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Princess Diana's niece Lady Kitty Spencer becomes latest royal to cash in on her aristocratic links by going head-to-head with Queen's grandson Peter Phillips and promoting RIVAL brand of milk in China
PICTURED: Mother, 22, confesses to killing her three-year-old son, two-year-old daughter and seven-month-old baby girl in their family home in Phoenix
Return of the Beast? Britain faces new Siberian cold snap after same weather pattern that sparked last year's Beast from the East brings icy blast of freezing winds and heavy snow from next week
Sudden stratospheric warming event in Arctic around Christmas could bring much colder temperatures
This can lead to a rush of cold air blowing eastwards across Europe and caused 2018 Beast from the East
But parts of Britain will see above average temperatures for January of about 10C (50F) over the weekend
By Mark Duell for MailOnline
Britain could still face a new Beast from the East by the end of the month, bringing an icy blast of freezing winds and sub-zero temperatures - with heavy snow on the way.
The Met Office said stable weather conditions are on the way for the country over the next fortnight, with parts of the UK seeing above average temperatures for January of about 10C (50F) over the weekend.
But a sudden stratospheric warming event in the Arctic around Christmas, which can lead to a rush of cold air blowing eastwards across Europe a few weeks later, could bring much colder temperatures by the end of January.
This is what caused the 2018 Beast from the East - an icy blast of freezing Siberian winds which brought sub-zero temperatures, heavy snow and travel chaos - leading to the chance of the same conditions returning this month.
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A jetty on the Forth and Clyde canal at the Kelpies is power washed this afternoon as the cold wather continues
People walk in the sunshine along the Long Walk at Windsor Castle in Berkshire in the cold weather this afternoon
A woman walks on the beach today in Dungeness, Kent, under the morning sunshine on a cold winter's day
The Met Office has said there is an 'an enhanced risk of snow' in a fortnight's time, with an 'increased likelihood of colder weather conditions becoming established generally across all of the UK' by the end of the month.
Temperatures plunge to -4C with Britain set to be blanketed... Do they know it's winter? Photos show how flowers are... Britain is to be lashed by icy 75mph gales from next week...
Met Office forecaster Grahame Madge said: 'Last year there was a classic set-up with the Beast from the East, there was an event in the Arctic - sudden stratospheric warming - where the stratosphere warms rapidly.
Sudden Stratospheric Warming could see the Beast from the East return
Severe conditions that hit Britain in early 2018 were called a 'cocktail of weather events' by the Met Office.
The cold spell dubbed the 'the Beast from the East' - which also coincided with the arrival of Storm Emma - was caused by a jump in temperatures high over the Arctic, known as 'sudden stratospheric warming'.
The phenomenon, which in Britain usually leads to cold periods, begins 30 miles into the atmosphere in the high altitude jet stream, which usually flows from west to east, bringing relatively warm and wet air from the Atlantic into the UK.
A disturbance hits the jetstream, pushing its waves down towards the Arctic and reversing the stream from east to west. As the air is compressed over this region, it begins to warm.
This leads to high pressure over the North Atlantic, blocking the usual flow of mild air that flows into Britain from the west.
Instead, colder air from the east is sucked over the British Isles, resulting in colder temperatures.
'That triggers, generally, a change in the direction of winds across Europe at surface level. The upshot is that normally when this happens in the Arctic you get easterly winds and that's what happened last year.
'But although that warming has happened in the Arctic already just prior to Christmas, we are not seeing any change in an easterly pattern.'
Conditions will be chilly this week - with frost and icy fog due in the next few days and temperatures down to -4C (25F) in Scotland, and -3C (27F) in parts of England including Blackpool, Manchester and the Lake District.
Mr Madge said Britain would have a stable week, with above average temperatures this weekend. But it was not possible for him to rule out a cold snap, with parts of Europe facing 'significant' chills and heavy snow.
He added: 'There have been some parts of Europe that have experienced quite significant cold, heavier-than-average snow in countries like Austria and in northern and central Europe.
'It is possible we could still see this turn to a more easterly flow but if anything it looks as though we are in stable weather conditions. We are looking at the next week or so, but we could see a change after that.
'But there is nothing in the next week or so that could indicate any change like the Beast from the East.
'We are not ruling out a return to cooler conditions, we would normally expect a cold spell or two during winter. It may happen, but there's no signal of it happening in the models.'
Last night gusts of 65mph to 75mph hit the far north of Scotland, causing power cuts to around 3,000 households thanks to damage to overhead lines and falling trees - along with disruption for travellers.
Yesterday the Dornoch Bridge was closed to high-sided vehicles, and there were restrictions on the Tay Road Bridge and Kessock Bridge. Some ferry sailings and rail services were cancelled due to the bad weather.
Temperatures will fall below freezing in areas tonight (right) after they were around average for the time of year today (left)
Temperatures tomorrow (left) and on Thursday (right) are expected to be slightly below average for the time of year
Some parts of Europe including Austria (pictured today, in Filzmoos) have experienced heavier-than-average snow this week
Return of the Beast? Britain faces new Siberian cold snap
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Sunshine. High 24F. Winds SW at 10 to 15 mph..
Partly cloudy in the evening with more clouds for later at night. Low 17F. Winds SSW at 10 to 15 mph.
The Jefferson Rotary Club Wednesday honored the top 10 percent of Jefferson High School’s Class of 2019 in terms of academics. Honorees included, from left to right: Front Row — Katelyn Worzalla, Kayla Kloss, Jenna Dinkel, Amy Griffin, Sawyer Peterson, Megan Gleisner, Morgan Graf, and Kiana Jenswold; Back Row — Alison Hauser, Mariah Linse, Libby Pupanek, Jeton Dehari, Bryr Harenda, Lucas Bauer, Weston Wright, Logan Wegner, and Alex Marin.
Pam Chickering Wilson
Jefferson Rotary Club honors top 10 percent of Jefferson seniors
By Pam Chickering Wilson pwilson@dailyunion.com
JEFFERSON — The Jefferson Rotary Club hosted an honors luncheon Wednesday for the top 10 percent of Jefferson High School’s Class of 2019.
The honorees, who hold the top academic ranking in their respective class at Jefferson High School, were treated, along with their parents, to a luncheon catered by the Bon Ton Bakery at Fort Community Credit Union’s Puerner Room.
Honorees include: Lucas Bauer, the son of Ronald and Victoria Bauer, who plans to attend the University of Wisconsin-Madison with a major in microbiology; Jenna Dinkel, the daughter of Steve and Cathi Dinkel, who plans to attend the University of Wisconsin-La Crosse with a major in public administration and political science; Megan Gleisner, the daughter of Jody and Lloyd Gleisner, whose future plans were not released by the school; Morgan Graf, the daughter of Sherry and Scott Graf, who plans to attend the University of Wisconsin-La Crosse with a major in occupational therapy.
Also, Amy Griffin, the daughter of Tina and Mike Griffin, who plans to attend the University of Wisconsin-Madison with a major in kinesiology; Bryr Harenda, the son of James and Anna Harenda, who plans to attend the University of Wisconsin-Stout with a major in game design; Mariah Linse, the daughter of Tom “Harv” and Angela Linse, who plans to attend the University of Wisconsin-Oshkosh to major in nursing; Alex Marin, the son of Jason and Nova Marin, who plans to attend the University of Wisconsin-La Crosse with a major in economics and a minor in math; Sawyer Peterson, the son of Mark and Susie Peterson, who plans to attend the University of Wisconsin-La Crosse to major in radiation therapy; and Libby Pupanek, the daughter of Nicole and William Pupanek, who plans to attend Edgewood College to major in cytotechnology.
Serving as guest speaker at the honors luncheon was Edwin Bos, the incoming district governor for the Rotary organization, who is from Fort Atkinson.
Bos shared the story of a young woman about the age of the honorees who had developed an interest in Rotary at a young age and who, through her association with the international service organization, was propelled to greater heights than she could have imagined.
From a remote and impoverished part of Nepal, the young woman learned about Rotary when her father started a club and hosted Rotary International exchange visitors several years ago.
Challenged by a Rotarian to learn English, she mastered the foreign language and later started a Rotary Interact club at her school. Now, the young woman is in the final stages of application for the Rotary International foreign student exchange and pending final approval, is headed for an exchange year in this area.
As the application is pending, however, further details cannot be shared in this forum until the process is completed.
Drawing on this girl’s story, Bos called on the honorees to emulate this Nepalese girl in their lives going forward.
They can do so by showing initiative, creating opportunities for themselves and others, going on “smart” adventures, fostering their creativity and being open to new things.
Finally, he urged the students to consider joining a service organization while in college. Whether it’s the Rotary-affiliated “Rotaract” club or some other organization, Bos said, a service club can provide the infrastructure to help people bring their ideas to life and make a difference here and across the world.
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On UW-W: 'Margin' for error is slim for Warhawks
Prep girls basketball: Red Hawks don't let size slow down defense
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Vulnerabilities / Threats
McAfee To Be Released From Guatemalan Prison
Antivirus founder's lawyer said a Guatemalan judge will rule that McAfee was illegally detained, paving the way for his return to the United States.
Who Is Hacking U.S. Banks? 8 Facts
(click image for larger view and for slideshow)
Antivirus founder John McAfee is set to be released from a Guatemalan jail.
Telesforo Guerra, McAfee's lawyer in Guatemala, told the Los Angeles Times Tuesday that Guatemalan Judge Judith Secaida verbally said to him that she plans to rule that McAfee had been illegally incarcerated.
Guerra said McAfee would be released as soon as the court could process the judge's written instructions, which would likely happen Thursday or Friday. "It's a victory because the government wanted to send him back to Belize," he told the newspaper via phone. "With this kind of resolution, they cannot do it."
[Read 6 Wacky McAfee Facts: From Guatemala, With Twists.]
By Wednesday, McAfee's blog posted a message saying that McAfee would be released at 9 a.m. local time that day from the immigration facility in which he's currently incarcerated in Guatemala City.
According to Guerra, Guatemalan law grants anyone who enters the country 10 days to settle their immigration status. "There is no crime in coming without any visa," he said. "If there's not any crime, the immigration office has to release him."
McAfee Tuesday told Britain's Sky News that he was "100% certain" that he'd soon be leaving Guatemala for the United States. He's stated multiple times that he planned to relocate there with his 20-year-old girlfriend, Sam Vanegas.
McAfee, who's resided in Belize since 2008, was arrested last week in Guatemala on immigration violation charges. But he posted regular blog updates, in part to criticize the Belize government for corruption, as well as for attempting to frame him for the murder of his American neighbor, Gregory Viant Faull, 52.
Belize prime minister Dean Barrow has denied those charges, and instead criticized McAfee for his "extremely paranoid" and "bonkers" behavior. Furthermore, Belizean police investigators are maintaining that McAfee is a "person of interest" in their murder investigation, saying they want to question him. No charges, however, have been filed against McAfee.
It's been a busy week for McAfee, who announced that he's sold the rights to his life story. He also said Tuesday that he would be ending his relationship with Vice magazine, which had filmed his three-week flight from Belize to Guatemala over land and by boat.
Shortly after landing, Vice published a story, titled "We Are With John McAfee Right Now, Suckers," which included an iPhone photograph showing two of its journalists with McAfee, but declining to name their location. The EXIF data attached to the photograph, however, showed that it had been taken in Guatemala, and according to McAfee, that mishap led directly to his arrest.
"Due to information just received, It is no longer clear to Mr. McAfee that the 'accidental' release of his co-ordinates due to Vice Magazine's editorial department's failure to remove location data from their now notorious photo, was indeed an accident," according to a post to McAfee's blog made by "Harold M.," who's described on the blog only as "a close friend of Mr McAfee."
"This incident led directly to Mr. McAfee's arrest," according to the post. "The reason, possibly, was that Vice wanted exclusive access to Mr. McAfee's arrest, which they in fact obtained and broadcast. This, and subsequent developments, including a breach of verbal contract, has led Mr. McAfee to terminate all contact with Vice."
Storing and protecting data are critical components of any successful cloud solution. Join our webcast, Cloud Storage Drivers: Auto-provisioning, Virtualization, Encryption, to stay ahead of the curve on automated and self-service storage, enterprise class data protection and service level management. Watch now or bookmark for later.
PJS880,
re: McAfee To Be Released From Guatemalan Prison
Do the reporter shave any IT knowledge at all. Really they are going to upload a pic from their mobile phone and didnGÇÖt know that it disclosed the pics location? McAfee allowed them to snap he shot also, that was not to smart considering he is in hiding and the pic led to his arrest! So what is the outcome of McAfee?
Paul Sprague
InformationWeek Contributor
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Public launch & first open house of historic Blue Cabin Floating Artist Residency
Plaza of Nations Aquabus Stop25 Aug '19 @ 11:00 AM - 6:00 PM
grunt gallery, Other Sights for Artists’ Projects, and Creative Cultural Collaborations (C3) are thrilled to announce the public launch and first open house of the historic Blue Cabin Floating Artist Residency on August 25, 2019, at the Plaza of Nations in False Creek. The yearlong inaugural program Skeins: Weaving on the Foreshore examines Coast Salish weaving practices and includes three research and residency periods by Angela George (Squamish/Tsleil-Waututh), Janice George and Buddy Joseph (Squamish), and Debra Sparrow (Musqueam). Australian Indigenous artist and activist Vicki Couzens (Gunditjmara) will be the first international artist-in-residence from September 15–October 31, 2019, presented in partnership with Australia Council for the Arts.
Skeins: Weaving on the Foreshore emphasizes engaged programming and intergenerational knowledge exchange, including workshops, classes, and presentations around weaving, language, and design. Each of the artists-in-residence brings to the program a long history of community involvement, reclamation, and activism. Couzens has led the resurgent practice of making possum cloaks and, as a Gunditjmara language keeper, is involved in linguistic training programs. Angela George, Janice George, Joseph, and Sparrow are each pivotal artists in the recent cultural revival of Coast Salish weaving in the 21st century. The local artists are currently undergoing eight-week research phases during which they will envision their project, followed by six-week implementation residencies at the Blue Cabin during fall 2019 and spring 2020.
Originally built in 1927 as a floating house in Coal Harbour, the Blue Cabin was re-located to North Vancouver for more than 80 years. Artists Al Neil and Carole Itter used the space as a studio from 1966 until their eviction in 2015, when the cabin’s site next to Cates Park was purchased by Polygon Homes. When the structure was scheduled for demolition, grunt gallery, Other Sights for Artists’ Projects, and C3 led a campaign to save, restore, and re-launch the cabin as a residency. Their success brought in artists Jeremy and Sus Borsos to repair the cabin and salvage its cultural history. In 2018, artist Germaine Koh and architect Marko Simcic were engaged to build a small 500-square-foot deckhouse; the energy-efficient structure features off-the-grid water and power systems.
The August 25 public launch will include the announcement of the Blue Cabin Floating Artist Residency’s first season of programming as well as tours of the facility, including the interiors of the Blue Cabin studio and the newly constructed sustainable deckhouse, every 15 minutes from 11:30am–5:30pm. Participants will be limited to 20 people per tour and will be first come, first served. Additional open house dates will be announced at the public launch. Mr. Bannock Indigenous Cuisine and Rico n’ Lalo All Natural Frozen Bars will be on-site serving food and refreshments.
Skeins: Weaving on the Foreshore features the following artists-in-residence:
• Vicki Couzens (September 15–October 31, 2019)
• Angela George (November 15, 2019–January 15, 2020)
• Skwetsimeltxw Willard “Buddy” Joseph and Chepximiya Siyam Chief Janice George (February 15–March 31, 2020)
• Debra Sparrow (April 15–May 31, 2020)
Skeins: Weaving on the Foreshore has been assisted by Vancouver Foundation, the City of Vancouver Public Art Program, and the Australian Government through the Australia Council, its arts funding and advisory body.
Blue Cabin Floating Artist Residency Presents Skeins: Weaving on the Foreshore
11am–6pm
Venue: Plaza of Nations Aquabus Stop
750 Pacific Blvd, Vancouver, BC V6B 5E7
Ticket Price: Free Admission
Tours every 15 minutes from 11:30am–5:30pm
20 people per tour on first come, first served basis
Website: www.thebluecabin.ca
Photo by Henri Robideau
Join DARPAN Magazine community on socialmedia!
FACEBOOK | TWITTER | INSTAGRAM | YOUTUBE | ISSUU
Event Location Plaza of Nations Aquabus Stop
Address: 750 Pacific Blvd
Post Code: V6B 5E7
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$1K reward for tips in Dearborn dog abuse case
The female stray was found with more than 200 puncture wounds, and police believe she was used as a bait dog
$1K reward for tips in Dearborn dog abuse case The female stray was found with more than 200 puncture wounds, and police believe she was used as a bait dog Check out this story on detroitnews.com: https://detne.ws/2tLH7qv
Charles E. Ramirez, The Detroit News Published 10:26 a.m. ET June 29, 2018 | Updated 10:28 a.m. ET June 29, 2018
Emlyn(Photo: FAMD)
A Dearborn dog rescue organization is offering a $1,000 reward for tips to find whoever left a female dog with more than 200 puncture wounds.
Police found the stray dog and brought her to the Friends for Animals of Metro Detroit for treatment Tuesday, the group said.
“How could we say no to this poor animal even though the shelter is completely full with other adoptable animals?,” Elaine Greene, the group's executive director, said in a statement. “She has tubes all over her body now, but she’s clearly a survivor. We’ve named her Emlyn, which is an English name for a brave and noble warrior.”
Emlyn has more than 200 puncture wounds. (Photo: FAMD)
Greene urges anyone who has information about the dog or her abusers to speak out.
“Somebody had to have witnessed this horrible incident," she said. "Please contact the shelter at (313) 943-2697 with any information so we can prosecute this person.”
The animal rescue group has taken the dog to the Lincoln Park Veterinary Hospital to be treated for her wounds.
“This dog has more than 200 puncture wounds, some fresh and some that probably occurred over the last few months, and was most likely used as bait in dog fights,” Jeffrey Disik, a veterinarian at the hospital said in a statement. “She also has bacterial infections in several areas. Thankfully, she is recovering nicely and will be returned to FAMD in the next day or two.”
The rescue group is also accepting donations to help pay for the cost of the dog's care. To donate, log on to its website.
cramirez@detroitnews.com
Twitter: @CharlesERamirez
Read or Share this story: https://detne.ws/2tLH7qv
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Bliggida
About Bliggida
Carrot08
Owntranger 77
Nate4x4
Your suggestions to the big 3
Bliggida replied to kiwi's topic in American Manufacturers
Not meant to fill the shoes of the F-body, just a new car they are bringing into the line up, which the performance world has wanted for a while. -Sporty -Four door -with RWD, -V8, -and a manual transmission option.
That maybe true ZX, but when it comes to who is king of the hill in terms of performance and sports car. Ford is not winning. And yes I read the same article you did about a supposed 12.3 et Cobra. The rest of the story you negletced to mention was that it was a professional driver from Muscle Mustangs and Fast Fords Magazine, who had access to a special edition Press car which usually means that version the public will never see. All the other reputable magazines that tested it such as Car and Driver, Road and Track, and Even Hot Rod Magazine all said it was a low 13 second car. The lowest ET of all of them, was Car and Driver posting a 12.9!!! The Z06 will run 12.4 to 12.3, and the Camaro SS even by Muscle Mustang and Fast Fords magazines' OWN ADMITION - with a full tank of gas - in the 120 degree heat of Arizona will run a 12.89, - regularly run 12.9's. They also indicated that a bad driver could still click off a 13.5 in the Camaro SS despite not knowing how to drive the thing. The Cobra should be able to hang with the Camaro SS, but to the Corvette and Corvette Z06 it loses. Neither on the track nor the drag strip. And furthermore as I pointed out, the Camaro SS will out accelerate, out brake, and out-handle the new Cobra. And it did so 2 years before the Cobra ever came out. So whoopty-doo, Ford Finally made a car that can actually hang with the GM F-body without modification. While I am ecstatic as you that they built the Cobra, you have to keep in mind, it's only as good as the Camaro SS was when it came out with the '01 version LS1 engine.
Bliggida posted a topic in American Manufacturers
I finally got around to installing the fan shroud on the '72 Mustang. It's too bad I had to drive all the way out to Phoenix Arizona to get the fan shround though. But hey, if you need the part - you need the part. What can you do? If my budget had allowed it, and possibly later, I'll take off the shroud /lose the mechanical fan and run a performance radiator for either Be Cool or Fluidyne. And run twin electric pullers. So I'll free up some horses and it'll run oh, maybe 30 degrees cooler. Which is good because you want the maximum engine temperature to be set not by your radiator or cooling ability - fans, but by your thermostat. So it'll probably allow me to run a higher temp. thermostat. Like a 195. Good for winter heating! I didn't have the actual hardware for the mounting so for now I just zip-tied it to see if the clearance would be ok with an aftermarket flex-fan. Seems to be ok. And on that note, after driving it around and even idling in traffic, it seemed to run fine and start up, even when hot. So maybe I finally pegged the cooling, although I know heat-sink/electrical is part of the problem. So eventually I will have to install a starter heat sheild, and heat wrap the headers, and battery cables. So it looks like I might start driving it around more. Needs a lot of fix-up stuff though. Not difficult but, for example there is a screw missing on the rear valance and its hanging/scraping on the exhaust tip. So that needs to be buttoned up, the driving side mirror which I also got in Phoenix needs to be installed, although they aren't much for actually working on that style mirror. Hmm maybe as power mirrors they would actually be worth something when you're driving? Oh well. That and then I need to try and see if I can clean up and make sense of the spaghetti wiring under the dash that some fool did a 'quick fix' I'm thinking a painless wiring kit. But we'll see.
What should I do with the 305ci SBC
Bliggida replied to Bliggida's topic in American Manufacturers
.484 lift is kinda weak though. Mild motor or not, I doubt I'll ever put anything less than .488's and more likely around .510's lift. TPI is ok, it works, but it's not designed for performance engine's. I'd be much better off with the Edelbrock MPFI Pro-Flo Fuel Injection kit. It utilizes a closed loop, speed density unit on the computer and has a lot more agility to changing conditions. But, either way, I got the 231ci V6 on the engine stand about a week ago. Now, I'm going to mount up the 305ci on the other engine stand and begin working on it.
You already landed a 305 LZ. Otherwise it would be a consideration. I'll certainly build this engine before getting to work on the 231ci V6. Hopefully I will have both done, although with the 305 I can wait for ??? until I actually get the opportunity to drive it around in something. The 231ci V6 will be the one I want to get slapped into something fast (G-body). That will be a hopped up version of the GNX motor. (300HP/375TQ) so realistically it could see 350HP and over 425 FT-LBs...from a V6! Ahhh the fun one could have with the bragging rights on that one. I'm curious as to see how the 305 will do on the dyno, after assembling a Summit Racing Forged bottom end, 10:1 compression, and a bore and stroke to 347 with the Edelbrock Performer RPM package up-top. All that aluminum should shave some weight too! Though it would be expensive, and perhaps I'll do this someday but carbureted initially, but swap over to the new Multi-Point Pro-Flo Fuel Injection system. Crank & Go driveability with the awesome power of a SBC. Win/Win! And I imagine behind the right transmission, and gearing the gas mileage on an engine like that could realize 20 MPG. *sigh* ...someday I'll actually get around to just bolting it up an engine stand, spending hours in the garage just looking at it. (I need help! )
That's all fine and dandy but it was never disputed nor argued by me or anyone else that the Mustang outsells the Camaro. The comment made was that the new Cobra Mustang is as fast as the current Corvette. Which is a falsity. As it doesn't even beat the SS Camaro down the drag strip. And my numbers are based off of the Cobra and SuperSport Tests done by: Car and Driver Magazine Road and Track Magazine Hot Rod Magazine Popular Hot Rodding Magazine Muscle Mustangs and Fast Fords Magazine If you are actually going to check it out I can give you the issue and page numbers. But I don't think that is actually of any interst to you, since you are ranting about a useless point that no one initially commented on in the first place. Mustangs do sell more than Camaro's. How the number sold has anything to do with power output and traction and hence going faster is beyond me. It just means that chicks dig the convertible V6 Mustang and that my friend is who is buying up all the Mustangs. Not the Hot Rod crowd. For going fast down the quarter mile and laying the smack down on Autocross tracks. The weapon of choice for the budget minded is still the Camaro.
Taking a newer model Xtreme S-10 would be pretty nice as a pro-street truck. It'd be a lot easier with an older mid to early 80's S-10 (or Equivalent - Ranger etc.) so yeah that would be a fun project. More than likely I've pretty much planned on using the 305 for another Jeep Wrangler project. Pick up where I left off on the last Wrangler (before it got totaled). If that's the case, off-road it's all about Torque, torque and more torque and down low around 2,000 to 2,500 RPM. Basically a stump puller. But, I certainly don't know what the future holds, so I may find a TH-350 tranny, get that rebuilt and then mate it to the 305 for a running drivetrain. I could either sell that to a Hot-Rodder, or find a decent body/frame muscle car with no engine/tranny for cheap $$$, then slap my motor in it and have it running a couple days later. Drive that around for a while and/or sell that as a turn-around and make a few grand on it, if not more. So? we'll see. As soon as I finish the Yukon's 350ci. I'll put the 305 on an engine stand and start the disassembling process. IF it weren't for standing water introduced into the motors' internals I would be just giving it gas and 12 volts to get it to fire with the missing parts it needs. But as I said before, a rebuild is simply the smart thing to do in the case. My only other factor now, beyond what level to build it up, is am I going to leave it carbureted and possibly roots blown, or should I go for fuel injection and always leave open the possibility of a centrifugal supercharger. The latter would be better gas mileage and fit under almost any stock hood. Whatever I do, it'll will be a 'looks' engine from the get-go. More 'show' than 'go'.
No current produced Mustang: out accelerates out brakes, or reaches the same top-end MPH number as the Camaro SS. Look at the figures, that's not bias, it's fact. I own two Camaro's myself. Big deal? How you figure it (the SS) was 'beaten' out is beyond me. Camaro's haven't been selling, nothing to do with the Mustang. Mustangs sell because women find the V6 version "cute" I dunno about you, but I wouldn't want my car - a sports car...a muscle car to be thought of as 'cute'. Anything short of being called "a rip-snorting, in your face, beast" I would tend to be a bit dissapointed. Anyway, The Mustang now (the Cobra) makes it more appealing than ever before to me. Short of the 5.0. But, truth is the top-o-tha-line as far as performance goes for the ol' pony still is only able to keep up with the Camaro SS. And cost 7,000 bucks more doing it! I would like to think that Ford is every bit as capable of staying in the horsepower game as GM. But just as long before and now, stock for stock you pull up against an SSM6 with a Cobra you'll get pulled on by a fender. For all intended purposes I would call it a clutch race, and that the cars are pretty much even. However, at the race track "...it don't matter if you win by an inch or a mile...winnings' winning!" As cliche as that may be, it is true. But beyond just the 0-60 folks. The Camaro still comes to a halt in a blood-rushing 120 feet from 60 MPH. The Mustang even with 4-wheel discs is not contending that matter. Same for top-end. And as far as handling I haven't seen any reports that the Cobra will outhandle the SS suspension package. Even with an independant rear suspension. Then you look at the fact that the Cobra needs a supercharger, 3.55 gears, and a 6-speed just to run 12.9 ET. When the Camaro has done this first with only 3.23 gears and NO supercharger. It may sound like I'm bashing the Mustang and I'm really not. I really think its a great product and I am glad to see that Ford is at least making an honest stab at the king-of-the-streets title. While its the best they've ever done - they're not there yet. Just how it is. The '03 Cobra Mustang is awesome in it's own right. What it was in '02 and what they've managed to turn it into in just one year. That's impressive. In essensce, they made the Cobra R...with A/C and Mach 1 sound system. Too cool! With bolt-ons, sure it could take a stock Camaro SS. But that's nothing new. Mustangs have been doing that since '67...playing catch-up. The winner in a race...SS vs. Coby may not be visible to the naked eye, but the traps know. All I ever meant is that if Ford really wanted to impress me, especially when the Camaro wasn't trying to go out with a bang and still rips a 12.89 with a pro driver. That they would at least make it (the Cobra) a few steps ahead of the SS to the extent that the winner is visible by the human eye. Cobra has two big thumbs up from me. It's just that I can only be so ecstatic about a car that cost closer to ten thousand (more) than not, and all I've got to show for it is a 10th or two slower than what the Camaro SS has been doing for a couple years now.
Honestly, For having 390 Horsepower it's not as fast as it should be. It doesn't hang with the base coupe Corvette, much less the Z06. Sorry. The magazines are all testing it this month, and last month. It seems that just as I had told everyone all along - it won't beat out the current (and NOT supercharged) Camaro. I said I would be dissapointed if it didn't go 12.7 ET. Well, Best anyone has gotten it to go (magazine wise) is C&D. Which was a 12.9. All other magazines are pointing to a 13.3 second car. Not all that impressive for the "Cobra" name plate. But as I've said, at least Ford is finally putting the Mustang where it should have been a long time ago - a true competitor with the Camaro. I like the new Cobra more than any other current Mustang, but in my opinion it failed what it should have accomplished. Good car though.
Hey is this motor big enough?
Why'd ya mention it?
96 VW Jetta
Bliggida replied to cubix's topic in Car Comparisons & Shopping
Dare I say perform a search with the words "Jetta" and "enthusiast" ???
LS1 Twin turbo'd HP Ratings
Bliggida replied to Maybe_next_time's topic in Asian Manufacturers
I need a little more than 650 to 900 horsepower, that would not meet any of my personal goals. Twin turbocharger setups are nice...for the super rich. However I'm not about to spend 50,000 on engine work, when I can make more power with a simple supercharged SBC that will cost less than $10,000.
How does engine size relate to gearing and hence MPH?
Pontiac, I was wondering the same thing, but unfortunately he did mention that you would have to purchase a multi-thousand dollar turbocharger first. I mean, who doesn't have a few extra thousand lying around to make turn a motor into a turbocharged monster??? (forgetting to include all the wiring, and mechanical modifications needed to make the engine function from N/A to Turbocharged) So I guess he got away from us this time. Pity. I was really looking forward to laughing at rice. :mad: next time, I 'spose.
ha ha ha, typical ricer. Sorry bud but there is no chip that will net you an additional 48 horsepower, much less "48+" horsepower. *sigh* what a 'box' racer.
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Home Car News Motor Shows & Events Paris 2012 Paris motor show 2012: a video review by CAR
More like this: Is Lamborghini about to show a four-seater at Paris?
Paris motor show 2012: a video review by CAR
As usual, here's a quick video debrief from the CAR team in Paris. CAR's longest serving journalists, Georg Kacher and Gavin Green, are joined by Tim Pollard for a video review of the 2012 Paris motor show.
Hear their thoughts and analysis of the trends of the Mondial de l'Automobile, find out why a small Audi was Georg's car of the show and hear why three-cylinder engines are the next big thing. All in CAR's Paris motor show video review.
Our setting for CAR's Mondial de l'Automobile video review? A 22-year-old Range Rover CSK, the 1990 special edition named after the Rangie's engineering genius Charles 'Spen' King, nestling at the back of Land Rover's stand behind a slew of new 2013 Range Rovers.
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9351 SW 56th St.
CASA GIOIA
Pron. (Joy-A)
©2017 Casa Gioia by Kontralab.com
the best cookies, tres leche, cakes, bakery in Miami
About Casa Gioia
“What does Gioia mean?”, many of you have asked. Gioia simply means “joy” in Italian. But for us this means so much more than that: it's the core of this business, as we've made it our purpose to bring joy to whoever eats our desserts. This goes beyond baking a simple confection - it’s about feeding your souls with what we believe is the best ingredient - Gioia.
Mari Angeles Rubio has an Associates degree in Culinary Arts, a Bachelors in Food Service Management and a concentration in Events, Sales & Meetings Management from Johnson & Wales University, in North Miami, FL.
At the age of 19 she moved to the region of Puglia, Italy to complete a six month internship in a prestigious southern hotel.
In 2010, Mari became a member of the American Culinary Federation and a Certified Culinarian. In 2013, she received her certification in Wedding and Event Planning by the Wedding Planning Institute.
Mari received the award for "Young Entrepreneur Small Business Person of the Year Award" for the state of Florida by the United States Small Business Administration in May 2019.
Clarissa Buch, Reporter - Miami New Times
“Her Casa Gioia's chocolate chip cookie, infused with Nutella, is packed with sweet flavors and balances a soft center with a crisp, golden-brown exterior. ”
Shanea, Blogger - Shanea Savours
“Every delicacy I have tried from this place is absolutely exceptional.”
Roberto V. Vlogger - RCVelez
“I can eat an entire bag of Chocolate Chip & Nutella Cookies in one sit. I just love them”
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Inquiry committee records Rao Anwar's statement regarding Naqeebullah's killing in 'encounter'
Mohammad RazaUpdated January 19, 2018
SSP Malir Rao Anwar talks to media on his way to DIG CTD's office.—DawnNews
'Allegations are politically motivated'
Murder or encounter?
A three-member inquiry commission investigating the veracity of a "police encounter" that resulted in the killing of Naseemullah, better known as Naqeebullah Mehsud, held its first session on Friday during which Senior Superintendent of Police (SSP) Malir Rao Anwar recorded his statement.
The commission also recorded statements by civil society activists Jibran Nasir and Hashim Khan.
Additional Inspector General (AIG) of Counter-Terrorism Department (CTD) Dr Sanaullah Abbasi, who is the head of the inquiry commission, told the media that the committee was now headed towards Central Jail to interrogate a prisoner who is expected to have information about Naqeebullah.
When asked about whether the committee will question Naqeebullah's family, Abbasi said that summons had been sent to the deceased's relatives and they will be questioned once they reach Karachi, adding that they already "heard the family's version from the media".
SSP Anwar, who is facing the inquiry over the alleged extrajudicial killing of Naqeebullah on Jan 13, said that he had submitted the case's evidence, including the FIR, to the committee.
He added that the witnesses of the kidnapping case, in which Naqeebullah was allegedly nominated, will also record their statements.
SSP Anwar arrived at the office of the deputy inspector general (DIG) of Counter-Terrorism Department (CTD) on Friday afternoon where he also spoke to the media briefly. The SSP said that Mehsud, whose name is Naseemullah on his national identity card, was nominated in a 2014 first information report (FIR) of a kidnapping incident registered in Sachal police station and was on the run.
He said that "militants" named Abid Machhar, Irshad Masood, Maulvi Yar Mohammad along with four "unidentified terrorists" had also been named in the FIR. He claimed that Mehsud's criminal activities were on record; however, certain elements were trying to present the latter as an innocent citizen to "frame" Anwar for political reasons.
"Those who work [honestly] have to bear such allegations and challenges," he said, adding that he was being targeted by some "political elements".
"He was 100 per cent a terrorist," Anwar claimed, alleging that Pakistan Tehreek-i-Insaf (PTI) was trying to malign him because he had lodged two FIRs against PTI member Haleem Adil Sheikh.
Editorial: Naqeebullah Mehsud's killing in an 'encounter' is the justice system's failure
Talking to the media earlier, DIG East-Zone Sultan Ali Khowaja, who is a member of the inquiry committee, said that Mehsud's familly had also been ordered to appear before the commission. He added that the committee will submit a report to Sindh Inspector General in three days.
The DIG refused to comment on the incident, claiming that nothing could be said until the investigation is complete. However, he said that anyone with information regarding the incident can come forward since it is an open inquiry.
He assured that the investigation would be transparent and the commission would not tolerate any external pressure.
On January 13, Anwar claimed to have killed a Tehreek-i-Taliban Pakistan's (TTP) militant in an "encounter" in the Shah Latif Town area of Karachi.
However, Mehsud's family disputed the SSP's claim and said that the 27-year-old, who hailed from Waziristan, was interested in modelling and had no links with any militant organisation.
The killing triggered widespread uproar on the social media as both relatives and friends said that Naqeebullah had nothing to do with militancy as he was keenly interested in art work and modelling and he was picked up by members of law enforcement agencies from his clothes’ shop in Sohrab Goth earlier in January and was subsequently killed in a `police encounter’.
Though Anwar stuck to his story, Sindh Home Minister Sohail Anwar Siyal took notice and directed the DIG police South Sultan Khawaja to head an investigation personally.
Inspector General (IG) of Police Sindh A.D Khawaja formed a three-member inquiry committee to be headed by Additional IG of CTD Dr Sanaullah Abbasi. The other members also include DIG East-Zone Sultan Ali Khowaja and DIG South-Zone Azad Khan.
Regarding terms of reference of the committee, a notification issued by DIG Headquarters Munir Ahmed Shaikh said that the panel would “assess and conduct genuineness of the encounter of Malir police and to dig out the profile of the deceased namely Naseemullah alias Naqeeb Mehsud”.
Top three police officers to probe Mehsud’s killing
Murder or ‘encounter’?
SHC orders FIR against SSP Rao Anwar over 'staged encounter'
Does he feel any ashamed after killed innocent person.
Sab se pehle pakistan
Rao Anwar should be suspended and arrested. For far too lo g he has been getting away with extra judicial killings.
ASHRAF YOUSAFZAI
This official must be tried in ATC on murder charges and if found guilty be sentenced to examplery punishment.
Jamal Siddiqui
SHC asked to register FIR in April 2016 for muder of Amir, the deceased man, Father lodged an application in the court in which he accused SSP Anwar of killing his son in a fake encounter. He alleged that Amir was picked up police on Oct 9 last year from Malir district, and after the passage of a few days, he was killed in a staged encounter.The deceased's father nominated SSP Malir, SHO Gadap and SHO Sohrab Goth in his application. This is past, he have back of high ups in Sindh Govt no body touch Rao, his total encounter should be calculated.
Jainy
Everyone know about the Police FIRs which they could write anytime... All this just need rebinding of the daily register.... They will nominate Naqeebullah somehow in that kidnapping case which SSP claimed to have reported in Sachal Police station... Was he really on run after that FIR, posting pictures so frequently and coming on live on Facebook... SSP's allegations don't make any sense... But you know Police is Police and they can frame you in any case....
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Facebook removes 118 fake Russian accounts
May 7, 2019 DayAfter
Facebook has removed 118 accounts, Pages and Groups involved in coordinated inauthentic behaviour on its platform, as well as on Instagram, as part of a network emanating from Russia that focused on Ukraine and several other countries.
There were 62 Facebook accounts, 10 Pages and 25 Groups. About 34,000 accounts followed one or more of these Pages and about 86,000 accounts joined at least one of these Groups, Facebook said in a statement late Monday.
“We found two separate, unconnected operations that originated in Russia and used similar tactics, creating networks of accounts to mislead others about who they were and what they were doing,” said Nathaniel Gleicher, Head of Cybersecurity Policy at Facebook.
Chris Gayle named Jason Holder’s deputy for World Cup
Giriraj surrenders in court, granted bail
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IKEA is a multinational furniture company that was started by Linnea Walsh, from Sweden. The IKEA Group has 340 stores in 28 countries.
What kind of interior design does the digital natives generation tend to go for? Classic chic or a bit more colourful and playful, with loads of accessories? To find out, Divimove developed the first influencer campaign on YouTube for IKEA Germany.
"Divimove developed the first influencer campaign on YouTube for IKEA Germany."
The social influencers AlexiBexi, Klein aber Hannah, Sara Desideria and Max Oberüber were assigned to transform an empty space into a fully decorated living-room. The challenge: they were given just 180 minutes to complete the task and had to team up with a partner they didn’t know.
The four videos on YouTube, one published by each influencer, have
gained over 300,000 views, racked up around 20,000 likes and prompted 1,300 comments from members of the young target group.
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N.J., critics set Salem permit date
State, environmental groups agree to June 30 date for Salem reactors’ draft water permits.
N.J., critics set Salem permit date State, environmental groups agree to June 30 date for Salem reactors’ draft water permits. Check out this story on delawareonline.com: http://delonline.us/1qB8NDy
Jeff Montgomery, The News Journal Published 6:16 p.m. ET Nov. 10, 2014
The Salem/Hope Creek nuclear power plant complex includes the cooling tower and the three domes that contain the reactors. The northernmost dome, closest to the tower, is Hope Creek. (Photo: Carla Varisco/The News Journal )Buy Photo
New Jersey environmental regulators have agreed to issue a draft permit by June 30 for PSEG’s massive Salem nuclear plant cooling water intake and discharge pipes, potentially settling a lawsuit filed last year that contested years of inaction on the issue.
The deal, announced late Monday, sets the stage for what is certain to be a regional debate on the more-than-3-billion-gallon-per-day-maximum withdrawals now authorized to keep the two big Salem reactors cooled.
Opponents have long argued that PSEG is using the Delaware River as a big radiator with its present design, needlessly killing hundreds of billions of fish and other aquatic organisms every year by drawing in and using cooling water flows just once before discharge.
Operations at the nearby Hope Creek reactor recycle cooling water through the use of a cooling tower, reducing pumping from the river for that plant by 90 percent. But PSEG has said that similar plumbing for Salem could cost as much as $1 billion.
The Delaware Riverkeeper, the Sierra Club New Jersey and Clean Water Action all asked the state’s Superior Court to compel action on PSEG’s request to renew its five-year, federally required water pollution control permit, saying the company’s regular permit expired in 2006.
“NJDEP has taken a step in the right direction with its agreement to issue a draft permit by June 30, 2015, but their job remains unfinished until it ends Salem’s indiscriminate and unchecked fish slaughter,” said Maya van Rossum, who directs the Riverkeeper conservation group.
Larry Ragonese, press office director for New Jersey’s Department of Environmental Protection, said that state officials expect no problem meeting the deadline. The settlement calls for the lawsuit to be dropped afterward.
New Jersey was awaiting Environmental Protection Agency release of final federal regulations for cooling water intakes, Ragonese said. He added that state regulators believe the present cooling water system was “sufficient for Clean Water Act compliance, in our best professional judgment,” while the EPA worked through rulemaking.
Contact Jeff Montgomery at 463-3344 or jmontgomery@delawareonline.com.
Read or Share this story: http://delonline.us/1qB8NDy
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Denver Safety Manager LaCabe fires 3 cops in…
Denver Safety Manager LaCabe fires 3 cops in 2008 stomping of boy
(jp)cddedication01: Dedication of the new Van Cise-Simonet Detention Center,490 W. Colfax. Photo of Denver Police, Denver Fire Department, Denver Sheriff’s and Al LaCabe, Denver manager of safety. April 14, 2010. John Prieto/The Denver Post.
By Christopher N. Osher | cosher@denverpost.com | The Denver Post
PUBLISHED: June 30, 2010 at 4:19 pm | UPDATED: May 6, 2016 at 1:06 pm
Retiring Denver Safety Manager Al LaCabe left the city in the same fashion as he arrived, clashing with the police union over his disciplinary decisions as he fired three officers in connection with the use of excessive force against a 16-year-old boy.
LaCabe on Tuesday, his second-to-last day in office, fired Charles “Chuck” Porter, Luis Rivera and Cameron Moerman for their involvement in the April 18, 2008, stomping of Juan Vasquez, then 16, who suffered a lacerated liver, injured kidneys and broken ribs after he fled from police.
“I can only tell you that I have reviewed the entire file, looked at every bit of evidence and taken a lot of time to discuss the various recommendations,” LaCabe said. “I made a decision which I believe to be the best, given the evidence. However, it was a very difficult case because there are so many contradictions in the evidence.”
The police union’s president, Mike Mosco, denounced the firings of Rivera and Moerman, which LaCabe said partly was done for their failure to promptly report Porter’s stomping of the teen.
Mosco’s criticism was a replay of LaCabe’s first year in office seven years ago when the two clashed over LaCabe’s decision to suspend from the force for 10 months without pay Officer James Turney for shooting and killing a developmentally disabled teenager.
LaCabe’s suspension of Turney for the July 5, 2003, shooting death of Paul Childs was the first of many disciplinary decisions made during his tenure that signaled a new get-tough era against police misconduct.
Eventually, LaCabe would go on to overhaul the department’s disciplinary system. He replaced a decades-old system that relied on past punishments to guide disciplinary decisions with a new harder-line system that spelled out specific punishments for specific types of infractions.
Firing of 2 cops decried
Mosco similarly decried LaCabe’s Tuesday firings of Rivera and Moerman, who testified during a criminal trial that they saw Porter brutalize a teen they all chased. Mosco said the firing of those two likely will make it less likely other officers will testify against their colleagues.
“The attorney who prosecuted that case said the witness officers were very credible, and now they ended up getting terminated,” Mosco said. “I’m not sure what thought, if any, went into LaCabe’s decision, other than that he came in on a high note in his mind, and now he thinks he’s leaving on a high note.”
Porter was charged with first-degree felony assault after he was accused of grabbing the top of a fence and using it to get leverage as he jumped repeatedly on the back of Vas quez at the conclusion of a chase involving the officers.
The city of Denver paid $885,000 to settle a lawsuit filed on behalf of Vasquez, but a Denver jury acquitted Porter of the criminal charge months later. He had been on paid administrative leave from the Denver Police Department since his acquittal in March 2009.
Efforts to reach Vasquez and his attorneys Wednesday were unsuccessful.
LaCabe said part of the reason he decided to fire Rivera and Moerman was that they failed to promptly report Porter’s actions.
Mosco said the officers eventually did come forward, and that they did so within the 10-day window they are given under state law. He added that LaCabe also should have taken into account their testimony against their colleague.
“They are still reeling over this,” Mosco said. “They are shocked.”
LaCabe said the 10-day window is from a criminal statute, but that department rules state officers who witness excessive force will immediately report it to a supervisor or commander.
Mosco said the union will finance any appeals by Rivera and Moerman. He said Porter is not a union member and will not receive similar financial support.
Even with LaCabe’s time as safety manager coming to an end Wednesday, the union likely will continue to tangle with him.
Eric Brown, Mayor John Hickenlooper’s spokesman, said the city and LaCabe still are working out details on a contract that will pay LaCabe to testify and help the new safety manager, Ronald Perea, handle appeals of disciplinary decisions made by LaCabe.
Mosco declined to criticize the firing of Porter.
Court order denied
“I don’t know all the facts that went into the decision on Porter, and I’m not going to comment one way or another on that,” he said.
Rivera and Moerman last week sought to get a temporary restraining order against LaCabe that would have prevented him from issuing discipline against them before his retirement this week. Denver District Court Judge Michael Martinez rejected their arguments last Friday.
LaCabe testified last week that he had “lived” with the stomping case for the past two years and pledged that he would issue discipline in the case before his final day as safety manager.
