion can be the main driving force in their lives. And if they do that, they will be happy people.
MULTIPLICITY 2017: SHERRY MCCONKEY ON OVERCOMING TRAGEDY, CARRYING ON A LEGACY AND FINDING HER OWN PASSION
Through both her life with Shane, and his death, Sherry has come to believe that with desire, passion, and a goal, anything is possible. Despite the grief after losing him, Sherry knew she wanted to carry on Shane’s legacy. She turned moments of sadness into inspiration and used the power of positivity to build The Shane McConkey Foundation, and Executive Produce the movie, McConkey… Read more
MULTIPLICITY 2017: BRETT TIPPIE AND THE BIRTH OF FREERIDE MOUNTAIN BIKING
Brett Tippie is a legend, no question. He was among the first to snowboard at Sunshine and Blackcomb (at the time two of the only places you could in Canada), he’s competed in over 25 World Cup events and represented Canada on the National Team in Snowboardcross and Giant Slalom. But Tippie is most recognized for two things… Read more
Mountain Life Media is Proud to Present the 5th Annual MULTIPLICITY at WSSF
Adventure stories are best told first-hand and with a hefty dose of authenticity. At MULTIPLICITY, harrowing stories from around the globe are delivered up close and personal by eight world-class athletes, explorers and outdoor personalities. Combining photography, video and top-shelf storytelling, MULTIPLICITY has quickly become the hottest event at the World Ski & Snowboard Festival at Whistler Blackcomb.
WHEN: Sunday, April 9th 2017 7:00 PM
WHERE: The Whistler Conference Centre, part of the World Ski & Snowboard Festival
TICKETS: Now available at wssf.com
“I was blown away,” says bestselling author and adventurer Bruce Kirkby. “MULTIPLICITY is a beautiful reminder–in this era of distraction, hype, texts and tweets—that a good, simple story is still king. Especially the bare-knuckled, whiskey-scented, gut-wrenching, mind-scrambling, tear-laced campfire variety.
A flagship fundraiser for the Spearhead Huts Project, the event has been described as “a TED Talk on adrenalin,” and “the most inspiring night of the year.” Kirkby, the MULTIPLICITY keynote speaker last year calls it “the biggest, brightest story- telling gathering of its kind. Grab yourself a seat before they’re gone.”
2017 MULTIPLICITY Presenters
Aaron and Hawkeye Huey
Sherry McConkey
Brett Tippie
Ken Achenbach
Colin Angus
Leslie Timms
Tamo Campos
Jon Turk
Posted in MULTIPLICITY, Paddling, The Great OutdoorsTagged Ellesmere Island, Eric Boomer, Jon Turk, MULTIPLICITY
Last Col with Pete Oswald
One Shot: Jussi Grznar
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Upper Lonsdale neighbourhood in North Vancouver (Wikimedia Commons)
Municipal spending outpaces population growth 4-fold in B.C.: report
Canadian Federation of Independent Business has released its annual operational spending report
With the municipal election just over a month away, those in the running are going to need to address the million-dollar problem in civic government: overspending.
According to the Canadian Federation of Independent Business, it’s a problem that plagues every major municipality, defined as a city with a population larger than 25,000 residents.
In the business group’s annual municipal spending report, released this week, spending increased an average of 43 per cent in cities between 2006 and 2016. That’s compared to populations growing about 12 per cent.
In dollars, that’s $1,243 per person on average across B.C in 2016, and $1,537 per capita in the province’s 20 major cities.
“Only eight out of 152 municipal governments in B.C. have kept operational spending at or below levels of inflation plus population growth over the 10 year period examined,” the report reads.
Meanwhile, two of B.C.’s largest cities, Vancouver and Victoria, each increased their operating spending per person by 32 per cent and 30 per cent respectively from 2006 to 2016, according to the report data.
In its rank of the 20 large municipalities with the best operating spending per capita growth, Port Coquitlam topped the list.
That’s because the city had relatively low spending of $1,235 per person but controlled spending increases over the decade, at just 7.6 per cent.
Maple Ridge and Kelowna ranked second and third best respectively. Surrey had the lowest per capita spending in 2016 at $1,057.
The Township of Langley ranked as the worst major municipality, CFIB said, due to the large per capita increase between 2006 and 2016, of 50.1 per cent growth. Still, the township’s per-capita expenditures remain below average, so curbing spending could improve that rate, the report suggests.
The CFIB said cities have ample opportunity to diversify revenue sources and cut costs without cutting services – with some municipalities already taking on initiatives.
“Some municipalities have already started doing this by sharing resources, making the most of publicly owned assets, investing in new technologies, and changing inefficient practices,” the business group said. “For example, the City of Victoria was able to reduce paper use through the development of an online parking application.”
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IAG Developments has proposed a multi-building development on city’s waterfront
LETTER TO THE EDITOR: People experiencing homelessness unlucky
Poverty, illness and marginalization don’t equate to decrepitude, says letter writer
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