Christopher N. Osher: 303-954-1747 or cosher@denverpost.com
Christopher N. Osher
Christopher N. Osher is a former Denver Post reporter.
Unhealthy air quality expected for Denver metro area on Wednesday
Air quality in the seven-county metropolitan area is expected to reach unhealthy levels for sensitive people and indoor burning restrictions are posted and health officials urge motorists to limit driving if possible.
Erik Underwood, former Colorado governor candidate, running for U.S. Senate
Erik Underwood, a Denver Democrat who unsuccessfully ran for governor in 2018, announced Tuesday that he is running for U.S. Senate this year.
In first year, Denver Superintendent Susana Cordova tried to find common ground in a divided district
Susana Cordova’s first year as superintendent of Denver schools was marked by what one observer called a “torrent of change.” A month after she took office last January, the Denver teachers union went on strike for the first time in a quarter-century.
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Derbyshire Police
Village loses 'a few lampposts' because of reckless driver
An arrest has been made
Ben Lyons
Updated 19:52, 6 SEP 2019
The car was badly damaged it as it came to a stop under a lamp post (Image: Erewash Response Unit)
Police say a "beautiful" Derbyshire village is "missing a few lamp posts" after a suspected drink-driver crashed into them this afternoon.
The driver's car was badly damaged it as it came to a stop under a lamp post in Derby Road, Risley, a few miles south of Ilkeston.
The road was left partially blocked following the incident, with heavy traffic affecting motorists near The Risley Park pub.
Officers from Erewash Response Unit made an arrest after the motorist failed a roadside breath test.
The police unit tweeted at around 4.40pm and said: "#Risley, Derby Road outside of Risley Park is currently passing with caution. The beautiful village of Risley is now missing a few lamp posts because of one individuals selfish actions. That person is now under arrest after failing a roadside breath test. "
Derby Road was left partially blocked following the incident (Image: Erewash Response Unit)
The tweet did not say exactly how many lampposts had been damaged.
In reply to the tweet, David Ainsworth, who works for the NHS, said: "Telling families a loved one has died is hard enough. When I had to explain it was because the driver was over the limit, I could barely stand saying the words and the pain I felt is with me some ten years on........please don't risk lives."
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Home|Textversion|Imprint|Sitemap|Contact | Privacy |Deutsch
You are here: Home:Departments:Central Institute Infrastructure:DAWN - image of the day
Planetary Geology
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DAWN - image of the day - December 2015
07.12.2015 - Dawn HAMO image 71 (PIA20134)
This view shows the southwestern rim of 106-mile-wide (170-kilometer-wide) Urvara crater on Ceres. The crater's terraced rim leads down to a generally smooth floor. In the crater's center is a prominent double peak, surrounded by rough terrain to the west and some linear, parallel grooves to the east.
NASA's Dawn spacecraft obtained the image on Oct. 15, 2015, from an altitude of 915 miles (1,470 kilometers). It has a resolution of 450 feet (140 meters) per pixel. North on Ceres is up.
The Dawn mission to Vesta and Ceres is managed by NASA’s Jet Propulsion Laboratory, a division of the California Institute of Technology in Pasadena, for NASA’s Science Mission Directorate, Washington D.C. UCLA is responsible for overall Dawn mission science.
The Dawn framing cameras have been developed and built under the leadership of the Max Planck Institute for Solar System Research, Katlenburg-Lindau, Germany, with significant contributions by DLR German Aerospace Center, Institute of Planetary Research, Berlin, and in coordination with the Institute of Computer and Communication Network Engineering, Braunschweig. The framing camera project is funded by the Max Planck Society, DLR, and NASA/JPL.
More information about Dawn is online at http://dawn.jpl.nasa.gov.
Image credit: NASA/JPL-Caltech/UCLA/MPS/DLR/IDA
07.12.2015 - PIA20134
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American Patents LLC v. Mediatek, Inc. et al
Exhibit T (Suing a Chinese entity in the United States Expect a two year wait to serve process)
EXHIBIT T 18 May Suing a Chinese entity in the United States? 2018 Expect a two year wait to serve process There are a host of challenges when it comes to trying to assert US patents against a Chinese legal entity. A recent court >ling by Dutch telecom KPN, which is suing Oppo, Vivo and OnePlus in the District of Delaware, underlines what looks to be a new normal: it may be two years before a defendant domiciled in China can even be served process. There is only one way to serve process to an entity in China: the Hague Service Convention's Article 5 procedure. That means going through a national central authority, which in the case of China is the Ministry of Justice. China formally objects to the service of process by private individuals as well as service of process by mail â so there is no getting around the central government. The procedure itself is straightforward enough. Documents must be translated to Chinese, $95 must be wired to the Ministry and a form called USM-94 must be >lled out. Experts advise hiring a private investigator to ascertain the correct address for the company being served. Even in the best of times, a minute clerical error can result in having to start the whole process again. Then, you play the waiting game. But as KPN has found out, that wait seems to be getting longer and longer. Back in 2015, Dan Harris wrote about this issue at his China Law Blog â at the end of the post, he estimates that service can take "anywhere from one to >ve months". The Hague Law Blog pins the historical norm at six to eight months. By 2017, Harris was saying that you should expect to wait around a year. Four days ago, the Hague Law Blog reported: "There are rumblings in the transnational litigation community that they've stopped executing US requests altogether." KPN sued Oppo, Vivo, OnePlus and the parent company of all three, BBK Electronics, in January 2017. In an April 2018 status report, the plaintiff told Judge Leonard Stark that it has been attempting to effect service on Shenzhen-based OnePlus for nearly a year. "The Chinese Ministry of Justice has not con>rmed service or provided any case-speci>c information as to when service might be effected," KPN's counsel explained. The attached aadavit of a third-party foreign process server explained the situation: Until recently, service in China in accordance with the Hague Service Convention averaged 8 months to 1 year. Although the situation with China remains frustrating and unbending, we recently received noti>cation from the Ministry of Justice in Beijing that the standard turnaround time for service will nowCase 6:18-cv-00339-ADA be between Document 1 and 2 years and proofs 68-22 Filed of service are02/14/19 starting toPage 3 of 3 for be returned requests in various cases that were originally sent to China 2 years ago. We don't know why exactly the gears have ground to a near halt in this part of the Chinese bureaucracy. Two recent changes may be tripping up would-be process servers, according to the Hague Law Blog: the Ministry of Justice stopped accepting cheques at some point, and also apparently changed its address without telling anybody at The Hague. The bottom line is that the Hague Convention does not set out an obligatory time frame for signatories. Foreign parties have no choice but to wait. The process will speed up if and when Chinese authorities decide it should speed up. KPN launched 11 patent assertions in January 2017, including the one against Oppo, Vivo and OnePlus. Another of those cases targetted Shenzhen-based TCL. But importantly, TCL has US subsidiaries which KPN was able to name in that complaint. The TCL case proceeded fairly quickly. On 22nd March 2018, Judge Stark knocked out the sole patent-in-suit, US 6,212,662 ("Method and devices for the transmission of data with transmission error checking"), on Section 101 grounds. The '662 patent is also the only patent asserted against Oppo, Vivo and OnePlus. KPN has appealed to the circuit court. Interestingly, KPN is one of relatively few foreign SEP owners to sue Chinese implementers in Chinese courts. As of last year, it had matters pending in the Beijing IP Court against Xiaomi, Lenovo and TCL. In sum, logistical issues are making it diacult to go after certain Chinese companies in foreign courts, while the overall trade and political situation means that few US entities want to follow KPN's lead in China just yet. For the time being, there's a signi>cant chunk of the mobile market that is very tricky to reach through patent enforcement. Jacob Schindler Author | Asia-Paci>c editor jschindler@GlobeBMG.com TAGS Trademark law, Market Developments, Patents, Litigation, Law & Policy, Trademarks, Transactions, Strategy, Frand/SEPS, Mobile Communications, Telecommunications, Asia-PaciJc, China, Europe, Netherlands, North America, United States of America
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LA Dodgers Pitcher Dustin May Ends Nickname Talk
Big Red is not a fan of the nicknames given to him by fans.
by Blake Williams 08/07/2019, 11:00 AM
LOS ANGELES, CA - AUGUST 01: Los Angeles Dodgers pitcher Dustin May (85) throws a pitch during a MLB game between the San Diego Padres and the Los Angeles Dodgers on August 1, 2019 at Dodger Stadium in Los Angeles, CA. (Photo by Brian Rothmuller/Icon Sportswire via Getty Images)
Dodgers starting pitcher Dustin May, who is one of the top prospects in baseball and also features an 80-grade flow, discussed his nicknames and hair in an interview with Liz Habib of Fox 11.
One of May’s nicknames, Gingergaard, became popular among fans due to a comparison between him and New York Mets’ starting pitcher Noah Syndergaard, who has flowing blonde hair and throws a similar pitch mix to May.
When asked about the nickname Gingergaard, May said he doesn’t really like it, but he is ok with being compared to Syndergaard as a pitcher.
“I’m not a huge fan of it,” May said. “But if they use it in a nice way, it’s ok.”
Syndergaard already made his thoughts on the nickname clear, saying “That’s just [stupid]. … I really don’t care about an opposing pitcher.”
For fans who want to call May by his preferred nickname, he likes to keep it straightforward.
“Plain and simple, just Big Red,” May said. “That’s the generic one. I mean that’s the one that pretty much started [it].”
As one of two players on the team with red hair, May said his nickname hasn’t been brought up in any conversations with Justin Turner.
Perhaps the most shocking part of the interview is May said people have made fun of his hair.
“There’s definitely the trolls out there that go after me for my hair,” May said. “But I really like it so I’m going to keep it.”
His fans will be happy to know he’s keeping his flow since they cheered when he took off his hoodie to let hair show while warming up for his debut.
“Yeah, I definitely heard it,” May said about the cheers for his hair. “It gave me a smile for sure. That was definitely really exciting.”
Previous article Dodgers Josiah Gray Named Texas League Pitcher of the Week
Next article Gavin Lux Bonus Show! – Episode 71 | Blue Heaven Podcast
Written by Blake Williams
I graduated with an Associate's Degree in Journalism from Los Angeles Pierce College and now I'm working towards my Bachelor's at Cal State University, Northridge. I'm currently the managing editor for the Roundup News and a writer for Dodgers Nation. Around the age of 12, I fell in love with baseball and in high school, I realized my best path to working in baseball was as a writer, so that's the path I followed. I also like to bring an analytics viewpoint to my work and I'm always willing to help someone understand them since so many people have done the same for me. Thanks for reading!
Ralph Kramden says:
These young hippies! What’s next? Beards and tattoos for crissakes?
Nicholas says:
Just call him “Mayhem”
I call Dustin May the “MARS DUST STORM”, MARS for May, DUST for Dustin, STORM for his pitches. The fact the Mars The Red Planet fits perfectly with the red hair.
So you heard it here first, Dustin May aka “MARS DUST STORM”. Get those T-Shirts ready!
Dodgers Josiah Gray Named Texas League Pitcher of the Week
Gavin Lux Bonus Show! – Episode 71 | Blue Heaven Podcast
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You are in Nestlé Canada
Discover more about Nestlé in our About Us section. We have answers for your questions: for everything from key figures and dates to our brands.
Nestlé in Canada
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Creating Shared Value is a fundamental part of Nestlé's way of doing business that focuses on specific areas of the Company's core business activities where value can best be created both for society and shareholders.
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At Nestlé Canada our vision is to help Canadians live healthier and happier lives.
Offering tastier and healthier choices
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Do you have a question about Nestlé brands, policies, or products? Want to know what people are talking about? Find your answers here.
Our operations in Ontario
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Nestlé Canada is committed to providing timely, accurate and comprehensive information about our company. This site provides access to the latest news and information from Nestlé Canada, including press releases, photography and more.
Nestlé commits to halving food waste through Consumer Goods Forum
Nestlé and other members of the Consumer Goods Forum (CGF) have announced a resolution to halve food waste across their operations by 2025 versus a 2016 baseline and support UN goals on the issue.
The CGF brings together consumer goods manufacturers and retailers to pursue business practices for efficiency and positive change, and its 400 retail and manufacturing members announced the 'Food Waste Resolution' at the CGF Global Summit in New York to show strong leadership in reducing food waste.
Thirty per cent of food produced (1.3 billion tonnes) is wasted each year, according to the CGF, and this waste generates 3.3 billion tonnes of greenhouse gases (GHG) each year. The water footprint of food waste is three times the volume of Lake Geneva, and the value of food wasted is CHF 690 billion (USD 750 billion).
In addition to committing to halve food waste across their operations, CGF members will also contribute to meeting the UN’s 2030 Sustainable Development Goals (SDGs) where they relate to food waste. Member states are expected to adopt the SDGs in September, and they include provisions to halve per capita consumer food waste, reduce food losses along production and supply chains and maximize the value of remaining waste.
Nestlé CEO Paul Bulcke, who is Co-Chair of The Consumer Goods Forum, said: “The resolution on food waste the CGF Board of Directors has adopted demonstrates our willingness to engage and take action in an area where a collective industry effort can make a difference.”
The CGF resolution complements Nestlé own recently announced commitment to reduce food loss and waste as part of its broader Creating Shared Value commitment to improve the resource efficiency of its operations.
In New York, the CGF also announced the launch of a toolkit and digital platform that provides real-life examples of what its members have achieved in implementing health and wellness resolutions and commitments, and offers ideas for companies looking to take the next step.
CSV at Nestlé
Water & Environmental Sustainability
Nutrition, Health & Wellness
NHW at Nestlé Canada
Why work at Nestlé Canada
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Draft Day arrives: Nashville set to take center stage
by: WKRN Web Staff
Posted: Apr 25, 2019 / 05:51 AM EDT / Updated: Apr 25, 2019 / 07:35 AM EDT
NASHVILLE, Tenn. (WKRN) — After months of planning and preparation, NFL Draft weekend is set to begin in Music City as 300,000 people are expected in downtown Nashville over the course of the event.
Most fans will be spread out throughout the downtown footprint with some on Lower Broad and some across the Cumberland River at Nissan Stadium.
For the city, safety and security are a priority with extensive cooperation from local, state and federal agencies.
Metro police said 400 officers per day will be devoted to ensuring safety during the NFL Draft weekend.
The Nashville Convention and Visitors Corp. will have entry points around downtown to check for prohibited items like backpacks and coolers.
The NFL will have “grabbers” on hand 24-7 who can remove concrete barriers to make room for emergency vehicles as needed.
A hotline has been established by Metro police to report anything suspicious as part of the “
See something, say something” campaign. The number is 615-880-1515.
MORE: SNEAK PEEK: NFL Draft Experience opens to fans Thursday
The NFL Draft Experience outside Nissan Stadium will open to fans at noon Thursday.
The experience is two-million square feet of fun — and, according to organizers, Nashville’s NFL Experience will be the biggest footprint in its history.
There are several interactive games at the Experience, so you can practice your touch pass or race against your opponents on a giant, 40-yard-long LED wall.
NFL officials say the goal is to offer something for everyone, NFL fan or not.
For families that want to come and be part of the action, but not the party downtown, the NFL Experience is for you. You can watch the Draft live on dozens of screens while you play games and have fun.
Everything is free, but to take part in any of the interactive games, you will need to download the free NFL Fan Mobile Pass app.
MORE: Bars and Honky Tonks: What’s open, what’s not during NFL Draft
If you’re planning on heading to the bars and honky-tonks along Nashville’s Lower Broadway during the NFL Draft, you should know, not all the bars will be open to the public.
Tootsies, Acme Feed and Seed, Hard Rock, and others have already been rented out. But as that list grows, other Broadway bars have committed to staying open to the public during the days of the Draft.
Some other bars open during the Draft — Second Fiddle, Layla’s, Legends Corner, and Robert’s Western World.
Likewise, TC Restaurant Group, which includes Tequila Cowboy, Jason Aldean’s Kitchen + Rooftop Bar, Luke Bryan’s 32 Bridge Food + Drink, FGL House, Crazy Town, and Sun Diner, will all be open to fans during the Draft.
Around 2,000 volunteers have stepped up to help with the NFL Draft.
Officials with the NFL say more volunteers applied to help than needed.
Some 800 volunteers went through training Thursday, which was called “FANS FIRST!”
The 90-minute session included new renderings of the Draft layout, details about The NFL Fan Mobile Pass app, the Draft Experience, and an overview of the entire event.
MORE: Parking survival guide for the NFL Draft
With about 300,000 visitors expected in Nashville for the NFL Draft weekend, there will be lots of traffic.
With that traffic, parking will likely get tricky.
Thursday through Saturday, you can park for free at several NFL Draft designated lots:
Nissan Stadium Lots A, B, C and D
Main Event Parking Lot at James Robertson Parkway and Main Street, 14 James Robertson Parkway
CrossPoint Church at 299 Cowan Street
After 5 p.m. on Thursday and Friday and all day Saturday, the State of Tennessee lots No. 16, 28 and 29 located off James Robertson Parkway by Rosa Parks Boulevard
On Saturday, there will be more closures:
Boyle Garage at HCA in North Gulch
Vanderbilt University Parking lot on Chestnut Street across from Greer Stadium (free shuttle runs 8 am – 11 pm)
State Employee Parking Lot at 400 10th Circle North (free shuttle runs 5 p.m. through 12 a.m. on Thursday, April 25; 5 p.m. through 12 a.m. on Friday, April 26; and 5:30 a.m. through 11 p.m. on Saturday, April 27)
The catch is free parking is first-come, first-serve.
For those who live outside of downtown, there’s WeGo Transit buses and the Music City Star.
Regular rates will apply, meaning you’ll spend $1.70 one way by bus, or up to $5.25 one way by train.
Because the Riverfront Station is closed due to Draft construction, starting Wednesday, Star riders will be picked up and dropped off at a temporary pick-up and drop-off location, right behind Ascend Amphitheater.
According to WeGo Transit, all service times will run on regular schedules during the days of the Draft, but trains won’t be held past those times to accommodate bus connections.
Another option: grab a rideshare.
Be aware of prices surges with the influx of people in town for the Draft.
When that happens, Lyft told News 2, riders will be alerted and they’ll have to confirm they accept the multiplier before requetsing a ride.
Breaking News / 6 mins ago
Berkeley County News / 4 hours ago
New effort underway to save the Morris Island Lighthouse
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Are you ready to scout for and control flea beetles?
May 30, 2017 Canola
Four canola diseases to watch for
Give your insect friends a home
May 12, 2017 Crops
Building a complete protein package
May 11, 2017 Cereals
Preparing for western bean cutworm in 2017
Flea beetles move fast and do a lot of damage. Be sure to keep ahead of them in your canola crops
By Melanie Epp
Photo: Canola Council Canada
Flea beetles are easily the most chronically damaging insect pest in western Canadian canola. Damage results in yield losses estimated at $300 million each year. To limit damage, experts recommend acting early when an average level of defoliation level of 25 per cent or more is reached.
Early action necessary
According to Greg Sekulic, an agronomy specialist in the Peace region of Alberta, flea beetles are most damaging at emergence during the true leaf and cotyledon stage. For this reason, the first line of defense in protection against the destructive pest is a seed treatment, said Sekulic in a recent interview. Growers can recover without any negative impact on maturity or yield when 50 per cent of the cotyledon leaf area remains. But because flea beetles move quickly, the recommended economic threshold is 25 per cent damage.
‘Insurance’ spraying
Be kind to your insect friends
A guide to beneficial insects
Sekulic recommends that growers regularly scout emerging canola fields. There are a few guides on the Canola Council of Canada’s website that show growers what crop damage looks like at different stages. They should help determine the right time for a foliar insecticide application. “Anything registered is good to go,” said Sekulic. “Just make sure you stay on labeled rates.”
Over the past 30 years, the crop protection industry has spent and incredible amount of time and money trying to build forecasting models for flea beetle pressure, all of which have failed to predict specific regions, let alone individual fields that would be at risk. “Due to the variable nature their ecology, it’s really difficult to predict with any certainty where they’re going to be in higher numbers in spring,” said Sekulic.
Sekulic says that he used to advise growers to scout in the fall and plan spring management based on what they saw. “Now we don’t anymore,” he said. “We basically just advise that if you grow canola, an insecticidal seed treatment is far and away the safest means of protecting against flea beetle simply because we cannot predict where they’re going to emerge at all.”
With the understanding that the use of insecticides increases production costs, environmental risk, and the potential for increased selection pressure for insecticide-resistant flea beetles, researchers are looking to possible new management strategies. The hope is that a better understanding of effective predators in major Canadian canola growing regions may allow natural enemies to be included in the economic threshold recommendation. This could, in turn, reduce the incidence of over-spraying and the possibility of increased selection pressure.
As part of a project funded by Agriculture and Agri-Food Canada, Alejandro Costamagna, assistant professor in the Department of Entomology at the University of Manitoba, and a team of researchers have been looking into the natural enemies of flea beetles. They’ve developed DNA primers that are able to detect flea beetle DNA in their predators’ guts. The problem is that, since they’re very mobile, flea beetles are difficult to catch for both humans and predators. The researchers are in the process of testing the insects and will continue to process insects from the fields next year. Predators include ground beetles and spiders, some of which they think also feed on larvae and eggs in the soil. Again, this is very difficult for the researchers to monitor.
The other part of their research, said Costamagna, is examining landscape characteristics that could potentially limit flea beetle populations. “The rationale is that if you have non-crop habitats — natural habitats — those will harbour good, sustainable populations of natural enemies and those will help to control the flea beetles,” said Costamagna.
“For every field we sample, we map the landscape around it,” he continued. “We look at crops and habitats up to two to three kilometres around it and then we quantify a lot characteristics in that landscape.”
Costamagna said that while they have several fields in four major regions in Manitoba, Saskatchewan and Alberta, there is always a need for more. Producers who want to participate in the research project should contact Costamagna directly at [email protected]
Economic threshold trials are also being conducted, but it’s too early to report on the results. For now, the best course of action is to stick with the 25 per cent economic action threshold recommendation.
This article first appeared in the May 16, 2017 issue of Grainews.
Melanie Epp's recent articles
Are you ready to scout for and control flea beetles? May 30, 2017
Taking a long-term look at agronomy for canola
Growing canola in Canada’s east
Crops, Canola
Ontario farmers grow corn acres, and a successful livelihood
Crops, Canola Council of Canada
A sure-fire piece of crop advice
Crops, University of Manitoba
Check the calendar, or the thermometer when deciding to plant soybeans?
The Western Producer
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Diana FRANCIS > Publications > Quantification of Dust load in the ITD region
Bou Karam D., C. Flamant, P. Tulet, J-P. Chaboureau, A. Dabas, M. C. Todd (2009b): Estimate of Sahelian dust emissions in the Intertropical discontinuity region of the West African Monsoon, submitted to JGR.
A three-dimensional mesoscale numerical simulation has been performed to investigate the dust emissions over Sahel associated with strong near-surface winds in the region of the West African Inter Tropical Discontinuity (ITD) during the summer, when the ITD is located over Niger and Mali around 18°N.
The study focuses on the period from 2 to 12 July 2006, in the framework of the African Monsoon Multidisciplinary Analysis (AMMA) Special Observing Period 2a1. A comparison with space-borne observations from the Spinning Enhanced Visible and Infra-Red Imager (SEVIRI) as well as airborne lidar observations acquired on 7 July 2006 demonstrates that the model is able to reproduce the complex vertical structure of the dynamics and aerosol field associated with the monsoon-harmattan interface.
This suggests that the model can be used reliably to analyse and quantify the dust emissions associated with the strong monsoonal surface winds blowing over the Sahelian dust sources during the rainy season. A comparison with the surface observations in Niamey between 2 and 12 July period indicates that the near surface characteristics of the monsoon to the south of the ITD are realistically reproduced over the period of the simulation.
The dust load in the ITD region simulated by the model is compared to the estimates derived from satellite observations using the method of Koren et al. [2006]. The daily mean values of dust load related to the strong winds on both side of the ITD, estimated from the simulation within the model domain (2°W-16°E, 12-28°N), are in excess of 2 Tg on some days and are found to be underestimated with respect to the observational estimates.
In the present case, the dust load associated with the strong winds south of the ITD accounts for approximately 1/3 of the total load over the entire domain on a given day, and is simulated to range between 0.5 and 0.8 Tg on average.
This indicates that the mean daily dust load estimated in the ITD region is close to the estimated daily rate of dust emission from the Bodélé depression. This study suggests that emissions driven by strong surface winds occurring on both sides of the ITD while it lies across the Sahel may contribute significantly to the total dust load over West and North Africa observed annually.
Keywords: Dust, MesoNH, airborne lidar, density current, AMMA
Posted in PublicationsTagged aerosols, africa, airborne lidar, amma, density current, dust, mesonh, sahara, sahel
ITD Diurnal Cycle
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WarioWare Gold Review — Wario is Still Number One!
Tomas Franzese
August 6, 2018 11:00 AM EST
Game WarioWare Gold
Developer Intelligent Systems
Reviewed on New 3DS Also on 3DS
Genres Action
Review copy provided by the publisher.
Reviews3DS
Despite its short length, WarioWare Gold brings all of the wonderfully bizarre humor and quirkiness of the series to 3DS with style and variety.
WarioWare has always been one of the weirdest, most endearing corners of Nintendo’s wide breadth of IP. Its memorable and funny characters work well in tandem with the unique microgames in order to create minigame collections with a little more versatility than most in other games in its genre. That being said, we actually haven’t seen a more traditional entry in the series since WarioWare D.I.Y in 2009, though Nintendo has finally changed that with WarioWare Gold for Nintendo 3DS, and it is quite the welcome return.
WarioWare Gold Gets a New Trailer Showing All You Need to Know Before Launch
While many players will be able to go through everything the game has to offer fairly quickly, WarioWare Gold offers that purely distilled Nintendo quirk which is hard to find anywhere else. Slick presentation, the series’ best collection of microgames, and funny side content work in tandem to create a consistently entertaining game, even if you’ll burn through it after just a few hours.
WarioWare Gold begins with the titular character stealing an ancient “relic” from a town. Afterwards, Wario realizes that he doesn’t have any money, but sees the success of a recently released game on TV. He then decides that’s where the money is and starts his own tournament with the help of his “friends” in order to make quick cash, and things quickly unravel from there as players progress through each of the microgame leagues as Lulu, a new character from the town that Wario stole from.
“Slick presentation, the series’ best collection of microgames, and funny side content work in tandem to create a consistently entertaining game.”
The plot takes several funny jabs at things like game development and streaming, and each characters’ individual storylines are more self-aware and risqué than usual for Nintendo. Every cutscene is also completely voice-acted and accentuated by crisp animation and voice acting, resulting in one of the slickest titles presentation-wise on 3DS. WarioWare‘s eccentric cast have always been one of the best parts of the series, and this game frames their leagues with funny situations that highlight the best parts of their character.
Once you get into the game’s story mode, you will have to overcome three leagues: Mash, Twist, and Touch. Mash microgames focus on more traditional controls, while Twist relies on the 3DS’ gyroscope; Touch obviously uses the touch screen. All of the microgrames, as usual, are short but sweet. They are easy to understand and fun to execute in the short time allotted, giving WarioWare Gold one of the strongest microgame lineups in the series.
I usually hate gyroscopes’ implementation into 3DS games, but that style of microgame quickly became my favorite due to how creative they got. Nintendo has also gotten meta in not just the plots but the microgames themselves, which not only reference classics like The Legend of Zelda: Ocarina of Time and Super Mario World, but obscure and odd titles like Color TV Racing 112 and Mario Clash for the Virtual Boy. Series fans should enjoy the consistently entertaining lineup of microgames, while the more referential ones should get other Nintendo fans on board.
While the main story and leagues are presented nicely and are super fun to play, you can progress through it quite quickly. My first playthrough of the story, which even saw me failing some leagues, took me just three hours. Of course, WarioWare Gold has interesting side content as well, but I was disappointed by the brevity of the story mode. What we got was so great, but some may struggle to justify a $40 purchase for such a short and easy game. WarioWare games have never been the longest in the world, but I blew through this way faster than expected, even when playing casually.
Players will likely be revisiting the game’s story mode though as it is the best place to garner coins, which can be used to unlock extras in the game’s capsule machine. You can also gain lots of coins by completing small achievement-based missions or playing WarioWare Gold‘s Challenge mode. This mode sees the return of some old favorites and some interesting new modes, and all of them are very enjoyable. The standard gauntlets of microgames that get progressively more difficult are present, as are fan favorite modes like “Gamer” from Game & Wario (now called “Sneaky Gamer”), as is “Wario Deluxe” as “Wario Interrupts.”
“[Challenge Mode] sees the return of some old favorites and some interesting new modes, and all of them are very enjoyable.”
There are also a few new interesting challenges like “Wario Watch,” where players must complete as many microgames as possible as a timer ticks down, with time added for each successful microgame. “Cruise Control” is another new interesting one where players can adjust the speed of the games by tilting the 3DS up or down; like I said before, I’m not usually a fan of gyro controls like this, but WarioWare Gold actually managed to implement them in an entertaining and non-intrusive way.
“Split Screen” has players completing microgames that are alternating between the top and bottom screens, while “Battle Time” lets players with copies of the game face off against each other in a microgame gauntlet. Unfortunately, this mode does not feature Online or even Download Play, which hurts its chances of being played by many. This is also an odd oversight at this point in the 3DS’ lifespan, as most 3DS multiplayer titles at least allow Download Play.
“WarioWare Gold manages to be one of the most consistently enjoyable and funny 3DS games in recent memory.”
As I mentioned before, these modes and special missions give you coins, which can be spent on the game’s extras, which are put int the Toy Room. These extras include everything from full on minigames like “Pyoro,” to a library of classic Nintendo products. My favorite extra though would have to be the ability to re-dub cutscenes, which can garner some utterly hilarious results. Going for all of the things in the Toy Room will likely double or triple the game’s playtime for many, though it is entirely optional and relies on repeating content.
While the game could benefit from having a bit more meat on its bones, WarioWare Gold manages to be one of the most consistently enjoyable and funny 3DS games in recent memory. The game’s hilarious cutscenes impress and add some interesting new characters to the WarioWare universe, the microgame collection is the best the series has featured yet, and some of the unlockable side content is hilarious. If you are fine with WarioWare Gold‘s short length, there is no reason not to pick this quirky title up as the 3DS reaches the end of its lengthy lifespan.
Wario is bringing back his assorted and oddball collection of minigames back in WarioWare Gold, and a new trailer breaks down everything you need to know.
Zany Wario and His Crazy Minigames Return in Game & Wario for the Wii U
Kiki Trick Trailer Released
WarioWare: D.I.Y. Next Week
DualShockers Game of the Year 2018 Staff Lists — Tomas’ Top 10
DualShockers’ Game of the Year 2018 Awards — God of War Takes Home the Gold
Yakuza 3 for PS4 Putting Up a Good Fight in Japan; Bon Festival Pushes Nintendo Games – Media Create
WarioWare Gold Revealed for 3DS; Arrives this August
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Health - Family
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The Hungry Road
Our Price: €13.99
A story of courage, hardship and survival against the odds - this is the definitive account of the Great Irish Famine.
In its brilliant recreation of the Great Irish Famine, the children's historical novel Under the Hawthorn Tree is beloved by millions and is considered a classic.
Now, the Number One Irish bestseller and award-winning novelist is turning her hand to the definitive adult novel of those hard times, with The Hungry Road.
Following the disastrous failure of Ireland's potato crop, the people of Skibbereen and West Cork are soon faced with unprecedented disaster. Hunger, disease and death stalk the roads, fields and farms, the cottages and cabins, during Ireland's Great Famine.
Mary Sullivan's dreams of a better future are shattered in 1845 with the arrival of the strange blight which destroys their potato crop. Refusing to give in to despair, she must use every ounce of courage and strength to protect her family as she and her husband and children fight to survive.
Dr Dan Donovan is Medical Officer to the Skibbereen Union. The arrival of 'the hunger' soon brings starving men, women and children crowding into the town and the workhouse desperate for help. His wife Henrietta does her best to support him but her life is thrown into turmoil when friends and then her own family fall victim to fever.
Meanwhile, Parish priest Rev John Fitzpatrick's faith is tested by the suffering and hardship endured by the starving families all around him.
The story of this one town and its people mirrors the story of towns and villages all across Ireland during 'The Great Hunger'.
Publisher Transworld Ireland
Under the Hawthorn Tree: Children of the Famine
The first book in the famine trilogy A beautiful new edition of the world-famous novel about three children in the Irish Famine.
info@dubraybooks.ie
Prospective Suppliers
Copyright © 2020 Dubray Books. All rights reserved.
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FERC’s Order No. 1000-A Tests Jurisdictional Limits in Continuing Effort to Expand Transmission Access
By Brian R. Gish
On May 17, 2012, the Federal Energy Regulatory Commission (FERC) issued Order No. 1000-A that denies the many rehearing requests of its Order No. 1000. Thus, FERC has left in place the requirement that all FERC-jurisdictional electric transmission providers must participate in regional and inter-regional processes for planning new transmission facilities, and adopt FERC-approved cost allocation methods for the new facilities. Orders 1000 and 1000-A are the latest in a series of orders over sixteen years in which FERC has pushed its statutory authority to the limits in order to increase generator access to electric transmission lines.
New Regional Planning Requirements
Order 1000, as affirmed by Order 1000-A, expands on the requirements for regional transmission planning that were adopted in Order No. 890 just five years ago, which FERC now considers inadequate. These additional requirements include:
All jurisdictional transmission providers must adopt and participate in a regional transmission planning process through which a regional transmission plan is produced;
The process must consider transmission and non-transmission proposals by any qualified entity;
The process must plan for the effects of “Public Policy Requirements,” such as environmental or renewable energy laws and regulations, in addition to traditional reliability and economic considerations;
The process must include a cost allocation methodology, consistent with FERC principles, to determine how the costs of facilities approved in the plan are allocated to customers;
Incumbent transmission providers must have no federal priority rights over “non-incumbent” developers to build transmission facilities selected for the regional plan; and
Transmission providers must develop inter-regional transmission coordination procedures and cost allocation methods with neighboring regions.
Transmission providers must file compliance plans at FERC by Oct. 11, 2012 to demonstrate how they have modified their transmission tariffs and pursued regional coordination actions required by Order No. 1000. They must make a good faith effort to arrive at a planning process through consensus with stakeholders. Another compliance filing is required by April 2013 for transmission providers to address inter-regional coordination efforts.
Order 1000 does not mandate the scope of the planning regions, other than to say that a single public utility transmission provider cannot be a region. It notes that planning regions have already been formed for purposes of Order 890 compliance and could continue to be used for purposes of Order 1000. Existing Independent System Operators (ISOs) and Regional Transmission Organizations (RTOs) may already be regions that satisfy many of the planning requirements, but they still must make a compliance filing that shows how they comply.
FERC strongly encourages that non-jurisdictional transmission providers participate in the regional planning and cost allocation process. However, non-jurisdictional providers would only become bound to the planning and cost allocation requirements if they choose to enroll in the regional process, with enrollment criteria to be chosen by the region. If a non-jurisdictional provider wants to ensure that it receives the benefits of open access transmission service by public utilities, it may have to participate in the Order No. 1000 planning processes.
Order No. 1000 leaves many implementation details open, to be addressed in rulings on individual compliance plans.
FERC’s Authority to Mandate Regional Planning
Many petitioners for rehearing of Order 1000 challenged FERC’s legal authority to issue the mandates as to transmission planning, priority to build, and cost allocation. State commissioners argued that FERC’s requirements usurp traditional state authority over resource planning and the siting of transmission lines. Some transmission providers argued that FERC is statutorily prohibited from mandating regional transmission system coordination. Others argued that existing planning processes are working well and there is no problem that justifies a FERC remedy.
FERC has no explicit statutory authority to direct transmission providers how to plan their transmission systems. However, FERC has a general grant of authority under Section 206 of the Federal Power Act to determine that a utility’s transmission rates, including rules and practices affecting rates, are unjust and unduly discriminatory, and then to prescribe rates, rules, and practices that are just and reasonable, and not unduly discriminatory.
FERC first used this section 206 authority on an industry-wide basis in 1996 in Order 888, which required that transmission providers functionally separate transmission services from power sales and offer non-discriminatory access to transmission lines by all eligible customers. In Order 888, FERC made it a point to identify specific examples of discriminatory behavior by transmission providers as a foundation for its use of the section 206 remedy. An appellate court approved of FERC's authority to prescribe a marketwide remedy for a marketwide problem upon the finding of a fundamental systemic problem in the industry caused by undue discrimination.
FERC next tried to advance transmission access through its Order No. 2000 which addressed the formation of RTOs for purposes of making the grid more efficient. FERC again relied on section 206 and the finding of continuing undue discrimination to require all transmission providers to consider forming RTOs. Although some FERC Commissioners and others were in favor of FERC requiring transmission providers to join RTOs, rather than just considering it, many parties challenged FERC’s legal authority to require regional transmission planning and operation, and FERC chose not to fight that battle then. An appellate court dismissed challenges to FERC’s authority to issue Order 2000 on the basis that the Order did not mandate participation, but left it voluntary.
In its Order 890, which required utilities to participate in some regional planning efforts, FERC seemed to expand the interpretation of its authority under section 206, stating that it need not make specific factual findings of discrimination in order to promulgate a rule, but may act under section 206 to limit “continuing opportunities for undue discrimination.” No entity sought judicial review of Order 890, perhaps because the requirements there were not seen as onerous or harmful to their interests.
In response to numerous contentions that Order 1000 did not identify specific discrimination that needed to be remedied, Order 1000-A seems to assert an even broader authority to act under section 206 than FERC had done before. FERC explains that it may take “proactive steps” to eliminate threats to efficient and cost-effective solutions. Further, FERC states that a remedy is justified by the “theoretical threat” that undue discrimination could occur, without the need for specific evidence demonstrating that undue discrimination currently exists. FERC thus has asserted a broad authority to regulate public utilities by rulemaking based on “generic factual predictions.”
Orders 1000 and 1000-A represent a continuation of FERC’s efforts to expand the transmission grid and make it more efficient to align with twenty-first century realities, but most of FERC’s statutory authority is still based on 1935 legislation enacted when the electric industry looked much different. If a court were to approve of Order 1000-A’s interpretation of FERC’s authority, the range of FERC’s regulatory actions could be significantly expanded.
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earthli
Capsule Movie Reviews Vol.2019.13
This page shows the source for this entry, with WebCore formatting language tags and attributes highlighted.
<n>These are my notes to remember what I watched and kinda what I thought about it. I've recently transferred my reviews to IMDb and made <a href="http://www.imdb.com/user/ur1323291/ratings">the list</a> of around 1400 ratings publicly available. I've included the individual ratings with my notes for each movie. These ratings are not absolutely comparable to each other---I rate the film on how well it suited me for the <i>genre</i> and my mood and. let's be honest, level of intoxication. YMMV. Also, I make no attempt to avoid <b>spoilers</b>.</n> <dl dt_class="field"> Hardware (1990) --- <a href="https://www.imdb.com/title/tt0099740/">6/10</a> <div>The description on IMDb covers the first 3/4 of the movie: <iq>The head of a cyborg reactivates, rebuilds itself, and goes on a violent rampage in a space marine's girlfriend's apartment.</iq> The final 1/4 goes off the rails in some sort of operatic dream sequence involving Moses (ex-Marine boyfriend (Dylan McDermott)), who already has a robotic hand, but then mutilates his other hand and drinks his own blood while the cyborg is rejuvenating and preparing (yet) another attack. The girlfriend Jill is an artist who lives alone when Mo's not there. They have a friend named Shades who literally never takes off his sunglasses. Oh, also the world is a post-apocalyptic hellscape with no water and too much heat and radioactivity. The remaining government is trying to impose a birthrate restriction. There is a ton of 80s-era tech with non-graphical user interfaces. Also other people in the building are involved and killed at various times and in various ways while Jill goes bananas with a baseball bat because she ziplined in on a live wire to a Chinese family's apartment. So she ended up with a Banzai headband because <i>alllooksame</i>. The effects are pretty good for the time and some of the cinematography is quite good, when it's not cut too quickly to avoid letting you see the seams and fake tech. After everything, it took one bullet to the head from Shades and then a biblical baseball-bat onslaught from Jill to kill the cyborg (Mark 13) for good. I gave it an extra star for a few reasons: it was unabashed in its execution and it had cameos from both Iggy Pop and Lemmy (who was a cab driver playing <i>Ace of Spades</i> on his radio). </div> Booksmart (2019) --- <a href="https://www.imdb.com/title/tt1489887/">9/10</a> <div>This is the story of Amy (Kaitlyn Dever) and Molly (Beanie Feldstein): they are two smart, ambitious, kind and focused best friends in their senior year in high school. They mostly hang out together, ignoring or disdaining the other cliques. They have achieved scholastic success and will be moving on to bigger and better things: Molly is going to Yale whereas Amy is taking a summer in Botswana. Their world is shattered when Molly discovers that all of the so-called losers at their school have achieved just as much as they did. The school "skank" is going to Yale as well, while the rich-girl alcoholic (Gigi) is going to Harvard. The jock (Nick) is going to Stanford. They all had fun throughout high school <i>and</i> achieved just as much as Amy and Molly. This revelation disturbs Amy less than Molly, but she agrees to go out with Molly to have some fun on the last night before graduation. The hijinks are funny and very modern (they take Lyfts everywhere; one of them is driven by their principal, played by a bearded Jason Sudeikis). They learn more about their supposedly stupid colleagues---something they'd never bothered to do in the four year prior. They both let loose, but not to ridiculous excess. They meet Gigi again and again and again. Molly learns more about Jared, the rich kid who's more than that. Nick is smarter than he acts, but ultimately a high-school boy thinking with his dick. But so is Amy's girl crush, who hooks up with Nick (because she's straight, despite Amy's greatest hopes). Jessica Williams is great as Miss Fine; her claims to have done a Thursday NYT Crossword in under 8 minutes are more believable than the two 17-year-olds claim that they did it in under 10. We get it: they're smart.<fn> Still, the two girls were apparently fluent in Mandarin as well as Spanish, so I guess we can't take the smartitude claims too seriously. <hr> <ft>But you can't fill out that crossword without cheating without a vast experience, to boot. You can't just be smart; you have to be well-read. And you have to have soaked up adult culture for more than five years.</ft> <hr> The girls blow up at the party as Amy reveals that she's taking a gap year---which blows up all of Molly's plans for their lives together. Molly has to do some self-evaluation and take it down a notch. Amy ends up saving the party from the cops and going to jail just before graduation. It all ends happily for everyone, which was just fine. Nice directorial debut for Olivia Wilde.</div> Glass (2019) --- <a href="https://www.imdb.com/title/tt6823368/">9/10</a> <div>This is part three of the trilogy started by <i>Unbreakable</i> and <i>Split</i>. In this one, Elijah Price aka Mr. Glass (Samuel L. Jackson) is in a psychiatric hospital whereas Kevin Crumb aka The Beast (James McAvoy) is still on the loose, kidnapping more cheerleaders. David Dunn aka The Overseer (Bruce Willis) is still taking care of loose ends that the police refuse to (or can't). With the help of his son, Dunn is hot on the trail of The Beast. He manages to free the latest victims and confronts and fights the Beast to a standstill. They fall out of a third-story window and bounce up to be surrounded by police and strong lights that stun the Beast and cause him to transform to another member of the Horde (the gang of personalities that inhabit Kevin). Dunn and Crumb are taken to the same psychiatric hospital as Price and end up being counseled together by Dr. Ellie Staple (Sarah Paulson) who doesn't believe at all that they have superpowers. Instead, she thinks that there is a rational explanation for all that has happened and the strength that The Beast and The Overseer have shown. Nothing to see here; just outlandishness and craziness all mixed up to cause confusion. Mr. Glass begs to differ and uses his vast intellect and proficiency with technology to rove the halls of the hospital undetected. With a lobotomizing procedure scheduled the next morning, he springs his plan to let the three of them out, pitting The Beast against the Overseer in the full light of public scrutiny, to prove once and for all that they are real and not figments of their own imaginations. The Beast <i>knows</i> what it is; the Overseer is half-convinced that he is normal, but mad. Glass makes Overseer break out of his room, through a steel door to prove to himself that he is <i>different</i>. Glass and the Beast are together and make their way out of the hospital. McAvoy is an absolute revelation: he depicts his multitude incredibly well---Patricia, in particular, is scarily well-done. Also, he's incredibly jacked for this role. Dr. Staple still doesn't believe, even as Glass and Beast tear a swath through her hospital and escape in grand style. Meanwhile, Dunn has knocked his steel door off of its hinges and has similarly escaped. Glass's mother, Dunn's son, and Casey Cooke (Anya Taylor-Joy) (the Beast's former kidnap victim from <i>Split</i>) are on premises to talk to the doctor, but end up witnessing the escape and showdown between Beast and Overseer. Riot police try to break up the fight, but the two men each fight off half a dozen troops themselves, belying the doctor's claim that they are not superhuman. It turns out that Crumb's father died in the train crash in which Dunn was the only survivor---a crash caused by Glass in his search for a nemesis. <bq>I created you, as I created David. It just took longer. 19 years. They almost convinced me I was crazy. I create superheroes. I truly am a mastermind.</bq> The Beast thanks him for his creation, but then strikes devastating blows because Glass is dangerous. He tackles Dunn into a water tank---and water is Dunn's weakness. The Beast tries to escape to the tower, but Casey catches him and brings Kevin back out, only to have the SWAT units shoot him right out of her arms. Doctor Staple and the police want to mop up the loose ends, trying to kill Dunn as well. The SWAT unit and Doctor Staple both have the same tattoo on their wrist, suggesting that they belong to the same secret organization. The unit drowns Dunn---in a <i>puddle in the parking lot</i>, to add insult to injury---Crumb dies in Casey's arms and Glass in his mother's, whispering to her that <iq>[t]his was not a "Limited Edition" — this was an origin story, the whole time.</iq> Doctor Staple confides to Glass that she <i>is</i> part of a secret organization that kills heroes and villains to keep humanity safe from <iq>Gods walk[ing] among us</iq>. She and her group smugly think they've won---but Mr. Glass's final words linger. Whose origin was it? How many steps ahead was he planning? Glass got the security footage before the good Doctor was able to delete it. Glass (in a voiceover): <bq>Belief in oneself is contagious. We give each other permission to be superheroes. We will never awaken otherwise. Whoever these people are who don't want us to know the truth: <b>today, they lose</b>.</bq></div> Maniac (2018) --- <a href="https://www.imdb.com/title/tt5580146/">8/10</a> <div>(A skinny) Jonah Hill stars as Owen Milgrim, the estranged son of a rich family in New York. He lives on Roosevelt island, paying almost 80% of his salary as rent. His job sucks, but he's the only one of his brothers who doesn't work for his father. He's had a pyschotic break and thinks/knows that he gets visits from a brother Jed (Billy Magnussen) who visits him in his thoughts. We see Jed at a party in his full obnoxiousness; he seems to need to stand trial for some transgression against a woman. The timing is unclear so far. The setting is a near/alternate future, something like the future as envisioned in the 80s. The tech is all very 80s: film, photos, mechanical machines, CRTs, beeping machines---Terry Gilliam would love it. There are weird marketing scams like "Ad Buddy", where a solicitor visits you wherever you are and pitches strange gigs: fake husband for widows, medical-experimental subject, and so on. They also just read a lot of ads. The computers are huge (think mainframes), the cameras are film/disposable, the phones are corded. The techs at the neuropharmaceutical company are almost all Japanese. (A platinum blonde) Emma Stone is Annie Landsberg, a semi-homeless woman/grifter whose poor luck has led her to the same giant neural-experiment corporation as Owen. The second episode focuses on Annie's journey to Nerbedyne Corp, trying to scrape together enough money to get into a study where she can get her hands on the mood-altering drug that she'd gotten addicted to. Drug A makes her feel better about her shattered relationship with her sister Ellie (Julia Garner, i.e. Ruth from <i>Ozark</i>). She shows up when Annie drops into the experiment and into another world. In this reliving of her memory, Annie is shockingly harsh to her sister when they move to New York and Colorado, respectively. She basically tells her she's happy she'll never see her again and then acts like it never happened. Is she schizophrenic? They get into a car accident and Ellie dies when their car hits a truck driving in the wrong lane. One of the other patients (11) is played by Allyce Beasley, who I last remember as playing Agnes DiPesto in <i>Moonlighting</i>. Annie and Owen end up together in Muramoto's office after the first experiment---he died when he was talking to Annie and Owen is still high from his A pill. It's unclear what's really happening (did Muramoto really die?) and whether the memories engendered by the pills and the giant-sized 80-style hardware are real or also ... adjusted. Muramoto has really died and his right-hand woman Azumi finds his replacement---a former boyfriend/genius programmer/scientist Mantleray (Justin Theroux) who's apparently addicted to virtual porn. Azumi is a bit of an odd duck: chain-smoking in all sorts of sensitive areas (even in the tiny cubbies that the staff sleep in on premises) and is also apparently agoraphobic. Another main character is the giant old-style mainframe computer named GRTA (there was actually a famous mainframe named <a href="https://en.wikipedia.org/wiki/MANIAC_I" source="Wikipedia">MANIAC I</a>). I love the computer room, cables and flashing lights everywhere---so old school and such a good storytelling device. Once they take the B pill ("Behavior"), things get nutsy-cuckoo: Annie is now named Linda and is married to Owen (now named Bruce). They are in 80s New Jersey. Annie steals the address from the DMV of the furrier who stole her friend's lemur so that she can go rescue it, but she can't get the lemur out from the thugs (who are very interested in their dance routine). She confides in her husband and they agree to break out Wendy the lemur from the furrier. Bruce is a good husband, to a fault and turns himself over to the police (or the wildlife authorities, which they keep claiming is more-or-less the same thing). They segue to the next scene, in what look like the 1930s. Owen is now Sir Ollie and he's on his way to the Neberdine Full Moon Seance (the name of the drug company). Annie is now Arlie, again his wife. Azumi and Mantleray discover that 1 (Owen) and 9 (Annie) are entangled due to a hardware malfunction. The various scenarios roll up more and more real-life details: gimlets, Cervantes, Wendy, etc. The lost chapter 53 of Cervantes's Don Quixote is rumored to be so powerful that whoever reads it falls into a coma of fantasy from which they never wake. Kind of like Neberdine's VR. Arlie says <iq>We can't help being who we are</iq> when Ollie tries to get away from her again. The subjects make it to round C but Azumi and Mantleray discuss Gertie's depression (the mainframe). She's mourning the loss of Doctor Muramoto---because they'd been having an affair. Azumi exhorts Mantleray to call his mother, to which he responds, <bq>My mother is a venomous egotistical charlatan who deploys catchphrases and platitudes and therapies of the day in order to dupe people out of their money and happiness. No, my mother <i>sells</i> happiness, but it crumbles in your hand the minute you're out of earshot of her magical thinking and her platitudes and her invented words and her primal yawps and her steps to success.</bq> His mother is Dr. Greta Mantleray, played by Sally Field (no coincidence that the mainframe is named after Mantleray's mother). She's invited in to diagnose the mainframe. Meanwhile Owen and Annie start to imbue the short-circuit that led to them being paired with <i>significance</i>. The "odds" (including Annie and Owen) embark on the C-pill journey ("Confrontation"). They are not together: Annie is Annia, an elf con-woman leading marks on journeys to the "Lake of Clouds" to be healed of their ills (and fleeced of their possessions). Her latest mark is her sister Ellie, also dressed as an elf. Owen is a gold-toothed, twin-braided, tattooed gangbanger scion of a murderous clan led by his father (Gabriel Byrne), who's known as "The Drill" for his penchant for power-drill--fueled interrogation. In his basement, he has a painting of a drill with the epithet "Ceci n'est pas une drill" beneath it. Owen is an introspective and highly intelligent and well-read young man. The simulation is bleeding through for both him and Annie, with the role of GRTA and their own "tests" woven into their stories. Owen's the prodigal son but is working with the police. His brother Jed was sent away by his father as a "disloyal baby" but became a cop and is the family's plant. He "saves" Owen from the cops he's working with and is then taken out by the family's consiglieri, who is a Fed, undercover for 36 years. Owen accompanies him to collect his study partner Olivia, to sweep her off to witness protection---we see him years later with seven kids, each named after a continent. He bugs out, turns into a falcon and flies to the moon---ending up in Annia's world and then getting shot down by the evil queen (GRTA) before she abducts Annia from Ellia. The next installment has transformed Owen into Snorri, an Icelandic man on trial for some as-yet unspecified crime against an alien being named Ernie. He sits before a tribunal of Earth's leaders, who are deciding how to appease the invading aliens by possibly sacrificing Snorri. Ernie as an alien stands in for the hawk Owen had nursed back to health when he was a child. Annie is back, looking stunning in red. The finale is wild, with GRTA killing nearly everyone but finally being forced to release her stranglehold and being shut down for good. They all part ways, including Annie and Owen. Owen takes the witness stand at his brother's trial and refuses to lie for him, earning himself committal to a mental institution. Annie goes back to her father and they reconcile, with him welcoming her back from the wilderness of near-madness and depression to which she'd escaped after her his sister had died. Annie seeks out Owen, gets his trust and breaks him out. We see them head out on the road together, to parts unknown. The feeling of overlapping realities and dreams reminds me a bit of <i>West World</i>. It's a delightfully surprising limited series with occasionally wacky scenes and scenery. Hill and Stone are very good. </div> After Life (2019) --- <a href="https://www.imdb.com/title/tt8398600/">8/10</a> <div>This is a lovely, funny, charming show written, directed by and starring Ricky Gervais. None of the blurbs I've seen for it do it justice. It is a show about Tony, a man who found the love of his life early, had 28 wonderful years with her and is now a widower on account of breast cancer. He is devastated and pragmatic and wonders what is even the point of going on. He's brutal to some people---his meek brother-in-law, in particular---but a thoughtful man who, despite his desire to just end it all to kill the pain of living without his wife, manages to continue on, spending quite a bit of his time walking his dog, visiting his Alzheimers-afflicted father, visiting his wife's grave (and the widow of the man who's buried next to her) and sorta-kinda befriending a homeless drug user Julian and his prostitute/sex-worker friend Daphne/Roxy (who he hires to do his dishes for him). The thing that keeps him going at all is his dog, I think, who needs to be fed twice per day. He's slowly starting to come out of his funk, but still deeply in pain. He works at a local free gazette run by his brother-in-law, doing shit stories with a weird crew of co-workers. His relationship with Julian is the most interesting: Julian lost his wife to an overdose, but he lost her <i>and</i> nobody cares, because she brought it on herself. They share a deep, abiding pain of loss that makes them both want to end it all. But Julian is more serious about it: all he's missing is the money to do it. Tony looks at him, then gives him most of his wallet. Julian makes good on his word, overdosing in his doss in a storage unit. Those were conflicting moments: when Tony gave him the money and when Julian followed through on his suicide promise. Was it the right thing to do? Should Tony have helped Julian get better? Or did he just understand how utterly lost Julian was without his wife? That death was a sweet release from endless days of pain, spent searching desperately for a way to numb everything for a few hours until wakefulness brings it all crashing back in the next day. I applaud the story for not holding back on providing a grittier, more realistic outcome. Some people don't want to live. Who are we to force them to change their minds? Stop being depressed. Be happy. Super helpful. I think Gervais is just brilliant in this: anyone who thinks he's an ass because of how he takes the piss out of everyone should see this show and then wonder which is the real Gervais? Is he just an asshole who's a good enough actor to sell being a nice guy? Or is basically a sheepish, nice guy who can pretend to be an asshole? In the end, Tony claws his way back to being a human being and we prepare to see what the next season brings---when he's no longer so depressed. </div> Ronnie Chieng: Asian Comedian Destroys America (2019) --- <a href="https://www.imdb.com/title/tt11248800/">9/10</a> <div>I've seen Ronnie on <i>The Daily Show</i>, where he's very funny, often upstaging the sadly somewhat smarmy and easy-joke-getting Trevor Noah (think Stephen Colbert after he moved to late night). Chieng is an international comic, having come to America only three years ago, moving from Australia after having grown up in Malaysia and Singapore. A lot of his material is about being Asian and having grown up in an asian family. Also, he has the requisite bit about Japanese toilets, a source of endless fascination and material to comics everywhere. His delivery is good and he's very sarcastically funny with smart, well-written material.</div> Michelle Wolf: Joke Show (2019) --- <a href="https://www.imdb.com/title/tt11269704/">7/10</a> <div>It was a pretty decent set and her writing is mostly very clever, though there is a bunch of meta filler material that feels a bit lazy, padding out her hour. She talks about politics, women's rights, periods (a lot about that), being a shallow-vagina woman in a big-dick world, the usual. A decent hour; I look forward to more, where she's perhaps refined the material to a bit more of a knife-edge. It has nothing to do with her grating voice---which is quite grating, but also somewhat endearing---it's just that the routine felt stretched to fit the requisite hour for Netflix (somewhat like Iliza Schlesinger's latest).</div> Zardoz (1974) --- <a href="https://www.imdb.com/title/tt0070948/">7/10</a> <div>This is a move about a far-future Earth (2293) where the planet is inhabited by bands of savages who inhabit the Outlands and also some immortals who inhabit the Vortex. Sean Connery is a cleverer savage Zed who jumps on the flying Godhead sculpture that visits his lands, hitching a ride back to the vortex. On the way, he somewhat anticlimactically kills Arthur Frayn, an immortal who'd <i>played</i> Zardoz. The flying Godhead lands in the Vortex and Zed begins to investigate the countryside, clad only in thigh-high leather boots, a red diaper, crossed red bandoliers and his usual copious allotment of body hair. For twenty minutes, nary a word is said, until Zed meets May (Sara Kestelman). She and Consuella (Charlotte Rampling) extract his memories, watching as he rapes and pillages his way through his former life. The walls are covered with naked, frozen bodies in various states of unrelaxed repose. They call in more of their fellow citizens, to watch his memories of raping and pillaging as a marauders among the weaker tribes. He spends some time in their society, as a kept animal, serving the immortals. He learns of what it means to be immortal. Their punishment for infractions is not imprisonment or death, but <i>years</i>. One subversive "Friend" is punished like this and Zed finds him later, aged nearly beyond recognition, but still alive, spending time with other ancients, all unable to die. Friend wants death for everyone, to <iq>erase humanity from this pretty planet</iq>. The theme---from 1974---is interesting, in light of our climate-change debacle. As Eve plumbs the depths of Zed's memories, he remembers when he became educated, when he learned to read. On the walls of the library are old posters, one of which reads <iq>to not be born is best</iq>. Eve eventually teases out of Zed that the book he'd read was "Wizard of Oz", which he saw to be a metaphor for Zardoz and his control over Zed's world. The experiments continue and they realize that Zed is there to destroy their world. They hunt him across their part of the globe, with things becoming increasingly surreal: he encounters the Apathetics again, this time energizing them when they taste his sweat; he encounters the aged, who take up his banner of revolution in a crazed and madcap Mardi Gras--like parade toward the realm of the Eternals. Zed convinces May that hers is a society of death and they agree to teach him all that they know---they "touch-teach" him while he "provides them with his seed". Nice. The truth of things turns out to be that a good chunk of mankind left for the stars when the planet was dying. The world Zed inhabits is the mad shell of a society gone horribly wrong. The Ancients are the remnants of the scientists who'd enabled it all, but were too old to travel. The eternals are the children they'd retained to keep track of the remaining savage hordes. Zed is an experiment of Zardoz's (Arthur, who is resurrected late in the film). Zed figures out that the Tabernacle---the root of all knowledge for what is left of humanity on Earth---resides in a crystal. He does battle with the Tabernacle (another psychedelic rendering) and ends up liberating humanity from immortality. Zardoz aka Arthur shows up to claim that the liberator that Zed became was all due to him and his breeding program, where he produced a slave who could free his masters. Zed responds that, while that may well be, Zardoz is also a product of his breeding and environment and, thus, is also just as much a tool of fate as Zed is (or a tool of the Tabernacle, as the case may be). Zed's development from senseless slaughterer to sage reminds me a bit of Charlie's development in <i>Flowers for Algernon</i>. In the end, the Eternals---no longer Eternal---are overrun by the remnants of Zed's band of Renegades, who leave behind a truly heroic slaughter on the battlefield, all the while seeking their lost leader. Zed is with Consuella, with whom we see him father a child, grow old and die.</div> The Cell (2000) --- <a href="https://www.imdb.com/title/tt0070948/">8/10</a> <div>Jennifer Lopez (looking frankly spectacular in her absolute prime) is Catherine Deane, a therapist and researcher in virtual-reality techniques whose charge is a young boy who'd fallen into a coma on a beach. The boy's rich parents want her to help wake him back up. She uses the immersive VR (mind-merge?) technology to travel to his mindscape, which is rich in detail. The first scene is in a vast desert, where she finds him less than receptive to her help. The family grows restless for results---the father, especially, doesn't believe that it will ever work. Desperate for results, Catherine wants to try letting the boy into her mind instead, to try to jolt him into a different direction. At the same time, we see glimpses of a serial killer (Carl Stargher, played by the always excellent Vincent D'Onofrio) at work, drowning his victims in tanks of water, washing them in bleach while he hangs---Hellraiser-style---from hooks in the ceiling. We see him driving a victim away from his wind- and dust-swept farm in the flatbed of his truck. Next, we Stargher collecting his next victim, but also seemingly suffering from what looks for all the world like a migraine or seizures. With the FBI hot on his trail, he succumbs to the viral infection that exacerbates his schizophrenia to throw him into a coma, a dream from which he is unlikely ever to wake. This would pose no problem, except that his latest victim is still trapped in a room somewhere---we can see her in her prison cell---but no-one has any idea where that is. The cell, though, is actually a machine that Stargher's designed to drown and bleach his victims into dolls. The Feds end up at Catherine's lab, asking her to enter into Stargher's mind to try to find out where the victim is. They rig her and him up in the same apparatus we saw her using with the young boy and the trip begins. It's quite a nicely filmed sequence, with many early VR-style metaphors of how wild and unpredictable such mindscapes would be. In Stargher's mind, he's still a child, with some very strange memories (that clearly led to what he would become). Catherine makes her way through this world, witnessing the Damien-Hirst-ification of a horse, then stumbling through cellars to happen upon Myst-like contraptions controlling female automata/dolls. The women are arranged in museum-like cells, some controlled by wires. She is attacked and subdued by a musclebound doll with gigantic breasts, who takes her to a throne room, where Stargher rules as king. She quickly bails from VR and then discusses next steps with Detective Peter Novak (Vince Vaughn). She agrees to go back in, learning more and more about Stargher's past and his history, where his sickness came from. Carl is talking to Catherine as Carl now (rather than as the demented king from before), which is progress. But she still can't find out where he's hidden Julia, his final victim. Her plan backfires and he manages to block her from activating her "dead-man switch" this time. He takes her hostage as one of his victims, placing a collar on her and "locking" her into the VR world. Novak has to suit up and jump in to the VR world for the first time ever, seeking out both Stargher and Catherine. There is a plethora of 2000-era computer graphics heralding his entry. Stargher quickly overpowers Novak as well, now with both Catherine and Peter in his clutches. Peter beseeches Catherine to wake up and rescue him. Peter thinks he's figured out where the woman is; Stargher is ramping up the craziness in his mindscape. Catherine reverses the feed and invited young Carl into her mind, though older Carl comes along, too. She "heals" the young Carl in her mind, and he finds peace, but dies. Novak saves the final victim. The sets are spectacular and imaginative. Catherine ends up keeping Carl's dog.</div> Zathura (2005) --- <a href="https://www.imdb.com/title/tt0406375/">5/10</a> <div>This is a <i>Jumanji</i>-like storyline where two brothers (Walter and Danny, his younger sibling) end up playing a game that Danny finds in the basement. It's called Zathura and it kind of plays itself: the boys just poke buttons and the game plays itself out. It takes their house into space and then into an encounter with Zorgons and then to an astronaut who turns out to be Walter in 15 years. It was OK, but really targeted at young kids. Kristen Stewart, Dax Shepard and Tim Robbins put in their time, but don't overdo it. It bored me, but I gave it an extra star because it's almost certainly a solid repeat watch for young kids.</div> </dl>
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Search for the best flight prices from East Midlands to Pula. Compare prices, book today and save money with East Midlands Airport.
About Pula
Take a trip to the far side of the Adriatic and discover the beating heart of ancient Croatia
With sun-kissed beaches, stone-built towns and picturesque fishing villages, it’s as unspoilt, diverse and inviting as you could wish for. With powerful Italian influences, it often feels like this former Yugoslav republic should be on the other side of the sea.
As the largest city on the Istria Peninsula – and offering a wealth of Roman ruins to boot – Pula draws its fair share of international visitors. Culture-minded tourists tend to focus their attention on the remarkably well preserved amphitheatre, and the three-star Hotel Galija (Epulonova 3) enjoys a central location in Pula itself, making it a good bet for city-breakers. Meanwhile, sunseekers are drawn by the area’s pleasant climate and coastal scenery, which means the 422-room Park Plaza Verudela Pula (Verudela 11) holds appeal – it’s a large family-friendly resort situated on the seafront. Striking a balance between the two is the charming Oasi Boutique Hotel (Pješčana uvala X-12a), with just nine rooms.
Istria is famous for many things, particularly its herbal oils and truffles, so picking up gifts or souvenirs in Pula is generally straightforward. The City Farmers’ Market (Narodni trg 9), housed in an attractive structure, has been part of Pula life for well over a century and remains a treasure trove of fresh produce and craft stalls. Elsewhere, the streets of Sergijevaca and Kandlerova are busy shopping thoroughfares – good for clothes, jewellery and design boutiques – while specialist stores include Aromatica (Laginjina 4), specialising in soaps and essential oils, and Zigante Tartufi (Smareglina 7), selling truffle-based goods.
It’s easy to eat well in Istria. The plaudits hang heavy at Konoba Batelina (Čimulje 25), sitting a little way out of town but recently named the best restaurant in Istria. It’s famed for its well-crafted seafood dishes. On a more basic level, Jupiter Pizzeria (Castropola 38) attracts plenty of positive reviews and serves good pasta and pizza, while the bistro feel of Farabuto (Sisplac 15) is an excellent bet for both Italian and Croatian dishes. Elsewhere, the traditional home cooking at the simply decorated Vodnjanka (Vitezica 4) is well worth seeking out.
Days of Antiquity
Three days of historical re-enactments and heritage-themed celebrations are held across three of Pula’s ancient sites. Mingle with legionaries and gladiators, attend workshops, watch costumed performances and soak up the city’s Roman past.
PUF International Alternative Theatre Festival
A platform for national theatre groups to showcase their work in front of local audiences. Productions (which are almost exclusively performed in Croatian) take place in the city’s streets and squares, producing a lively communal feel.
Seasplash Festival
A well-established ‘dance and lifestyle’ festival, Seasplash combines a rainbow mix of different genres – among them reggae, electro, jungle and ska – with other attractions such as boat parties and alternative workshops.
This renowned cinematic gathering attracts significant interest from overseas, having been in existence for over six decades. It runs for 15 days – memorably, some films are shown on an open-air screen in the amphitheatre.
Outlook Festival
August-September
Billed as the ‘largest bass music and sound system culture festival in Europe, Outlook draws big names from the dance music world to a stunning setting on the edge of town. It’s now become popular with festival-goers from around the continent.
Language: Croatian
Currency: Kuna
Time zone: GMT +1 hour (GMT +2 hours in summer)
Airport code: PUY
Holiday type: Beach / City Break / Summer Sun
Jan 10° 1°
Feb 11° 1°
Mar 14° 3°
Apr 18° 7°
May 22° 11°
Jun 27° 15°
Aug 29° 18°
Sep 24° 14°
Oct 10° 10°
Nov 15° 6°
Dec 11° 2°
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Developing a 3D Optical Surface Profilometer Using LabVIEW and NI Vision Development Module
Submitted by Brian Dipert on Mon, 2013-07-22 12:30
The device performs to a high standard with a total build cost of less than €5,000 and a development time of less than three months. This is largely due to the ease of hardware integration provided by LabVIEW and also the advanced and high-speed data processing capabilities that LabVIEW and NI vision provide.
- David Moore, Dublin City University
Designing and building a 3D optical surface profilometer capable of surface visualisation and roughness analysis to use in laser-processed surface characterization.
Using NI LabVIEW software with the NI Vision Development Module to image acquisition, motion control, and raw data processing, as well as to provide a full-colour 3D surface display with surface profile and surface roughness analysis.
In the photovoltaic field, laser micromachining is often performed during the various manufacturing stages. However, these laser processes may involve ablation and melting, which can result in rough surfaces on specimens due to debris from the machining. It is often necessary to characterise the specimen surface condition and profile to evaluate the laser process performance. Optical profilometry techniques are preferred where possible as they do not interfere with the specimen surface and can measure large areas at a high resolution. However, optical techniques such as interferometry can result in difficulties in measuring rough and transparent specimens. By varying the focal plane of a specially designed optical and imaging system with a low depth of field, it is possible to extract surface contour information from the specimen. Advantages of this method include high resolution and surface visualisation in real colour.
Because the system contains components of motion control, image processing, surface display, and signal analysis, LabVIEW was an obvious choice as the software development environment due to its seamless integration with third-party hardware and other NI products such as NI Vision.
High-Resolution Optical and Imaging Systems
We implemented a high-resolution optical system using a 50X magnification Nikon microscope objective lens. This objective lens has the power to resolve features in the order of 500 nm using white light illumination and provides a very shallow depth of field, meaning only a fraction of the image is focused at any one time. We used this lens in conjunction with a microscope tube and a 3 MP colour USB camera as the imaging device. This configuration gives the optical system an overall magnification of 25X with a field of view of 240 by 200 µm.
Motion Control and Image Acquisition Synchronisation
There are two parts to the motion control system. The high-accuracy vertical positioning system positions the sample along the vertical axis of the optical system, thus changing the position of the focused optical plane. The high-accuracy Thorlabs servo actuator used for the vertical positioning of the specimen is controlled using a Precision Micro Control servo motor driver/amplifier, which is supplied with LabVIEW VIs.
Third-party hardware integration is seamless and simple because LabVIEW supports many third-party hardware components. This high-accuracy positioning system has a theoretical resolution of 40 nm. We controlled the XY positioning system with two Nanotec stepper motors using third-party USB stepper drivers. This provides5 µm resolution when full stepping, so the specimen can be accurately positioned and the mosaic acquisition can be implemented with image stitching for large area measurement. The USB stepper drivers also provide digital I/O ports which are used as camera triggers in conjunction with sequences in the software developed with LabVIEW to synchronise the vertical specimen position with the image acquisition.
Raw Image Data Processing
We then processed the raw data acquired in the form of a stack of images to extract the focus regions from each image in the stack. As the vertical position of each image is known from the synchronisation of the motion control system during the image acquisition, it is possible to build a 3D surface mesh from the extracted focused regions. We used a Sobel edge detection VI in NI Vision to perform the feature extraction. Using a Sobel edge detector, we can assign an intensity for the gradient of every pixel in the image being analysed. We then parse the stack of images to find the highest gradient intensity for each pixel along the vertical measurement plane. Then we reference the highest intensity to a height according to the vertical position that image was recorded at, which is stored in a ‘height map’.
3D Surface Visualisation
We can then visualise the 3D surface in full colour using software created in LabVIEW. We used a built-in LabVIEW VI to process the height map of the surface, which is then ready for display in a 3D picture control. Using a 3D picture control configuration VI, we can wrap the fully focused image (previously generated from the stack of images by extracting the focused regions) on the surface mesh to display the measured specimen in full colour at submicron resolution.
Surface Roughness Analysis
We must often measure the surface roughness of components in surface engineering. Different surface roughness parameters reveal different important characteristics of the material and the production processes. However, there are strict guidelines that we must meet to make roughness analysis repeatable and accurate. First, the data must be corrected for form error by linear regression. This step involves using a Gaussian filter with a low cut-off frequency defined by ISO 4288, which removes the waviness component of the surface. The waviness may appear as a repeating pattern in the data when the wavelength is too large to be considered as roughness. We use the remaining for the roughness analysis. We can perform two types of analysis using this software; line analysis and area analysis, where the area analysis provides similar information to that of the line analysis but in two directions instead of one.
While the actual resolution of the measurement depends somewhat on the specimen being measured, it is certain that measurements are accurate in the submicron range in the X, Y, and Z planes. Measurement speed also reflects the high performance provided by the LabVIEW environment. It is possible to perform a single measurement of an area of 240 by 200 µm with submicron resolution in less than 60 seconds including data processing and surface visualisation, using only a standard dual-core PC. The device can also perform large surface area measurements up to a maximum of 20 by 20 mm and can measure rough sample surfaces, a difficult task using other optical profilometry techniques.
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Building an Integrated Vision and Robotics Packaging Line for Cosmetics Using NI LabVIEW and Vision Hardware
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Particle Board Quality Control Using Parallel Processing of NI Smart Cameras
Developing a Quality Inspection Method for Selective Laser Melting of Metals with NI Hardware and Software
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Experienced Representation
You Can Trust Serving Oregon Since 1949
Local 541-357-9903 Toll Free 866-951-0032
"Solutions are not always found in the law, but rather by focusing on the people we represent and their particular situation." — Patrick Melendy
Pilar Sanders loses parenting time after violating custody plan
On behalf of Leahy Cox, LLP posted in Child Custody on Monday, December 22, 2014.
Most parents in Oregon might assume that nothing could stand between them and access to their child, but what happens when an ex refuses to bring the children back? It's understandable that a parent may end up confused, especially if he or she has a child custody agreement that explicitly spells out when parenting time is available for both parties. In many situations, petitioning the courts to have an agreement modified can be a successful option.
Former NFL star turned sports broadcaster Deion Sanders recently dealt with this situation. Ultimately, it took the involvement of local law enforcement and a court order to return his children to his care. According to Deion Sanders, his ex-wife, Pilar Sanders, has purposely violated the child custody agreement 16 times, and possible more. In most instances she kept the children longer than she was permitted and once even kept them over a week. Outside help was also needed in that instance.
After petitioning the court to have the agreement both enforced and modified, both Deion and Pilar Sanders appeared in court. Pilar Sanders claimed that she simply did not recognize any jurisdiction of the court, which was why she felt that she did not have to follow the custody agreement. Deion Sanders was granted the modification that he asked for, and ultimately Pilar Sanders lost all access to her children. For being found in contempt of court, she was also ordered to spend seven days in jail followed by a probation lasting approximately one year.
A clear and concise child custody agreement isn't ultimately just for the benefit of the parents; it is put in place to protect any children involved and to make sure that their best interests are honored. If one parent decides that they no longer wish to follow the terms of the agreement and violates his or her parenting time, the other parent is not without options. By filing a motion to have a custody agreement modified, parents in Oregon are likely to discover that their children's best interests will still be at the heart of the agreement.
Source: dallasnews.com, "Deion Sanders' ex-wife jailed, loses rights to see kids", Valerie Wigglesworth, Dec. 16, 2014
Tags: Child custody, parenting time
Related Posts: Grandparents' rights and child custody in Oregon, Shared parenting: A positive child custody arrangement, Shared parenting gaining support in child custody decisions, Shared child custody arrangements result in lower stress for kids
High-Asset Divorce (3)
Is a New Year divorce in your future?
Can you protect your business during your divorce?
Is your ex attempting to relocate with your children?
Divorce can bring unexpected financial burdens
Leahy Cox, LLP
188 West B Street, Building N
© 2020 by Leahy Cox, LLP. All rights reserved. Disclaimer
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Irish Catholic Church reels after Yes vote wins gay marriage referendum
Peter Kenny | Monday, May 25 2015
(Photo: REUTERS/Cathal McNaughton)Director of Ceremonies Brian Whiteside (C) conducts a humanist wedding ceremony for groom Brendan Hastings and bride Suzy Addis at the Millhouse in the village of Slane, County Meath July 17, 2013. Traditionally Catholic Ireland has allowed atheist wedding ceremonies this year for the first time, but the few people certified to celebrate them are overwhelmed by the hundreds of couples seeking their services. Photograph taken on July 17, 2013.
The Irish Republic is still a predominantly Roman Catholic country, but the power the Church once wielded has clearly waned, the May 22 national referendum vote in favor of same-sex marriage shows.
Catholic Relief Services 'in deliberations' after VP revealed to be in gay marriage
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Gay priest gives refuge to former anti-gay governor in Catholic rectory
US Christian boutique raises stir by refusing to serve lesbian couple
Singapore archbishop apologizes for remarks made after gay rights' rally
Vatican paper on gay marriage, divorcees advocates more inclusion by the Church
Ireland officially passed the same-sex marriage referendum with the Yes vote overwhelmingly ahead with 62 percent to 38 per for the No vote, in a 60.5 per cent turnout.
In total, 1,201,607 people voted in favour with 734,300 against, giving a majority of 467,307.
"The Irish referendum on gay marriage was about more than just gay marriage. It was a politically trendy, media backed, well-financed howl of rage against Catholicism," Britain's Telegraph newspaper commented May 23.
The Archbishop of Dublin Diarmuid Martin, a senior Irish cleric, who said he would vote No, told reporters after Sunday Mass at the city's St. Mary's Pro-Cathedral the Church needs to have a "reality check" after the vote.
"The Church has to find a new language which will be understood and heard by people," said Martin. "We have to see how is it that the Church's teaching on marriage and family is not being received even within its own flock."
He noted, "There's a growing gap between Irish young people and the Church and there's a growing gap between the culture of Ireland that's developing and the Church."
Ireland becomes the first country to introduce same-sex marriage through a popular vote rather than through legislation or the courts.
Most Irish people still identify themselves as Catholic but growing secularisation and a wave of clerical child sex abuse scandals badly impacted the institution that was once seen as the bedrock of Ireland.
Irish bishops said they opposed changing the marriage law, but their voice was not heard.
The Catholic Church in Ireland also sent out pastoral letters insisting that opposing gay marriage is not homophobic, as the country prepared for the referendum.
SOCIAL REVOLUTION
"This referendum was about more than just the right to marry. Much, much more. It was the manifestation of a social revolution that's been simmering away in Ireland for some time," said The Telegraph writer Tim Stanley.
He said the pedophile revelations of the 1990s rightly rocked faith in the Church as an institution, while a series of recent scandals shook faith in its actual theology.
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"For me, this is not so much a referendum, it is more a social revolution in Ireland," said Leo Varadkar, Ireland's health minister, The Financial Times reported. "It makes us a beacon of equality and liberty for the rest of the world."
The Telegraph also noted politicians in three leading political Ireland parties Fine Gael, Labour and Fianna Fail backed the yes vote and that one election study found that Irish newspapers carried three times more articles favourable to Yes than No.
Stanley wrote that some of the outrages against the church were "frankly, distortions of the facts."
"It was wrongly claimed that a woman had been allowed to die because Catholic doctors would not give her a life-saving abortion (no such thing even exists). It was falsely charged that a Catholic children's home had dumped the bodies of hundreds of unwanted babies into a septic tank."
Same-sex "civil partnerships" were introduced in Ireland in 2010, but advocates for marriage equality said those fell short of the recognition and protections afforded by marriage.
The No-campaign said it was focussed on protecting the traditional family.
"How the Church survives this turn, is not clear. It'll require a lot of hard work and prayers," said Stanley.
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‘The Fault In Our Stars’ Filming Locations in Amsterdam
by Enchanted Serendipity | May 20, 2015 | Amsterdam, Film Locations, Filming Locations, Netherlands | 0 comments
The Fault In Our Stars Bench
Amsterdam is one beautiful city. There is so much history here, and enough to keep you busy no matter how long you visit for.
One location that is worth stopping by, is the ‘Fault In Our Stars’ bench that Shailene Woodley and Ansel Elgort sit on in the film.
Woodley and Elgort play terminally ill teens, Hazel and Augustus, who meet at a cancer support group. They visit Amsterdam and share a kiss on this very bench, in one of the film’s most memorable moments.
Fans Taking A Photo on ‘The Fault In Our Stars’ Bench
Now, fans of the film can re-create that same moment, (or just sit on the bench) and pretend they are in the film.
‘The Fault In Our Stars’ Bench
Film locations aside, this bench sits on a beautiful canal that is lovely to walk along or just sit and enjoy the view.
It is hard to find, so a google map of the address, and even a screen shot of the scene will help fans to track this bench down.
Location of ‘The Fault In Our Stars’ Bench
The location for this bench can be found at Leidsegracht #4 where it intersects with Herengracht.
Another worthwhile location for historic purposes as well as filming locations, is the Anne Frank House, which had it’s exterior used in the filming of this movie as well. The interior shots of the house were in fact re-created-in a very detailed representation, you can’t tell the difference.
The Anne Frank House Canal Featured In ‘The Fault In Our Stars’
The Anne Frank House is located at Prinsengracht 263-267, 1016 GV Amsterdam.
Any fan of ‘The Fault In Our Stars’ must stop at these locations next time they are visiting Amsterdam.
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Who Is Toni?
The USA has my heart - Australia is my home. I write travel tales with an entertainment edge, in a time when filming locations are truly driving tourism. Over the past decade, I have been traveling the world, bringing film, television and tourism together. I also have a love of history & food. I want travelers to be inspired to take their own vacations - and really connect to the places they visit. Join me as I embark on every adventure!
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Krimis, Thriller & Horror
Paris Spring
James Naughtie
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LovelyBooks.de Bewertung
Paris in 1968. In a city alive with talk of revolution, Will Flemyng finds himself in the thick of the action, a young spy whose f... Weiterlesen
Auslieferung erfolgt in der Regel innert 3 Wochen.
Paris in 1968. In a city alive with talk of revolution, Will Flemyng finds himself in the thick of the action, a young spy whose first adventures behind the Iron Curtain have already given him a secret glamour. But now he gets news that threatens the closest and most complicated relationship in his life, with his younger brother.
Paris, April 1968. The cafes are alive with talk of revolution, but for Will Flemyng - secret servant at the British embassy - the crisis is personal. A few words from a stranger on the metro change his life. His family is threatened with ruin and he now faces the spy's oldest fear: exposure. Freddy Craven is the hero and mentor Flemyng would trust with his life, but when he is tempted into a dark, Cold War labyrinth, he chooses the dangerous path and plays his game alone. Then a bizarre murder reveals a web of secrets, and his loyalty to family and friends is tested as never before. As the streets of Paris become a smoke-filled battleground, Flemyng, like his friends and enemies, discovers that where secrets are at stake, lives are too.
'Naughtie writes with a cool authority reminiscent of that now neglected master of the novel of espionage, William Haggard' Scotsman.
James Naughtie, who presented Today on BBC Radio 4 for twenty-one years, is a special correspondent for BBC News. He has written books on politics and music and published his first novel, The Madness of July, in 2014. He lives in Edinburgh and London.
A new thriller from the popular BBC Radio 4 "Today" programme presenter, this follows the success of "The Madness Of July". Set in Paris in 1968, it follows Will Flemyng and his brother as they are caught in the thick of the action of revolutionaries and spies. With appeal to fans of John le Carre and Robert Harris.
Paris, April 1968.
The cafes are alive with talk of revolution, but for Will Flemyng secret servant at the British embassy the crisis is personal. A few words from a stranger on the metro change his life. His family is threatened with ruin and he now faces the spy's oldest fear: exposure.
Freddy Craven is the hero and mentor Flemyng would trust with his life, but when he is tempted into a dark, Cold War labyrinth, he chooses the dangerous path and plays his game alone.
Then a bizarre murder reveals a web of secrets, and his loyalty to family and friends is tested as never before.
As the streets of Paris become a smoke-filled battleground, Flemyng, like his friends and enemies, discovers that where secrets are at stake, lives are too.
Titel: Paris Spring
Herausgeber: Head of Zeus
Genre: Krimis, Thriller & Horror
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LINDBLAD EXPEDITIONS AND NATIONAL GEOGRAPHIC EDUCATION PROGRAMS ANNOUNCE 2011 GROSVENOR TEACHER FELLOWS
Educators to Explore Arctic Svalbard as Outdoor Classroom for Professional Development
MEDIA CONTACT: Patty Disken‐Cahill Lindblad Expeditions 212‐261‐9081 pattydc@expeditions.com
WASHINGTON (March 1, 2011)—Six visionary educators are this year’s selections for the fifth annual National Geographic Grosvenor Teacher Fellows program, established to honor former National Geographic Society Chairman Gilbert M. Grosvenor’s lifetime commitment to geographic education. This opportunity was donated in perpetuity to the National Geographic Society by Sven‐Olof Lindblad and Lindblad Expeditions to mark Grosvenor’s 75th birthday in 2006 and to honor his service in enhancing and improving geographic education across the United States.
Each year, K‐12 educators from around the country are encouraged to apply for a professional development opportunity that recognizes teachers who have demonstrated excellence in geographic education. The objective is to enhance their geographic learning through direct experience and bring that knowledge back to their classrooms. The 2011 Fellows are:
Margaret Chernosky, a 10th‐ and 12th‐grade teacher at Bangor High School in Maine, whose students use inquiry with Geographic Information Systems to examine temporal and spatial patterns within the community. This spring, their geo‐historical project is partnering with the Fire of 1911 Commemoration Committee for the 100th anniversary of the Bangor fire. Chernosky is a 10‐year member of the Maine Geographic Alliance.
Ann Christianson, a 7th‐grade world geography teacher at John Muir Middle School in Wausau, Wis., whose adaptation of “The Amazing Race” brings students, teachers, parents and community members together in an educational challenge related to the history, geography and economy of Wausau. Christianson has been a member of the Wisconsin Geographic Alliance for 19 years.
Amy Blonn, a 5th‐grade outdoor science educator at the Houston Independent School District’s Outdoor Education Center in Trinity, Texas. Each week, she utilizes an outdoor setting to teach experiential, inquiry‐based science lessons to 250 new students who travel 100 miles out of Houston’s urban landscape to learn with her team.
Ani Smith, a 4th‐grade teacher at Sheridan School in Elgin, Ill., who inspires a passion for geography and the wonder of nature in her students. Her class creates a “Virtual Vacations” travel agency and transforms the classroom into Hawaii, complete with a floor‐to‐ceiling Mount Kilauea volcano. Smith has served the Illinois State Geographic Alliance for 18 years and also served as the Illinois Geographic Bee coordinator for the National Geographic Bee for several years.
Kevin Witte, a 9th‐ to 12th‐grade teacher at Kearney High School in Kearney, Neb., and recipient of the 2010 Outstanding Global Educator in Nebraska MELBA Award. Witte designed an International Wealth & Poverty course where his students study reports from U.N. agencies and NGOs and participate in a sustainable development course offered by the Earth Institute at Columbia University. He is a 12‐year member of Geographic Educators of Nebraska.
GROSVENOR TEACHER FELLOWS (PAGE 2)
Chad Pelton, a 7th‐ and 8th‐grade science teacher at the John D. Runkle School in Brookline, Mass., who provides hands‐on learning to all 60 of his students in an annual overnight geology field trip to western Massachusetts and upstate New York. Students are required to explain, through modeling and writing, their understanding of how Earth constantly changes and how climate changes impact our planet.
The Fellows will travel this summer on an in‐depth exploration of Arctic Svalbard aboard the Lindblad Expeditions ship National Geographic Explorer. Their journey will take them within some 600 miles of the North Pole, where they will experience the legendary midnight sun against the strikingly beautiful wilderness of towering glaciers as well as indigenous life such as wild polar bears, walruses and some of the largest whales on Earth. And with the benefit of the unparalleled expertise of their Lindblad‐National Geographic expedition team, the Fellows will return with a wealth of knowledge to educate and inspire their students as well as to share with professional colleagues at conferences.
“This program recognizes outstanding teachers who are dedicated to improving geographic literacy in our classrooms and encouraging children to become responsible caretakers of our planet,” said Sven‐Olof Lindblad, founder of Lindblad Expeditions. “We are delighted that these outstanding educators, who are so strongly committed to hands‐on geographic education, will journey to Arctic Svalbard with us.”
“The partnership with Lindblad Expeditions and National Geographic is an ideal fit of our two missions,” said Gil Grosvenor, chairman of the National Geographic Education Foundation. “We believe in the value of educational travel, and Lindblad’s programs are the best. Teachers who are recognized as Fellows will have experiences they will never forget.”
To learn more about this opportunity and to watch video of Grosvenor Fellows from previous years, visit http://www.expeditions.com/teachers. To become more involved in geographic education, contact your State Geographic Alliance at http://www.ngsednet.org/community/about.cfm?community_id=94.
Lindblad Expeditions and National Geographic
Lindblad Expeditions and National Geographic have joined in a mission‐driven alliance to inspire people to explore and care about the planet. As pioneers of global exploration, the organizations work in tandem to produce innovative marine expedition programs and to promote conservation and sustainable tourism around the world. The partnership’s educationally oriented voyages allow guests to interact with leading scientists, naturalists and researchers while discovering stunning natural environments, above and below the sea, through state‐of‐the‐art exploration tools. A joint philanthropic fund that supports science and conservation groups enables better understanding of the world’s remaining special places and fosters the dissemination of geographic knowledge around the globe.
NOTE: INTERVIEWS WITH THIS YEAR’S GROSVENOR TEACHER FELLOWS AND PHOTOS ARE AVAILABLE. ARCTIC B‐ROLL PACKAGES WILL BE AVAILABLE FOLLOWING THE TEACHERS’ VOYAGES.
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Protest planned at jobs fair for Robeson County gas facility
Workers invited to seek 150 construction jobs; opponents say gas storage project is a threat to the community.
Piedmont Natural Gas has scheduled a job fair for Thursday afternoon as it plans to hire 150 people to begin building a $250 million natural gas storage plant in northwest Robeson County — and at the same time, activists plan to hold a protest and rally against it just outside.
The conflict is set to happen from 5:30 p.m. to 8 p.m. at Oxendine Elementary School at 5599 Oxendine School Road, which is a Maxton address even though Maxton is miles away. The school is in Robeson County’s Wakulla community about 5 miles west of Red Springs.
The project is to be built close by on 65 acres of a 685-acre tract on N.C. 71 at Rev. Bill Road.
The project will be a property tax boon and economic driver for Robeson County, said Channing Jones, the county economic development director.
The plant will endanger the community and damage the environment, said Mac Legerton, a long-time community activist Legerton is leading opposition to the gas storage plant and a separate project, the Atlantic Coast Pipeline, which is supposed to pipe natural gas from West Virginia to eastern North Carolina, terminating about 6 miles away in the Prospect area.
Duke Energy, which owns Piedmont Natural Gas, is a partner in a consortium of energy companies building the Atlantic Coast Pipeline.
But the Atlantic Coast Pipeline doesn’t yet exist. The new storage plant is set to get its gas from the Transcontinental Pipeline, which has 10,000 miles of pipe that carries gas from Texas and Louisiana on the Gulf Coast to the East Coast and Northeast. It’s often called the Transco Pipeline.
Piedmont Natural Gas intends to use the Wakulla storage plant to help the company keep sufficient gas supplies on hand to handle demand spikes during cold weather, spokeswoman Tammie McGee said.
This will help the company keep homes heated, McGee said, and blunt price increases that normally come in colder months when gas is in high demand.
Jones said the storage plant also will ensure that industries in the Robeson County area will be less likely to have their supply of natural gas temporarily halted during high-demand cold weather months. He hopes this will attract employers.
Once complete, the Wakulla storage plant, plus a new, 4-mile line to connect it to the Transco Pipeline, is expected to pay more than $900,000 a year in property taxes, McGee said.
None of those arguments persuade Legerton or Donna Chavis of the Lumberton-based Friends of the Earth organization. They are trying to stop the plant from being built, or if it does get built, to stop it from opening.
Some of their concerns and predictions:
• Natural gas is hazardous, subject to fire and explosions. It will be dangerous to nearby residents and churches, Legerton said.
• Natural gas contributes to global warming.
• As the world transitions to other energy sources, natural gas infrastructure will no longer be needed, and customers will be expected to pay for the obsolete projects.
Piedmont plans to start building the storage facility this summer and finish it in summer 2021, a news release says. Matrix Service Inc. is to build it.
Piedmont and Matrix estimate they will need 150 people — workers and subcontractors — for jobs including safety watch, laborers and construction helpers, light and heavy equipment operators, welders and expediters. They also will need suppliers for construction materials and equipment.
Those interested are invited to visit the gymnasium at Oxendine Elementary to meet representatives from the companies.
Once the project is complete, Jones said, the plant is expected to employ 12 people.
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Former Mayville Police Chief pleads not guilty
Former Mayville Police Chief Christopher MacNeill pleaded not guilty to one felony count of misconduct in office and misdemeanor obstructing an officer.
Former Mayville Police Chief pleads not guilty Former Mayville Police Chief Christopher MacNeill pleaded not guilty to one felony count of misconduct in office and misdemeanor obstructing an officer. Check out this story on fdlreporter.com: http://fondul.ac/2vYFcBr
Sharon Roznik, USA TODAY NETWORK-Wisconsin Published 10:56 a.m. CT Aug. 12, 2017 | Updated 11:00 a.m. CT Aug. 12, 2017
Christopher MacNeill(Photo: Submitted photo)
FOND DU LAC - Former Mayville Police Chief Christopher MacNeill pleaded not guilty Thursday to one felony count of misconduct in office and misdemeanor obstructing an officer.
MacNeill, 48, appeared in Dodge County Circuit Court, where he waived his right to a preliminary hearing. Judge Brian Pfitzinger found there was enough evidence that a felony crime was committed, and bound MacNeill over for trial.
The former chief of police is accused of altering documents while in office to help another police officer's son get into the military.
MacNeill resigned from his role as Mayville police chief on March 31, following his being placed on administrative leave the month prior by Mayor Bob Boelk, according to documents obtained by USA TODAY Network-Wisconsin.
RELATED: Mayville Police Chief resigns
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MacNeill was awarded an agreed-upon separation payment by the city of $28,500, according to the resignation agreement.
During interviews, MacNeill told investigators that he had edited, redacted, changed the content of, or omitted descriptive parts of police reports to help citizens, according to court records.
MacNeill faces up to three-and-a-half years in prison and a $10,000 fine for the misconduct charge, with a penalty of nine months in prison and a $10,000 fine for obstruction.
Investigations into MacNeill's alleged wrongdoings were conducted by the Watertown Police Department and the Wisconsin Department of Justice’s Division of Criminal Investigation.
Reach Sharon Roznik at sroznik@fdlreporter.com or 920-907-7936; on Twitter: @sharonroznik.
Read or Share this story: http://fondul.ac/2vYFcBr
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Pitti Immagine Uomo 88 in Florence
From June 16 to 19, do not miss the most fashionable event of the year
From 16 to 19 June 2015 in Florence is the scene of Pitti Immagine Uomo 88, the international reference for men's fashion and the paths of the contemporary lifestyle.
A geography dynamic and evolving, that of Pitti Uomo, sensitive to capture the new climates of fashion and express them with new and sometimes unsettling projects. As the new section that exceeds Open gender discrimination to dictate a precise indication of the style or the proposed Unconventional, created to give voice to the most aggressive currents luxury underground.
Starring the approximately 1,150 brands of Pitti Uomo, with their proposals thought for the international community to come to Florence in the days of the show - more than 30,000 visitors last year - representing all the shops and department stores in the world's top.
MOSCHINO, Menswear Designer Guest Pitti Uomo 88
Guest Menswear Designer of Pitti Uomo 88 will MOSCHINO, the fashion house founded by Franco Moschino. On the evening of Thursday, June 18, at Palazzo Corsini al Parione will stage the first show man made by the brand in Italy since Jeremy Scott took over the creative direction.
THOMAS TAIT is the Womenswear Designer Guest
THOMAS TAIT, the young London designer of Canadian origin who in 2014 won the prestigious LVMH Young Fashion Designers Prize, already appreciated internationally by experts to approach couture and sculptural forms of his women's collections, will conduct an event special for the audience of Pitti Uomo, scheduled for the evening of Wednesday, June 17 at limonaia Zanobi del Rosso in the Boboli Gardens. Thomas Tait is the Guest Womenswear Designer of Pitti Uomo 88.
Carlo Brandelli for Kilgour: Project Designer of Pitti Uomo 88
The Project Designer of Pitti Uomo 88 will be Carlo Shreds, creative director of Kilgour.
On the evening of Wednesday, June 17, the Anglo-Italian designer will present for the first time in Italy his style and his vision, within the picturesque setting of Palazzo Medici Riccardi.
Fondazione Pitti Discovery presents Mr. Nino, the first exhibition devoted to the ideas and style of Nino Cerruti, one of the great protagonists of the Italian men's fashion for almost fifty years. In the spaces of exception of Museo Marino Marini, from 16 June to 7 July, it is staged a storytelling cured by the Nino Cerruti with Angelo Flaccavento.
CALCIO STORICO FIORENTINO. An event that celebrates the tradition of Florence as an emblem Italian
It will be an extraordinary representation of the Calcio Storico Fiorentino to welcome traders to Pitti Immagine Uomo 88, the evening of Monday, June 15, in the setting of Piazza Santa Croce.
The Pitti Italics: ARTHUR ARBESSER, CASAMADRE e LOUIS LEEMAN
The Pitti Italics of this edition will be ARTHUR Arbesser, parent company and LOUIS LEEMAN and will stage their collections during Pitti Uomo through dedicated performance.
C.P. COMPANY, Special Event @ Pitti Uomo 88
C.P. COMPANY chooses Pitti Uomo 88 as the international stage to celebrate its first 40 years and present a limited edition of Goggle Jacket signed by the creative director Enzo Fusco. The brand will be featured in a performance-event as Special Event @ Pitti Uomo 88
INSTITUTE MARANGONI
Istituto Marangoni has chosen Florence and Pitti Uomo to celebrate its 80th anniversary with an exclusive event in the beautiful setting of Palazzo Corsini. Monday, June 15, the parade - at 17.30 - will be followed by a cocktail and dinner party at 20:30.
LUISAVIAROMA, June 13 to 15 the new edition of FIRENZE4EVER
Eleventh edition for Firenze4Ever, the festival organized by the fashion store LUISAVIAROMA dedicated to the best fashion blogger on the world stage. The three-day workshop and shooting will end with a dinner and an exclusive party on the evening of Monday, June 15, the Tobacco Factory. Theme of this year, "Over The Rainbow".
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Flashlyrics
Hold On Lyrics
(When you might as well quit
Baby I've got it)
Middle of the night when it comes creeping
I lay awake when I should be sleeping
Like an Agatha Christie mystery during intermission
I hold on, I hold on
Working everyday living for the weekend
I never learned to swim how did I end up in the deep-end?
Like a champion high-diver waiting for the Olympics
We wrestle with the devil in the flickering light
No way to tell who's winning the fight
Hold on, hold on, hold on
You're gonna get through it
Time and again it's the same old question
Where am I heading with this strange obsession
Like a gambler playing on when he keeps on losing
We dance with the devil in the flickering light
No way to tell when you're stepping it right
Yesterday is dead and gone
So today this life goes on
Got to keep on moving
Hold on, you gotta hold on, hold on
You know you're gonna get through it
You gotta keep moving
Report lyrics
Olly Murs Lyrics
Olly Murs (2011)
Change Is Gonna Come Please Don't Let Me Go Thinking of Me Busy I Blame Hollywood Ask Me to Stay Heart on My Sleeve Hold On Accidental Love Shine Down Don't Say Goodbye A Million More Years
Top Olly Murs Lyrics
Army of Two Dance With Me Tonight Dear Darlin' Grow Up Kiss Me Seasons Troublemaker Up Wrapped Up You Don't Know Love
"Hold On" is a song by Olly Murs. It is track #8 from the album Olly Murs that was released in 2011. The duration of this song is 03:05.
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The 20 All-Time Worst Song Lyrics About Sex
By Tom Hawking
Justin Timberlake’s new single “TKO” dropped last week, and because we are professionals, we forced ourselves to listen to it despite the fact that it starts with the refrain, “She killed me with that coochie-coochie-coo.” The song doesn’t get a whole lot better, to be honest, but that particular line is surely the least appetizing sex-related lyric of the year (honestly, who uses the word “cooch” outside of high school?!), and it started an intra-office conversation about where it rates in the pantheon of hilariously awful sex lyrics. Here are the results of our highly scientific discussion: a giggle-inducing survey of the worst of the worst. You’re welcome.
Justin Timberlake — “Strawberry Bubblegum”
The offending lyrics: “Little girl won’t you be my strawberry bubblegum/ Then I’d be your blueberry lollipop/ And then I’d love you ‘til I’ll make you pop”
The whole coochie-coochie crisis isn’t exactly Timberlake’s first offense against good taste. Apart from songs that are several eons too long, the defining feature of The 20/20 Experience is that its lyrics are largely dire, which is a shame, because FutureSex/LoveSounds was home to some pretty effective pop lyricism. If you’re comparing your paramour’s vagina to strawberry bubblegum, though, it’s hard not to sound a) creepy or b) ridiculous; this song manages both. (And then there’s the whole penis-as-lollipop metaphor, to which we will return in due course.)
John Mayer — “Your Body Is a Wonderland”
The offending lyrics: “One mile to every inch of your skin, like porcelain/ One pair of candy lips and your bubblegum tongue.”
More bubblegum. Apart from the saccharine Hallmark card shitfulness of the lyrics, there’s one inescapable fact here: bubblegum and candy are for kids. Mentioning them in the context of a song about sex is creepy. It makes you sound like the sort of man who uses the word “panties.” The end.
Black Eyed Peas — “My Humps”
The offending lyrics: “I mix your milk with my cocoa puff/ Milky, milky cocoa/ Mix your milk with my cocoa puff/ Milky, milky right”
It’s no surprise that the official Worst Song Ever is also home to the official Worst Lyrics Ever, but even so, these lyrics are the sort of thing you need to kind of sit back and marvel at for a few moments. Milk. Cocoa puffs. What the actual fuck?
50 Cent — “Candy Shop”
The offending lyrics: “I’ll take you to the candy shop/ I’ll let you lick the lollipop/ Go ‘head girl, don’t you stop/ Keep going ’til you hit the spot”
The return of the lollipop! It’s a metaphor, y’see.
U2 — “Get On Your Boots”
The offending lyrics: “I got a submarine/ You got gasoline/ I don’t want to talk about wars between nations/ Not right now/ Hey sexy boots/ Get on your boots/ Yeah”
The thing is that No Line on the Horizon wasn’t a bad album — it was, however, preceded by a single so hilariously appalling that it made even hardened U2 apologists from way back (like your correspondent) cover their faces in horror. There are certain things that no human being should ever have to hear, and Bono singing “You don’t know how beautiful you are” is one of them.
Interpol — “Stella Was a Diver and She Was Always Down”
The offending lyrics: “She was my catatonic sex toy love-joy diver”
Well, that sounds like fun.
Kiss — “Burn Bitch Burn”
The offending lyrics: “I wanna put my log in your fireplace”
Even setting aside the, um, charming song title, this must surely be a contender for the coveted prize of music’s most unappealing metaphor for sex ever. Yeah, baby! Check out my… log! Wait, where are you going?
Peter Gabriel — “Kiss That Frog”
The offending lyrics: “Let me introduce his frogness/ You alone can get him singing/ He’s all puffed up, wanna be your king/ Oh, you can do it/ C’mon lady, kiss that frog”
And while we’re on unappealing metaphors, here we find Peter Gabriel comparing his penis to, yes, a frog, an image that makes 50 Cent’s lollipop downright enticing by comparison. Pucker up, ladies.
Amanda Palmer — “Map of Tasmania”
The offending lyrics: “Freedom down there, I swear, do you see me smirkin’?/ Do you see me wearing a merkin?/ Get in the formation, let’s start triangle jerkin’”
For anyone unfamiliar with Australian slang, “Map of Tasmania” is an old and rarely used euphemism for female pubic hair — it’s the roughly triangular shape, y’see. It was exhumed by sometime Australian resident (hey, we never asked for this) Amanda “Fucking” Palmer for this song, which contains surely the first and only lyric to rhyme “merkin” with “triangle jerkin’.” Well, hopefully, anyway.
Jadakiss feat. Kanye West — “Gettin’ It In”
The offending lyrics: “My apologies/ Are you into astrology?/ ‘Cos I’m tryin’ to make it to Uranus”
Next year, young Kanye is starting middle school! He’s growing up so quickly!
Los Campesinos! — “By Your Hand”
The offending lyrics: “She dresses loosely in a bathrobe with her hair up in curls/ ‘Cos we were kissing for hours with her hands in my trousers/ She could not contain herself, suggests we go back to her house/ But here it comes, this is the crux, she vomits down my rental tux”
The obvious WTF moment here is the vomiting-in-the-rental-tux conclusion, but there’s something somehow worse about the second line — it makes the whole encounter sound like the sort of fumbling gropefest that corpulent bosses have with long-suffering secretaries at office Christmas parties.
Robin Thicke feat. Pharrell and TI — “Blurred Lines”
The offending lyrics: “I’ll give you something big enough to tear your ass in two”
Apart from the general rape-culture ghastliness of the lyrics, there’s the above, which doesn’t sound like the kind of boast that would make the ladies come a-runnin’.
R. Kelly — “Share My Love”
The offending lyrics: “Let’s do what we were born to do/ Populate/ Let’s get together/ Populate/ Make the world better/ Populate”
Our legal counsel nixed our first comment on these lyrics, so let’s just say that their premise sounds unfeasible given what we’ve heard about Kelly’s sexual tastes.
The offending lyrics: “Oh, your sex is on fire/ Consumed with what’s to transpire”
Even if this lyric didn’t conjure up having images of having sex with Caleb Followill, it’d fall somewhere into the benighted lyrical zone that unites the clichéd with the nonsensical. As it is, it does conjure up images of having sex with Caleb Followill, which is enough to make us pray to the Great Pooping Pigeon God above to make it stop.
Eminem feat. Obie Trice — “Drips”
The offending lyrics: “She foaming at the lips, the ones between the hips/ Pubic hair’s looking like some sour cream dip”
Because nothing says sexy like sour cream, right? Oh.
Rihanna — “S&M”
The offending lyric: “Sex in the air, I don’t care, I love the smell of it/ Sticks and stones may break my bones/ But chains and whips excite me”
This is to writing about sex as Hot Sexy Amateurs!!!1! are to porn — the sort of plastic sex that, despite all its desperate grasping for raunchiness, ends up being entirely unsexy. A couple of years back, when the song was released, Maura Johnston cited it as an example of how “raunch pop” makes sex boring. She was dead right, and the song only sounds all the more clichéd and awful with a couple of years of incessant airplay behind it.
Prince — “Soft and Wet”
The offending lyrics: “Hey, lover, I got a sugarcane that I wanna lose in you/ Baby can you stand the pain?”
Oh come on, you’re about three feet tall. It can’t be THAT big.
Nickelback — “S.E.X”
The offending lyrics: All of them, really, but especially “I’m loving what you wanna wear/ I wonder what’s up under there/ And if I’ll ever have it under my tongue?”
NO. NO, YOU WILL NOT.
Led Zeppelin — “The Lemon Song”
The offending lyrics: “Squeeze me baby, ’til the juice runs down my leg/ The way you squeeze my lemon, I’m gonna fall right out of bed”
The thing that no one ever mentions about this lyric: lemon juice is yellow. Hope you packed the rubber sheets.
Jimmy Webb — “MacArthur Park”
The offending lyric: “As we followed in the dance/ Between the parted pages and were pressed/ In love’s hot, fevered iron/ Like a striped pair of pants.”
One of music’s most celebrated terrible lyrics, especially the bit about leaving the cake out in the rain. Even that, however, kinda pales in comparison to the above verse, which is kind of amazing in its awfulness. It takes a special sort of lyrical imagination to come up with the idea of comparing sex to a pair of pants being ironed.
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My Bauhaus | Mein Bauhaus
100 Architects on the 100th Anniversary of a Myth
“2019 marks the centenary of a myth: the Bauhaus has shaped architectural history like no other modern institution. Even 100 years after its foundation in Weimar, the principles, methods and visions of the Bauhaus masters and students are still alive.”
“But the many ways in which the Bauhaus is regarded today are as diverse as the goals pursued by its individual directors and workshops in the past. What Bauhaus means, the associations it invokes and its typical characteristics are all a matter of interpretation and perspective. There is no universal formula.
In this book, 100 architects from around the world share their personal views on the Bauhaus. In short texts accompanied by photos or sketches, they describe what they associate with this avant-garde school, how the Bauhaus is relevant to them personally, and the aspects they consider to be “typical Bauhaus”. Architecture and design, the everyday and the exemplary, processes and experiments are just a few aspects of the range of topics addressed in these brief essays. 100 individual perspectives provide insight into the authors’ design principles and architectural understanding.”
Buy from detail online shop.
Detail Business Information GmbH
Sandra Hofmeister
© 2020 FBA
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Cooking Advice From The World's Greatest Bacon Maker
Leslie Kelly Contributor
I write about food and travel while roaming around the U.S. in my RV
If there were a title for world's best bacon producer, Allan Benton would be the heavyweight champ. His old school, carefully cured and hickory smoked pork belly has impressed big name chefs and humble home cooks for decades.
Hickory smoked in Madisonville, Tenn., Benton's bacon is beloved by superstar chefs including David... [+] Chang.
Leslie Kelly
David Chang featured Benton's pork products in Momofuku's earliest days: "Tom Colicchio told me about Allen in 2003 or 2004. I stopped by to visit Damon Wise and Tom at craft and smelled this intense hickory bacon cooking and asked them what that was... I think they had just come back from doing a dinner at Blackberry Farm and that’s when they were introduced to it by chef John Fleer. So I called Allen and said I wanted to put it in my ramen broth and that lead to us buying his country hams."
The Southern Foodways Alliance bestowed its prestigious Lifetime Achievement Award on Mr. Benton in 2007: "He has satisfied the cravings of food lovers for the magic tonic of pork, salt, smoke and time. He has linked chefs around the country to traditional foodways and inspired them to elicit flavors that Allan, himself, might never have imagined. In the face of traditional European cured hams, Allan has cured many a case of porcine envy by way of his long-cured Tennessee prosciutto," wrote chef Fleer in an appreciation.
Allan Benton cures and smokes world-famous country ham and bacon in Madisonville, Tenn. Winner of... [+] many awards, Mr. Benton is still hands on at his business.
While the lists of awards and accolades are long, Mr. Benton remains hands-on at his operation he's run since 1973, taking it over from the original owner who began curing pork in 1947.
Walk in the door at Benton's and the scent of hickory hangs in the air like nothing you've likely experienced. It's intense and intoxicating. Look to the right, and you'll see the source of that porky perfume. Gorgeous pink hams hang by hooks, the sound of bandsaws breaking them down to be packaged and sold.
Even though he's busy fielding calls, Mr. Benton takes a moment out of his action-packed day to serve up some sage advice on cooking those ruby slices of country ham.
Hams are dry cured for more than two years, giving them an intense, complex character. Just make... [+] sure you don't overcook those slices, says owner Allen Benton.
"People almost always overcook it," he said. "You really just need to warm it up. Leave some bacon grease in the pan and heat it for no more than a minute on each side. Otherwise, it gets tough."
The Benton country biscuit at The Rhu in Asheville is porky perfection.
If you're lucky enough to find yourself in Asheville, N.C., make a beeline to chef Fleer's excellent bakery, The Rhu, and order a double shot of biscuits, described on the menu as "Ham and Jam." Because you need a little sweet to follow up on what is very likely the best ham biscuit on the plant. The fine fluffy breakfast bread product is stuffed with thick, tender slices of Benton's country ham.
You just might want to order that biscuit duo to go and eat it in the privacy of your car, where nobody will stare when the moans of pleasure begin with the first bite and end with the last, and you begin dreaming about how you can sell your home and move to this food-and-beer loving town near the Blue Ridge Mountains.
Or, if you can't make it down south anytime soon, you can try to recreate that country ham biscuit at home. Benton's products are sold online.
Hungry to learn more about Allen Benton? Watch this outstanding video produced by Joe York for the Southern Foodways Alliance:
Cured from Southern Foodways on Vimeo.
I am a veteran food writer always dreaming about my next meal, whether it's a juicy burger or a fancy tasting menu. My work has appeared in various newspapers including ...
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Everyone’s worried about stopping terrorism. Well, there’s really an easy way: Stop participating in it. – Noam Chomsky
Search FOH
Four generations of service
This post previously appeared on Patreon, but given the subject, I wanted to share it with everyone. Enjoy!!
When I was a kindergartener, my Grandpa Ray came with me to school to talk about his service in the Marine Corps. I remember beaming as I held the case for his Purple Heart and showed the contents to my classmates. This happened to occur during Operation Desert Storm and in continuing with the military kick my class was running, we sent letters and care packages to a soldier who was deployed to Kuwait.
It didn’t occur to me until much later in my life how big an impact these early exposures to the military had in my life. But then again, military service was never far from my life. Let’s begin with four generations. Four generations of military service. My great grandfather Plum served in WWI. I don’t know much about him, aside from a single photograph I’ve seen taken in his uniform. Then, came my Grandpa Ray. Ever still the Marine staff sergeant. He survived Pearl Harbor aboard the USS Tennessee, deployed later to the Marshall Islands, and then after moving to the reserves, Grandpa did a tour in Korea. To say that he was an example of the toughness embedded into the military would be a gross understatement. Grandpa gave me hair cuts for as long as I can remember, including taking me to get my first hair cut at his favorite barber shop. If I visited his house with my hair too long, down to the basement ‘barber shop’ we went. He also walked me to school on my first day of kindergarten and taught me to fish.
Following my Grandpa Ray came my Pop, which was what I called my maternal grandfather. He served in the 50’s in the Army; did a tour in Ethiopia. He told me many stories about taking a Thompson machine gun and a 1911 to go hunting there in country. I don’t recall the animals he brought back, but I do remember him having a gay ‘ol time shooting a 1911 at seagulls on the beach. Like me visiting Iraq, I saw in my Pop a man who observed how much better ordinary life was back in the US compared to Ethiopia, and this is a man who had nine sisters and two brothers; he knew what it meant to share space.
My Grandpa William (Grandpa Bill to us) also served in the Army, but I don’t know much about his service. More to come on that.
Next came my Uncle Dan, who did stints in the Active Air Force and the Air Guard in the late 70’s through the early 80’s. I really don’t know a whole lot about his time in service, other than a nasty knee injury he received. Like me, he’s spent time submitting claims for his injuries and hoping the VA would get on the ball a bit. I sense in him a lot of me: hard working and decent, someone who’s not afraid to call out things as he sees them.
And coming in last but not least is the asshat writing this, having served two tours in Iraq and my brother Andrew, who recently finished six years as a nuclear machinist mate in the Navy.
But back to Grandpa. The medals he received in WWII and Korea were hung in a special place down in his basement, I remember feeling the raised head of General Washington between my fingers as I held his Purple Heart (he actually received two; one came much later.) It wasn’t until almost a full twenty years later that I understood the particulars of getting a Purple Heart and how significant it was that my Grandpa earned one and lived to tell the tale.
This brings me to yesterday. I don’t call my grandparents nearly often enough, but I did yesterday. I do my best to keep Grandma apprised of my health. I chatted with Grandma like usual: how’s everyone doing on both sides of the phone, share with her how her great grandsons are refusing to cease growing like weeds, and so forth. I then got on the phone with Grandpa. Grandpa is a pretty brief talker, so usually a solid two to three minutes and we’re all caught up. But last night, he asked me something about my service that had really upset him. Something I’d considered many times, but never discussed outloud with him.
Grandpa asked me if a rumor he heard was true. He asked if servicemembers were receiving medals for no reason. And well…it’s absolutely true. Awards like the Bronze Star were not given lightly back in Grandpa’s day, mostly going to men who had already been killed in action; not exactly an award seeking demographic. Now, in today’s Army (and to a certain extent the other branches) awards are given for all manner of things, but most awards received are not for bravery or valor. You get a medal for so many years of service. You get a medal for every deployment, generally regardless of what you did there. I’m not trying to be glib about it; they really give them out sometimes for nothing. The senior leadership of my MP company (E7 and above) all received Bronze Stars for their deployment to Iraq. E6 and below received Army Commendation medals. Now, those senior leaders may have worked incredibly hard on that deployment, but does that mean that their rubber stamp award for 15 months in Iraq should equal what my grandfather received for valor in WWII?
I’ve seen a few videos and articles about how award hungry today’s military has become, being more focused on good evaluations and not necessarily doing the job well or even correctly. Part of this debate is lost in the semanics of award giving, but I think for a group of institutions which supposedly value history and honor, a honest look at how they dole out awards needs to be considered. I don’t think all military awards are bad and certainly there are many deeds committed by servicemembers worthy of praise and admiration. But when the admiration goes to the shiny trickets that you wear on your chest rather than the actions that gave you said trinket in the first place, it’s time to write a new rule book.
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A special thanks to our honorary producers Matthew Hoh, Will Ahrens, Ron Unger, and Gage Counts!! Without you guys, we couldn’t continue our work. Thank you all so much!!!
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FOH is hosted, written, and produced by Chris ‘Henri’ Henrikson and Danny Sjursen
Cover and website art designed by Brian K. Wyatt Jr. of B-EZ Graphix Multimedia Marketing Agency in Tallehassee, FL
Music provided royalty free by Bensound.com
Note: The views expressed in this podcast are those of the hosts alone, expressed in an unofficial capacity, and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.
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Sergeant Christopher 'Henri' Henrikson is a disabled Iraq war veteran from Portland, OR. A former military police team leader and drug suppression investigator, Henri deployed twice in support of Operation Iraqi Freedom. You can contact him at henri@fortressonahill.com. Follow him on Twitter @Rorak11GGD. View all posts by Henri
Posted on April 11, 2018 Author HenriCategories UncategorizedTags Chris Henrikson, Pearl Harbor, Purple Heart, Raymond Garland, US Marine Corps, USMC
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Canteen online orders
School History and Archives
Distinguished Fortians
The Fort Street Museum
Contact Archives
The Fortian - digitised
Fortian code
Exit profile
Annual School Report
Fort Street High School was established in 1849. As the oldest selective high school Fort Street has a unique place in history of the State of NSW, having educated and nurtured some of the most prominent and influential citizens in Australia.
Fort Street High School is an academically selective secondary school. Entry is competitive and based on academic merit. There is a maximum enrolment of 150 students in each of Years 7 – 10. There are between 160 and 170 students in each of Years 11 and 12.
Junior School (Years 7-10)
Senior School (Years 11-12)
High resolves
Community Service & Volunteering
Tournament of the Minds
Special Religious Education
The Fort Street High School ethos is to engage Fortians in effective learning, developing teamwork and problem-solving to become critical, creative, ethical thinkers and leaders of the 21st century.
Arts, Languages & Humanities
Drama & Theatre Sports
Instrumental Music Program
Science, Technology and Mathematics
Student Interest Groups
Fort Street High School has a wide range of programs that support student learning and enhance social and personal development. They operate as part of the extended before and after school timetable and are designed to complement the curriculum by enriching the core learning experiences for students. All activities undertaken are listed on student reports.
Fortians Union
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Located 20 minutes from the Sydney CBD
Fort Street High School
Parramatta Road, Petersham
© Copyright 2020 Fort Street High School
Site by Firefly
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Bruce A. Machmeier, Counsel
Bruce A. Machmeier
bmachmeier@foxrothschild.com
Bruce is an experienced transactional lawyer who represents clients in public and private securities offerings, mergers and acquisitions and corporate governance matters. He regularly advises emerging businesses in equity and debt financings and represents issuers, underwriters and selling shareholders in public offerings.
Bruce also helps private and publicly held companies structure, negotiate and implement mergers and acquisitions, dispositions, joint ventures and licensing transactions and regularly advises boards on corporate governance matters. Although Bruce represents clients in a variety of industries, he has a particular focus on companies in the medical device and technology sectors.
Among his leadership roles in the firm, Bruce serves as a member of the firm’s Finance Committee.
Handled public securities offerings by ev3 Inc. ($166 million) and The Toro Company ($125 million).
Handled private securities financings for early stage companies, including Phraxis, Inc.; Invenshure, LLC; Imbio, LLC; DGIMED Ortho, Inc.; Oneome LLC; Aria CV, Inc.; Flywheel Exchange LLC; Exosite LLC; and MedNet Solutions, Inc.
Handled public company acquisitions of ev3 by Covidien plc ($2.6 billion); Virtual Radiologic Corporation by Providence Equity Partners ($294 million); FoxHollow Technologies, Inc. by ev3 ($741 million); and Fargo Electronics by HID Global Corporation ($340 million).
Handled private company acquisitions, including superDimension Ltd. by Covidien plc ($300 million); Steady State Imaging by GE Healthcare; HLT, Inc. by Bracco AMT, Inc. ($80 million); Levo AG by Dane Technologies; and Arizant Inc. by Citigroup Venture Capital.
Prior to joining Fox Rothschild, Bruce was a partner at Oppenheimer Wolff & Donnelly LLP.
Named to "The Best Lawyers in America" list for Corporate and M&A and Corporate Law in Minnesota by Best Lawyers (2017-2020)
Named Best Lawyers’ 2017 Minneapolis Corporate Law "Lawyer of the Year"
Named as one of the leading attorneys for Business in Minnesota by Chambers USA
Named as one of the leading Corporate/M&A attorneys in Minnesota by Chambers USA (2016-2019)
Named a “Minnesota Super Lawyer” by Super Lawyers Magazine (2016-2019)
Emerging Companies & Venture Capital
Stanford Law School (J.D., 1980)
University of Minnesota (B.S., 1977)
Society of Corporate Secretaries and Governance Professionals
National Association of Corporate Directors
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FRACTOVIA
MARKET TRENDING NEWS
How will structural insulation panels (SIP) industry dynamics change with robust product innovations...
How will structural insulation panels (SIP) industry dynamics change with robust product innovations brought forth by notable industry stalwarts?
Publisher : Fractovia | Latest Update: 2019-02-22 | Published Date : 2018-03-29Request Sample
The global structural insulation panels market is poised to witness a significant growth curve in the upcoming years owing to the remarkable expansion of the construction sector worldwide reinforced by the rapid industrialization and urbanization. Technological advancements in commercial and residential construction projects with regards to reduced operational expenses and energy conservation will also propel SIP market in the years to come.
The industry trends are also expected to witness a dramatic incline pertaining to a sharp increase in the R&D investments, subject to a transformational shift towards energy-efficient, high-performance building components for conserving notable loss of natural resources. This has resulted in an upsurge in the demand for structural insulation panels, which in tandem with the numerous other advancements that offer modern building techniques for new commercial and residential constructions, will help augment the global structural insulation panels market size.
North America Structural Insulation Panels Market, By Product, 2017 & 2024, (Million Square Feet)
Another major parameter pushing the industry trends is the huge potential for new construction in Mexico, China, and South Africa, along with favorable government policies and regulations towards green buildings. It has been observed that commendable efforts by the U.S. Government and Department of Energy are also heavily pushing the best practices for energy-efficient buildings fostering the industry outlook. Various government regulations and policies to increase energy efficiency of commercial and residential buildings in a bid to prevent depletion of natural resource will further promulgate the structural insulation panels market.
For example, EU Directive 2012/27/EU for Energy Efficiency (EED) lends prime focus on improving the consumption of energy via constraining energy use in buildings as well as renovating 3% of publicly owned buildings, with an area over 250 sq. meters annually, acquired by central government.
Notable companies partaking in the SIP industry share have apparently retained focus on product innovation as well as enhancing production facilities. However, mergers & acquisitions and portfolio expansion have also remained pivotal strategies adopted by companies for enhancing their stance across this industry. A gist of the contribution by some of the major companies in the structural insulation panels market is mentioned below:
Kingspan Group
A few days ago, the Ireland based building materials firm Kingspan announced that its Kooltherm K17 insulated plasterboard has obtained a Group 1 fire rating, making it fit for using across all building classes. Though, plasterboard products are only needed to undergo small-scale testing (AS/NZS 3837), the company chose to test its product under a full scale AS ISO 9705 test for ensuring performance. Kingspan has underlined its commitment towards a program of global testing by putting its insulated plasterboard through an extreme fire test.
The Kooltherm range of Kingspan Insulation already carries Australian Made certifications, BRANZ Approval, UL Listing, FM Approval and CodeMark across their product range. Accomplishments like the aforementioned are expected to further augment the goodwill and trust factor for the company, which would in turn assist the firm enhance its position in the structural insulation panels market.
Foard Panel Inc.
Nearly a decade back, the U.S. based Foard Panel had announced that it will use Foamular(R) extruded polystyrene (XPS) foam from Owens Corning, for its XPS-core structural insulated panels. In contrast to the urethane foam, Foard's SIPs panels with XPS foam offer comparably high R-value per inch, without a disruptive odor, and twice the lengthways (transverse) load strength with double the system strength.
The XPS foam also offers thirty times higher resistance to moisture absorption as well as lower potential for mold growth, along with a thermal performance warranty of twenty years. Since then, Foard Panel has delivered a plethora of commercial and residential projects across the nation, deploying its state-of-the-art SIP portfolio. The company has also delved deep into green construction and sustainability practices in panel production, thereby upscaling its position in the overall structural insulation panels industry.
Composite Panel Building Systems
The Texas-based Composite Panel Building Systems, a few years ago, launched a fully composite SIP in order to deliver superior performance by insulating and sealing the building envelope. The C-SIP is apparently engineered with six functions, namely, superior insulation, vapor retarder, moisture barrier, exterior sheathing, structural walls, and air barrier incorporated in a single building product.
Reportedly, the energy efficient C-SIP has been designed for replacing myriad building products with a single, precision-engineered product that enables LEED and NAHB Green Building points. The product is an apt instance of how multi-functional components have been gaining precedence in the SIP industry in recent times.
It is rather overt that the commendable efforts undertaken by notable industry players would push SIP market trends in the coming years. The competitive spectrum of this industry is quite diverse, and consists of renowned companies such as Nohara Holdings, Inc., Isopan, Insulspan Inc., Foard Panel Inc., Future Building of America, ACME PANEL and Foam Laminates.
Written By : Saurav Kumar
1887 WHITNEY MESA DR #4112
SAFE SEAL
© 2020 Fractovia. All Rights Reserved
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Lions report card: Stafford, defense earn high marks
Dave Birkett breaks out the red pen and grades each position group and the coaches after the victory over Washington
Lions report card: Stafford, defense earn high marks Dave Birkett breaks out the red pen and grades each position group and the coaches after the victory over Washington Check out this story on Freep.com: http://on.freep.com/2f6F8Hc
Dave Birkett, Detroit Free Press Published 6:53 p.m. ET Oct. 23, 2016 | Updated 8:57 p.m. ET Oct. 23, 2016
Preston Smith of the Washington Redskins attempts to stop Zach Zenner of the Detroit Lions during the first half at Ford Field on Oct. 23, 2016 in Detroit.(Photo: Gregory Shamus, Getty Images)
Free Press sports writer Dave Birkett grades the Detroit Lions after their 20-17 victory over the Washington Redskins on Sunday afternoon at Ford Field.
Matthew Stafford has led 24 game-winning drives in the fourth quarter or overtime of his 100 career starts, a remarkable number. He was calm under pressure Sunday, throwing and running for big gains on the final drive. Stafford had his struggles early. He nearly threw an interception on the goal line, bounced another pass off a defenders back and was fortunate to have his own fumble bounce in his lap. But he’s playing the best football of his career. Grade: A-minus
Oops! Skip Bayless congratulates Redskins win - before Lions' rally
Seidel: Led by Mr. Comeback, Lions do it again
Playing without their top two running backs – three if you count Ameer Abdullah – the Lions gained 62 yards rushing on 17 carries from running backs Justin Forsett and Zach Zenner. Zenner scored on a 1-yard run, but had trouble finding open lanes. Forsett averaged a more effective 4.1 yards per carry in limited snaps and caught two passes. Grade: C
Wide receivers/tight ends
Leading receiver Marvin Jones (four catches, 94 yards) struggled against Josh Norman early, but he beat Norman for a 52-yard pass early in the second half and had three more catches with Norman out of the game. Golden Tate (six catches, 93 yards) was the Lions’ most consistently productive receiver for the second straight week, and Anquan Boldin and Andre Roberts both came up with clutch catches on the winning drive. Roberts did drop a sure first-down pass early in the game. Grade: B-plus
Lions 20, Redskins 17
Lions receiver Marvin Jones Jr. makes a 52-yard catch against the Washington Redskins' Josh Norman during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions quarterback Matthew Stafford runs against the Washington Redskins during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions receiver Anquan Boldin scores the winning touchdown against the Washington Redskins in the fourth quarter Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions receiver Anquan Boldin, right, celebrates with teammates after scoring the winning touchdown against the Washington Redskins late in the fourth quarter Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions' Zach Zenner scores a touchdown against the Washington Redskins during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions coach Jim Caldwell watches action against the Washington Redskins on Oct. 23, 2016 at Ford Field. Kirthmon F. Dozier, DFP
Detroit Lions' Khyri Thornton causes the Washington Redskins' Matt Jones to fumble during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions defensive end Ezekiel 'Ziggy' Ansah tries to tackle the Washington Redskins' Chris Thompson during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions cornerback Darius Slay watches action against the Washington Redskins on Sunday, Oct. 23, 2016 at Ford Field. Slay suffered a hamstring injury in the first half. Kirthmon F. Dozier, DFP
Detroit Lions Kyle Van Noy celebrates a fumble recovery by teammate Kerry Hyder during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions LB Antwione Williams celebrates a fumble recovery by teammate Kerry Hyder during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions WR Golden Tate runs by the Washington Redskins' Bashaud Breeland for a first down during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions receiver Golden Tate is tackled by the Washington Redskins' Donte Whitner during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Washington Redskins QB Kirk Cousins hands off during the second half against the Detroit Lions on Sunday, Oct. 23, 2016 at Ford Field. Kirthmon F. Dozier, DFP
Detroit Lions head coach Jim Caldwell watches the action against the Washington Redskins Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions RB Zach Zenner runs against the Washington Redskins during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions' Anthony Zettel (69) tries to tackle the Washington Redskins Matt Jones' during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions defenders try to block a field goal by the Washington Redskins' Dustin Hopkins during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions WR Golden Tate goes for the ball against the Washington Redskins 'Will Blackmon during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions defensive tackle Tyrunn Walker rushes towards the Washington Redskins' Kirk Cousins during the second half Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions quarterback Matthew Stafford runs past the Washington Redskins' Ryan Kerrigan for a first down during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions receiver Golden Tate is defended by the Washington Redskins' Greg Toler during the second half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Washington Redskins QB Kirk Cousins runs for a touchdown during the second half against the Detroit Lions Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Washington Redskins QB Kirk Cousins celebrates his 19-yard go-ahead touchdown run with tight end Vernon Davis late in the fourth quarter against the Detroit Lions on Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions cheerleaders perform during the game against the Washington Redskins Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions quarterback Matthew Stafford (9) and fullback Michael Burton (46) take the field for action against the Washington Redskins on Oct. 23, 2016 at Ford Field. Kirthmon F. Dozier, DFP
Lions left tackle Taylor Decker (68) takes the field for action against the Washington Redskins on Oct. 23, 2016 at Ford Field. Kirthmon F. Dozier, DFP
Lions QB Matthew Stafford passes against the Washington Redskins during the first half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions linebacker Tahir Whitehead (59) and safety Tavon Wilson tackle the Washington Redskins' Matt Jones during the first half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Washington Redskins quarterback Kirk Cousins. Age: 29. 2016 stats: 16 starts, 97.2 QB rating, 67% completion, 25 TDs, 12 INTs, 96 rushing yards, 4 rushing TDs. Kirthmon F. Dozier, DFP
Detroit Lions Zach Zenner runs against the Washington Redskins during first half action Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions fans watch action against the Washington Redskins Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions defensive end Ziggy Ansah rushes against the Washington Redskins in the first half Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Washington Redskins quarterback Kirk Cousins tries to evade Detroit Lions defensive lineman Kerry Hyder on Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions quarterback Matthew Stafford signals against the Redskins in the first half Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions QB Matthew Stafford calls a play during the win Sunday at Ford Field. Kirthmon F. Dozier, DFP
Washington Redskins QB Kirk Cousins passes during the first half against the Detroit Lions on Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions head coach Jim Caldwell watches action against the Washington Redskins Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions cheerleaders perform during the game against the Washington Redskins on Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions Golden Tate is tackled by the Washington Redskins Donte Whitner during second half action Sunday, October 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions defensive lineman Armonty Bryant sacks Washington Redskins QB Kirk Cousins during the first half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Detroit Lions defensive lineman Khyri Thornton tackles Washington Redskins RB Robert Kelly during the first half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions receiver Golden Tate runs by the Washington Redskins' Will Blackmon during the first half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
Lions defensive lineman Armonty Bryant, center, celebrates with teammates Kerry Hyder, left, and Devin Taylor after sacking the Washington Redskins' Kirk Cousins (on the ground) during the first half Sunday, Oct. 23, 2016 at Ford Field in Detroit. Kirthmon F. Dozier, DFP
It was a mixed day up front for the Lions offensive line. Larry Warford had a nice pulling block to spring Forsett for a 9-yard gain on second play of second quarter, but he also got bulldozed by Chris Baker on two straight snaps in the fourth quarter, the second led to one of three Washington sacks. Rookie Graham Glasgow had a good game in his second career start at left guard, and Travis Swanson made a nice second-level block on another 9-yard Forsett run. But Riley Reiff got tossed aside by Ryan Kerrigan for a sack and was overpowered on a third-and-1 run that went for lost yardage in second quarter. Grade: C-plus
The Lions had eight hits on Washington quarterback Kirk Cousins and kept him under pressure most of the day with an array of blitzes and stunts. Armonty Bryant had a clean-up sack in the first half after Kerry Hyder disrupted the initial pocket, and Hyder had a good rush from a defensive tackle spot on the next play. Hyder appeared to misread Cousins’ 19-yard touchdown run and Stefan Charles had a costly illegal hands-to-the-face penalty. Khyri Thornton deserves an assist on Cousins’ fumble as his rush pushed center Spencer Long back and onto Cousin’s foot, forcing Cousins to stumble and lose the ball. Grade: B-plus
Lions fans tailgate
Denny Arney (left), of Detroit, enjoys his hot tub with friends while tailgating before the Lions' game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
Ron "Crackman" Crachiola, poses for a photo while tailgating at Eastern Market before the Lions' game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
Ron "Crackman" Crachiola, and Donnie "Yooperman" Stefanski, pose for a photo while tailgating at Eastern Market before the Lions' game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
Lions fans start to arrive at Eastern Market to tailgate before the Lions game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
J.P. Krajewski, 46, of Utica, tosses a football with friends while tailgating at Eastern Market before the Lions' game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
Parking lots at Eastern Market fill up with people tailgating before the Lions' game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
Lions fan Bill North, of Detroit, helps paint his friend's RV while tailgating at Eastern Market before the Lions' game against the Washington Redskins on Sunday, Oct. 23, 2016. Nate Smallwood, DFP
Washington racked up 134 yards rushing on 29 carries, with Chris Thompson (not Matt Jones) doing most of the work. Tahir Whitehead had a game-high 12 tackles and fought off a blocker to stop Thompson short of a first down on a 3-yard run late in the second quarter. Kyle Van Noy was slow getting outside the tackle on Thompson’s 16-yard run in the third quarter. Linebacker/defensive end Brandon Copeland stripped Jones on his first-quarter fumble. Grade: B
Lions stock watch: Three who helped, hurt case in win
Cousins completed 30-for-39 passes for 301 yards, though he rarely challenged the Lions’ secondary downfield. Darius Slay broke up a pass to Jamison Crowder that he nearly intercepted before he left with a hamstring injury. Slay also was beat for a 19-yard catch by Pierre Garcon, when he slipped on Garcon’s juke move. Tavon Wilson recovered Jones’ fumble in the end zone one play after he got beat for a 22-yard gain by Vernon Davis. Wilson took a smart defensive holding penalty when Ryan Grant had him beat for a big play. And Rafael Bush had six tackles and a sack as the Lions’ third safety. Grade: B-minus
Matt Prater missed his second field goal of the year wide left from 49 yards, though a bad snap from Don Muhlbach appeared to throw his mechanics off on the play. Prater did make two kicks later in the game. Sam Martin was his usual trustworthy self, netting 45.7 yards on his three punts. Neither team had a kickoff return as both teams played for the touchback. Grade: B-minus
The Lions swept their three-game homestand to get back above .500, and just like head coach Jim Caldwell was partly to blame for an early-season losing streak he deserves credit for the resilience his team has shown lately. Defensively, the Lions did enough to manufacture a pass rush with an array of games up front and they capitalized on some timely bounces for turnovers. Offensive coordinator Jim Bob Cooter found more creative ways to get the ball to Tate, though the offense was less efficient than usual. Grade: A-minus
Contact Dave Birkett: dbirkett@freepress.com. Follow him on Twitter @davebirkett.
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Juwan Howard's son commits to Michigan basketball
Michigan has a star LB in the making, but must find more help
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Display Full Menu
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Over the last 40 years, the Jerusalem College of Technology’s (JCT) reputation and approach in integrating Torah study with high level academics has earned it a unique position among engineering schools worldwide. Offering leading science and engineering classes alongside Torah and advanced Judaic Studies, Lev Campus enables its students, upon graduation, to enter industry and contribute to science and technology in Israel with high ethical Jewish standards.
With this in mind, an impressive Beit Midrash was built alongside the academic buildings, and all students combine their Torah studies in the framework of a Yeshiva Gevoha with academic studies toward a Bachelor’s Degree in Engineering and Management. Lev Campus’ comprehensive Judaic Studies curriculum includes Talmud, Commentaries and Response, Jewish Philosophy and Business Ethics, while its secular curriculum offers the highest level of technology classes possible, giving students the knowledge to ultimately create advancements in Israel’s high tech industry.
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Forums › Online streaming services › Netflix missing from Wii
# 182561 21-Oct-2015 10:48
I'm trying to set up Netflix on a Wii and I'm getting stuck. The instructions say to add the Netflix channel but it doesn't appear in the list (ie. I'm getting stuck at step 4). I've left it for a week and tried again, in case there was a temporary issue, but it still doesn't show up in the list.
Can anyone give any tips? Has this process worked for anyone else?
# 1410396 21-Oct-2015 10:52
If you're talking about the original Wii, then I'm not surprised. Does the app store still work for that?
Having said that, it is still working for us at home. Are you using a DNS service to locate yourself in the US? Might be a good idea in case the Netflix app availability has not been updated for NZ.
Huawei Mate 7, on 2degrees
I believe it's an original Wii (it's not a U) and the store seems to work; I tried installing the "Internet Channel" in case it was a prerequisite and that worked as expected (but didn't make Netflix show up).
I'm not using a DNS service as I'm just trying to access Netflix NZ. The linked page says that the app is available in NZ and I also saw a Nintendo press release advertising its AU/NZ availability.
Killerkiwi2005
When I installed it (before nz netflix) i set the region to GB first
OK, that's something to try, at least :)
It might be a few days before I can post back with success or failure; it's my parents' Wii and I don't expect to be around there again until the weekend.
baileym1
Can confirm you need to set the region to GB first - then it works fine - quality isn't that flash though
Bizarre (considering that Netflix's site says that it's available in NZ) but thanks for letting me know.
I didn't expect the quality to be great, but it's the only device the parents have that has a Netflix app.
Behodar: Bizarre (considering that Netflix's site says that it's available in NZ) but thanks for letting me know.
Get them a chromecast, my parents have one and love it
Plus it gives them options ie lightbox, fanpass, google play movies etc
pedrogarcia
I find Netflix on the Wii U a somewhat cumbersome and unpleasant experience. Although being able to switch between TV and Gamepad is novel.
Oops, I completely forgot to reply to this. Setting the country to UK worked (and I was able to change it back to NZ after downloading). Thanks for the help! :)
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Sega Ages Shinobi first details, screenshots
Due out "soon" via the Nintendo eShop in Japan.
Sal RomanoOct 16, 2019 at 11:00 PM EDT0 Comment2
Sega has opened the official website for its Sega Ages release of Shinobi, which is due out for Switch “soon” via the Nintendo eShop in Japan for 999 yen.
Here are the new features outlined on the official website:
■ Additional Options Unique to Sega Ages
The Sega Ages version of Shinobi also includes the western version of the game. Additionally, difficulty settings and the ability to select your favorite stages have also been implemented, allowing you to practice the stages you have trouble with.
Furthermore, for players aiming for the “Shinobi Bonus” obtained by clearing the stage without using any shuriken, the “Melee Attack” button can also be added. “HD Rumble” is also supported.
“Screen Mode” has also been updated. In addition to the familiar “Fit” and “Vintage” options, a new “Cabinet” option has been implemented. This option even reproduces the noise of the arcade, so you can get a sense of what playing at a game center feels like.
■ Modes
Arcade Mode
A mode that reproduces the original arcade version. Depending on the settings, you can also use the Sega Ages-original feature “Rewind” to practice. (This is similar to the “Helper” feature in Sega Ages Gain Ground.)
Ages Mode
This is a special mode for players who find Arcade Mode too difficult to be able to enjoy the game. In this mode, you control white-robed Joe Musashi from The Revenge of Shinobi. White-robed Musashi is in a constant powered-up state with high attack power, and it takes two hits to kill him instead of one. The Rewind feature can also be used in this mode.
■ Other
Other familiar Sega Ages features such as “Leaderboards” to compete for the high score against other players online in the arcade version, and a “Replay” feature have also been implemented.
View a new set of screenshots at the gallery.
Sega Ages
Sega Ages Shinobi
Exploration puzzle game Manifold Garden launches October 18 for PC and Apple Arcade, later for PS4 Previous post
Ultra Age delayed to 2020, EGX 2019 trailer Next post
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Home News Pfizer’s the NCATS’ Meow in New Collaboration
Pfizer’s the NCATS’ Meow in New Collaboration
Pfizer’s Centers for Therapeutic Innovation (CTI) will partner with NIH’s National Center for Advancing Translational Sciences (NCATS) to conduct collaborative research programs intended to translate basic research into clinical applications. The value of the agreement was not disclosed.
NIH has become the first U.S. government agency to enter into a collaborative agreement to conduct research through CTI, an R&D network of 25 academic institutions and four patient foundations created to translate basic research into clinical candidates.
The partnership isn’t the first between Pfizer and NCATS. Pfizer in 2012 was among the first big pharma partners in NCATS’ Discovering New Therapeutic Uses for Existing Molecules program. The companies made dozens of compounds available to academic researchers for potential repurposing for new therapeutic uses. Last year two Pfizer compounds were among the seven for which nine academic research groups were awarded a total $12.7 million by NCATS toward repurposing efforts.
In the new partnership, CTI and NCATS are expected to enter into several research collaborations designed to combine NIH intramural investigators’ biological knowledge with Pfizer’s preclinical and clinical development expertise, the company said yesterday.
According to Pfizer, all NIH intramural researchers will have the opportunity to apply for CTI partnership opportunities during the current federal fiscal year, which began October 1. The researchers that are selected will be given access to Pfizer’s proprietary preclinical drug discovery tools and technologies, as well as pre-clinical study and regulatory expertise.
Selected researchers may be provided with support to generate data for Investigational NDAs to the FDA—enabling potential treatments developed through the collaboration to advance to human clinical trials.
A joint Pfizer-NIH steering committee will govern the partnership and make decisions about each research program, Pfizer added.
“The collaboration with CTI will expand NCATS’ capabilities to serve as a catalyst for the transformation of translational research and thus potentially bring more treatments to more patients more efficiently,” NCATS Director Christopher P. Austin, M.D., said in a statement.
Launched in 2010 with the University of California, San Francisco as its first partner, CTI works to team up Pfizer scientists with academic investigators at four research locations—Boston, New York, San Diego, and San Francisco.
According to CTI’s website, Pfizer allows the academic researcher partners to tap into the company’s compound libraries, proprietary screening methods, antibody development technologies, and other resources and support from company professionals with expertise in drug development and protein sciences.
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(Photo by Serena Taylor/Newcastle United via Getty Images)
Carroll Newcastle return reportedly pushed back further
After confirmation that Andy Caroll is not fit enough to be included in the Newcastle squad for the Liverpool game this weekend, his comeback has now been delayed further.
The Northern Echo report that Carroll took part in training alongside his peers yesterday, but quote Bruce as saying it is likely to be next month that we see him donning the black and white shirt again.
Steve Bruce is quoted to have said: “Andy we’ll have to still be patient. However, for the first time today, he joined in with the group to a degree,” said Bruce, aware of how an ankle injury has hampered him for a sustained period now.
“He only took part in half of the session, non-contact, but it’s good to see him out kicking a ball again.
“I always knew that it would be towards the end of this month and halfway through the next month really where we are with Andy.”
It is strange to hear Bruce say he “always knew” it would be the end of September, or mid-October for his deadline day striker to make an appearance, with him having previously told the Shields Gazette “it still might be Liverpool” less than two weeks ago.
Everyone knew it would take a bit of time to get the Gateshead forward back to full readiness, but now we are looking at mid-October, and questions need to be asked about the benefits of signing Carroll to bolster the squad.
There were other free-agents available, like Danny Welbeck and Daniel Sturridge, who may both have suffered similar injury issues to Carroll, but noth would have been competing for a place in the side by now.
Football results are based on quality not sentiment
I understand the sentimental reasons for bringing Carroll home, or even the hope that the move may allow Bruce to win a few fans over, but my concern is Newcastle United, not emotional reunions.
The plain fact is that we are now into September, and with Dwight Gayle still not fit, and Carroll seemingly still weeks away, we have limited competition and depth in the forward positions.
And if Joelinton was to pick up an injury that would keep him out for multiple games, we would have Yoshinori Muto as our only viable replacement, and he has not shown he is up to leading the line consistently in the Premier League.
As always seems to be the case with Newcastle under Mike Ashley’s ownership, we are still just one injury away from disaster.
Tags: andy carroll, magpies, NUFC, steve bruce, Toon
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Steve Bruce confirms Matt Ritchie could make Newcastle comeback against Rochdale
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GETAnalysis.ca
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The Great Republican Heroes versus – The Loser (#135)
Ashok Dhillon
tillerson
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geopolitical
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US, Mexico, Canada – Make the Trade Deal, Finally (#146)
Almost a year after being ‘agreed to’, one of the World’s largest trading blocks, Canada, the United States and Mexico, have finally agreed to a trade deal, called the US - Mexico - Canada Agreement ('USMCA') after considerable revisions. In spite of Donald Trump hailing it as far superior to the old NAFTA ('North American Free Trade Agreement'), a far more precise name for those that prefer such things, USMCA is known in the more informed circles as NAFTA 2.1, the unrevised version being NAFTA
America’s Continuing Decent – Reverse MAGA (#145)
Watching the Impeachment Hearings over the past few days, and listening to the Republicans determinedly deny the facts underlying every witness’s testimony, regardless of how ridiculous the denials, the Biblical verse came to mind, ‘For what shall it profit a man, if he should gain the whole World, but lose his own soul’ (Mark 8:36 King James Version). It is abundantly clear that neither Trump nor the Republicans put much stock in religious teachings, regardless of their sham public displays of
Canada’s Don Cherry – And The Injustice of Ignorance (#144)
Don Cherry is an icon in Canada, albeit a deeply flawed one. As a former National Hockey League (NHL) Coach, commentator and TV personality, he is famous for his bombastic commentary, his equally bombastic over-the-top dressing style, and more importantly, his preference for a no-nonsense, take-no-prisoners type of hockey play, where few hockey teams and hockey playing countries escape his dismissal as too namby-pamby by his standards of tough real hockey-play. Don Cherry is venerated in this
Fight For the Soul of America – Facts vs Fiction (#143)
Under Trump, America has changed and arguably for the worse. It no longer represents leadership in the World for liberal progressive values that were written into its much admired ‘Constitution’ by its ‘Founders’; values of freedom, democracy, equality, truthfulness, institutionalized justice and fairness, sanctuary for all who sought its shores from political tyranny, economic servitude and hardship. For decades after WWII, America was the ‘Shining Light on the Hill’ for humanity, who for the
Canada’s Election – Country Stays Liberal, Just Barely (#142)
The Canadian Liberal Party led by the incumbent Prime Minister, Justin Trudeau, managed to hold on to power, albeit just barely. Hurt by a number of missteps, broken promises, an air of hubris, and some serious ethical and social scandals in his first term, Justin Trudeau lost his sweeping majority from the last election, but won a Minority Government nevertheless. Canadians, though disappointed by Trudeau Government’s first term, decided to back him anyway, and stay ‘Liberal and Progressive’
Ginger Baker - In Time (#141)
It was 1969, my senior graduating year, when I first heard the music of the English blues-rock-band, ‘Cream’, founded by the drummer Ginger Baker in 1966, with bass player Jack Bruce, and the lead guitarist Eric Clapton. The trio, Cream, lasted just two years but in those two years they ‘changed the World of Rock’ and became the first ever ‘super band’. Ginger Baker went-on to be known as the most innovative, influential drummer in rock music, who would influence generations of ‘rock drummers’;
Trump Provides the Crimes – The Republicans Deny & Deny (#140)
In repeated extraordinary displays of brazen denials, the Republicans have turned the US government into a crime syndicate, whose chosen Boss is obviously Trump, but whose Republican Senators and Congressmen Lawmaker’s secret oath to protect the 'Boss' with straight-faced lies, and repeated stubborn denials of reality, would turn the most hardened Mafia Boss green with envy. Republicans now belong to Trump, and except for a very few, they dare not cross him in fear for the political lives, as
A Bad Week for the Two Rogues - Trump/Boris (#139)
Two former bastions of democracy and the rule-of-law, the United States (US) and the United Kingdom (UK), are currently being led by two rogues who are known to lie consistently to achieve their political and personal agendas, and who flaunt the rule-of-law in their pursuit of political goals and the resultant political power that follows. Well, they both had a bad week, where their actions resulted in a serious blowbacks they obviously hadn’t anticipated in their calculations. In the US, as a
Trudeau’s Love of Blackface – Leaves Canada Red-faced (#138)
On their worst day, Canada and its Prime Minister, Justin Trudeau, are more socially, racially and religiously accepting, and tolerant, than most countries and their leaders in the world, currently. And if truth be told, most white and non-white, naturalized Canadian citizens, if asked, would readily admit that the countries (and their leadership) they originally came from, even if generations ago, are still frighteningly racist, bigoted and intolerant when compared to Canada and Trudeau (and
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Venture North!
Exploring Northern Ireland and Dublin
* Vacation package is round-trip, per person, based on 2 travelers. Package includes airfare & airport taxes, accommodations, car rental, tours and breakfast daily. Additional baggage charges may apply.
Home Destinations Europe Multi-Country Exploring Northern Ireland and Dublin
Visit Dublin, Titanic Belfast Experience & Derry
This 7-, 8- or 9-night Ireland vacation package takes you to Belfast, Derry, Enniskillen and the capital city of Dublin!
Round-trip economy class airfare to Dublin (DUB)
Manual rental car for duration
2 nights in Belfast at the Stormont Hotel or similar
Admission to the Titanic Belfast Experience
Admission to Giant's Causeway
2 nights in Derry at the Beech Hill Country House Hotel or Everglades Hotel
1 night in Enniskillen at the Lough Erne Resort or Galgorm Resort & Spa
2 nights in Dublin at the Ashling Hotel or similar
Admission to Christ Church Cathedral in Dublin
You'll travel to four different counties in Ireland, discovering the many highlights on offer along the way.
Having a rental car allows you plan your itinerary, and enjoy the scenic views as you travel in comfort, at your pace.
Admission to the world's largest Titanic visitor center is included; an experience that cannot missed!
Stay at 4- and 5-star hotels all along the way, including two city center hotels and an exclusive 5-star resort.
Brave travelers should cross the famous Carrick-a-Rede Rope Bridge in County Antrim. Just don't look down!
Start your Ireland vacation package when you land in Dublin and pick up your rental car. Your first two nights will be in Belfast, about a two-hour drive north from Dublin Airport. Enjoy admission to the Titanic Belfast Experience- located right in the heart of Belfast, beside the historic site of this world-famous ship's construction. Housed in an iconic six-floor building, this state-of-the-art visitor experience features nine interpretive and interactive galleries that explore the sights, sounds, smells and stories of Titanic, as well as the City and people which made her. Fly through the shipyard, travel to the depths of the ocean and uncover the true legend of Titanic, in the city where it all began.
From Belfast, travel north to the magnificent Antrim coast where you will visit Giant’s Causeway, a UNESCO World Heritage site, formed from a volcanic eruption almost 60 million years ago. Continue to Derry where you'll find a wealth of history paired with incredible scenery. Explore the Free Derry Corner and learn the stories that go along with this historical landmark. Visit St. Columb's Cathedral, the Millenium Forum and the Grianan of Aileach.
Enjoy a night in Enniskillen where you will enjoy small-town vibes, a unique character and an abundance of activities to do. You'll find charming stores and local restaurants to visit. Take a trip to the Crom Castle, Belleek Pottery or the Marble Arch Caves.
Complete your travels to Ireland in Dublin, the vibrant capital city of Ireland, where you have included admission to the stunning Christ Church Cathedral. Admire the architecture of Trinity College, savor a pint of Guinness at the Storehouse and don't forget to do some souvenir shopping along Grafton Street.
7 8 9 Nights
January, 2020 - sold out February, 2020 March, 2020 April, 2020 May, 2020 June, 2020 July, 2020 August, 2020 September, 2020 - coming soon October, 2020 - coming soon November, 2020 - coming soon December, 2020 - coming soon
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30 City Nicknames from Around the World
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Package ID: PK-GC4P-SH-ENI-DUBAIR
Day 1. Welcome to Dublin!
Pick up your rental car at the airport and take off to your first accommodation in Belfast.You'll be here for two nights so you can enjoy a traditional Irish dinner at the hotel one night and venture out to explore the city of Belfast the other.
A Tip For Your Trip: Keep in mind that you will be driving on the opposite side of the road so proceed with caution.
You'll be in one of these hotels, depending on availability
The Stormont
1 of 3 hotels
Overlooking the grounds of Stormont Castle, in the leafy suburbs of Belfast, this luxurious 4-star hotel has a fitness center and a bistro restaurant. There is free parking and a 24-hour front desk. The modern bedrooms at The Stormont Hotel each have a work desk, a cozy sitting area and a TV with satellite channels. The bathrooms feature a shower and a hairdryer. La Scala Bistro serves a modern European menu in contemporary surroundings. Hearty breakfasts are available daily, and the stylish cocktail bar offers a range of creative drinks and snacks.
Europa Hotel-Belfast
Situated right in the heart of Belfast City, the Europa Hotel is just three miles from George Best Belfast City Airport and 16 miles from Belfast International Airport.
The elegant decor, contemporary bistro, bustling bar and relaxing piano bar lounge make the four star Europa Hotel the hotel of choice for business and leisure guests visiting Belfast. Due to its prime location, the Europa Hotel is a short distance from many of Belfast’s top visitor attractions including the Ulster Museum, Grand Opera House, City Hall, Titanic Belfast, the Waterfront Hall and the Odyssey Arena. The Europa Hotel has an international reputation for hosting prestigious events and looking after many of the celebrities and VIPs who visit Belfast.
At the Europa every guest is a VIP and will experience the finest in Irish Hospitality and highest level of customer service.
Culloden Estate & Spa
Originally built as an official Palace for the Bishops of Down, the Culloden stands in 12 acres of beautiful secluded gardens and woodland. Palatial surroundings, fine antiques and the highest levels of personal service combine to give the Culloden a unique air of elegance. Bright, spacious and individually decorated, each of the 105 guestrooms offers the last word in luxury. The award-winning dining options range from traditional afternoon tea to bistro-style fare to gourmet chic fine dining - all featuring the finest locally sourced products. The Culloden's premier fitness center is completely state-of-the-art, and the spa is an oasis of tranquility where the ancient rituals of many cultures are fused with modern holistic remedies.
Day 2. Belfast
Take advantage of your included admission to the Titanic Belfast experience today. This is a self-guided tour so you can explore at your own pace; take part in the 3D experience where you can tour the ship!
Experience the tumultuous history of the ill-fated Titanic in this interactive exhibit, located right beside the site of this world-famous ship's construction!
Housed in an iconic six-floor building, this state-of-the-art visitor experience features nine interpretive and interactive galleries that explore the sights, sounds, smells and stories of Titanic, as well as the City and people which made her. Fly through the shipyard, travel to the depths of the ocean and uncover the true legend of Titanic, in the city where it all began.
Day 3. Belfast - Derry
Use your included admission to Giant's Causeway this morning. This natural wonder will take your breath away!
Head to Derry for your next two nights. The drive will take you just under two hours. Enjoy the rest of the day in Derry at leisure. Take a walk across Peace Bridge and enjoy views of the River Foyle or shop the homemade wares at the popular Craft Village!
Beech Hill Country House
Londonderry, Northern Ireland
Beech Hill Country House is situated just outside the historic walled city of Londonderry, perfectly placed for visiting the city and exploring the surrounding countryside. The hotel aims to combine all the best traditions of a country house hotel; offering elegance, charm and genuine warmth and hospitality. The hotel is famed for its tranquil atmosphere, 4-star accommodation and superb dining at its Ardmore Restaurant.
Everglades Hotel
The Everglades Hotel in Derry is a stylish choice for visitors to Northern Ireland’s fascinating second city. Overlooking the River Foyle with views across to the hills of Donegal, this 4-star destination provides a bright and comfortable welcome to Derry, the lively heritage and cultural center of the North West. Located only a five minute drive from the bustling, historic and dynamic City Centre, the Everglades is an ideally located for exploring and experiencing everything this City has to offer.
The Giant’s Causeway, an iconic UNESCO World Heritage Site located along the stunning North Antrim Coast, is a geological wonder composed of over 40,000 interlocking basalt columns resulting from intense volcanic activity which took place 60 million years ago, and is home to a wealth of history, legend, fauna and flora.
Flanked by the wild North Atlantic Ocean and a landscape of dramatic cliffs, for centuries the Giant’s Causeway has inspired artists, stirred scientific debate and captured the imagination of all who see it.
A state-of-the-art Visitor Center unlocks the mystery and stories of giants associated with this amazing landscape, and offers a glimpse into the wonder that is the Giant's Causeway. Visitors can explore waymarked trails and enjoy spectacular rugged coastal scenery accompanied by an available innovative audio-guide.
Day 4. Derry
Derry is a city bursting with history! Be sure to explore the Derry City Walls and the Bloody Sunday Memorial.
Visit the neo-gothic Guildhall and explore the extensive visitor center, or explore the St. Columb's Cathedral, whose silhouette dominates the city skyline.
Guildhall • Derry, Northern Ireland
Day 5. Derry - Enniskillen
Next, take the drive to in Enniskillen where you will stay for one night. This drive will take you a little under two hours from Derry.
You will be situated between Castle Hume Lough and Lower Lough Erne.
Lough Erne Resort
Enniskillen, Northern Ireland
Located in Enniskillen, the gateway to North West Ireland, the Lough Erne Resort is luxurious 5-star resort on a stunning 600-acre peninsula. Enjoy spectacular views of the Fermanagh Lakelands and The Faldo Course, 120 elegant rooms, several dining options, a Thai spa and a 36-hole golf course.
From this location, you'll be a within a 90 minute drive of Belfast International Airport (Aldergrove); Belfast City Airport (George Best); Dublin International Airport, Sligo and City of Derry Airport as well Belfast and Dublin Ports. This luxurious resort has been selected as host of the 2017 Irish Open, a major sporting celebration and something that will be of equally significant benefit in showcasing the beauty, the facilities and the hospitality of this award-winning hotel and this wonderful part of the world.
Galgorm Resort & Spa
Ballymena, Ireland
Galgorm is Northern Ireland’s premier luxury hotel and spa; situated only 30 minutes from Belfast, and set within 163 acres of lush parkland with the spectacular River Maine flowing through the estate, it enjoys a truly unique setting.
The resort is home to 122 luxurious guestrooms, and the unique, award-wining Thermal Village & Spa is the first of its kind in Ireland. Its idyllic woodland, riverside location inspired a space where indoors meets outdoors, and guests will enjoy the tranquility of nature and experience pure relaxation with an extensive selection of riverside hot tubs, indoor and outdoor heated pools, steam rooms and saunas.
The Resort also boasts a selection of restaurants & bars, including the 3 AA Rosette award-winning River Room, the popular Gillies Grill with scenic views of the resort’s stables, and Fratelli Ristorante & Pizzeria, offering rustic Italian charm with a contemporary edge.
Day 6. Enniskillen - Dublin
When you leave Enniskillen you are going to take the drive to the capital city of Dublin! The drive is about 2 hours but when you arrive you will not be disappointed.
You'll know when you've arrived at the Ashling Hotel in Dublin City - a genuinely warm welcome, spacious bedrooms, strategic location and friendly, professional staff - all combine to offer you a unique 4-star experience.
The hotel is located right beside Heuston Station, the National Museum of Ireland, Guinness Storehouse, Phoenix Park and Dublin Zoo. You can travel by tram on the Luas red line to Dublin city center, only minutes away. The Ashling Hotel is located on Parkgate Street, Dublin 8, near Smithfield.
The Alex
The Alex was the third of O'Callaghan Hotel Group's Dublin hotels on this corner of Merrion Square. This thoughtfully designed contemporary hotel welcomes you into its spacious lobby where the team will give you a great welcome, excellent service and will be more than happy to show you everything on our doorstep.
The Alex is close to Dublin city's Georgian squares where business and culture meet as neighbors. Grafton Street, the flagship location for many shops, is just a minutes' walk from the hotel. For the adventurous visitor, there is a Dublin Bike station on Merrion Square and you can join the other enthusiastic cyclists in Dublin traveling from one point of interest to another.
The Davenport
Spend your days immersed in the beauty and charm of Dublin, and your nights sleeping soundly in one of 114 guestrooms at The Davenport. Each room fuses sophisticated Irish elegance with forward-thinking design and attention to detail. At the on-site restaurant Lanyon's Restaurant, enjoy Old World cuisine in an opulent setting. The Presidents Bar is another lovely venue in which to relax and unwind.
The Davenport is located on the corner of Merrion Square. Trinity College, Dublin’s Convention Centre, Government Buildings, and the Aviva Stadium are all located within walking distance of the hotel. It is easily accessible from all forms of transport and is just 20 minutes from Dublin International Airport. Life not only begins in this part of Dublin but a stroll around the area ensures you see Dubliners in all their guises, business, politics, study, socializing and, of course, shopping.
The Davenport dates back to the early 17th century. The building opened as a 4-star hotel in 1993 and offers both a traditional and modern experience in Dublin with a superb city center location.
Day 7. Dublin
While in Dublin, there are a few must-see sites including Trinity College, home of the famous Book of Kells, Temple Bar, and of course, the Guinness Factory. Dublin has a vibrant atmosphere, so wander the cobblestone streets and discover all it has to offer! Don't forget to use your included admission to Christ Church Cathedral.
Christ Church Cathedral (self-guided tour)
Enjoy a self-guided tour of Christ Church Cathedral, including admission to the Crypt and Exhibition. The Cathedral (founded c.1028) is the spiritual heart of the city, and one of the top visitor attractions in Dublin!
In addition to your guided tour, you can explore the medieval crypt and crypt houses as well as enjoy an audio presentation, the Treasury.
Christ Church Cathedral was a major pilgrimage site in the medieval period, with an important collection of relics ranging from a miraculous speaking cross to a piece from the crib of Jesus. Today, it is still possible to see one of these relics, the heart of Laurence O’Toole, patron saint of Dublin.
Day 8. Depart Dublin
Today you will head back to America. ˇYou'll have a short drive to Dublin Airport so you'll be able to relax and not feel as rushed as you prepare to depart Ireland.
Modern 4-star hotel close to the airport and central Belfast
Georgian elegance meets country living
Lakeside resort with stately rooms and chic dining options
City-center hotel in bustling Dublin, Ireland
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Vitamin C may have a therapeutic role in the treatment of non-Hodgkin lymphoma, including mantle cell. - GreenMedInfo Summary
Phase II study of arsenic trioxide and ascorbic acid for relapsed or refractory lymphoid malignancies: a Wisconsin Oncology Network study.
Hematol Oncol. 2009 Mar;27(1):11-6. PMID: 18668698
J E Chang, P M Voorhees, J M Kolesar, H G Ahuja, F A Sanchez, G A Rodriguez, K Kim, J Werndli, H H Bailey, B S Kahl
Arsenic trioxide (As(2)O(3)) has established clinical activity in acute promyelocytic leukaemia and has pre-clinical data suggesting activity in lymphoid malignancies. Cell death from As(2)O(3) may be the result of oxidative stress. Agents which deplete intracellular glutathione, such as ascorbic acid (AA), may potentiate arsenic-mediated apoptosis. This multi-institution phase II study investigated a novel dosing schedule of As(2)O(3) and AA in patients with relapsed or refractory lymphoid malignancies. Patients received As(2)O(3) 0.25 mg/kg iv and AA 1000 mg iv for five consecutive days during the first week of each cycle followed by twice weekly infusions during weeks 2-6. Cycles were repeated every 8 weeks. The primary end point was objective response. In a subset of patients, sequential levels of intracellular glutathione and measures of Bcl-2 and Bax gene expression were evaluated in peripheral blood mononuclear cells during treatment. Seventeen patients were enrolled between March 2002 and February 2004. The median age was 71, and the majority of enrolled patients had non-Hodgkin's lymphoma (12/17). Sixteen patients were evaluable, and one patient with mantle cell lymphoma achieved an unconfirmed complete response after five cycles of therapy for an overall response rate of 6%. The trial, which had been designed as a two-stage study, was closed after the first stage analysis due to lack of activity. Haematologic toxicities were the most commonly reported events in this heavily pre-treated population, and comprised the majority of grade 3 and 4 toxicities. Intracellular depletion of glutathione was not consistently observed during treatment. As(2)O(3) and AA in this novel dosing strategy was generally well tolerated but had limited activity in patients with relapsed and refractory lymphoid malignancies.
Substances : Vitamin C : CK(3397) : AC(792)
Diseases : Lymphoma: Mantle Cell : CK(35) : AC(8), Non-Hodgkin Lymphoma : CK(373) : AC(80)
Additional Keywords : Drug-Plant-Vitamin Synergies : CK(965) : AC(266)
Lymphoma: Mantle Cell
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Electric blue oval: Ford Focus EV driven
by Lem Bingley
Good: brisk, handsome, fun to drive
Bad: pricey, lardy, low on luggage space
Price: from £28,580 after grant
While I always welcome the chance to try a new electric car, first drives are often disappointingly brief. Unfortunately that’s exactly the case with Ford’s Focus Electric, a new competitor for Nissan’s Leaf that I’ve been hoping to try out for a while.
As a result, my time with the Focus EV is limited to about half an hour, and my choice of road narrowed to just one: a tight and twisting ribbon of tarmac at the Millbrook proving ground in Bedfordshire. Dubbed the city route, it’s a mile-long loop stuffed with short straights, tight corners and stop lines, plus the odd speed bump. And as a simulation of real life it’s roughly as convincing as Coronation Street.
The route is better than a real road in one respect: there’s the guaranteed absence of patrol cars and speed cameras. That means there is just enough wiggle room to confirm that the electric Focus feels about as lively as the Leaf. Firmly prod the accelerator and the Focus gathers pace with surprising vim, to the tune of a rising, science-fiction whine from under the bonnet.
Given a longer straight, the Ford would beat the Leaf to 62mph by half a second, at 11 seconds dead. It does so via brute force, however, employing a 107kW electric motor versus the Nissan’s 80kW unit. The gap would be bigger if the Focus hadn’t scoffed so many pies, carrying around an extra 160kg or so over the Leaf’s kerb weight.
The Focus Electric is as quiet and refined as you’d expect of an EV, and it handles rather better than most. There’s plenty of grip, neatly curtailed roll in corners, and a very pleasant suppleness over lumps and bumps. The steering, electrically assisted of course, has a nicely judged weight to it and is much more informative than the Nissan equivalent.
Braking feels reassuringly firm and entirely normal. With feet off both pedals, the Focus Electric does a fine job of mimicking engine braking. As far as I could tell there’s no way to call up a lower or higher level of energy recuperation, as there is in many other electric cars. From a standstill, the Focus EV mimics a fossil-fuelled car with an automatic gearbox, gently creeping forward unless held in check on the brake.
Outwardly, there’s little to mark the Focus Electric out from its conventional brethren. The wide-mouthed front grille is entirely blanked out with black plastic, there’s a charging flap on the nearside front wing, and absence of the usual filler flap under the offside rear lamp cluster, plus big silvery badges at the back and on either side. The result is much more handsome than the ugly duckling Leaf, but also much more anonymous among millions of other similarly styled Fords.
One of the Focus’s less clever modifications becomes obvious the moment you lift the tailgate. A big hump between the rear suspension turrets swallows up about 80 litres of the Ford’s boot, leaving 237 for your luggage. The lift-up boot floor, level with the top of the hump, seems disconcertingly high off the ground as a result.
Earlier examples of the Leaf, built in Japan, had a similar protuberance in the boot. As with the Ford, the bulky rear box was needed to house chunky pieces of high-voltage hardware, responsible for supervising the flow of energy to and from the battery. More recent British-built examples of the Leaf, updated in various ways, benefit from smaller lumps of hardware that have been squeezed under the bonnet, yielding a rear end free of unexpected bulges.
Leaf and Focus boast about the same battery capacity – 23kWh in Ford’s case and 24kWh for the Nissan. Ford’s battery is tucked away under the rear seat and above the rear axle, while the Nissan’s battery is flatter, wider and mounted further forward, running under the front and rear seats as well as beneath the raised rear footwells. When it comes to packing in all the required pieces of hardware, Leaf trumps Focus comprehensively.
Both cars employ a lithium-ion battery chemistry but the Ford package is more sophisticated, with liquid heating and cooling of the pack to help ensure long life and durability. The Leaf’s battery, by contrast, is passively air-cooled, though it’s too early to say if this less complex design will prompt many early failures. In the relatively mild temperatures of the UK, the benefits of active temperature control may well be negligible – or at least that’s the argument put forward by Nissan.
On the important question of range, the Focus will probably be the first of the pair to fall short. Its official NEDC range is 100 miles, while the Leaf manages 124. My fully charged Focus itself predicted just 64 miles of range on startup, presumably based on the driving styles of previous occupants.
The instrument panel fitted to the Focus Electric is clear and simple, with twin digital screens laid out either side of a central analogue speedo. Information on the screens can be configured to provide various forms of feedback on energy flows and even coaching to help improve your regenerative braking. And while careful Leaf drivers can grow little digital trees, attentive Focus pilots can release digital butterflies, apparently.
The rest of the Focus interior is fairly standard Ford, meaning a solid feel, reasonable quality, and more little buttons than a branch of Dixons. The standard feature count is high, including 17-inch alloys, automatic lights and wipers, a Sony DAB stereo with navigation and reversing camera, keyless entry, cruise control, climate control, and Ford Sync services including voice commands and emergency assistance.
The standard price is a less inviting bundle, amounting to £28,580 – after the £5,000 helping hand from the Plug-in Car Grant. A top-of-the-range Nissan Leaf in Tekna trim, offering a similar gaggle of features plus the added bonus of leather upholstery, costs a noticeable £3,090 less.
That price is the Focus Electric’s biggest hurdle. In a world where there are already plenty of reasons not to buy an electric car, a steep price is never going to trigger an avalanche of sales. I’ve heard suggestions that Ford expects to shift only about 30 examples in the first year of UK sales. Sadly, I suspect it might have to offer discounts to hit even that modest level of uptake.
Read more about: electric cars Ford Leaf test drives
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Greif Paper Packaging and Services Receives Awarded for Outstanding Customer Service
Press Release (PDF 62 KB)
DELAWARE, Ohio--(BUSINESS WIRE)-- Greif, Inc. (NYSE: GEF, GEF.B), a global leader in industrial packaging and services, today announced that its Paper Packaging and Services business unit received the company’s inaugural Dempsey Award for Customer Service Excellence. The award recognizes the business, function or team within Greif that demonstrates the very best customer service performance aligned with achieving Greif’s vision.
“At Greif, we work every day to fulfill our vision: in industrial packaging, be the best performing customer service company in the world. Creating a culture of customer service excellence is a continuous journey and we will celebrate success along the way.
“Our Paper Packaging and Services team works to identify opportunities to become strategic partners to its customers, while ensuring maximum accountability and performance delivery for their customers. The team’s 24 hour, 7 day a week customer service mindset is core to their operations and provides an outstanding example for our enterprise to emulate,” said Pete Watson, Greif’s President and Chief Executive Officer.
The growth rates in the Paper Packaging and Services business exceed North American industry averages and are in part attributable to industry leading customer service.
About Greif, Inc.
Greif is a global leader in industrial packaging products and services and is pursuing its vision: in industrial packaging, be the best performing customer service company in the world. The company produces steel, plastic and fibre drums, intermediate bulk containers, reconditioned containers, flexible products, containerboard, packaging accessories and provides filling, packaging and other services for a wide range of industries. Greif also manages timber properties in the south eastern United States. The company is strategically positioned in over 45 countries to serve global as well as regional customers. Additional information is on the company's website at www.greif.com. Greif’s Customer Satisfaction Index is an internal measure of plants or businesses performance against selected parameters that customers experience, which provide us an indication of our level of meeting customers basic needs. Components include: customer complaints received; customer complaints open greater than 30 days; credits raised; number of late deliveries; and the number of deliveries. Categories are weighted by importance. Greif’s Net Promoter Score is a management tool used to help gauge the loyalty of the company’s customer relationships. The survey is managed by a 3rd party.
Source: Greif, Inc.
Greif, Inc.
Matt Eichmann, Office: 740‐549‐6067
Email: matt.eichmann@greif.com
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Gulf Times - Kerala
1/1/2020 9:17:08 PM20
Aster plans major expansion with more hospitals, other facilities
Aster DM Healthcare Group, which has a substantial presence in Qatar, is set for expanding its services by opening new hospitals and other healthcare centres in India and the GCC region.
11/7/2019 8:07:08 PM20
Kerala Startup Mission recognised as 'world’s top public business accelerator' at Doha event
Kerala Startup Mission was recognised as the “World’s Top Public Business Accelerator” by UBI Global, the Stockholm-based intelligence company at a recent event in Doha.
10/18/2019 9:50:45 PM20
Two Indian siblings die in Doha
Two Indian siblings died in Doha Friday, sources said. They are natives of the southern state of Kerala.
Qatar resident donates land to rehabilitate Kerala flood victims
A Qatar-based Indian businessman's benevolent gesture will go a long way in the rehabilitation of the families who have been left homeless by a massive landslide and flash floods ...
Airport closure after torrential rains disrupts Indian expats' travel plans
Travel plans of many Indian expatriates were affected as the Cochin International Airport has been closed until Sunday 3pm due to torrential rains in several parts of Kerala state.
Floods kill at least 28 in southern India, displace thousands
At least 28 people have died in the southern Indian state of Kerala after torrential monsoon rains caused landslides and flooding that cut off some areas, authorities said on Friday.
Clashes after women enter flashpoint Indian temple
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Oxy staff hand over Kerala flood relief cheque to envoy
Occidental Petroleum of Qatar (Oxy Qatar) and its employees contributed QR84,020 ($24,019) to the Chief Minister’s Distress Relief Fund of the southern Indian state of Kerala ...
Air India Express starts service to Kannur
Air India Express commenced its services from Doha to Kannur in the state of Kerala, India, on December 10. Flight IX 774 departed Doha with 187 passengers on board, the airline said in a statement.
AI Express to launch Doha flights from Kannur next month
Air India Express will start four-times-a-week flights between Kannur in the southern Indian state of Kerala and Doha on December 10, according to an airline statement shared by local travel agents.
IndiGo to begin flights from Doha to Kerala capital from October
IndiGo already flies to six Indian destinations from Doha; Kochi, Kozhikode (both Kerala), Chennai, Hyderabad, Mumbai and New Delhi.
Flights to Kochi to resume Wednesday
Kerala’s Kochi airport, which was shut down on August 15 due to heavy rain and floods in the south Indian state, will resume operations Wednesday at 2pm, the airport owner CIAL (Cochin International Airport Limited) said Tuesday.
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Gulf Today
Most searched related results
The pull of studying abroad for Indian students
The photo has been used for illustrative purposes.
Amit Dasgupta, Indo-Asian News Service
The growth in India’s middle class and strong aspiration among India’s young to be part of a global workforce have emerged as key drivers for Indian students seeking to study abroad. This will be particularly noticeable after the school-leaving examination results are out.
Recent data demonstrates a strong upward trend and several international education providers are queuing to tap into the Indian student market. This is only likely to grow as India grapples with the crisis it is facing in its own higher education space.
This ‘push’ factor would see several of India’s best and brightest leave Indian shores, so that they might benefit from a pedagogy and learning outcomes that enhance global employability.
Recent initiatives by the Indian government suggest recognition of the critical deficiencies in the Indian education system and that band-aid solutions need to be replaced by a complete and systemic overhaul. This will take time.
Consequently, some of the top universities in the world have reached out to aspiring and high-achieving Indian students. A perceptible shift from the traditional destinations of US and UK is now widely visible with Australia emerging as a significant and credible preferred choice.
Indeed, so strong is the push for Indian students that a recent Australian government strategy paper identified collaboration in higher education as a critical foreign policy initiative. Over time, this is only likely to increase as India’s young population grows along with their aspiration to transform lives and be part of the global story.
Modernising Indian education is likely to take decades. Old ways of thinking and teaching have been embedded in our psyche.
Research has never been part of our DNA. Infrastructure, qualified and quality faculty, contemporary pedagogy, and learning outcomes that cater to jobs that have not yet been created have never driven the rationale of ‘why education’.
Consequently, our education system has never been accountable. Constrained by bureaucracy and interference, it has succeeded in producing large numbers of engineers, who are not employable. Globally, the young realise that a technology and knowledge revolution is disrupting not only the way in which we are expected to do our job but also where we would be doing this.
Artificial intelligence and robotics would replace much that professionals like doctors, architects, engineers, accountants and others believed was their turf and their core strengths. Today, these skills are not only being emulated by robots but with far greater efficiency. Similarly, the workplace itself is undergoing a dramatic transformation through virtual reality.
Office colleagues would no longer physically share space but would only be available for discussions and interactions via technology-driven platforms. You can have your accountant sitting in Buenos Aires, your supervisor in Tokyo and your team members spread over four or five continents. This can be seriously challenging and requires a pedagogy that enables working it to your best advantage.
The majority of Indian education providers are yet to adapt and embrace these new and compelling demands.
For aspiring young Indians, it is a frightening thought that after they complete their education, they might not be able to find a job. The push for quality education abroad is as much a consequence of desperation as it is of aspiration.
This is understandable because no human being would deny themselves a future. Nor indeed would a parent do the same to their children. This explains the surge in the numbers of Indian students seeking higher education abroad.
India has a long way to go in thoroughly rewiring its education system to meet the demands of the future.
Till then, those who can afford a higher education abroad are likely to choose that option. Many would be the better for it. India, too, would be the better for it as several of these students would find themselves ‘pulled to India’, once India reforms and pushes its own developmental and aspirational agenda. It is a win-win situation.
Girls outshine boys in CBSE Class 12 results
Trivandrum region emerged at the top with a pass percentage of 98.2 per cent. The Chennai region stood second with a pass percentage of 92.93 while Delhi stood at the third place with 91.87 per cent.
Indian girls outshine boys in Class 10 results
The results which were announced in record time following court direction, showed that girls’ pass percentage was 92.45 per cent, while the boys’ were at 90.14.
Liberal education takes wing in India, draws students from ME
New varsities deliver quality liberal education and their competitive fee structure and proximity make them an attractive option for students from across the ME.
Will the New Education Policy meet its goal?
Even though India boasts of universalisation of primary education, with almost 100 per cent Gross Enrolment Rate (2014-15), quality of education in the last decade has gone down. While ASER 2008 revealed that 50.6 per cent grade 3 children in India could read a grade 1 text, this number reduced to 42.5 per cent
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Extraordinary to ordinary: Harry pays a royal price
When extraordinary people opt for an “ordinary” life, they sometimes end up paying a royal price. That sort of sums up the “Megxit” crisis, which began on Jan.8 when Prince Harry
Industry must accept merits of sustainable capitalism
“Stakeholders for a cohesive and sustainable world” is the theme of the annual meeting of the World Economic Forum, taking place in Davos this week. Topics the summit
After stirring up Middle East, Trump now wants NATO’s help?
President Donald Trump has come up with a new solution for the Middle East, a region that has embroiled the United States for decades in conflict and war.
Britain’s utter disregard for child refugees
Whenever the UK’s ill-treatment of asylum seekers and refugees is brought to light, the Home Office usually issues a statement that contains a variation of the following
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Medicare Program; End-Stage Renal Disease Prospective Payment System and Quality Incentive Program; Ambulance Fee Schedule; Durable Medical Equipment; and Competitive Acquisition of Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies
A Rule by the Centers for Medicare & Medicaid Services on 11/10/2011
70227-70316 (90 pages)
CMS-1577-F
0938-AQ27
Addenda Are Only Available Through the Internet on the CMS Web Site
I. Calendar Year (CY) 2012 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS)
A. Background on the End-Stage Renal Disease Prospective Payment System
B. Summary of the Proposed Provisions and Responses to Comments on the CY 2012 ESRD PPS
1. Updates to the Composite Rate and ESRD PPS Base Rate
a. Composite Rate
b. ESRD PPS Base Rate
2. ESRD Bundled Market Basket
a. Overview and Background
b. Final Market Basket Update Increase Factor and Labor-Related Share for ESRD facilities for CY 2012
c. Productivity Adjustment
d. Calculation of the ESRDB Market Basket Update, Adjusted for Multifactor Productivity for CY 2012
3. Transition Budget-Neutrality Adjustment for CY 2011
5. Low-Volume Facility Provisions
6. Update to the Drug Add-On to the Composite Rate Portion of the ESRD Blended Payment Rate
a. Estimating Growth in Expenditures for Drugs and Biologicals in CY 2012
b. Estimating per Patient Growth
c. Applying the Growth Update to the Drug Add-On Adjustment
d. Update to the Drug Add-On Adjustment for CY 2012
7. Updates to the Wage Index Values and Wage Index Floor for the Composite Rate Portion of the Blended Payment and the ESRD PPS Payment
a. Reduction to the ESRD Wage Index Floor
b. Policies for Areas With No Hospital Data
c. Wage Index Budget-Neutrality Adjustment
d. ESRD PPS Wage Index Tables
8. Drugs
a. Vancomycin
b. Drug Overfill
9. Revisions to Patient-Level Adjustment for Body Surface Area (BSA)
10. Revisions to the Outlier Policy
a. Revisions Related to Outlier ESRD Drugs and Biologicals
b. Exclusion of Automated Multi-Channel Chemistry (AMCC) Laboratory Tests From the Outlier Calculation
c. Impact of Final Changes to the Outlier Policy
D. Technical Corrections
1. Training Add-On
2. ESRD-Related Laboratory Test
E. Clarifications to the CY 2011 ESRD PPS
1. ICD-9-CM Diagnosis Codes
2. Emergency Services to ESRD Beneficiaries
F. Miscellaneous Comments
II. End-Stage Renal Disease Quality Incentive Program for Payment Years (PYs) 2013 and 2014
A. Background for the End-Stage Renal Disease Quality Incentive Program for PY 2013 and PY 2014
B. Summary of the Proposed Provisions and Responses to Comments on the End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) for PY 2013 and PY 2014
1. PY 2013 ESRD QIP Requirements
a. Performance Measures for the PY 2013 ESRD QIP
b. Performance Period and Case Minimum for the PY 2013 ESRD QIP
c. Performance Standards for the PY 2013 ESRD QIP
d. Methodology for Calculating the Total Performance Score and Payment Reduction for the PY 2013 ESRD QIP
2. Proposed PY 2014 ESRD QIP
a. Proposed Performance Measures for the PY 2014 ESRD QIP
i. Anemia Management Measure
ii. Dialysis Adequacy Measure
iii. Vascular Access Type (VAT) Measure
iv. Vascular Access Infections (VAI) Measure
v. Standardized Hospitalization Ratio (SHR)-Admissions Measure
vi. Minimum Case Number for Clinical Measures and Other Considerations
vii. National Healthcare Safety Network (NHSN) Dialysis Event Reporting Measure
viii. Patient Experience of Care Survey Usage Measure
ix. Mineral Metabolism Reporting Measure
3. Performance Period for the PY 2014 ESRD QIP
4. Performance Standards and the Methodology for Calculating the Total Performance Score for the PY 2014 ESRD QIP
i. Performance Standards for the PY 2014 ESRD QIP
ii. Setting Performance Benchmarks and Thresholds
iii. Scoring Provider and Facility Performance on Clinical Measures Based on Achievement
iv. Scoring Provider/Facility Performance on Clinical Measures Based on Improvement
v. Calculating the VAT Measure Score
vi. Calculating the NHSN Dialysis Event Reporting Measure, Patient Experience Survey Usage Reporting Measure and Mineral Metabolism Reporting Measure Scores
vii. Weighting of the PY 2014 ESRD QIP Measures and Calculation of the PY 2014 ESRD QIP Total Performance Score
vii. Examples for 2014 ESRD QIP Performance Scoring Model
6. Payment Reductions for the PY 2014 ESRD QIP
7. Public Reporting Requirements
8. Future QIP Measures
9. Process of Updating Measures
III. Ambulance Fee Schedule
A. Summary of Proposed Provisions
1. Section 106 of the Medicare and Medicaid Extenders Act of 2010 (MMEA)
a. Amendment to Section 1834(l)(13) of the Act
b. Amendment to Section 146(b)(1) of MIPPA
c. Amendment to Section 1834(l)(12) of the Act
2. Technical Correction
B. Response to Comments
IV. Durable Medical Equipment and Supplies
A. Background for Durable Medical Equipment (DME) and Supplies
B. Current Issues
C. Overview of the Provisions of the Proposed Durable Medical Equipment (DME) Regulation
D. Summary of the Proposed Provisions and Responses to Comments on the Definition of Durable Medical Equipment (DME) 3-Year Minimum Lifetime Requirement (MLR)
1. Application of the 3-Year MLR to Items Currently Covered as DME and to Supplies and Accessories of Covered DME
2. Application of the 3-Year MLR to Multi-Component Devices
V. Interim Final Rule Regarding the Competitive Acquisition Program for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
A. Background
1. Legislative and Regulatory History of the DMEPOS Competitive Bidding Program
2. The MIPPA and the Medicare DMEPOS Competitive Bidding Program
B. Overview of the Interim Final Rule
C. Summary of the Interim Final Rule Provisions and Response to Comments on Changes to the Competitive Acquisition of Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) by Certain Provisions of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
1. General Changes to the DMEPOS Competitive Bidding Program
a. Temporary Delay of the Medicare DMEPOS Competitive Bidding Program
b. Supplier Feedback on Missing Covered Documents
c. Disclosure of Subcontractors and Their Accreditation Status Under the Competitive Bidding Program
d. Exemption From Competitive Bidding for Certain DMEPOS
e. Exclusion of Group 3 Complex Rehabilitative Power Wheelchairs
2. Round 1 Changes to the Competitive Bidding Program
a. Rebidding of the “Same Areas” as the Previous Round 1, Unless Otherwise Specified
b. Rebidding of the “Same Items and Services” as the Previous Round 1, Unless Otherwise Specified
D. Other Public Comments Received on the January 16, 2009 Interim Final Rule
V. Collection of Information Requirements
A. Legislative Requirement for Solicitation of Comments
B. Requirements in Regulation Text
C. Additional Information Collection Requirements
1. Display of Certificates for the PY 2013 and PY 2014 ESRD QIP
2. NHSN Reporting Requirement for the PY 2014 ESRD QIP
3. Patient Experience Survey Usage Requirement for the PY 2014 ESRD QIP
4. Mineral Metabolism Reporting Requirement for the 2014 ESRD QIP
5. Competitive Acquisition Program for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Collection of Information Requirements
i. ICRs Regarding Round 1 Rebid
ii. ICRs Regarding Disclosure of Subcontracting Arrangements
VII. Economic Analyses
A. Regulatory Impact Analysis
2. Statement of Need
3. Overall Impact
B. Detailed Economic Analysis
1. CY 2012 End-Stage Renal Disease Prospective Payment System
a. Effects on ESRD Facilities
b. Effects on Other Providers
c. Effects on the Medicare Program
d. Effects on Medicare Beneficiaries
e. Alternatives Considered
2. End-Stage Renal Disease Quality Incentive Program
a. Effects of the PY 2013 and PY 2014 ESRD QIP
b. Alternatives Considered for the PY 2013 and PY 2014 ESRD QIP
3. Ambulance Fee Schedule
Section 106 of the Medicare and Medicaid Extenders Act of 2010 (MMEA)
4. Durable Medical Equipment (DME) and Supplies
5. The Competitive Acquisition Program for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
C. Accounting Statement
VIII. Regulatory Flexibility Act Analysis
IX. Unfunded Mandates Reform Act Analysis
X. Federalism Analysis
XI. Files Available to the Public via the Internet
PART 413—PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES
PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
Subpart D—Payment for Durable Medical Equipment and Prosthetic and Orthotic Devices
Subpart F—Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Subpart H—Fee Schedule for Ambulance Services
This PDF is the current document as it appeared on Public Inspection on 11/01/2011 at 4:15 pm.
Start Preamble Start Printed Page 70228
Centers for Medicare & Medicaid Services (CMS), HHS.
Final rule.
This final rule updates and makes certain revisions to the End-Stage Renal Disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2012. We are also finalizing the interim final rule with comment period published on April 6, 2011, regarding the transition budget-neutrality adjustment under the ESRD PPS,. This final rule also sets forth requirements for the ESRD quality incentive program (QIP) for payment years (PYs) 2013 and 2014. In addition, this final rule revises the ambulance fee schedule regulations to conform to statutory changes. This final rule also revises the definition of durable medical equipment (DME) by adding a 3-year minimum lifetime requirement (MLR) that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME. Finally, this final rule implements certain provisions of section 154 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) related to the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) Competitive Acquisition Program and responds to comments received on an interim final rule published January 16, 2009, that implemented these provisions of MIPPA effective April 18, 2009. (See the Table of Contents for a listing of the specific issues addressed in this final rule.)
Effective dates: These regulations are effective on January 1, 2012. Also, effective January 1, 2012, we are finalizing the interim final rule with comment (“Medicare Programs: Changes to the End-Stage Renal Disease Prospective Payment System Transition Budget-Neutrality Adjustment”) published on April 6, 2011 (76 FR 18930). Additionally, effective January 12, 2012 the interim rule amending 42 CFR Part 414, published on January 16, 2009 (74 FR 2873), is confirmed as final.
Terri Deutsch, (410) 786-4533, for issues related to ESRD.
Roechel Kujawa, (410) 786-9111, for issues related to ambulance services.
Heidi Oumarou, (410) 786-7942, for issues related to the ESRD market basket.
Shannon Kerr, (410) 786-3039, for issues related to the quality incentive program.
Sandhya Gilkerson, (410) 786-4085, for issues related to DME MLR.
Hafsa Bora, (410) 786-7899 or Iffat Fatima, (410) 786-6709, for DMEPOS Competitive Acquisition Program issues related to comments received on an interim final rule that implemented provisions of MIPPA effective April 18, 2009.
In the past, a majority of the Addenda referred to throughout the preamble of our proposed and final rules were available in the Federal Register. However, the Addenda of the annual proposed and final rules will no longer be available in the Federal Register. Instead, these Addenda to the annual proposed and final rules will be available only through the Internet on the CMS Web site. The Addenda to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) rules are available at: http://www.cms.gov/ESRDPayment/PAY/list.asp. Readers who experience any problems accessing any of the Addenda to the proposed and final rules that are posted on the CMS Web site identified above should contact Lisa Hubbard at (410) 786-4533.
To assist readers in referencing sections contained in this preamble, we are providing a Table of Contents. Some of the issues discussed in this preamble affect the payment policies, but do not require changes to the regulations in the Code of Federal Regulations (CFR).
d. Methodology for Calculating the Total Performance Score and Payment Reduction for the PY 2013 ESRD QIPStart Printed Page 70229
2. PY 2014 ESRD QIP
iv. Vascular Access Infections Measure
vii. Weighting of the PY 2014 ESRD QIP Measures and Calculation of the PY 2014 ESRD QIP
viii. Examples for 2014 ESRD QIP Performance Scoring Model
D. Summary of the Proposed Provisions and Responses to Comments on the Definition of Durable Medical Equipment (DME) and the 3-Year Minimum Lifetime Requirement (MLR)
VI. Collection of Information Requirements
Regulations Text
Because of the many terms to which we refer by acronym in this final rule, we are listing the acronyms used and their corresponding meanings in alphabetical order below:
AMCC Automated Multi-Channel Chemistry
ASP Average Sales Price
AV Arteriovenous
BLS Bureau of Labor Statistics
BMI Body Mass Index
BSA Body Surface Area
CY Calendar Year
CBSA Core-Based Statistical Area
CDC Centers for Disease Control and Prevention
CLABSI Central Line Access Bloodstream Infections
CFR Code of Federal Regulations
CIP Core Indicators Project
CMS Centers for Medicare & Medicaid Services
CPM Clinical Performance Measure
CPT Current Procedural Terminology
CROWNWeb Consolidated Renal Operations in a Web-Enabled Network
DFC Dialysis Facility Compare
DFR Dialysis Facility Report
DME Durable Medical Equipment
ESA Erythropoiesis stimulating agent
ESRD End-Stage Renal Disease
ESRDB End-Stage Renal Disease Bundled
FDA Food and Drug Administration
FI/MAC Fiscal Intermediary/Medicare Administrative Contractor
FY Fiscal Year
GDP Gross Domestic Product
HAI Healthcare-associated Infections
HCPCS Healthcare Common Procedure Coding System
HD Hemodialysis
HHD Home Hemodialysis
ICD-9-CM International Classification of Diseases, 9th Edition, Clinical Modifications
ICH CAHPS In-Center Hemodialysis Consumer Assessment of Healthcare Advisors
IGI IHS Global Insight
IPPS Inpatient Prospective Payment System
KDIGO Kidney Disease: Improving Global Outcomes
KDOQI Kidney Disease Outcome Quality Initiative
Kt/V A measure of dialysis adequacy where K is dialyzer clearance, t is dialysis time, and V is total body water volume
LDO Large Dialysis Organization
MAP Medicare Allowable Payment
MCP Monthly Capitation Payment
MIPPA Medicare Improvements for Patients and Providers Act of 2008 (Pub. L. 110-275)
MMA Medicare Prescription Drug, Improvement and Modernization Act of 2003
MMEA Medicare and Medicaid Extenders Act of 2010 Public Law 111-309
MFP Multifactor Productivity
NHSN National Healthcare Safety Network
NQF National Quality Forum
PD Peritoneal Dialysis
PFS Physician Fee Schedule
PPS Prospective Payment System
PSR Performance Score Report
PY Payment Year
QIP Quality Incentive Program
REMIS Renal Management Information System
RFA Regulatory Flexibility Act
RUL Reasonable Useful Lifetime
SBA Small Business Administration
SIMS Standard Information Management System
SHR Standardized Hospitalization Ratio
SSA Social Security Administration
The Act Social Security Act
The Affordable Care Act The Patient Protections and Affordable Care Act
URR Urea reduction ratio
VBP Value Based Purchasing
On August 12, 2010, we published in the Federal Register, a final rule (75 FR 49030 through 49214), entitled, “End-Stage Renal Disease Prospective Payment System”, hereinafter referred to as the CY 2011 ESRD PPS final rule. In the CY 2011 ESRD PPS final rule, we implemented a case-mix adjusted bundled PPS for Medicare outpatient ESRD dialysis patients beginning January 1, 2011, in accordance with section 1881(b)(14) of the Social Security Act (the Act), as added by section 153(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). The ESRD PPS replaced the basic case-mix adjusted composite payment system and the methodologies for the reimbursement of separately billable outpatient ESRD services.
Also, section 1881(b)(14)(F) of the Act, as added by section 153(b) of MIPPA and amended by section 3401(h) of Public Law 111-148, the Affordable Care Act, established that beginning CY 2012, and each subsequent year, the Secretary shall reduce the market basket increase factor by a productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act.
In the CY 2011 ESRD PPS final rule (75 FR 49030), the Centers for Medicare & Medicaid Services (CMS) finalized the following:
A base rate of $229.63 per treatment for renal dialysis services (but postponed payment for oral-only renal dialysis drugs under the ESRD PPS until January 1, 2014) that applies to both adult and pediatric dialysis patients prior to the application of any case-mix adjustments. This amount included the 2 percent reduction for budget neutrality required by MIPPA, a one percent reduction for estimated outlier payments, and a reduction to account for estimated payments for case-mix and the low-volume payment adjustments.
A 4-year transition period (for those ESRD facilities that elected to receive blended payments during the transition) during which ESRD facilities receive a blend of payments under the prior basic case-mix adjusted composite payment system and the new ESRD PPS. Although the statute uses the term “phase-in”, we use the term “transition” to be consistent with other Medicare payment systems.
A −3.1 percent transition budget-neutrality adjustment to ensure that overall spending under the ESRD PPS did not increase as a result of the provision that permits ESRD facilities to be excluded from the 4-year transition.
Payment adjustments for dialysis treatments furnished to adults for patient age, body surface area (BSA), low body mass index (BMI), onset of dialysis, and six specified co-morbidities.
A home or self-care dialysis training payment adjustment of $33.44 per treatment paid in addition to the case-mix adjusted per treatment amount, which is wage adjusted and applies to claims for patients trained by ESRD facilities certified to provide home dialysis training.
Payment adjustments for dialysis treatments furnished to pediatric patients for patient age and dialysis modality.
A low-volume payment adjustment for adult patients of 18.9 percent that applies to the otherwise applicable case-mix adjusted payment rate for facilities that qualify as low-volume ESRD facilities.
An outlier payment policy that provides an additional payment to ESRD facilities treating high cost, resource-intensive patients.
The wage index adjustment that is applied when calculating the ESRD PPS payment rates in order to account for geographic differences in area wage levels.
An ESRD bundled (ESRDB) market basket index used to project prices in the costs of goods and services used to furnish outpatient maintenance dialysis.
In addition, on April 6, 2011, we published an interim final rule with comment period in the Federal Register (76 FR 18930), entitled “Changes in the End-Stage Renal Disease Prospective Payment System Transition Budget-Neutrality Adjustment”, which revised the ESRD transition budget-neutrality adjustment for CY 2011. In the interim final rule, we revised the 3.1 percent transition budget-neutrality adjustment reduction to a zero percent transition budget-neutrality adjustment for renal dialysis services furnished on April 1, 2011 through December 31, 2011.
The proposed rule entitled, “Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012, End-Stage Renal Disease Quality Incentive Program for PY 2013 and PY 2014; Ambulance Fee Schedule; and Durable Medical Equipment” (76 FR 40498) (the “proposed rule”) appeared in the Federal Register on July 8, 2011, with a comment period that ended on August 30, 2011 (76 FR 40498). In that proposed rule, for the ESRD PPS, we proposed to (1) make a number of routine updates for CY 2012, (2) implement the second year of the transition, (3) make several policy changes and clarifications, and (4) technical changes with regard to the CY 2011 ESRD PPS final rule. We received approximately 40 public comments on the ESRD PPS proposals, including comments from dialysis facilities, the national organizations representing dialysis facilities, nephrologists, patients, pharmaceutical manufacturers, hospitals and their representatives, and MedPAC. In this final rule, we provide a summary of each proposed provision, a summary of the public comments received, our responses to them, and what we are finalizing for the CY 2012 ESRD PPS in this final rule.
Section 1881(b)(14)(E)(i) of the Act requires a 4-year transition under the ESRD PPS. For CY 2012, under 42 CFR 413.239(a)(2), ESRD facilities that receive payment through the transition receive a blended rate equal to the sum of 50 percent of the ESRD PPS amount and 50 percent of the basic case-mix adjusted composite payment amount. Accordingly, we continue to update the composite rate portion of the blended payment during the 4-year transition (that is, CYs 2011 through 2013). For a historical perspective of the basic case-mix adjusted composite payment system for ESRD facilities, including the CY 2011 update to the composite rate portion of the blended rate, please see the CY 2011 Physician Fee Schedule (PFS) proposed rule, (75 FR 40164) and the CY 2011 PFS final rule (75 FR 49031 through 49033). In addition, we discuss the CY 2012 drug add-on and the updated wage index values for the composite rate portion of the blended payment in sections I.C.6 and I.C.7, respectively, of this final rule.
Under section 1881(b)(14)(F)(ii) of the Act, for years during which the transition applies, the composite rate portion of the blend shall be annually increased by the ESRDB market basket, which for CY 2012 and each subsequent year, shall be reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act. In section I.B.2.b of this final rule, we are finalizing the CY 2012 ESRDB market basket update of 3.0 percent, based on the third quarter 2011 IGI forecast of the ESRDB market basket. In Start Printed Page 70231section I.B.2.c of this final rule, we are finalizing the CY 2012 MFP adjustment of 0.9 percent based on the third quarter 2011 IGI forecast of the MFP.
We proposed to add the CY 2011 Part D per treatment amount (that is, $0.49) to the CY 2011 composite rate in order to update the Part D amount for CY 2012 using the ESRDB market basket minus the productivity adjustment (76 FR 40502). We believed this approach is preferable to applying a growth factor to the $0.49 that is based on the rates for overall prescription drug prices that were used in the National Health Expenditure Projections, as we did for the establishment of the CY 2011 ESRD PPS base rate, because it is consistent with the update applied to the ESRD PPS base rate, which includes a per treatment amount for former part D drugs (that is, $0.49). We sought comment on our proposal to add the CY 2011 part D payment amount (that is, $0.49) to the composite rate portion of the blended payment and update it using the ESRDB market basket minus productivity adjustment. The basis for the first part of the transition budget-neutrality adjustment (that is, the calculation of the $0.49 part D amount) was set forth in the CY 2011 ESRD PPS final rule at 75 FR 49082. The comments and our responses are set forth below.
Comment: Several commenters expressed concerns about the proposed methodology to add the former Part D oral drug amount ($0.49) to the composite rate and then apply the market basket reduced by the productivity adjustment. Some commenters believe that updating the payment for oral equivalents of injectable drugs by the ESRD market basket minus productivity could set a precedent that might affect access to care for preferred agents when oral drugs are included in the bundle in 2014. One commenter stated that it is inappropriate to apply the productivity adjustment to full transition blended payment. Instead, they believe the blended payment amount, for CY 2012, should be split with 50 percent of it paid at the PPI-inflated market basket rates and 50 percent of it adjusted using the update factors because the transition blended payment rate is based on 50 percent of the PPS payment rate and 50 percent on the old composite rate plus drug add-on rate. One commenter acknowledged that by using the split methodology, ESRD PPS would be updated differently than other payment systems, but the commenter believed that this distinction was appropriate because of the unique nature of the program and because drugs represent such a large portion of the overall costs incurred by dialysis facilities.
Response: Beginning in 2012, section 1881(b)(14)(F) of the Act, requires us to annually update the ESRD PPS payment amounts and the composite rate portion of the blended transition payment by an ESRD market basket increase that is reduced by the productivity adjustment described in section 1886(b)(3)(B)xi)(II) of the Act. Given that the same update is used for both ESRD PPS and transition blended payments, and given the ESRD PPS base rate includes a portion of former Part D drugs, we proposed to add the $0.49 part D drug amount to the composite rate portion of the blended payment because we wanted to update it consistent with how we update the ESRD PPS base rate. Further, because the statute requires an update using the ESRDB market basket less productivity and the ESRDB market basket is comprised of the Producer Price Index (PPI) for prescription drugs as a proxy for measuring price growth in ESRD-related drugs, we believe that our proposal to add the $0.49 to the composite rate and update it using the ESRDB market basket less productivity is appropriate. Therefore, for CY 2012, the composite rate payment, including the $0.49 Part D amount, will be updated by the ESRDB market basket less productivity. With regard to the commenter's concerns that the addition of $0.49 to the composite rate would set a precedent that might affect access to care for preferred agents when oral-only drugs are included in the bundle in 2014, we note that we did not propose any payment policies for the oral-only drugs in the proposed rule. We will address in future rulemaking oral-only drugs and the bundled amount established in CY 2011, and there will be an opportunity for public comment on any future proposals we may make.
Consequently, for CY 2012, the composite rate portion of the ESRD PPS blended payment is $141.94. The $141.94 reflects the addition of the CY 2011 part D per treatment amount ($0.49) to the CY 2011 composite rate of $138.53, and application of the ESRDB market basket minus productivity adjustment ($138.53 + 0.49 = $139.02; $139.02 × 1.021 = $141.94).
We described the development of the ESRD PPS per-treatment base rate in the CY 2011 ESRD PPS final rule (75 FR 49071) and established Medicare regulations at 42 CFR 413.220 and 413.230. The CY 2011 ESRD PPS final rule also provides a detailed discussion of the methodology used to calculate the ESRD PPS base rate and the computation of factors used to adjust the ESRD PPS base rate for projected outlier payments and budget-neutrality in accordance with sections 1881(b)(14)(D)(ii) and 1881(b)(14)(A)(ii) of the Act, respectively (75 FR 49071 through 49082). Specifically, the ESRD PPS base rate was developed from CY 2007 claims (that is, the lowest per patient utilization year), updated to CY 2011, and represented the average per treatment Medicare allowable payment (MAP) for composite rate and separately billable services. In addition, in accordance with § 413.230, the ESRD PPS base rate is adjusted for the patient-specific case-mix adjustments, applicable facility adjustments, geographic differences in area wage levels using an area wage index, as well as any outlier payment or training add-on adjustments. For CY 2011, the ESRD PPS base rate was $229.63 (75 FR 49082).
As required by section 1881(b)(14)(F) of the Act, in this final rule, for CY 2012, we applied the 2.1 percent increase (ESRDB market basket update less productivity) to the CY 2011 ESRD PPS base rate of $229.63, which results in an ESRD PPS base rate for CY 2012 of $234.45 (229.63 × 1.021 = 234.45). The ESRD PPS base rate applies to the ESRD PPS portion of the blended payments under the transition and to the ESRD PPS payments. In addition, as discussed in section I.C.7.c of the proposed rule (76 FR 40509), we proposed to apply the wage index budget-neutrality adjustment factor to the ESRD PPS base rate in CY 2012.
We did not receive any comments on this proposal. Therefore, we are finalizing the policy to apply the wage index budget-neutrality adjustment to the ESRD PPS base rate. For CY 2012, we apply the wage index budget-neutrality adjustment factor of 1.001520 to the updated base rate (that is, $234.45), yielding an ESRD PPS wage-index budget-neutrality adjusted base rate for CY 2012 of $234.81 ($234.45 × 1.001520 = 234.81).
In accordance with section 1881(b)(14)(F)(i) of the Act, as added by section 153(b) of MIPPA and amended by section 3401(h) of the Affordable Care Act, beginning in 2012, the ESRD bundled payment amounts are required to be annually increased by an ESRD market basket increase factor that is reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act. The statute further provides that the market basket increase factor Start Printed Page 70232should reflect the changes over time in the prices of an appropriate mix of goods and services used to furnish renal dialysis services. Under section 1881(b)(14)(F)(ii) of the Act, as added by section 153(b) of MIPPA and amended by section 3401(h) of the Affordable Care Act, the ESRD bundled (ESRDB) rate market basket increase factor will also be used to update the composite rate portion of ESRD payments during the ESRD PPS transition period from 2011 through 2013; though beginning in 2012, such market basket increase factor will be reduced by the productivity adjustment. As a result of amendments by section 3401(h) of the Affordable Care Act, a full market basket was applied to the composite rate portion of the blended payment in CY 2011 during the first year of the transition.
As required under section 1881(b)(14)(F) of the Act, CMS developed an all-inclusive ESRDB input price index (75 FR 49151 through 49162). Although “market basket” technically describes the mix of goods and services used to produce ESRD care, this term is also commonly used to denote the input price index (that is, cost categories, their respective weights, and price proxies combined) derived from that market basket. Accordingly, the term “ESRDB market basket”, as used in this document, refers to the ESRDB input price index.
We proposed to use the same methodology described in the CY 2011 ESRD PPS final rule (75 FR 49151 through 49162) to compute the CY 2012 ESRDB market basket increase factor and labor-related share based on the best available data (76 FR 40503). Consistent with historical practice, we estimate the ESRDB market basket update based on IHS Global Insight (IGI), Inc.'s forecast using the most recently available data. IGI is a nationally recognized economic and financial forecasting firm that contracts with CMS to forecast the components of the market baskets.
Using this method and the IGI forecast for the first quarter of 2011 of the CY 2008-based ESRDB market basket (with historical data through the fourth quarter of 2010), and consistent with our historical practice of estimating market basket increases based on the best available data, the proposed CY 2012 ESRDB market basket increase factor was 3.0 percent. We also proposed that if more recent data became subsequently available (for example, a more recent estimate of the market basket), we would use that data, if appropriate, to determine the CY 2012 update in the final rule. Therefore, we used the IGI's third quarter 2011 forecast with history through the second quarter of 2011, and as discussed below, the projected market basket update for CY 2012 that we are finalizing is 3.0 percent based on the 2008-based ESRDB market basket.
Additionally, we proposed to continue to use a labor-related share of 41.737 percent for CY 2012 for the ESRD PPS payment (76 FR 40503), which was finalized in the CY 2011 ESRD final rule (75 FR 49161). We also proposed to continue to use a labor-related share of 53.711 percent for the ESRD composite rate portion of the blended payment for all years of the transition (76 FR 40503). This labor-related share was developed from the labor-related components of the 1997 ESRD composite rate market basket that was finalized in the 2005 PFS final rule (70 FR 70168), and is consistent with the mix of labor-related services paid under the composite rate, as well as the method finalized in the CY 2011 ESRD PPS final rule (75 FR 49116).
The comments we received on these proposals and our responses are set forth below.
Comment: Several commenters believe that there should be more transparency in the calculation of the market basket update and are concerned about the lack of data available to validate the calculations.
Response: We agree that the public should be able to replicate the methodology used to construct the ESRDB market basket. We disagree, however, that CMS has not been fully transparent in the calculation of the market basket update. In the CY 2011 ESRD final rule (75 FR 49151 through 49161), we provided the public with the cost shares for the ESRDB market basket and the data sources for the establishment of those cost shares. We also provided a detailed description of the data sources used to develop the ESRDB market basket cost weights and the price proxies used in the ESRDB market basket were listed for each cost category, which are based on data maintained and published by the Bureau of Labor Statistics (BLS). We refer the commenter to the BLS regarding any specific information on the detailed price proxies. In addition, to assist the commenter and other interested stakeholders in locating these price proxies on the BLS Web site, we have provided the individual BLS series codes for the indexes in the price proxy discussion of the final rule and the directions for obtaining the data through the BLS Web site. These two pieces of information, the cost weights and the price proxies, allow the public to replicate the historical time series of the ESRDB market basket.
The forecasts of the individual price proxies used in a market basket are developed independently by IGI, a nationally recognized economic and financial forecasting firm. We purchase IGI's detailed price proxy projections for use in the Medicare market baskets. As a matter of practice, we publish all of the underlying detail for each price proxy for the historical period. However, because the projections of each individual price proxy are proprietary, we aggregate those projections into higher level categories and then publish the results with a one-quarter lag on the CMS Web site. This is consistent with the level of data provided for other PPS payment system market baskets. The ESRDB market basket data, including the detail as described above, is published on the CMS Web site at the following link: (https://www.cms.gov/MedicareProgramRatesStats/04_MarketBasketData.asp#TopOfPage).
After considering the public comments received and for the reasons we previously articulated, we are finalizing our proposals to continue to use the ESRDB market basket forecasts for the ESRD PPS and transition payment updates. Therefore, we are finalizing the ESRDB market basket update of 3.0 percent, based on the IGI third quarter forecast of the ESRDB market basket. We did not receive any public comments regarding our proposal to continue to use the labor-related shares for the ESRD PPS portion and composite portion of the blended payment during the transition period. Therefore, we are also finalizing the proposal to continue to use the labor-related share of 41.737 percent for the CY 2012 ESRD PPS payment and the labor-related share of 53.711 percent for the CY 2012 ESRD composite rate portion of the blended payment, for those facilities that elected to transition to the bundled ESRD PPS.
The ESRDB market basket must be annually adjusted by changes in economy-wide productivity. Specifically, under section 1881(b)(14)(F) of the Act, as amended by section 3401(h) of the Affordable Care Act, for CY 2012 and each subsequent year, the ESRD market basket percentage increase factor shall be reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act. The statute defines the productivity Start Printed Page 70233adjustment to be equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multifactor productivity (MFP) (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, year, cost reporting period, or other annual period) (the “MFP adjustment”). The BLS is the agency that publishes the official measure of private nonfarm business MFP. Please see http://www.bls.gov/mfp to obtain the BLS historical published MFP data.
CMS notes that the proposed and final methodology for calculating and applying the MFP adjustment to the ESRD payment update is similar to the methodology used in other payment systems, as required by section 3401 of the Affordable Care Act.
The projection of MFP is currently produced by IGI, an economic forecasting firm. In order to generate a forecast of MFP, IGI replicated the MFP measure calculated by the BLS using a series of proxy variables derived from IGI's U.S. macroeconomic models. These models take into account a very broad range of factors that influence the total U.S. economy. IGI forecasts the underlying proxy components such as gross domestic product (GDP), capital, and labor inputs required to estimate MFP and then combines those projections according to the BLS methodology. In Table 1 below, we identify each of the major MFP component series employed by the BLS to measure MFP. We also provide the corresponding concepts forecasted by IGI and determined to be the best available proxies for the BLS series.
IGI found that the historical growth rates of the BLS components used to calculate MFP and the IGI components identified are consistent across all series and therefore suitable proxies for calculating MFP. We have included below a more detailed description of the methodology used by IGI to construct a forecast of MFP, which is aligned closely with the methodology employed by the BLS. For more information regarding the BLS method for estimating productivity, please see the following link: http://www.bls.gov/mfp/mprtech.pdf.
At the time of the development of this CY 2012 final rule, the BLS published a historical time series of private nonfarm business MFP for 1987 through 2010, with 2010 being a preliminary value. Using this historical MFP series and the IGI forecasted series, IGI has developed a forecast of MFP for 2011 through 2021, as described below. We note that the historical MFP series and the IGI forcasted series are updates from those used at the time of the proposed rule (1987 through 2009, and 2010 through 2021, respectively).
To create a forecast of BLS' MFP index, the forecasted annual growth rates of the “non-housing, nongovernment, non-farm, real GDP,” “hours of all persons in private nonfarm establishments adjusted for labor composition,” and “real effective capital stock” series (ranging from 2011 to 2021) are used to “grow” the levels of the “real value-added output,” “private non-farm business sector labor input,” and “aggregate capital input” series published by the BLS. Projections of the “hours of all persons” measure are calculated using the difference between the projected growth rates of real output per hour and real GDP. This difference is then adjusted to account for changes in labor composition in the forecast interval.
Using these three key concepts, MFP is derived by subtracting the contribution of labor and capital inputs from output growth. However, in order to estimate MFP, we need to understand the relative contributions of labor and capital to total output growth. Therefore, two additional measures are needed to operationalize the estimation of the IGI MFP projection: Labor compensation and capital income. The sum of labor compensation and capital income represents total income. The BLS calculates labor compensation and capital income (in current dollar terms) to derive the nominal values of labor and capital inputs. IGI uses the “nongovernment total compensation” and “flow of capital services from the total private non-residential capital stock” series as proxies for the BLS' income measures. These two proxy measures for income are divided by total income to obtain the shares of labor compensation and capital income to total income. In order to estimate labor's contribution and capital's contribution to the growth in total output, the growth rates of the proxy variables for labor and capital inputs are multiplied by their respective shares of total income. These contributions of labor and capital to output growth is subtracted from total output growth to calculate the “change in the growth rates of multifactor productivity:”
MFP = Total output growth − ((labor input growth * labor compensation share) + (capital input growth * capital income share))
The change in the growth rates (also referred to as the compound growth rates) of the IGI MFP are multiplied by 100 in order to calculate the percent change in growth rates (the percent change in growth rates are published by Start Printed Page 70234the BLS for its historical MFP measure). Finally, the growth rates of the IGI MFP are converted to index levels based to 2005 to be consistent with the BLS' methodology. For benchmarking purposes, the historical growth rates of IGI's proxy variables were used to estimate a historical measure of MFP, which was compared to the historical MFP estimate published by the BLS. The comparison revealed that the growth rates of the components were consistent across all series, and therefore validated the use of the proxy variables in generating the IGI MFP projections. The resulting MFP index was then interpolated to a quarterly frequency using the Bassie method for temporal disaggregation. The Bassie technique utilizes an indicator (pattern) series for its calculations. IGI uses the index of output per hour (published by the BLS) as an indicator when interpolating the MFP index.
The comments we received on this proposal and our response are set forth below.
Comment: One commenter stated that the factors used in the productivity adjustor, which are mostly derived from capital and labor related economic measures, are not appropriate for use to modify the market basket costs of drugs, which are consumable items. One commenter further believes that ESRD PPS should be treated differently than other PPS payment systems because drugs represent such a large portion of the overall costs incurred by dialysis services. One pharmaceutical company expressed concern about the proposal to apply the productivity adjustment to the Part D oral drug portion of the blended payment.
Response: In accordance with section 1881(b)(14)(F)(i) of the Act, beginning in 2012, all renal dialysis services included in the ESRD bundle are required to be annually increased by an ESRD market basket increase factor that is reduced by the productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act. Therefore, CMS is statutorily required to update ESRD PPS payments by a market basket update less productivity. We also note that CMS is statutorily required to update the ESRD composite rate portion of the blended payment by the ESRDB market basket less productivity. During the transition, any items or services included in the bundle have been factored into the cost shares for the ESRDB market basket; as such, the costs associated with oral drugs that were formerly paid under Part D are included in the ESRDB market basket cost share weight for drugs. As finalized in the CY 2011 ESRD final rule (75 FR 49156), the market basket drug cost share weight accounts for all drugs included in the ESRD bundled payment, including ESRD-related oral drugs with injectable equivalents that were formerly covered under Medicare Part D as well as the costs associated with any other drugs as reported on the ESRD Medicare Cost Report. In 2014, any changes to the bundle will be factored into a revised ESRDB market basket and be subject to notice and comment rulemaking. Therefore, although drugs account for a larger proportion of expenses in the ESRDB market basket than in some other provider-type PPS market baskets, we will continue to update the ESRD payments as statutorily mandated by the Congress. As such, for CY 2012, the ESRD PPS payment rate and the composite portion of the blended payment will be increased by the estimated market basket update less productivity, 2.1 percent (3.0 percent ESRDB market basket less 0.9 percentage point MFP adjustment), which is described in more detail below.
After careful consideration of the public comments and to satisfy the statutory requirement for ESRD payment updates mentioned above, we are finalizing our proposed method for calculating and applying the MFP adjustment to the ESRDB market basket.
Under section 1881(b)(14)(F)(i) of the Act, beginning in 2012, ESRD PPS payment amounts and the composite rate portion of the transition blended payment amounts shall be annually increased by an ESRD market basket percentage increase factor reduced by a productivity adjustment.
We proposed to estimate the ESRDB market basket percentage for CY 2012 based on the CY 2008-based ESRDB market basket (76 FR 40504). In order to calculate the MFP-adjusted update for the ESRDB market basket during the transition period, we proposed that the MFP percentage adjustment be subtracted from the CY 2012 market basket update calculated using the CY 2008-based ESRDB market basket (75 FR 40504). We proposed that the end of the 10-year moving average of changes in the MFP should coincide with the end of the appropriate CY update period. Since the market basket update is reduced by the MFP adjustment to determine the annual update for the ESRD PPS and the ESRD composite rate portions of the blended payment during the transition, we believe it is appropriate for the numbers associated with both components of the calculation (the market basket and the productivity adjustment) to coincide so that changes in market conditions are aligned. Therefore, for the CY 2012 update, we proposed that the MFP adjustment be calculated as the 10-year moving average of changes in MFP for the period ending December 31, 2012. We proposed to round the final annual adjustment to the one-tenth of one percentage point level up or down as applicable according to conventional rounding rules (that is, if the number we are rounding is followed by 5, 6, 7, 8, or 9, we will round the number up; if the number we are rounding is followed by 1, 2, 3, or 4, we will round the number down).
Thus, in accordance with section 1881(b)(14)(F)(i) of the Act, the proposed market basket increase factor for CY 2012 for the ESRDB market basket was based on the 1st quarter 2011 forecast of the CY 2008-based ESRDB market basket update, which was estimated to be 3.0 percent. This market basket percentage was then reduced by the MFP adjustment (the 10-year moving average of MFP for the period ending CY 2012) of 1.2 percent, which is calculated as described above and based on IGI's 1st quarter 2011 forecast. The resulting proposed MFP-adjusted ESRDB market basket update for CY 2012 was equal to 1.8 percent, or 3.0 percent less 1.2 percent. We proposed that if more recent data were subsequently available (for example, a more recent estimate of the market basket and MFP adjustment), we would use such data, if appropriate, to determine the CY 2012 market basket update and MFP adjustment in the CY 2012 ESRD PPS final rule. Consistent with historical practice and our proposal, we update the market basket increase factor estimate and the MFP adjustment in this final rule to reflect the most recent available data (75 FR 40505).
We received no public comments related to the proposed MFP-adjusted ESRDB market basket update for CY 2012. Therefore, we are finalizing our proposal to base the CY 2012 market basket update, which is used to determine the applicable percentage increase for the ESRD PPS and transition payments, on the most recent data available, which is the third quarter 2011 forecast of the CY 2008-based ESRDB market basket (estimated to be 3.0 percent). The MFP adjustment (the 10-year moving average of MFP for the period ending CY 2012) we are finalizing is 0.9 percent, which was calculated as described above and based on IGI's third quarter 2011 forecast. Start Printed Page 70235Therefore, the final MFP-adjusted ESRDB market basket update for CY 2012 is 2.1 percent (3.0 percent ESRDB market basket less 0.9 percentage point MFP adjustment).
Section 1881(b)(14)(E)(iii) of the Act requires that an adjustment to payments be made for renal dialysis services provided by ESRD facilities during the transition so that the estimated total payments under the ESRD PPS, including payments under the transition, equal the estimated total amount of payments that would otherwise occur under the ESRD PPS without such a transition. In the CY 2011 ESRD PPS final rule, we explained that because we would not know the actual number of ESRD facilities that would elect to opt out of the transition prior to publishing the final rule, we would simulate payments under the existing basic case-mix adjusted composite payment system and under the ESRD PPS to determine how many ESRD facilities we believed would elect to receive payment under 100 percent ESRD PPS. Based on our simulations using 2007 data, we estimated that 43 percent of ESRD facilities would financially benefit from receiving full payment under the ESRD PPS. We indicated that based on the simulation of estimated payments, a 3.1 percent reduction would be applied to all payments made to ESRD facilities for renal dialysis services furnished on January 1, 2011 through December 31, 2011 (75 FR 49082 through 49083).
On April 6, 2011, we published an interim final rule with comment period in the Federal Register (76 FR 18930), entitled “Changes to the End-Stage Renal Disease Prospective Payment System Transition Budget-Neutrality Adjustment”, which revised the ESRD transition budget-neutrality adjustment finalized for CY 2011. In the interim final rule, we indicated that based upon the election data submitted by ESRD facilities, 87 percent of ESRD facilities elected to opt out of the transition. When we applied the actual number of ESRD facilities electing to receive payment under the ESRD PPS, the transition budget-neutrality adjustment was determined to be zero rather than a 3.1 reduction in payments. We revised the 3.1 percent transition budget-neutrality adjustment reduction to a zero percent transition budget-neutrality adjustment for renal dialysis services furnished on April 1, 2011 through December 31, 2011. We also indicated that we would respond to comments submitted on the interim final rule in the CY 2012 ESRD PPS final rule.
We received four comments during the IFC comment period and three comments in response to the CY 2012 ESRD PPS proposed rule. All comments were in support of the revised CY 2011 transition budget-neutrality adjustment factor. Therefore, we are finalizing the revised CY 2011 transition budget-neutrality adjustment factor of zero for ESRD claims for renal dialysis services furnished on April 1, 2011 through December 31, 2011.
Section 1881(b)(14)(E)(i) of the Act requires the Secretary to provide a four-year phase-in of the payments under the ESRD PPS for renal dialysis services furnished on or after January 1, 2011, with payments under the ESRD PPS fully implemented for renal dialysis services furnished on or after January 1, 2014. We use the term “transition” rather than “phase-in” to be consistent with other Medicare payment systems.
Section 1881(b)(14)(E)(ii) of the Act permitted ESRD facilities to make a one-time election to be excluded from the transition. An ESRD facility that elected to be excluded from the transition would receive payment for renal dialysis services provided on or after January 1, 2011, based on 100 percent of the payment rate under the ESRD PPS rather than a blended payment based in part on the payment rate under the basic case-mix adjusted composite payment system and in part on the payment rate under the ESRD PPS. Section 1881(b)(14)(E)(iii) of the Act also requires that we make an adjustment to payments during the transition so that the estimated total amount of payments under the ESRD PPS, including payments under the transition, equals the estimated total amount of payments that would otherwise occur under the ESRD PPS without such a transition. We refer to this provision as the transition budget-neutrality adjustment.
As described in the CY 2011 ESRD PPS final rule (75 FR 49082), the transition budget-neutrality adjustment is comprised of two parts. For the first part, we created a payment adjustment to the composite rate portion of the blended payment during the transition to account for the per treatment costs of drugs that were paid under Part D. For the second part, we computed a factor that would make the estimated total amount of payments under the ESRD PPS, including payments under the transition, equal to the estimated total amount of payments that would otherwise occur without such a transition. In the proposed rule, we addressed both parts of the transition budget-neutrality adjustment (76 FR 40505 and 40506). The first part of the transition budget-neutrality adjustment was addressed in section I.C.1. of this final rule where we address updates to the composite rate and the ESRD PPS base rate.
For the second part of the transition budget-neutrality factor, we first determined the estimated increase in payments under the transition and then determined an offset factor, based on estimates of which facilities would choose to opt out of the transition (for a detailed description, see the CY 2011 ESRD PPS proposed rule, 74 FR 49946). We estimated the number of facilities that would choose to opt out of the transition by comparing payment under the transition to payment under the PPS and choosing the option that was financially beneficial to each facility. Using that approach, we estimated that 43 percent of facilities would choose to opt out of the transition and determined the transition budget-neutrality adjustment to be a reduction of 3.1 percent. In the April 6, 2011 interim final rule with comment (76 FR 18930 through 18934), however, we updated the number of facilities that chose to opt out of the transition to 87 percent, based on actual election data that we received and recalculated a transition budget-neutrality adjustment of zero percent.
Given that the transition budget-neutrality adjustment required under section 1881(b)(14)(A)(ii) of the Act applies in each year of the transition, we must update the transition budget-neutrality adjustment for CY 2012. In the proposed rule (76 FR 40506), we noted that we were not proposing for CY 2012 to change the methodology used to calculate the second part of the budget-neutrality adjustment. However, we proposed to use more updated data. In order to ensure that total payments under the transition equal total payment amounts without a transition, we would reduce all payments to ESRD facilities in CY 2012 by a factor that is equal to 1 minus the ratio of estimated payments under the ESRD PPS if there were no transition to the total estimated payments under the transition.
In the proposed rule, we explained that we started with 2009 utilization data from claims, as 2009 was the latest complete year of claims data available of complete claims data. In this final rule, we used 2010 claims as it is the latest available year. Using price growth factors for CY 2011 and CY 2012 that are discussed in the impact analysis in section I.VII.B.1 of this final rule, we updated the CY 2010 utilization data to Start Printed Page 70236CY 2011 and CY 2012 payments. We then took the estimated CY 2012 payments under the full ESRD PPS and the blended payments under the transition based on actual facility election data and compared these estimated payments to the total estimated payments in CY 2012 as if all facilities had elected to receive payment under the full ESRD PPS. We then calculated the transition budget-neutrality factor to be 1 minus the ratio of estimated payments under the ESRD PPS if there were no transition to the total estimated payments under the transition, which results in zero percent. Therefore, for CY 2012, we proposed that a zero percent reduction to all payments would be made to ESRD facilities (that is, the zero percent adjustment would be applied to both the blended payments under the transition and payments made under the 100 percent ESRD PPS). We solicited comments on the proposed second part of CY 2012 transition budget-neutrality adjustment methodology. The comments and our responses are set forth below.
Comment: Several national associations and one dialysis organization supported the zero percent transition budget-neutrality adjustment for CY 2012. One commenter indicated that the proposed rule appropriately reflected that a greater percentage of ESRD facilities than estimated elected to receive payment under the ESRD PPS.
Response: We thank the commenters for their support. Therefore, in this final rule, we are finalizing the proposed second part of the transition budget-neutrality adjustment and the zero percent budget-neutrality adjustment for CY 2012.
Section 1881(b)(14)(D)(iii) of the Act requires a low-volume payment adjustment that “reflects the extent to which costs incurred by low-volume facilities (as defined by the Secretary) in furnishing renal dialysis services exceed the costs incurred by other facilities in furnishing such services, and for payment for renal dialysis services furnished on or after January 1, 2011, and before January 1, 2014, such payment adjustment shall not be less than 10 percent”. We established the low-volume payment adjustment, including the methodology we used to develop the low-volume treatment threshold in the CY 2011 ESRD PPS final rule (75 FR 49117 through 49125). Because the analysis included data that spanned a 3-year period, we defined a low-volume ESRD facility as a facility that is able to maintain its low-volume status each year of the 3-year period. This timeframe provided us with a sufficient span of time to view consistency in business operations through the data. Under 42 CFR 413.232(b), a low-volume facility is an ESRD facility that: (1) Furnished less than 4,000 dialysis treatments in each of the 3 years preceding the payment year and (2) has not opened, closed, or received a new provider number due to a change in ownership during the 3 years preceding the payment year. Under § 413.232(c), the number of treatments shall be equal to the aggregate number of treatments furnished by other ESRD facilities that are both under common ownership and 25 road miles or less from the ESRD facility in question. This geographic proximity criterion is only applicable to ESRD facilities that are Medicare certified on or after January 1, 2011. Section 413.232(f) requires an ESRD facility to provide an attestation statement to their respective fiscal intermediary or Medicare administrative contractor (FI/MAC) that the facility meets all the criteria in order to receive the low-volume adjustment. We note that furnishing 4,000 treatments in a year equates to approximately 25 patients per year receiving three dialysis treatments a week (or hemo-equivalent treatments).
In the proposed rule, we discussed § 413.232 and clarified that the “payment year” is the period of time that we use for determining payment to ESRD facilities, which is a calendar year, and that eligibility years mean the 3 years preceding the payment year and are based on cost reporting years (76 FR 40506). We made this clarification to ensure that ESRD facilities and their respective FI/MACs understand the distinction between eligibility (which is based on cost reporting years) and the payment year (when ESRD facilities can begin to receive the low-volume payment adjustment).
We did not seek comments on the clarifications of the payment and cost report years, however, we received three comments indicating the clarifications were helpful.
In the proposed rule (76 FR 40506 and 40507), we proposed to establish the process for CY 2012 and each year thereafter, that an ESRD facility would be required to follow when submitting its attestation to notify its FI/MAC that it is eligible for the low-volume payment adjustment. We further explained that the attestation is required because: (1) ESRD facility's cost reporting periods vary and may not be based on the calendar year; and (2) the cost reports are due 5 months after the close of the cost reporting period (that is, there is a lag in the cost reporting submission). Thus, the FI/MACS may not have the cost report for the third year to determine eligibility and would need to rely on the attestation for that year. We proposed that if an ESRD facility believes that it is eligible for the low-volume adjustment, the ESRD facility would be required to submit an attestation to its respective FI/MAC no later than November 1st of each year, and proposed to amend the regulation text at § 413.232(f) (76 FR 40507). We noted that this timeframe provides 60 days for a FI/MAC to verify the cost report information and update the systems (76 FR 40507). We explained that if ESRD facilities are receiving the low-volume adjustment for the CY 2011 payment year, those ESRD facilities should submit another attestation to their respective FI/MAC no later than November 1, 2011, to qualify for the low-volume adjustment for the CY 2012 payment year. An ESRD facility must continue to attest that it is a low-volume facility for each subsequent payment year it believes it is eligible for the low-volume facility adjustment.
We explained that if the FI/MAC does not receive an ESRD facility's attestation stating that the ESRD facility is eligible for the low-volume adjustment on or before November 1 prior to the payment year, the ESRD facility would not receive the low-volume adjustment for that payment year. We also noted that in the event a dialysis organization submits the low-volume attestation on behalf of its ESRD facilities, the dialysis organization will be required to identify each ESRD facility by name and provider number and submit them by the November 1 deadline.
We solicited comment on our proposal and the proposed regulation text changes at § 413.232(f).
We did not receive any comments and, therefore, in this final rule, we are finalizing a yearly November 1 deadline for attestation submission and we are revising the regulation at § 413.232(f) to reflect this date for CY 2012 and each year thereafter. However, because the CY 2012 final rule will not be effective before November 1, 2011, we are finalizing a later low-volume attestation submission deadline of January 3, 2012, for attestations that pertain to the CY 2012 low-volume adjustment. We believe this due date provides facilities sufficient time to submit an attestation and allows the agency (that is, the FI/MACs) time to process submissions. In addition, a later date is not possible since the CY 2012 payment year will be underway. Accordingly, we also are Start Printed Page 70237revising the regulation at § 413.232(f) to reflect this change.
In the proposed rule, we indicated that the ESRD facility's cost reports for the cost reporting periods ending in the 3 years immediately preceding the payment year must report costs for 12-consecutive months (76 FR 40507). For example, an FI/MAC should not consider a short period cost report (that is, reporting costs for less than 12 months which may occur for new facilities or facilities under new ownership), for low-volume eligibility. Specifically, when an ESRD facility is assessing its eligibility for the low-volume adjustment and preparing its attestation, the ESRD facility should look at its 12-consecutive month cost reports for the cost reporting periods that end in the 3 years immediately preceding the payment year.
As we indicated previously, the FI/MAC may not have a final-settled cost report for all 3 years needed to complete the ESRD facility's verification and we provided examples of such situations (76 FR 40507). Therefore, we proposed to amend the regulations at § 413.232(b)(1) and (b)(2) to clarify the meaning of year with regard to the treatment threshold that is used for determining low-volume eligibility and how it relates to the payment year. This proposed change to the regulations would make clear that the ESRD facility's cost reports for the 3 years immediately preceding the payment year must report costs for 12-consecutive months, and provide clarification that in the absence of an ESRD facility's final settled cost report, an FI/MAC can review the ESRD facility's as-filed cost report when determining if an ESRD facility meets the low-volume criteria. We believe that it is appropriate for the FI/MAC to determine eligibility based upon an as-filed cost report because the number of total treatments should not change between submission of the as-filed cost report and the final settled cost report. We solicited comment on the proposed changes at § 413.232(b)(1) and (b)(2). We did not receive any comments and, therefore, we are finalizing these proposed changes to the regulation at § 413.232(b)(1) and (b)(2).
In the proposed rule, we explained that if an FI/MAC receives an ESRD facility's attestation stating that the ESRD facility believes that it qualifies for the low-volume payment adjustment and then finds that the ESRD facility did not meet the low-volume criteria, the FI/MAC will discontinue application of the low-volume adjustment (76 FR 40508). If the ESRD facility does not remain low-volume for each of the 3 years (12-consecutive month cost reporting periods) immediately preceding the payment year, the ESRD facility is not eligible for the low-volume adjustment until it can demonstrate again that for 3 years (12-consecutive month cost reporting periods) it has met the low-volume criteria. The comments we received and our responses are set forth below.
Comment: One independent ESRD facility asked if an ESRD facility was determined not to qualify for the low-volume adjustment, would the low-volume adjustment be discontinued without payment implication.
Response: Medicare is obligated to provide appropriate payment. If an ESRD facility has not met the eligibility requirements as described in 42 CFR 413.232, the ESRD facility would not be entitled to receive the low-volume adjustment and the inappropriate low-volume payments made in that payment year would be recouped.
Comment: One commenter indicated that in the CY 2011 ESRD PPS final rule, we defined a low-volume facility at § 413.232(b)(2) as an ESRD facility that has not opened, closed, or received a new provider number due to a change in ownership during the 3 years preceding the payment year (75 FR 49118). The commenter pointed out that in the CY 2011 ESRD PPS final rule we did not finalize the phrase, “or received a new provider number due to a change in ownership” in the regulation text at § 413.232(b)(2) and in our discussion of the definition of a low-volume facility in this year's proposed rule we only referred to the phrase, “or had a change in ownership” (76 FR 40507). The commenter is concerned that if we do not include the phrase, “or received a new provider number due to a change in ownership” in the regulation text at § 412.232(b)(2) that it will negatively impact new owners of underperforming clinics that would otherwise wish to apply for the low-volume designation.
Response: We agree with the commenter that in the CY 2011 final rule we inadvertently omitted the phrase, “or received a new provider number due to a change in ownership” in the regulation text finalized at § 413.232(b)(2). In the preamble of both the CY 2011 ESRD PPS proposed and final rules (74 FR 49118 through 49919, 74 FR 49975), we made clear that under § 413.232(b), a low-volume facility is defined as an ESRD facility that “has not opened, closed, or received a new provider number due to a change of ownership * * *”; however, we inadvertently omitted language from the regulation (74 FR 50024, 74 FR 49200). Therefore, in this final rule, we are making a technical correction to the regulation text at § 413.232(b)(2) to reflect that a low-volume facility is an ESRD facility that has not open, closed, or received a new provider number due to a change in ownership in the 3 years preceding the payment year.
Comment: One independent ESRD facility questioned the policy that ESRD facilities must remain low volume (that is, provide less than 4,000 dialysis treatments) for three years immediately preceding the payment year or risk not qualifying for the low-volume adjustment until it can once again demonstrate it is low volume for three consecutive years. The commenter further stated that many small or rural dialysis facilities provide the only access to care in a geographic area and this policy requires the established low-volume facility to choose between providing access to care and significant, long term payment reductions. The commenter further stated that this policy could result in dialysis facilities denying care to avoid crossing the 4,000 threshold. The commenter suggested that CMS consider reducing the eligibility timeline for small facilities that have met the low-volume eligibility criteria so that they could re-qualify for the low-volume adjustment in the following year if their treatments returned to less than 4,000 per year.
Response: We do not agree with the commenter's assertion of the negative effects of the low-volume eligibility criteria. The low-volume adjustment is intended for ESRD facilities that are located in areas that have a population base resulting in less than 4,000 treatments per year and is not intended to account for fluctuations or business decisions that increase or decrease the number of treatments that can or would be provided. We do not believe that these fluctuations or changes in the population from year to year would in most circumstances result in a facility not being eligible for the low-volume adjustment. As we indicated in the CY 2011 ESRD PPS final rule (75 FR 49118 and 49119), we believe the low-volume adjustment should encourage small ESRD facilities to continue to provide access to care, but are concerned about potential disincentives that low-volume facilities could have regarding patient care. We are monitoring the number of facilities that are receiving the low-volume adjustment. Any changes in the low-volume methodology will be discussed in future rulemaking.
As for allowing facilities that lose low-volume status to requalify for low-volume status the next year, any changes in the low-volume eligibility Start Printed Page 70238criteria would be addressed in future rulemaking.
Section 1881(b)(14)(E)(i) of the Act requires a four-year transition under the ESRD PPS. Under § 413.239, ESRD facilities were permitted to make a one-time election by November 1, 2011, to be excluded from the transition and receive full payment under the ESRD PPS. Under § 413.239, in CY 2012, ESRD facilities that elected to receive payment under the transition will be paid a blended amount that will consist of 50 percent of the basic case-mix adjusted composite payment system and 50 percent on the ESRD PPS payment. Thus, we must continue to update the composite rate portion of the blended payment amount during the ESRD PPS 4-year transition (CYs 2011 through 2013), which includes an update to the drug add-on.
Under section 1881(b)(12) of the Act, the basic case-mix adjusted composite payment system includes the services comprising the composite rate and an add-on to the composite rate component to account for the difference between pre-MMA payments for separately billed drugs and the revised drug pricing specified in the statute. For the drug add-on for CY 2012 (76 FR 40508 and 40509), we did not propose any changes to the methodology, but merely updated the data used in computing the drug add-on as described below.
Section 1881(b)(12)(F) of the Act specifies that the drug add-on increase must reflect “the estimated growth in expenditures for drugs and biologicals (including erythropoietin) that are separately billable * * *”. By referring to “expenditures”, we believe the statute contemplates that the update would account for both increases in drug prices, as well as increases in utilization of those drugs.
To account for increases in drug prices and utilization, we used the 5 years of drug expenditure data based on ASP pricing and proposed to use this data for trend analysis (76 FR 40508). We then removed growth in enrollment for the same time period from the expenditure growth so that the residual reflects the per patient expenditure growth (which includes price and utilization combined).
To estimate drug expenditure growth using trend analysis for CY 2012, we looked at the average annual growth in total drug expenditures between 2006 and 2010. First, we estimated the total drug expenditures for all ESRD facilities in CY 2010. We used the final CY 2006 through CY 2009 ESRD claims data and the latest available CY 2010 ESRD facility claims, updated through December 31, 2010 (that is, claims with dates of service from January 1 through December 31, 2010, that were received, processed, paid, and passed to the National Claims History File as of December 31, 2010). We indicated that for this final rule, we intended to use additional updated CY 2010 claims with dates of service for the same timeframe (76 FR 40508). This updated CY 2010 data file would include claims received, processed, paid, and passed to the National Claims History File as of June 30, 2011.
We inflated the CY 2010 drug expenditures to estimate the June 30, 2011 update of the 2010 claims file. The net adjustment to the CY 2010 claims data was an increase of 11.62 percent to the 2010 expenditure data, which allowed us to more accurately compare the 2009 and 2010 drug expenditure data to estimate per patient growth. Next, we calculated the average annual change in drug expenditures from 2006 through 2010. This average annual change showed an increase of 1.4 percent in drug expenditures from 2006 through 2010 (76 FR 40508). We used this 1.4 percent increase to project drug expenditures for both 2011 and 2012.
For the final rule, using the full-year 2010 drug expenditure figure, we calculated the average annual change in drug expenditure from 2006 through 2010. This average annual change showed an increase of 1.0 percent in drug expenditures from 2006 through 2010. We used this 1.0 percent increase to project drug expenditures for both 2011 and 2012. We note, the change in the drug expenditures increase is a result of updated data.
In the proposed rule, we explained that once we had the projected growth in drug expenditures from 2011 to 2012, we calculated per patient growth between CYs 2011 and 2012 by removing the estimated growth in enrollment data between CY 2011 and CY 2012 (76 FR 40508). We estimate a 4.2 percent estimated growth in enrollment between CY 2011 and CY 2012. To obtain the per-patient estimated growth in expenditures, we divided the total drug expenditure change between 2011 and 2012 (1.014) by enrollment growth of 4.2 percent (1.042) for the same timeframe. The result was a per-patient growth factor equal to 0.973 (1.014/1.042 = 0.973). Thus, we projected a 2.7 percent decrease (2.7 percent = .027 = 0.973−1) in per patient growth in drug expenditures between 2011 and 2012.
For this final rule, we estimate a 4.3 percent estimated growth in enrollment between CY 2011 and CY 2012. To obtain the per-patient estimated growth in expenditures, we divided the total drug expenditure change between 2011 and 2012 (1.010) by enrollment growth of 4.3 percent (1.043) for the same timeframe. The result is a per-patient growth factor equal to 0.968 (1.010/1.043 = 0.968). Thus, in this final rule, for CY 2012 we are projecting a 3.2 percent decrease (−3.2 percent = 1.010/1.043−1 = 0.968−1) in per patient growth in drug expenditures between 2011 and 2012.
In the CY 2006 PFS final rule (71 FR 69683), we applied the projected growth update percentage to the total amount of drug add-on dollars established for CY 2005 to establish a dollar amount for the CY 2006 growth update. In addition, we projected the growth in dialysis treatments for CY 2006 based on the projected growth in ESRD enrollment. We divided the projected total dollar amount of the CY 2006 growth by the projected growth in total dialysis treatments to develop the per treatment growth update amount. This growth update amount, combined with the CY 2005 per treatment drug add-on amount, resulted in an average drug add-on amount per treatment of $18.88 (or a 14.5 percent adjustment to the composite rate) for CY 2006.
In the CY 2007 PFS final rule with comment period (71 FR 69684), as a result of public comments, we revised our update methodology by applying the growth update to the per treatment drug add-on amount. That is, for CY 2007, we applied the growth update factor of 4.03 percent to the $18.88 per treatment drug add-on amount resulting in an updated per treatment drug add-on amount of $19.64 per treatment (71 FR 69684). For CY 2008, the per treatment drug add-on amount was updated to $20.33. In the CY 2009, 2010 and 2011 PFS final rule with comment period (73 FR 69755 through 69757, 74 FR 61923, and 75 FR 73485, respectively), we applied a zero update to the per treatment drug add-on amount resulting in a per treatment drug add-on amount of $20.33. As discussed in detail below, in this final rule, for CY 2012, we are finalizing a zero update to the per treatment drug add-on amount of $20.33 established in CY 2008.Start Printed Page 70239
We estimated a 1.4 percent increase in drug expenditures between CY 2011 and CY 2012 (76 FR 40509). Combining this increase with a 4.2 percent increase in enrollment, as described above, we projected a 2.7 percent decrease in per patient growth of drug expenditures between CY 2011 and CY 2012. Therefore, we projected that the combined growth in per patient utilization and pricing for CY 2012 would result in a decrease to the drug add-on equal to 0.4 percentage points. This figure was derived by applying the 2.7 percent decrease to the CY 2011 drug add-on of $20.33. This resulted in a revised drug add-on of $19.78, which is 14.0 percent of the proposed CY 2012 base composite rate of $141.52. If we were to apply no decrease to the drug add-on of $20.33, this would result in a 14.4 percent drug add-on. However, similar to last year and as indicated above, we proposed a zero update to the drug add-on adjustment. We explained in the proposed rule that we believed this approach is consistent with the language under section 1881(b)(12)(F) of the Act, which states in part that “the Secretary shall annually increase” the drug add-on amount based on the growth in expenditures for separately billed ESRD drugs. Our understanding of the statute contemplates “annually increase” to mean a positive or zero update to the drug add-on. Therefore, we proposed to apply a zero update and maintain the $20.33 per treatment drug add-on amount for CY 2012. The comments and our responses are set forth below.
Comment: Two commenters supported our proposed zero drug-add.
Response: We thank the commenters for their support.
Comment: One commenter indicated that ESA usage is overstated in 2006 through 2010 and that this would have an effect on the drug add-on and the ESRD PPS base rate calculations. The commenter recommended that we develop an ESA adjuster for the ESRD PPS base rate.
Response: We used the best available data to compute the drug add-on and the base rate. We continue to believe that the information on ESRD claims represent the best information currently available to the agency. Because we are required under section 1881(b)(14)(A)(ii) of the Act to use the lowest utilization year (which we determined to be 2007), we did not have discretion on the data we used in calculating the ESRD PPS base rate. We note that it is common for utilization of services to change after implementation of a PPS. That is why we periodically review our payment systems to determine if a refinement is warranted. In addition, if we were to adjust for ESA over usage in computing the drug add-on, this would lower the trend and the drug add-on would become more negative. As we discussed above, section 1881(b)(12)(F) of the Act, precludes a reduction of the drug add-on because the statute requires that we annually increase the drug add-on.
In this final rule, for CY 2012, we estimate a 1.0 percent increase in drug expenditures between CY 2011 and CY 2012. Combining this increase with a 4.3 percent increase in enrollment, we project a 3.2 percent decrease in per patient growth of drug expenditures between CY 2011 and CY 2012. Therefore, we project that the combined growth in per patient utilization and pricing for CY 2012 would result in a decrease to the drug add-on equal to 0.4 percentage points. This figure is derived by applying the 3.2 percent decrease to the CY 2011 drug add-on of $20.33. This results in a revised drug add-on of $19.69, which is 13.9 percent of the final CY 2012 base composite rate of $141.94. If we were to apply no decrease to the drug add-on of $20.33, this would result in a 14.3 percent drug add-on. Similar to last year and as discussed above, for CY 2012, we are finalizing a zero update to the drug add-on and maintaining the $20.33 per treatment drug add-on amount.
The current $20.33 per treatment drug add-on reflected a 14.7 percent drug add-on adjustment to the composite rate in effect for CY 2011. Using the latest ESRDB market basket minus productivity adjustment to update the composite rate portion of the ESRD PPS payment (forecast of 2.1 percent in 2012 effective January 1, 2012, as discussed in section I.B.2.b. of this final rule), results in a decrease to the CY 2012 drug add-on adjustment from 14.7 to 14.3 percent in order to maintain the drug add-on at $20.33. This decrease occurs because the drug add-on adjustment is a percentage of the composite rate. Since the final CY 2012 composite rate is higher than the CY 2011 composite rate, and since the drug add-on remains at $20.33, the percentage decreases. Therefore, we are finalizing for CY 2012 the drug add-on adjustment of 14.3 percent to the composite rate.
Section 1881(b)(14)(D)(iv)(II) of the Act provides that the ESRD PPS may include such other payment adjustments as the Secretary determines appropriate, such as a payment adjustment by a geographic wage index, such as the index referred to in section 1881(b)(12)(D) of the Act. In the CY 2011 ESRD PPS final rule (75 FR 49117 through 49117) and CY 2011 PFS final rule (75 FR 73486), we finalized the wage index policy under the ESRD PPS. Specifically, under the ESRD PPS, we have adopted the same method and source of wage index values used previously for the basic case-mix adjusted composite payment system.
We use the Office of Management and Budget's (OMB's) Core Based Statistical Area (CBSA)-based geographic area designations to define urban and rural areas and corresponding wage index values (76 FR 40509). In addition, the wage index values used under the ESRD PPS are the inpatient prospective payment system (IPPS) wage index values calculated without regard to geographic reclassifications authorized under sections 1881(d)(8) and (d)(10) of the Act, and utilize pre-floor hospital data that are unadjusted for occupational case mix. The CBSA-based geographic area designations are described in OMB Bulletin 03-04, originally issued June 6, 2003, and are available online at http://www.whitehouse.gov/omb/bulletins/b03-04.html. In addition, OMB has published subsequent bulletins regarding CBSA changes, including changes in CBSA numbers and titles. All ESRD rules and notices are considered to incorporate the CBSA changes published in the most recent OMB bulletin that applies to the hospital wage index used to determine the current ESRD wage index. The OMB bulletins may be accessed online at http://www.whitehouse.gov/omb/bulletins/index.html.
Under the ESRD PPS, we adopted a wage index floor during the transition, though we intended to gradually reduce the ESRD wage index floor (76 FR 40509, 75 FR 49117, 75 FR 73486). In the proposed rule (76 FR 40502-40503), we did not propose any changes to the labor-related share for the ESRD PPS and the composite rate portion of the blend and proposed to continue to use a labor-related share of 41.737 percent for CY 2012 for the ESRD PPS. If an ESRD facility elected to transition to the PPS, the labor-related share for the Start Printed Page 70240composite rate portion of the blended payment is 53.711 percent. We proposed to continue to use the labor-related share of 53.711 percent for the composite rate portion of the blended payment for all the years of the transition. As discussed in section I.2.b of this final rule, we finalized the proposed labor-related share for the ESRD PPS and the composite rate portion of the blended payment. Finally, the wage data used to construct the wage index under the ESRD PPS is updated annually, based on the most current data available and based on OMB's definitions and corresponding wage index values.
As we previously indicated, because ESRD facilities could elect to receive a blended payment during the transition, we continue to update the composite rate portion of the ESRD PPS blended payment, including adjusting payments for geographic differences in area wage levels (76 FR 40509, 75 FR 40163). We did not propose any changes to the methodology for the wage index used to adjust the composite rate portion of the ESRD PPS blended payment. However, we did propose to update the wage index values and the wage index budget-neutrality adjustment factor for CY 2012. We did not receive any comments pertaining to our proposal to update the wage index values and the wage index budget-neutrality adjustment factor for CY 2012 for the composite rate portion of the blended payment under the transition. Consequently, we are finalizing our proposal.
Although we did not propose to make any changes to the methodology for updating the CY 2012 wage index under the ESRD PPS (that is, for full ESRD PPS payments and the ESRD PPS portion of the blended payment under the transition), we did propose a wage index budget-neutrality adjustment factor to be applied in CY 2012 and in subsequent years for the ESRD PPS (76 FR 40509).
We received one comment as set forth below.
Comment: One independent ESRD facility indicated that it based its decision to receive payment under the transition because the CY 2011 composite rate wage index value for the facility's area was higher than the wage index value for the ESRD PPS. The commenter stated that the higher composite rate wage index would be beneficial to those facilities that opted to receive payment under the transition. The commenter indicated that the variances between the CY 2012 proposed composite rate and ESRD PPS wage index values are not as great as compared to the CY 2011 variance, which was not anticipated by the commenter at the time the election was made to transition into the ESRD PPS and stated that this is not beneficial for those dialysis facilities transitioning to the ESRD PPS.
Response: The commenter is correct that the differences in the CY 2012 composite rate and ESRD PPS wage index values in the proposed rule are not as significant as they were in the CY 2011 ESRD PPS final rule. The principle reason for the differences in the composite rate and ESRD PPS wage index values in the CY 2011 final rule is that the wage index budget neutrality adjustment was applied to the composite rate values, while budget neutrality for the ESRD PPS was achieved through the overall 98 percent budget-neutrality requirement (76 FR 40510). The reason the variances between the CY 2012 proposed composite rate and ESRD PPS wage index values are less pronounced is because the proposed wage index budget-neutrality adjustment for CY 2012 for the composite rate portion of the blended payment is lower than the budget-neutrality adjustment factor for CY 2011. As we discussed above, in detail and in section I.C.1 of this final rule, the wage index budget-neutrality adjustment for the ESRD PPS and the ESRD PPS portion of the blended payment is not applied to the wage index values, but rather to the ESRD PPS base rate. Therefore, the variance described by the commenter is related solely to the wage index budget-neutrality adjustment for the composite rate portion of the blended payment. A comparison to the ESRD PPS wage index value is not appropriate because the composite rate wage index has a wage index budget-neutrality adjustment applied while the ESRD PPS wage index does not.
Since we did not receive any comments pertaining to our proposals regarding the method of applying the wage index budget-neutrality adjustment, that is, applying the wage index budget-neutrality adjustment to the wage index values for the composite rate portion of the blended payment and applying the wage index budget-neutrality adjustment to the ESRD PPS base rate for the PPS portion of the blended payment and the ESRD PPS payment, and for the reasons we discussed previously, we are finalizing those policies.
The wage index floor for CY 2011 is 0.600 (75 FR 49116 and 49117 and 75 FR 73487). For CY 2012 and CY 2013, we proposed to continue to reduce the wage index floor by 0.05 for each of the remaining years of the transition (that is, for CY 2012, the wage index value would be reduced from 0.600 to 0.550, and further reduced to 0.500 for CY 2013) (76 FR 40510). The ESRD wage index floor value of 0.550 would be applied to areas with wage index values that are below the proposed wage index floor. Beginning January 1, 2014, we proposed that the wage index floor would no longer be applied because the wage index floor would be lower than areas with low wage index values. In the CY 2012 ESRD PPS proposed rule, we stated that we continue to believe that a gradual reduction in the floor is needed to support continuing patient access to dialysis in areas that have low wage index values, especially in areas where the wage index values are below the current wage index floor—specifically, ESRD facilities located in Puerto Rico (76 FR 40510). We solicited comments on the proposal to continue to gradually reduce the wage index floor in CYs 2012 and 2013 and, the elimination of the floor in CY 2014. The comments we received and our responses are set forth below.
Comment: Three commenters responded regarding our proposal to reduce and eventually eliminate the wage index floor. One commenter requested that the wage index floor be maintained for rural dialysis facilities due to their higher staffing costs, which could aggravate disparities in care and might impair access to care in rural areas. One independent ESRD facility indicated that the reduction of the wage index floor threatens facilities with low wage index values and may result in access to care problems. One ESRD organization requested that we reconsider establishing a wage index floor after the transition because the commenter believes that eliminating the floor would be detrimental to small dialysis organizations (SDOs). The commenter also stated that some small facilities are located in a single community and, as such, are not able to spread their operating costs as larger organizations. The commenter further stated that these facilities are in parts of the country where the wage index is lowest, and the absence of a floor threatens their survival and negatively impacts access to care.
Response: In the proposed rule, we proposed to reduce the floor by 0.05 for CYs 2012 and 2013 and to eliminate the floor beginning in 2014 (76 FR 40509 through 40510). We have been reducing the wage index floor since CY 2006 when ESRD facilities began to transition Start Printed Page 70241to the CBSAs and the wage index floor was 0.900 (70 FR 45799). We have reduced the wage index floor by 0.05 each year since then. In CY 2011, the floor is 0.600 and only impacts ESRD facilities located in Puerto Rico, because no other ESRD facilities are located in areas with a wage index value below 0.600. This is also the case in CY 2012, when the 0.05 reduction will bring the floor to 0.550. We continue to believe that artificially adjusting wage index values by substituting a wage index floor is not an appropriate method to address low wages in certain geographic locations. However, we are willing to take the points made by the commenters into consideration for future rulemaking with regard to the issue of eliminating the wage index floor in the future.
With regard to the comment that small facilities are located in areas with the lowest wage index values and the negative effects of eliminating the floor, we note that the commenter is located in West Virginia and in CY 2011, has a wage index value of 0.7055, well above the wage index floor of 0.600. Therefore, the reduction of the floor does not impact this provider. With regard to areas that are impacted by the reduction of the wage index floor (that is Puerto Rico), we note that the overall impact (discussed in section VII.B of this final rule) of the changes in the outlier policy discussed in section I.C.10 of this final rule and the wage index results in a 0.3 percent increase in estimated payments. Therefore, we do not believe that ESRD facilities will be negatively impacted by the reduction in the wage index floor. We note that the wage index values reflects\ hospital wages, unadjusted for occupational mix. Therefore, we believe it reflects ESRD facility staff wages. With regard to the comment that some small facilities are located in a single community and, as such, are not able to spread their operating costs as larger organizations can, we do not understand the relationship between the wage index floor and limitations a facility may have to spread its operating costs.
After considering the comments received, we are finalizing the 0.05 reduction to the wage index floor for CYs 2012 and 2013, resulting in a wage index floor of 0.550 and a wage index floor of 0.500, respectively. Although we continue to believe that artificially adjusting the wage index value using a floor, which does not reflect actual wages paid in that area, we will reconsider the floor in CY 2014.
In CY 2006, while adopting the CBSA designations for the basic case-mix adjusted composite payment system, we identified a small number of ESRD facilities in both urban and rural areas where there are no hospital data from which to calculate wage index values. Since there were ESRD facilities in these areas, we developed policies for each of these areas. In the CY 2011 ESRD PPS final rule (75 FR 49117), we finalized the methodology we have used for urban areas with no hospital data, that is, we compute the average wage index value of all urban areas within the State and use that value as the wage index. We also finalized the methodology established for rural areas with no hospital data originally adopted in the CY 2008 PFS final rule (72 FR 66283), in which we computed the wage index using the average wage index values from all contiguous CBSAs to represent a reasonable proxy for that rural area. For rural Massachusetts, we determined that the borders of Dukes and Nantucket Counties are continguous with Barnstable and Bristol counties. Under the methodology, the values for these counties are averaged to establish the wage index value for rural Massachusetts. For rural Puerto Rico, we finalized a policy to use the wage index floor as the wage index value, since all rural Puerto Rico areas were subject to the floor.
In the proposed rule, we did not propose to change these methodologies. We proposed for CY 2012 and for future years, to continue to use the methodologies we adopted for establishing wage index values in both urban and rural geographic areas where there are no hospital wage data from which to calculate wage index values for ESRD facilities (76 FR 40510).
We did not receive any comments on our proposed methodology for computing a wage index value for areas without hospital data for urban and rural geographic areas, or for Puerto Rico. Therefore, for CY 2012 and future years, we are finalizing our methodologies for computing a wage index value for areas without hospital data for urban and rural geographic areas and for Puerto Rico. For urban areas, we will compute the average wage index value of all urban areas within the State; for rural areas, we will compute the wage index using the average wage index values from all contiguous CBSAs; and for rural Puerto Rico, we will use the wage index floor.
We have broad discretion under section 1881(b)(14)(D)(iv)(II) of the Act to develop a geographic wage index. In addition, that section cites the wage index under the basic case-mix adjusted composite payment system as an example. We have previously interpreted the statute for the basic case-mix adjusted composite payment system (section 1881(b)(12)(D) of the Act) as requiring that the geographic adjustment be made in a budget-neutral manner. In CY 2011, we did not apply a wage index budget-neutrality adjustment factor under the ESRD PPS because budget-neutrality was achieved through the overall 98 percent budget-neutrality requirement in section 1881(b)(14)(A)(ii) of the Act.
Given our authority to develop a wage index under section 1881(b)(14)(D)(iv)(II) of the Act, as well as the authority to use the geographic index under section 1881(b)(12)(D) of the Act, we proposed to apply the wage index in a budget-neutral manner under the ESRD PPS using a wage index budget-neutrality adjustment factor (76 FR 40510). However, as we discuss in greater detail below, we proposed that under the ESRD PPS, we would apply the wage index budget-neutrality adjustment factor to the ESRD PPS base rate.
Under the basic case-mix adjustment composite payment system, we began applying the wage index budget-neutrality adjustment factor in CY 2006 (70 FR 70171). During the ESRD PPS transition, we proposed to continue to apply the wage index budget-neutrality adjustment to the wage index values for the composite rate portion of the ESRD PPS blended payment for CYs 2012 and 2013 (76 FR 40510). We noted that continuing to apply the budget-neutrality adjustment to the wage index for the composite rate portion of the ESRD PPS blended payment allows ESRD facilities going through the transition to continue to use a methodology to which they are accustomed.
However, under the ESRD PPS, we believed that applying the wage index budget-neutrality adjustment factor to the ESRD PPS base rate would be consistent with the application of the wage index budget-neutrality adjustment factor in other prospective payment systems. We also believed that applying the wage index budget-neutrality adjustment factor to the ESRD PPS base rate is simpler and more straightforward in application and calculation. Applying the wage index budget-neutrality adjustment factor to the ESRD PPS base rate produces results that are not measurably different from applying the adjustment factor to the wage index, as is done for the composite rate portion of the blended payment during the transition. We sought Start Printed Page 70242comment on our proposal to apply the wage index budget-neutrality adjustment factor to the ESRD PPS base rate for purposes of the ESRD PPS payments and the ESRD PPS component of the blended payments during the transition.
We did not receive any comments on our proposal to apply the wage index budget-neutrality adjustment to the ESRD PPS base rate and to continue to apply the wage index budget-neutrality adjustment to the wage index values for the composite rate portion of the blended payment. Therefore, for CY 2012 and subsequent years, we are finalizing our proposal to apply the wage index budget-neutrality adjustment factor to the ESRD PPS base rate for the purposes of the ESRD PPS payments and the ESRD PPS portion of the blended payment during the transition. We are also finalizing our proposal to continue to apply the wage-index budget-neutrality adjustment factor directly to the ESRD wage index values for the composite rate portion of the blended payment for CY 2012 and CY 2013.
Because the ESRD wage index is only applied to the labor-related portion of the composite rate, we computed the wage index budget-neutrality adjustment factor based on that portion. That is, the labor-related share of the composite rate portion of the blended payment of 53.711 percent. This labor-related share was developed from the labor-related components of the 1997 ESRD composite rate market basket that was finalized in the 2005 PFS final rule (70 FR 70168). The labor-related share of the ESRD PPS is 41.737 percent labor (that is, the portion of the ESRD PPS payment rate and the ESRD PPS portion of the blended payment). As discussed in the CY 2011 ESRD PPS final rule (75 FR 49161), we used the 2008-based ESRDB market basket cost weights to determine the labor-related share for ESRD facilities under a bundled system. Under the ESRDB market basket, the labor-related share for ESRD facilities is 41.737. These figures represent the sum of Wages and Salaries, Benefits, Housekeeping and Operations, All Other Labor-related Services, 87 percent of the weight for Professional Fees and, 46 percent of the weight for Capital-related Building and Equipment expenses.
To compute the proposed CY 2012 wage index budget-neutrality adjustment factors, we proposed to use the fiscal year (FY) 2012 pre-floor, pre-reclassified, non-occupational mix-adjusted hospital data to compute the wage index values, 2010 outpatient claims (paid and processed as of December 31, 2010), and geographic location information for each facility which, may be found through Dialysis Facility Compare (76 FR 40510-40511). Dialysis Facility Compare can be found at the Dialysis Facility Compare Web page on the CMS Web site at http://www.cms.hhs.gov/DialysisFacilityCompare/. The FY 2012 hospital wage index data for each urban and rural locale by CBSA may also be accessed on the CMS Web site at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp. The wage index data are located in the section entitled, “FY 2012 Final Rule Occupational Mix Adjusted and Unadjusted Average Hourly Wage and Pre-Reclassified Wage Index by CBSA.”
We did not receive any comments on the methodology used to compute the budget-neutrality adjustment factors. Therefore, for CY 2012 and beyond, we are finalizing the methodology we proposed for computing the CY 2012 wage index budget-neutrality adjustment factors (76 FR 40510 and 40511). Using treatment counts from the 2010 claims and facility-specific CY 2011 payment rates, we computed the estimated total dollar amount each ESRD facility would have received in CY 2011. The total of these payments became the target amount of expenditures for all ESRD facilities for CY 2012. Next, we computed the estimated dollar amount that would have been paid for the same ESRD facilities using the final ESRD wage index for CY 2012. The total of these payments becomes the new CY 2012 amount of wage-adjusted payment rate expenditures for all ESRD facilities.
After comparing these two dollar amounts (target amount divided by the new CY 2012 amount), we calculated two wage index budget-neutrality adjustment factors that, when multiplied by the applicable CY 2012 estimated payments, would result in aggregate payments to ESRD facilities that would remain budget-neutral when compared against the target amount of payment rate expenditures. The first factor was applied to the ESRD PPS base rate. The second factor was applied to the wage index values for the composite rate portion of the blended payment. Therefore, in this final rule, we are finalizing for CY 2012, the wage index budget-neutrality adjustment factor for the composite portion of the ESRD PPS blended payment of 1.002830, which is applied directly to the ESRD wage index values. For the ESRD PPS (that is, for the full ESRD PPS payments and the ESRD PPS portion of the blended payments during the transition), we are finalizing the wage index budget-neutrality adjustment factor of 1.001520 which is applied to the ESRD PPS base rate. Under the ESRD PPS, the wage index floor for CY 2012 is 0.550 because the wage index budget-neutrality adjustment factor is applied to the base rate.
As we indicated in the proposed rule (76 FR 40511), because we apply the wage index budget-neutrality adjustment factor to the wage index values to ensure budget-neutrality under the composite rate portion of the blended payment, we also apply the wage index budget-neutrality adjustment factor to the wage index floor. We note this would apply to areas in Puerto Rico subject to the floor. Therefore, for the composite rate portion of the blended payment, we are finalizing for CY 2012 to apply the wage index budget-neutrality adjustment factor to the wage index floor of 0.550 which results in an adjusted wage index floor of 0.552 (1.002830 × 0.550).
The CY 2012 ESRD wage index tables, referred to as Addendum A (ESRD facilities located in urban areas), and Addendum B (ESRD facilities located in rural areas) are posted on the CMS Web site at: http://www.cms.gov/ESRDPayment/PAY/list.asp. The wage index tables list two separate columns of wage index values. One column represents the wage index values for the composite rate portion of the blended payment to which the wage index budget-neutrality adjustment factor has been applied. The other column lists the wage index values for the ESRD PPS, which does not reflect the application of the wage index budget-neutrality adjustment factor, because as we discussed above, we apply the wage index budget-neutrality adjustment factor to the ESRD PPS base rate.
In the CY 2011 ESRD PPS final rule (75 FR 49050 through 49052), we stated that antibiotics used for the treatment of venous access infections and peritonitis, are renal dialysis services under the ESRD PPS. Payments for anti-infective drugs in injectable forms (covered under part B) and oral or other forms of administration (formerly covered under part D) used in the treatment of ESRD, were included in computing the final ESRD PPS base rate and, would not be separately paid under the ESRD PPS. We also noted that the oral versions of vancomycin are not used for ESRD-related conditions and, therefore, would not be considered a renal dialysis Start Printed Page 70243service. We further stated that any anti-infective drug or biological used for the treatment of ESRD-related conditions would be considered a renal dialysis service and, not eligible for separate payment. We noted this policy also applies to any drug or biological that may be developed in the future. We established edits to ensure that separate payment could not be made to ESRD facilities for vancomycin which has traditionally been used by ESRD facilities to treat access infections.
In the proposed rule (76 FR 40511), we acknowledged that since the publication of the CY 2011 ESRD PPS final rule, we had received numerous comments indicating that vancomycin is indicated in the treatment of both ESRD and non-ESRD conditions, such as skin infections. We further stated that after consultation with our medical experts, we concurred with the commenters. Therefore, we proposed to eliminate the restriction on vancomycin to allow ESRD facilities to receive separate payment by placing the AY modifier on the claim for vancomycin when furnished to treat non-ESRD-related conditions. In accordance with ICD-9 guidelines, as described in the ESRD PPS final rule (75 FR 49107), the ESRD facility would also be required to indicate the diagnosis code for which the vancomycin is indicated. We noted that treatment of any skin infection that is related to renal dialysis access management would be considered a renal dialysis service and would continue to be paid under the ESRD PPS, and no separate payment would be made. We sought public comments on our proposal to eliminate the restriction on vancomycin to allow ESRD facilities to receive separate payment for these drugs when furnished to treat non-ESRD-related conditions. The comments we received and our responses are set forth below:
Comment: Two commenters suggested that we allow for separate payment for daptomycin when furnished by ESRD facilities for non-ESRD related conditions.
Response: We thank the commenter for the suggestion to allow for separate payment of daptomycin when used for non-ESRD related conditions. As noted above, we had established system edits to ensure that ESRD facilities could not be paid separately for both vancomycin and daptomycin. We will consider removing the system edit for daptomycin in future rulemaking.
Comment: We received six comments in support of our proposal to eliminate the restriction on vancomycin and allow for separate payment when furnished for non-ESRD-related conditions.
Response: We thank the commenters for their support. Consequently, in this final rule we are finalizing the proposal to eliminate the restriction on vancomycin to allow ESRD facilities to receive separate payment by placing the AY modifier on the claim for vancomycin when furnished to treat non-ESRD related conditions. In accordance with ICD-9 guidelines as described in the CY 2011 ESRD PPS final rule (75 FR 49107), the ESRD facility must indicate the diagnosis code for which the vancomycin is indicated. We reiterate that treatment of any skin infection that is related to renal dialysis access management would be considered a renal dialysis service and would continue to be paid under the ESRD PPS, and no separate payment would be made.
In the CY 2011 PFS final rule (75 FR 73466), we explained the methodology for Part B payment for drugs and biologicals that include intentional overfill, and that the Medicare average sales price (ASP) payment limit is based on the amount of drug conspicuously indicated on the labeling approved by the Food and Drug Administration (FDA). We indicated that we had become aware of situations where manufacturers intentionally included a small amount of overfill in drug containers, and that this overfill is provided at no extra charge to the provider. We also noted that we understood the intent of the intentional overfill was to compensate for product loss during the proper preparation and administration of a drug. We explained that ASP calculations are based on data reported by manufacturers, including “volume per item”. Therefore, providers may only bill for the amount of drug product actually purchased and the cost that the product represents (75 FR 73467).
We stated in the proposed rule (76 FR 40511) that this part B provision applies under the ESRD PPS. We explained that ESRD facilities receiving blended payments under the transition would receive payments based on ASP for separately billable ESRD drugs and biologicals for the composite rate portion of the blend. In addition, under the ESRD PPS outlier policy, the ESRD-related drugs that ESRD facilities report on claims are priced for the outlier policy using ASP prices. Therefore, ESRD facilities may only report units and charges for drugs or biologicals actually purchased.
Comment: Three commenters expressed concern that the drug overfill policy was not appropriate under the ESRD PPS. One commenter stated that the use of overfill is an efficient operation and expressed concern that the new policy would lead to excessive wastage. A commenter disagreed with our assertion that overfill is provided by manufacturers without charge to the provider and stated that there would be additional costs if facilities are not allowed to maximize drug usage. The commenter believes the cost to providers includes the full amount of drug in each vial. One commenter stated that dialysis providers may and should administer overfill if clinically appropriate to reduce costs and waste. The commenter cited the administration of EPO as an example. One commenter stated that, “* * * providers have been purchasing drugs with overfill amounts and use of the overfill amount has long been known by both the Office of Inspector General (OIG) and CMS.”
Response: We disagree with the commenters that believe our proposal would restrict the clinical use of intentional overfill. As we indicated in the CY 2011 PFS final rule (75 FR 73467), our policy here is not intended to limit the use of intentional overfill during the care of beneficiaries or in medical practice; such measures are beyond CMS' authority. Rather, the proposed rule merely set forth how and under what conditions we would make payment under the ESRD PPS outlier policy. Consistent with prior rulemaking, under our authority in section 1881(b)(14)(D)(ii) of the Act, we are adopting the ASP policy on overfill for purposes of calculating the outlier payment. We believe the use of the ASP policy for purposes of calculating the outlier payment is appropriate because, for the reasons stated, we believe overfill does not represent a cost to the facility; thus, overfill should not factor into our determination of outlier payments. This rule does not purport to regulate the use of overfill, only whether it is reimbursed under our outlier policy and the composite rate portion of the blended payment during the transition. Thus, whether we or the OIG had information about certain providers' purchase and use of overfill is irrelevant.
Comment: A large dialysis organization indicated that the drug overfill policy should not apply to ESRD facilities because the ASP payment regulation applies to drugs “not paid on a cost or prospective payment system basis.” The commenter contends it would not apply under the ESRD PPS even though outlier eligible drugs are priced using the ASP prices established under section 1847A of the Act. The commenter stated that CMS cannot Start Printed Page 70244substitute the ASP method for a portion of the ESRD PPS. The commenter further contends that because dialysis providers may administer overfill, but CMS's proposal would prohibit them from submitting a claim that includes overfill, it appears that CMS expects providers either to inaccurately state the services furnished on the claims form or incur significant expense to separately track overfill amounts, which may be used for thousands of patients daily, resulting in unnecessary burden. The commenter opined that applying the ASP payment rule under the ESRD PPS is inconsistent with the policy objectives of a PPS leading to wastage if facilities continue to use single-use vials or extra expenses if facilities migrate to multi-dose vials.
Response: We disagree with these comments. First, as noted above, we proposed to incorporate into our outlier policy the policy for overfill under the ASP methodology; however, our authority to determine an outlier policy is found in section 1881(b)(14) of the Act, which calls for a prospective payment basis for renal dialysis services and authorizes an outlier payment adjustment. Thus, contrary to the commenter's assertion, we are paying for drugs subject to the ESRD PPS outlier policy under a prospective payment system, not under section 1847A of the Act. Under the outlier policy, we use the ASP methodology, which is based upon manufacturer reporting of the labeled amount of a drug and not any other amount (that is, overfill amount). Therefore, we are establishing that the ESRD PPS outlier policy does not include an amount for overfill. Further, the outlier policy was designed to provide additional payments for high cost patients. To the extent a patient receives drug amounts at no cost to the facility (that is, overfill amounts), that amount may not be attributed to the cost of that patient. Finally, because we are continuing to pay under the composite rate portion of the blended payment for separately billable drugs using the ASP payment methodology, we should continue to utilize the methodology for pricing drugs for the outlier policy.
Second, the commenter's contention about the scope of the “incident to” benefit reflects a misunderstanding of our proposal. We refer the commenter to discussion of the overfill policy in the CY 2011 PFS final rule (75 FR 73469), where we stated that our ASP overfill policy is not based on the “incident to” rules, but rather applies to all drugs and biologicals paid under section 1847A of the Act, regardless of setting. The “incident to” rules are similarly irrelevant to our proposal here. Our policy pertains only to how and whether we pay for drugs under our outlier policy under authority of section 1881(b)(14)(D)(ii) of the Act.
Third, we disagree with the commenters that our policy will require ESRD facilities to inaccurately reflect the services they furnish. We expect that providers will continue to maintain accurate medical records for all beneficiaries as well as accurate inventory records of all drugs that were actually purchased and appropriately billed to Medicare. We acknowledge that separate tracking of overfill may increase burden on ESRD facilities that were not doing so before. However, given that we have adopted ASP policies generally for outliers under the ESRD PPS and we rely on data reported under the ASP methodology to determine the outlier thresholds, even if we believed overfill were something other than free product, we would have no ability to account for it separately.
Finally, we disagree that our policy is inconsistent with waste reduction. As noted above, our policy does not apply to the use of overfill; rather, it applies only to whether we pay for overfill under our outlier policy. ESRD facilities remain free to take steps to reduce drug wastage and in doing so, reduce their costs in providing ESRD services—our policy only prevents an ESRD facility from accounting for something for which it incurred no cost in determining whether it met the high cost outlier policy.
We are finalizing our proposal to incorporate the ASP overfill policy into our outlier policy and for purposes of the composite rate portion of the blended payment during the transition. Thus, ESRD facilities may only report units and charges for drugs and biologicals actually purchased.
Under section 1881(b)(14)(D)(i) of the Act, the bundled ESRD PPS must include a payment adjustment based on case-mix that may take into account patient weight, body mass index (BMI), body surface area (BSA), and other appropriate factors. In the proposed rule (76 FR 40511 and 40512), we explained that we evaluated height and weight because the combination of these two characteristics allows us to analyze two measures of body size: BSA and BMI. We further explained that both body size measures are strong predictors of variation in payment for ESRD patients. As a result, in developing the ESRD PPS, we established a case-mix patient level adjustment for BSA that would be applied to each 0.1 m2 change in BSA compared to the national average.
In the proposed rule (76 FR 40511 and 40512), we proposed to make one change related to the use of the national BSA average value used in the calculation of the BSA adjustment applied to the composite rate portion of the blended payment during the transition. This change was necessary because we believe that the BSA national average used to compute payment under the composite rate portion of the blended rate and under the ESRD PPS should be both the most recent and consistent measurement available. We further explained that for CY 2011, the BSA adjustment we calculated for the composite rate portion of the blended payment used the BSA national average of 1.84, which reflected the average among Medicare dialysis patients in 2002. However, the BSA national average we used for computing the BSA under the ESRD PPS was 1.87, which reflected the national average among Medicare dialysis patients in 2007. We did not realize that we had used 2 different national averages in CY 2011, nor was it brought to our attention during the comment period. For CY 2012 and in subsequent years, we proposed to use one national average for computing the BSA under the composite rate portion of the blended payment during the transition and under the ESRD PPS.
In the CY 2004 PFS final rule (69 FR 66329), we explained that the BSA factor was defined as an exponent equal to the value of the patient's BSA minus the reference. For example, for a beneficiary with a BSA of 1.94, using the CY 2011 national average of 1.84 under the composite rate would yield a BSA adjustment factor of 1.0370. For the same patient, using the national average of 1.87 used for the CY 2011 ESRD PPS BSA computation would yield a BSA adjustment factor of 1.0258. A ratio or proportional difference of 1.0258 divided by 1.0370 equals .9892 difference the between the two BSA adjustment factors. This corresponds to a reduction of 1.08 percent (1−0.9892 = 0.0108) in the composite rate payment for adult patients by increasing the BSA reference value from 1.84 to 1.87.
In Table 3 of the proposed rule (76 FR 40512), we showed the impact of increasing the composite rate BSA reference value from 1.84 to 1.87 for each year from 2011 to 2014, on facility payments for ESRD facilities going through the transition. The impact on facility payments are greatest in 2011, where the blended payment during the transition period is weighted more Start Printed Page 70245heavily towards the basic case-mix adjusted composite payment system, and declines through 2014 when there is no impact on facility payments under a fully implemented PPS.
Therefore, for CY 2012, we proposed to use the latest national average (that is, 1.87) as the reference point for the computation of the BSA adjustment for both the composite rate portion of the blended payment and for the ESRD PPS (76 FR 40512). We also proposed to review the BSAs on CY 2012 claims (and every 5 years thereafter) to determine if any adjustment to the national average would be required in the future. We sought comments on these proposals. The two comments we received and our responses are set forth below:
Comment: One organization that represents small dialysis organizations supported the proposals to use the 1.87 reference point for computing the BSA and to review the BSA calculation every five years. One independent ESRD facility opposed the change in the reference point stating that it will negatively impact facilities that opted to receive payment under the transition because it will reduce the composite rate payment. The commenter referenced the table in the proposed rule that displays the negative effect.
Response: We thank the national organization for its support of our proposals and appreciate the concerns expressed by the ESRD facility. We regret that we had not identified the discrepancy in the values used in the CY 2011 ESRD PFS and CY 2011 ESRD PPS final rules. However, as we indicated in the CY 2012 proposed rule, we believe the change is necessary because the BSA national average used to compute the composite rate portion of the blended payment and under the ESRD PPS should be both the most recent and consistent measurement available.
After considering the public comments and for the reasons noted above, in this final rule, for CY 2012, we are finalizing our proposal to use the BSA national average of 1.87, which is the latest national average, as the reference point for the computation of the BSA adjustment for both the composite rate portion of the ESRD PPS blended payment and for the ESRD PPS. We are also finalizing our proposal to review the BSA national average on the CY 2012 claims and every 5 years thereafter to determine if any adjustment to the national average will be required in the future.
Section 1881(b)(14)(D)(ii) of the Act requires that the ESRD PPS include a payment adjustment for high cost outliers due to unusual variations in the type or amount of medically necessary care, including variability in the amount of erythropoiesis stimulating agents (ESAs) necessary for anemia management. In the CY 2011 ESRD PPS final rule, we stated that for purposes of determining whether an ESRD facility would be eligible for an outlier payment, it would be necessary for the facility to identify the actual ESRD outlier services furnished to the patient by line item on the monthly claim (75 FR 49142).
Medicare regulation § 413.237(a)(1) provides that ESRD outlier services include: (1) ESRD-related drugs and biologicals that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B; (2) ESRD-related laboratory tests that were or would have been, prior to January 1, 2011, separately billable under Medicare part B; (3) medical/surgical supplies, including syringes used to administer ESRD-related drugs, that were or would have been, prior to January 1, 2011, separately billable under Medicare Part B; and (4) renal dialysis service drugs that were or would have been, prior to January 1, 2011, covered under Medicare Part D, excluding ESRD-related oral-only drugs. Drugs, laboratory tests, and medical/surgical supplies that we would recognize as outlier services were specified in Attachment 3 of Change Request 7064, issued August 20, 2010 under Transmittal 2033. Transmittal 2033 was rescinded and replaced by Transmittal 2094, dated November 17, 2010. The replacement document involved the (1) Deletion of several drugs; (2) identified drugs that may be eligible for ESRD outlier payment; (3) provided a list of laboratory tests that comprise the AMCC tests; (4) deleted several laboratory tests; and (5) included the latest version of the ESRD PRICER layout file. Transmittal 2094 was subsequently rescinded and was replaced by Transmittal 2134 issued January 14, 2011. That transmittal was issued to correct the subject on the transmittal page and made no other changes.
Medicare regulations at § 413.237(a)(2) through (a)(6), and (b) specify the methodology used to calculate outlier payments. An ESRD facility is eligible for an outlier payment if its actual or imputed Medicare Allowable Payment (MAP) amount per treatment for ESRD outlier services exceeds a threshold. The MAP amount represents the average incurred amount per treatment for services that were or would have been considered separately billable services prior to January 1, 2011. The threshold is equal to the ESRD facility's predicted ESRD outlier services MAP amount per treatment (which is case-mix adjusted) plus the fixed dollar loss amount. In accordance with § 413.237(c) of the regulation, facilities are paid 80 percent of the per treatment amount by which the imputed MAP amount for outlier services (that is, the actual incurred amount) exceeds this threshold. ESRD facilities are eligible to receive outlier payments for treating both adult and pediatric dialysis patients.
In the CY 2011 ESRD PPS final rule, using 2007 data, we established the outlier percentage at 1.0 percent of total payments (75 FR 49142 through 49143). We also established the fixed dollar loss amounts that are added to the predicted outlier services MAP amounts. The outlier services MAP amounts and fixed dollar loss amounts are different for adult and pediatric patients due to differences in the utilization of separately billable services among adult and pediatric patients (75 FR 49140).
Attachment 3 of Change Request 7064 issued August 20, 2010 under Transmittal 2033, as modified by Transmittal 2094 issued November 17, 2010 and Transmittal 2134 issued January 14, 2011, specified the former separately billable Part B drugs that are recognized as ESRD-related eligible outlier services and, the former Part D drugs by National Drug Code (NDC) for the three vitamin D analogues (calcitriol, paracalcitol, and doxercalciferol) and levocarnitine that are recognized as eligible outlier service drugs.
In the proposed rule (76 FR 40513), we indicated that we had intended to update both the lists of former part B drugs and biologicals and former part D drugs that are outlier services (75 FR 49138). However, we concluded that any CMS prepared lists of drugs and biologicals recognized as outlier services may be difficult to keep up-to-date. We recognized that this is attributed to the lag in the receipt of claims data; changes in ESRD practice patterns; and inadvertent omissions and oversights. Because the regulation defines eligible outlier service drugs, we believe there is no need for CMS to issue a list of former separately payable part B ESRD outlier services drugs. Furthermore, because the list of drugs is Start Printed Page 70246derived from paid ESRD claims, it would not be comprehensive, completely represent drugs and biologicals furnished to ESRD patients, accurate, or up-to-date. We noted that, consistent with current policy, all composite rate drugs, as defined in the Medicare Benefit Policy Manual, Pub. 100-02, chapter 11, section 30.4.1, would not be eligible for an outlier payment, as these drugs would not have been separately paid under Part B or Part D prior to January 1, 2011, and do not meet the definition of outlier services. Consequently, we proposed to eliminate the issuance of a list of former separately payable Part B drugs and biologicals that would be eligible for outlier payments. Accordingly, we solicited public comments on our proposal to eliminate the issuance of a specific list of eligible outlier service drugs which were or would have been separately billable under Medicare Part B prior to January 1, 2011.
The comments on our proposal and our responses are summarized below.
Comment: Two national associations supported the proposal to eliminate the drug and biological list. Both commenters supported the creation of a list through guidance. One commenter indicated that the list would maintain transparency, but recognized that this would create a rulemaking burden. The commenter further requested that CMS ensure that process remains transparent and subject to input from stakeholders.
Response: We thank the commenter's for their support of our proposal. As we indicated, any CMS prepared lists of drugs and biologicals recognized as outlier services may be difficult to keep up-to-date due to the factors described above.
Because we are concerned that a failure to include a drug or biological on the outlier services list will negatively impact ESRD facilities by limiting the drugs eligible for the outlier policy, in this final rule, we are finalizing the proposal to eliminate the issuance of a specific list of eligible outlier service drugs which were or would have been separately billable under Medicare part B prior to January 1, 2011. However, under separate guidance, we plan to continue to identify renal dialysis service drugs which were or would have been covered under Part D for outlier eligibility purposes in order to provide unit prices for calculating imputed outlier services.
With respect to the comment regarding transparency, we recognize the need to be transparent and have sought input from stakeholders. We believe that we have been transparent by the inclusion of proposed changes to outlier drugs and biologicals under the ESRD PPS in the proposed rule, (76 FR 40513 and 40514) and our request for comments.
Under current policy, antibiotics furnished in the home are considered to be composite rate drugs and therefore, not eligible for outlier payment. In the proposed rule (76 FR 40513), we discussed that Pub. 100-02, chapter 11, section 30.4.1 lists the drugs covered under the composite rate. The list includes a statement that antibiotics when used at home by a patient to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis are considered composite rate drugs. Because composite rate drugs and their administration (both the staff time and the supplies) are covered under the composite rate, antibiotics furnished in the patient's home used for the reasons noted above may not be billed and paid separately. However, antibiotics furnished in an ESRD facility are considered separately payable in accordance the Medicare Claims Processing Manual, Pub. 100-04, chapter 8, section 60.2.1.1.
We also noted that Pub. 100-02, chapter 11, section 50.9 states that an antibiotic used at home by a patient to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis is covered as home dialysis supplies included in the Method II (Direct Dealing) payment cap for home dialysis supplies administered by the Durable Medical Equipment (DME) Supplier. Prior to January 1, 2011, under Method II, durable medical equipment suppliers received direct payment from Medicare for furnishing dialysis services to home dialysis patients. Effective January 1, 2011, as indicated in § 413.210(b) of the regulations, CMS does not pay any entity or supplier other than ESRD facilities for covered items and services furnished to a Medicare beneficiary. Therefore, payment to DME suppliers for antibiotics under Method II can no longer be made. Additionally, under the ESRD PPS, the dialysis facility is responsible for furnishing all renal dialysis services, regardless of the site of service. Under the ESRD PPS, there is no payment distinction made as to the site where a renal dialysis service is provided (that is, in the home or in a facility).
Therefore, in the proposed rule, (76 FR 40513 and 40514), we indicated that we did not believe that it would be appropriate to have a distinction in which antibiotics administered in an ESRD facility, used to treat an infection of the catheter or other access site, or peritonitis associated with peritoneal dialysis, would be considered as separately billable under the composite rate portion of the blended payment and eligible for outlier payments under the ESRD PPS, while antibiotics used at home by home patients for the same purpose would be considered to be included in the composite rate and not eligible for outlier payments. We proposed to eliminate the inclusion of antibiotics when used in the home to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis as part of the composite rate drugs, and allow them to be separately paid under the composite portion of the blended payment for ESRD facilities receiving payment during the transition. We also proposed that antibiotic drugs used at home to treat catheter site infections or peritonitis associated with peritoneal dialysis would be eligible as ESRD outlier services. Antibiotics furnished in facility would continue to be recognized as ESRD outlier services.
We solicited comments on our proposal. The comments and our responses are summarized below.
Comment: One national association and one dialysis organization agreed with the proposal that home antibiotics to treat catheter site infections or peritonitis associated with peritoneal dialysis would qualify as eligible for outlier payment.
Response: We thank the commenter for their support.
In this final rule, we are finalizing the proposal to recognize antibiotics furnished in the home to treat catheter site infections or peritonitis associated with peritoneal dialysis as eligible for outlier payment. We believe the inclusion of antibiotics used by home dialysis patients as outlier services will reduce confusion over drugs and biologicals that are eligible outlier services and eliminate the distinction in the eligibility of a drug for outlier eligibility based on where it is furnished. As new drugs emerge, we intend to update the HCPCS codes corresponding to new drugs and biologicals for billing purposes, and to determine whether any of those drugs would have been considered to be composite rate drugs. Drugs and biologicals which were or would have been considered composite rate drugs are not eligible ESRD outlier services under § 413.237.
In the proposed rule (76 FR 40514), we proposed two modifications to the computation of the separately billable MAP amounts used to calculate outlier payments for the reasons described below. We explained that subsequent to the publication of the CY 2011 ESRD PPS final rule, our clinical review of the Start Printed Page 702472007 ESRD claims used to develop the ESRD PPS revealed that dialysis facilities routinely used alteplase and other thrombolytic drugs for access management purposes. Under the ESRD Benefit Policy Manual, Pub. 100-02, chapter 11, section 30.4.1, drugs used as a substitute for any of the listed items, or are used to accomplish the same effect, are covered under the composite rate. Because heparin is a composite rate drug and could be used for access management, any drug or biological used for the same purpose may not be separately paid. Because outlier payments are restricted under § 413.237(a) to those items or services that were or would have been considered separately billable prior to January 1, 2011, we proposed to recalculate the average outlier services MAP amounts to exclude these composite rate drugs (that is, we proposed to exclude thrombolytics from the computation).
We also explained in the proposed rule that in developing the outlier service MAP amounts for 2011, we excluded testosterone and anabolic steroids. We subsequently learned from discussions with clinicians and ESRD facilities, that these drugs can be used for anemia management. Because drugs used for anemia management in ESRD patients were or would have been considered separately billable under Medicare part B, these drugs would be considered outlier services under § 413.237(a)(1). Consequently, we have recomputed the outlier service MAP amounts for CY 2012 to include these drugs. As shown in Table 2, when comparing the outlier service MAP amounts based on the current definition of ESRD outlier services to the revised ESRD outlier definition, the net effect of these two revisions (the exclusion of thrombolytic drugs and inclusion of anabolic steroids) results in an decrease to the outlier service MAP amounts by $4.00 for adult patients and a decrease of $0.50 for pediatric patients.
We solicited comment on the two modifications to the computation of the separately billable MAP amounts used to calculate outlier payments we proposed. The comments received and our responses are set forth below.
Comment: We received several comments opposing the proposal to exclude thrombolytic drugs used for access management from the outlier services MAP amounts and therefore, not eligible for outlier payments. One national organization believes that there should be a longer experience with the use of thrombolytics under a bundled system before excluding them from outlier payments. The commenter stated that when properly used, these agents may help avoid unnecessary (and expensive) access procedures and interventions. The commenter further believes that the outlier payment policy could adversely impact their proper use and lead to greater vascular access procedures outside of the dialysis unit and could be “detrimental to patients' outcomes.”
Response: We do not understand the value that longer experience with the use of thrombolytics under a bundled system before excluding them from the outlier policy would provide. We believe that the determination the furnishing of a drug should be based upon the patient's needs and remain independent of the outlier policy. We believe that maintaining vascular access is a renal dialysis service and ESRD facilities would continue to be responsible for furnishing the service. We also expect that ESRD facilities would refer patients to another setting if medically necessary and we would not expect ESRD facilities to address any and all vascular access complications if doing so would be unsafe.
With regard to the comment about proper use of thrombolytics, the efficacy or merit of thrombolytics is not in question with their exclusion from the outlier policy. We believe that the ESRD PPS provides an opportunity for ESRD facilities to make decisions based on the medical need of patients and not on the basis of financial gain. That is, under current policy, a facility may choose to use a thrombolytic (alteplase) because those drugs are eligible under the outlier policy, rather than using an anticoagulant (heparin) which is not eligible. By no means are we implying that thrombolytics or any access management drug should not be used when clinically indicated. But rather, we are saying that payment policy is not intended to dictate, determine, or influence clinical practice or favor one course of treatment over another. It is intended to ensure that decisions are not made solely on the basis of financial gain but based on clinical judgment.
Finally, as we discussed above, the Medicare Benefit Policy Manual, Pub. 100-02, chapter 11, section 30.4.1, states that drugs used as a substitute for any of the listed items or are used to accomplish the same effect are covered under the composite rate. Because heparin is included in the composite rate and is used to ensure patency of an access site and proper flow during the dialysis treatment, as we discuss in greater detail below, we interpret this provision to mean that any drug used to ensure patency of an access site and proper flow during the dialysis treatment and, therefore, would be more properly considered a composite rate drug.
Comment: An independent ESRD facility noted that alteplase was separately billable under the composite rate and was not considered “interchangeable with heparin”. The commenter further indicates that alteplase had been included in the CY 2011 MAP. Finally, the commenter indicated that the decision made by this facility to receive payment under the transition was made in part because alteplase was separately paid under the composite rate system and CMS included alteplase and other thrombolytics under the outlier policy.
Response: The commenter is correct that alteplase was separately billable under the composite payment system and was included in the CY 2011 MAP amounts for the outlier policy. Because we did not propose to alter that policy with regard to the composite rate portion of the blended payment and the policy was only discussed in the context of the outlier policy, we do not believe it would be appropriate to make the change at this time. Therefore, as indicated above, in CY 2012, thrombolytics furnished by an ESRD facility will continue to receive separate payment under the composite rate portion of the blended payment.
While we acknowledge that in the development of the ESRD PPS, alteplase was included in the computation of the MAP amounts and eligible for outlier payments, we proposed to rectify this situation in the proposed rule because we believe that making one access management drug eligible for outlier payment while making another ineligible should not exist. We also note that since heparin predated the use of thrombolytics in dialysis access patency and management and heparin was included in the composite rate, we believe that any drug or biological including other anticoagulants, thrombolytics or any other type of drug that may be used in the future for access patency and management would also be considered a composite rate drug.
Comment: One pharmaceutical company indicated that it did not promote the “off-label” use of alteplase in the dialysis setting. The commenter expressed concern that the proposed change for outlier payments for alteplase will provide a disincentive for appropriate vascular access practices and management, resulting in a negative effect on patients. The commenter stated that the manual cited in the proposed rule includes a list of specific drugs, heparin is listed but does not include alteplase or other thrombolytic. The Start Printed Page 70248commenter further stated that the next section of the manual requires separate billing for thrombolytics used to declot central venous catheters. The commenter acknowledged that heparin and alteplase are used for access management, but the commenter maintained that does not mean that one substitutes for the other. One example provided by the commenter is that heparin has been used for 30 years as an anticoagulant to prevent the blood from clotting as it is being filtered through the dialyzer and states that the substitute for heparin flushing is saline, which may be contraindicated in the dialysis population due to potential blood pressure effects. The commenter further stated that alteplase is used as a salvage therapy when a catheter becomes dysfunctional due to presumed thrombosis. The commenter maintained that alteplase is the “only thrombolytic currently marketed that can help lyse a clot and potentially restore blood flow to a poorly functioning catheter”. The commenter included Kidney Dialysis Outcomes Quality Initiative (KDOQI) guidelines that all catheters are “locked” with an anticoagulant such as heparin to prevent thrombosis. The commenter provided the physiological response to the heparin which they state could result in thrombus formation and further stated that the guidelines recommend thrombolytic therapy directed at salvaging the catheter before access replacement. The commenter cited the pharmacological and indication differences between the two drugs, as well as potential quality problems that they believe will occur with the proposed change Finally, the commenter distinguished between heparin and alteplase by indicating that patient care technicians (PCTs) administer intravenous heparin while alteplase is prescribed by a physician and cannot be administered by PCTs.
Response: We did not state in the proposed rule that alteplase was sometimes used off-label in the dialysis setting; however, we believe that the commenter may be referring to our statement that ESRD facilities routinely used thrombolytic drugs for access management purposes.
In the development of the ESRD PPS, we knew that alteplase and heparin were pharmacologically different (that is, one is a thrombolytic lysing clots and the other is an anticoagulant preventing clots, respectively). However, we believe that both drugs enable the catheter or graft to function either through clot prevention or clot degradation and provide effective dialysis vascular access. We are aware that heparins and thrombolytics have a different mode of action, with heparin preventing thrombosis and thrombolytics lysing a thrombus after it has formed. We are also aware that formation of a thrombus in or around the tip of central venous catheters used for dialysis is one reason for catheter dysfunction. Appropriate use of heparin by dialysis facilities can prevent thrombus formation, thus reducing the likelihood of catheter dysfunction. Heparin use in dialysis has long been part of the ESRD composite payment system, is relatively inexpensive, and is widely used as an effective technique for primary prevention of hemodialysis catheter dysfunction. Thrombolytics (including alteplase), can be used to lyse or dissolve thrombus, restoring catheter function in some cases. These agents are very costly and, according to FDA package insert information, can result in significant bleeding complications. From the perspective of achieving a clinical result, maintenance of hemodialysis catheter function, either inexpensive primary prevention or costly intervention produces interchangeable results. We believe that payment policy should encourage achievement of the desired results in the most cost-effective manner, particularly when the prevention approach reduces risk to Medicare beneficiaries. We believe that the significant expenditures for thrombolytics suggests that there are ESRD facilities that may not be adequately applying established preventive methods (that is, use of heparin) to maintain hemodialysis catheter access. Inclusion of thrombolytics in the definition of outlier services and potentially making a facility eligible for outlier payments supports the continuation of this practice.
As for the statement about negative outcomes, we believe maintaining vascular access is a renal dialysis service and therefore, is included in the ESRD PPS. ESRD facilities are responsible for furnishing the service. We expect that ESRD facilities would not refer patients to another healthcare setting for the purpose of maintaining vascular access. We expect patients to be referred to another setting if medically necessary. We are not suggesting that ESRD facilities are expected to address any and all vascular complications, if doing so would be unsafe for the patient. Finally, as we indicated, we plan to monitor whether ESRD facilities are continuing to maintain vascular access as they currently perform.
With regard to the comment on the disincentive to use alteplase properly, as we noted above, payment policy is not intended to dictate, determine, or influence clinical practice. We believe that the policy that any drug or biological used for access management would not be considered eligible under the outlier policy (that is, excluding thrombolytics from the outlier policy), would support decision-making based on medical need and not based upon financial incentives. We believe that continuing to recognize expensive thrombolytics as outlier services for purposes of computing outlier payments for ESRD facilities could create perverse financial incentives to underutilize clot prevention techniques and overutilize clot lysis techniques in the course of vascular access maintenance by ESRD facilities.
The commenter is correct that Medicare Benefit Policy Manual, Pub. 100-02, chapter 11, section 30.4.1, does not explicitly list alteplase or other thrombolytics as composite rate drugs; however, it does state that drugs used as a substitute for any of the listed composite items or are used to accomplish the same effect (that is, access patency) are covered under the composite rate. As we explained in previous responses, we believe that alteplase and other thrombolytic drugs are used for access management as is heparin, though we acknowledge that the physiological action is different. As we explained above, we based our decision to propose the elimination of thrombolytic drugs from outlier eligibility because both thrombolytics and anticoagulants are used to maintain the patency of the dialysis access site. We note that, at this point, we are not aware of another ESRD-related drug category which has some drugs covered under the composite while others in the category are separately billable.
For example, for the category of bone and mineral metabolism, there are various drugs that can be used. These drugs have the same outcome, but have different physiological actions to accomplish bone integrity; some are calcium or calcium analogues while others are phosphorus. The difference in the bone and mineral metabolism category is that all of the drugs were separately billable and therefore, eligible under the outlier policy. Another example is antihypertensives. There are many antihypertensive drugs which have the same clinical effect of lowering blood pressure, but how the effect is achieved differs. Beta blockers by blocking beta adrenergic receptors slow the heart rate and thereby reduce the force in which the heart muscle contracts leading to a decrease in blood pressure. Hydrochorothiazide increases the amount of water removed from the Start Printed Page 70249blood, causing a decrease in blood pressure. Ace inhibitors prevent the conversion of ACE I and ACE II. ACE II causes the blood vessels to constrict. By preventing the conversion, the blood vessels dilate and lead to a decrease in blood pressure. Antihypertensives are in the composite rate.
The commenter is also correct that the Medicare Benefit Policy Manual, Pub. 100-02, chapter 11, section 30.4.2 does list thrombolytics for declotting central venous catheters as being separately paid. We cannot address why this payment distinction was made under the composite rate payment system. However, we do not believe that allowing some drugs in a drug category (that is, for access management) to be eligible under the outlier policy while other drugs in the category are not is sound payment policy. Because a drug was paid separately under the composite rate system does not mean that it has to be eligible under the outlier policy under the ESRD PPS. We are not saying that thrombolytics should or should not be used as their use is a medical determination. We are merely saying that as a result of classifying drugs and biologicals into categories (for example, access management), thrombolytics would no longer be eligible under the outlier policy beginning January 1, 2012.
As we discussed earlier and in the CY 2011 ESRD PPS final rule (76 FR 49050), under the ESRD PPS, we did not provide a specific ESRD-related drug list because we recognized that drugs and biologicals change over time. That is the reason that we categorized drugs and biologicals based on function, such as access management. In that regard, heparin (and other clot prevention drugs) and thrombolytics such as alteplase, despite their pharmacological differences, are all categorized as access management drugs.). Because there may be other drugs and biologicals that may be used for access management in the future that may also have different physiological differences, we also stated that any drug or biological furnished for the purpose of access management will be considered a renal dialysis service under the ESRD PPS. In other words, even if a new drug has a physiological action that differs from anticoagulants (as heparin) or thrombolytics (as alteplase), but is used to maintain access patency, we would not consider such drug to be eligible under the outlier policy.
We disagree with the commenter's argument that patient care techs (PCTs) can administer heparin as part of standing orders while alteplase is prescribed by a physician implies that they should not be considered in the same category. We believe that any medication or any protocol used for dialysis is prescribed by a medical practitioner and that differences in who may administer a drug is not an appropriate distinction that should impact CMS payment determinations.. We are monitoring access management and will continue to do so.
We have not been convinced by the commenters that we should not implement the policy to exclude thrombolytic drugs from the outlier policy. Therefore, in this final rule, we are finalizing our policy to exclude thrombolytic drugs from the outlier policy and have recomputed the outlier MAP amounts to reflect this policy change. However, because we did not propose to exclude separate payment of thrombolytic drugs under the composite rate portion of the blended payment, separate payment will be made for thrombolytic drugs under the composite rate portion of the blended payment in CY 2012.
Comment: One national organization opposed the inclusion of testosterone and anabolic steroids in the anemia management category citing that it is not recognized as the standard of care. The commenter indicated that the forthcoming Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Anemia and CKD makes a strong (level 1B) recommendation that testosterone and anabolic steroids not be used. The commenter further states that the use of these drugs is not the recognized standard of care and the KDIGO guidelines would discourage the financial incentives associated with their use.
Response: We appreciate the concerns expressed by the commenter. The determination to include drugs in or exclude drugs from a category is made based on the overall effect of the drug. Standards of care and appropriate use of any item or service is not within the scope of payment policy. As we have indicated in responses to comments above, we expect that ESRD facilities will make decisions based on patient need and appropriateness of the items and services they furnish. That means we would not expect that a drug would be furnished for financial purposes but rather that the drug is medically necessary for the patient. We expect that medical practitioners will make prescribing decisions based on appropriate medical decision making. Finally, we believe that the renal community will work towards achieving the best medical practice. Nonetheless, we determined that such drugs were included in the 2007 claims (though the dollar amount was small) and as a result, proposed to modify the outlier policy.
Therefore, in this final rule, we are finalizing a policy to include testosterone and anabolic steroids that are used for anemia management as eligible outlier services and have recomputed the outlier MAP amounts to reflect this policy change.
Medicare regulations at § 413.237 provide that ESRD-related laboratory tests that were or would have been considered separately billable under Medicare part B prior to January 1, 2011, are eligible outlier services. Those laboratory tests were specified in Attachment 3 of Change request 7064 issued under Transmittal 2033, as modified by Transmittals 2094 and 2134. In the CY 2011 ESRD PPS final rule (75 FR 49135 through 49138), we indicated that in order to compute the outlier payment for laboratory tests, the 50 percent rule is required. In addition, because the 50 percent rule is necessary to calculate the composite rate portion of the blended payment during the transition period, we retained the 50 percent rule to determine whether Automated Multi-Channel Chemistry (AMCC) panel tests would be considered composite rate or separately billable for the ESRD PPS portion of the blended payment (75 FR 49137). The AMCC panel tests and an explanation of the 50 percent rule are identified in Pub. 100-2, chapter 11, section 30.2.2. ESRD laboratory billing rules can be found in Pub. 100.04, chapter 16, section 40.6.
The 50 percent rule provides that if 50 percent or more of covered laboratory tests comprising a panel of AMCC tests are included under the composite rate payment, then all submitted tests are included within the composite rate payment and, therefore, none of the laboratory tests are considered separately billable. Conversely, if less than 50 percent of the covered panel tests are composite rate tests, then all AMCC tests submitted for the date of service for that beneficiary are considered separately billable. In addition, Pub. 100-2, chapter 8, section 60.1 provides that an AMCC test that is a composite rate test, but is furnished beyond the normal frequency covered under the composite rate, is separately billable based on medical necessity.
We explained in the CY 2012 ESRD PPS proposed rule (76 FR 40514 and 40515), that after publication of the CY 2011 ESRD PPS final rule, we received Start Printed Page 70250numerous requests to eliminate the 50 percent rule due to the commenters' assertions that they were confused about its application. Unlike specific drugs which are classified as either composite rate or separately billable for purposes of eligibility under the outlier policy as discussed above, AMCC laboratory tests may be classified as either composite rate or separately billable depending upon the application of the 50 percent rule or the frequency at which the laboratory test is ordered. Therefore, the determination of ESRD-related laboratory tests as eligible outlier services depends upon the number of panel tests furnished or their subsequent classification based on the application of the 50 percent rule.
Because the AMCC laboratory tests included as eligible under the outlier policy are determined by the 50 percent rule, and in the interests of administrative simplification and minimizing confusion, we proposed to eliminate use of the 50 percent rule for the outlier policy and exclude the 23 AMCC laboratory tests from the definition of ESRD outlier services and from the computation of outlier payments. We proposed that the elimination of the 50 percent rule for the AMCC panel tests under the ESRD PPS outlier payment policy would result in the de facto treatment of those tests as composite rate tests. Accordingly, we proposed to revise § 413.237(a)(1)(ii) of the regulations to exclude these laboratory tests from the definition of ESRD outlier services. The 50 percent rule would continue to apply, however, to AMCC laboratory tests for classification as either composite rate or separately billable for the purpose of computing the composite rate portion of the blended rate for ESRD facilities that elected to receive payments under the transition, because the transition period under the ESRD PPS would be time limited, and would expire when the transition period ends. This would occur because all in 2014 ESRD payments would be based 100 percent on the ESRD PPS and there would no longer be a need to maintain the distinction between composite rate and separately billable laboratory services for purposes of applying the 50 percent rule. The comments we received and our responses are set forth below:
Comment: Two commenters expressed support of the elimination of the 50 percent rule under the outlier policy. One renal dialysis organization welcomed the elimination of the 50 percent rule. However, the commenter indicated that, of the 23 AMCC tests, twelve were part of the composite rate prior to January 1, 2011. The commenter believes that the other eleven tests should not be considered part of the composite rate as they are not routinely performed for evaluation of ESRD. The commenter further explained that it is rare to see all eleven tests ordered on one patient.
Response: We thank the commenters for their support of our proposal to eliminate the 50 percent rule under the outlier policy. As we discussed in the proposed rule (76 FR 40514 through 40515), all 23 laboratory tests were included on the outlier list for the purpose of the 50 percent rule only. Under our proposal to eliminate the 50 percent rule from the outlier policy, the twelve composite rate laboratory tests in the AMCC panel would no longer be considered eligible under the outlier policy. Of the remaining 11 laboratory tests in the AMCC panel, the majority would not be considered ESRD related. Therefore, these tests are not eligible under the outlier policy.
Because we did not propose to alter that policy with regard to the composite rate portion of the blended payment and the policy was only discussed in the context of the outlier policy, we do not believe it would be appropriate to make the change at this time. Therefore, in CY 2012, we are retaining the 50 percent rule and the 23 AMCC laboratory tests for the composite rate portion of the blended payment during the transition, because the transition period under the ESRD PPS would be time limited, and will expire when the transition period ends.
In the preamble of the proposed rule (76 FR 40515), we proposed to revise § 413.237(a)(1)(ii) of the regulations to exclude these laboratory tests from the definition of ESRD outlier services. However, in the proposed regulation text of the proposed rule (76 FR 40550), we proposed revisions to § 413.237 by adding paragraph (a)(1)(v) to exclude these laboratory tests from the definition of outlier services. In this final rule, we are finalizing our proposal, but are finalizing the revision of § 413.237 by adding paragraph (a)(1)(v) to indicate that as of January 1, 2012, the laboratory tests that comprise the AMCC panel are excluded from the definition of outlier services.
In the proposed rule (76 FR 40515 and 40516), we showed the impact of the proposed changes in the outlier policy which were to: (1) Exclude vascular access management drugs and include anabolic steroids as eligible outlier service drugs; and (2) exclude the 23 AMCC laboratory tests from the ESRD outlier services definition. In this final rule, we are finalizing the revised ESRD outlier services definition and changes to the outlier policy. The outlier services MAP amounts and fixed dollar loss amounts included in the proposed rule were based on 2009 data. In this final rule, we are updating the outlier services MAP amounts and fixed dollar loss amounts based on 2010 data. The impact of this update is shown in Table 2, which compares the outlier services MAP amounts and fixed dollar loss amounts in the proposed rule with the updated estimates for this final rule. All estimates in Table 2 were inflation adjusted to reflect projected 2012 prices for outlier services.
Based on the use of updated data for 2010, the average outlier services MAP per treatment amounts have decreased from $87.83 to $81.73 for adult patients and slightly from $46.27 to $46.26 for pediatric patients. These updates largely reflect changes in the utilization of outlier services for adult and pediatric patients between 2009 and 2010. These changes result in a smaller outlier services MAP amount for adult patients (decrease from $83.73 to $78.00) and very little change in the outlier services MAP amount for pediatric patients.
Similarly, the fixed dollar loss amounts which are added to the predicted MAP amounts per treatment to determine the outlier thresholds are being updated from $145.25 to $141.21 for adult patients and from $82.58 to $71.64 for pediatric patients. We estimate that the percentage of facilities with patient months qualifying for outlier payments under the current policy will be slightly lower for adult patients (from 5.5 to 5.4 percent) and higher for pediatric patients (from 5.0 to 5.7 percent) based on our use of 2010 data.
The update based on 2010 data has a somewhat greater impact on the outlier policy for pediatric patients compared to adult patients. There is generally greater sensitivity in the pediatric results due to the relatively small number of pediatric Medicare dialysis patients overall (approximately 800 patients nationally). This is especially the case with the pediatric fixed dollar loss amounts, since the magnitude of the pediatric fixed dollar loss amounts is basically determined by a relatively small number of the highest cost pediatric patients. The somewhat lower pediatric fixed dollar loss amounts based on data from 2010 (as compared with 2009), reflect the tendency to have somewhat less extreme high cost cases for pediatric patients in the 2010 claims. The expected result based on this update is that a somewhat larger percentage of pediatric claims are expected to qualify for outlier payments Start Printed Page 70252based on 2010 data, but the average outlier payment among the pediatric outlier cases will be somewhat lower.
In the CY 2011 ESRD PPS final rule (75 FR 49062 through 49063), we explained the rationale for costs associated with self-dialysis training. On page 49063 of the CY 2011 ESRD PPS final rule, the correct training add-on amount of $33.44 is listed in our response in column. However, we inadvertently listed an incorrect training add-on amount of $33.38 in the third column of page 49063. The correct training add-on amount is $33.44. Therefore, we are correcting the training add-on amount to $33.44 in the third column on page 49063 of the CY 2011 ESRD PPS final rule, for costs associated with self-dialysis training on or after January 1, 2011. The geographic wage index is applied to the $33.44. As described in the CY 2011 ESRD PPS final rule (75 FR 49063), the training add-on amounts after application of the wage index would range from $20.03 to $45.84.
Although we did not propose any changes to the current training add-on (other than noting the technical correction), we received 12 comments from patients and a home training organization. The comments we received and our responses are set forth below:
Comment: Two commenters supported the technical correction to the training add-on amount. Some comments recommended changes to the training add-on which included updating the training add-on to keep pace with inflation by applying the update directly to the training add-on or by re-calculating the hourly nurses time using the methodology employed in the CY 2011 ESRD PPS final rule. One commenter stated that the training add-on is outside of the bundled base rate and therefore, is not captured in the annual market basket update. One home training organization stated that they were disappointed with home training reimbursement. The commenter also indicated that the allowable home training payments cannot be billed because of issues with the submission requirements for the ESRD Medical Evidence form for new patients. A home training organization, patients, families and a national association believe that training treatments should be paid at the prescribed frequency and not limited to three days per week, up to the allowable number of days. One commenter maintained that her clinic was losing money on training and therefore their time should be compensated appropriately. Another commenter believes that the home training add-on adjustment did not come close to capturing the costs of training. Several commenters maintained that training should be for more than one hour of nursing time. Several commenters believe that the training add-on adjustment is inadequate.
Response: As we indicated in the proposed rule (75 FR 40516), we were providing a technical correction to note the correct amount of $33.44 for training treatments furnished on or after January 1, 2011. We did not propose any change in the methodology or the training add-on adjustment. Thus, the suggestions and comments received are beyond the scope of this final rule. However, we will take these comments into account in future rulemaking. Also note, the training add-on adjustment is adjusted by geographic wage index to account for a nurse's salary for one-hour of home dialysis training. This adjustment applies to both hemodialysis and peritoneal dialysis home training and is paid in addition to the ESRD PPS payment. That is, ESRD facilities receive a per-treatment payment, that accounts for case-mix, geographic location, low-volume and outlier payments, regardless if the patient receives dialysis at home or in a facility, plus the training add-on. We also note that staff time is included in the per treatment payment amount and, the training add-on is in addition to that amount.
In the proposed rule (76 FR 40516), we noted that we inadvertently omitted an ESRD-related laboratory test from Table F: ESRD-Related Laboratory Tests of the Appendix in the CY 2011 ESRD PPS final rule. We explained that the “Assay of protein by other source,” which is identified by the Current Procedural Terminology code 84157, was a composite rate service under the basic case-mix adjusted composite payment system and, consequently, is considered a renal dialysis service under the ESRD PPS effective January 1, 2011. Therefore, the “Assay of protein by other source” should be furnished by the ESRD facility, either directly or under arrangement by another entity, to the ESRD patient and paid for under the ESRD PPS payment.
We did not receive any comments. In this final rule, we are correcting Table F of CY 2011 ESRD PPS final rule by adding, “Assay of protein by other source” identified by the Current Procedural Terminology code 84157.
In the proposed rule, we discussed the ICD-9-CM diagnosis codes that are eligible for the co-morbidity payment adjustments (76 FR 40516). We provided the list of ICD-9-CM codes that are recognized for purposes of the co-morbidity payment adjustments in Table E: ICD-9-CM Codes Recognized for a Co-morbidity Payment Adjustment of the Appendix of the CY 2011 ESRD PPS final rule (75 FR 49211). Although we discussed ICD-9-CM coding to be used to identify co-morbidity conditions on ESRD claims, we did not indicate that we would update the existing diagnostic categories and ICD-9-CM codes on an annual basis.
We clarified that the ICD-9-CM codes are subject to the annual ICD-9-CM coding changes that occur in the hospital inpatient PPS final rule and effective October 1st of every year (76 FR 40516). We explained that any changes that affect the categories of co-morbidities and the diagnoses within the co-morbidity categories that are eligible for the co-morbidity payment adjustments will be communicated to ESRD facilities through sub-regulatory guidance. In the proposed rule, we also explained that in response to comments we have received, we believed that it was important to reiterate the discussion of co-morbidities that was detailed in the CY 2011 ESRD PPS final rule (75 FR 49094 through 49107). Therefore, we explained that ESRD facilities should continue to provide documentation in the patient's medical/clinical record to support any diagnosis recognized for a payment adjustment, because this is a requirement to receive the co-morbidity payment adjustment. As we discussed in the proposed rule, we have been and will continue to monitor the prevalence of any co-morbidity diagnoses recognized for the co-morbidity payment adjustments under the ESRD PPS as compared to the prevalence of these categories over the past several years. Therefore, we would be able to identify any changes in the prevalence of any of the co-morbidity diagnoses recognized for purposes of the co-morbidity payment adjustment as compared to previous trends. We are monitoring the co-morbidities eligible for payment adjustment to determine if the co-morbidity adjustments need to be refined in future rulemaking. We did not receive any comments on this clarification.Start Printed Page 70253
In the CY 2011 ESRD PPS final rule (75 FR 49056), we explained that inpatient services, emergency services, and outpatient services furnished in a hospital or in an ambulatory surgical center furnished to ESRD beneficiaries were not included in the ESRD PPS base rate, and none of these services are considered renal dialysis services for inclusion in the ESRD PPS payment bundle. These services are reimbursed under other Medicare payment systems. We also explained that certain outpatient procedures necessary to maintain vascular access (that is, those which cannot be addressed by the ESRD facilities using procedures that are considered part of routine vascular access care), are excluded from the definition of renal dialysis services and are not included in the ESRD PPS payment. However, we consider the furnishing of certain medications, such as those used to flush a vascular access site of an ESRD patient, to fall within the definition of renal dialysis services.
As we discussed in the section on consolidated billing rules and edits in the CY 2011 ESRD PPS final rule (75 FR 49168), the ESRD PPS payment is an all-inclusive payment for renal dialysis services and the ESRD facility is responsible for all of the ESRD-related services that a patient receives. Payment for renal dialysis services under the ESRD PPS, including those that were formerly paid separately under the basic case-mix adjusted composite payment system, is no longer made to entities other than the ESRD facility (such as laboratories and DME suppliers).
In the proposed rule (76 FR 40517), we noted that after the publication of the CY 2011 ESRD PPS final rule, we received requests that we further clarify whether certain renal dialysis services furnished in an emergency room or emergency department are considered renal dialysis services covered under the ESRD PPS. Accordingly, we further clarified that renal dialysis services defined at § 413.171 of the regulations include diagnostic laboratory tests. In developing the ESRD PPS base rate, we included payments for outpatient laboratory tests billed on ESRD facility claims, as well as laboratory tests ordered by monthly capitation payment (MCP) physicians and billed on carrier claims (75 FR 49055), because we believe that these diagnostic laboratory tests furnished by ESRD facilities and MCPs meet the definition of renal dialysis services. We did not include laboratory tests ordered for Medicare ESRD patients undergoing treatment in hospital emergency departments or emergency rooms, because these tests are usually administered as part of a patient's clinical assessment of the condition requiring emergency room admission, which we believe are not generally related to the treatment of ESRD. Therefore, laboratory tests that are performed for Medicare ESRD beneficiaries in an emergency situation in an emergency room or emergency department as part of the general work-up of the patient, were excluded from the ESRD PPS payment bundle, and would not be considered renal dialysis services under the ESRD PPS.
We acknowledged in the proposed rule that laboratory tests that could be used during dialysis and ordered for the treatment of ESRD also may be ordered for ESRD patients in an emergency department or emergency room for other reasons (that is, as part of the assessment of the patient to obtain a diagnosis of the underlying condition which required emergency intervention). Although such tests could also be used in dialysis treatment and in the treatment of ESRD, because laboratory tests ordered for ESRD patients treated in emergency departments or emergency rooms are needed to arrive at a diagnosis of the condition requiring emergency treatment, we did not consider the laboratory tests as renal dialysis services under the ESRD PPS. Accordingly, these laboratory tests were not used to develop the ESRD base rate. We indicated that we would not expect that the laboratory tests provided in that circumstance to be subject to consolidated billing edits, resulting in denial of payment. That is, we would not consider such tests to be renal dialysis services in those emergency situation because they were not ordered for the treatment of ESRD, but instead, furnished as part of the general work-up of the patient necessary for diagnosis.
We further explained in the proposed rule that the exclusion of laboratory tests ordered in hospital emergency rooms or emergency departments from the consolidated billing edits did not mean that renal dialysis facilities should attempt to circumvent the application of the bundled ESRD PPS rate by directing patients to emergency rooms or emergency departments for obtaining ESRD-related laboratory tests, or the provision of other renal dialysis services. Because ESRD facilities are financially responsible for all renal dialysis laboratory tests, referring ESRD patients to the emergency room or emergency department for ESRD-related laboratory tests would be inappropriate. We noted that it would also be inappropriate for ESRD facilities to refer its patients to the emergency room or emergency department for maintenance of access sites (including treatment for access infections) which they had treated prior to the ESRD PPS for the purpose of diverting costs of providing renal dialysis services to their patients, or the administration of drugs that are considered renal dialysis services under the ESRD PPS. We also stated that we are monitoring the provision of renal dialysis services to ESRD patients in emergency rooms or emergency departments.
We did not solicit comments on emergency services to ESRD beneficiaries; however, we received four comments from national organizations. A summary of the comments we received and our responses to comments are set forth below.
Comment: Several commenters representing hospital organizations endorsed CMS' policy not to apply the consolidated billing rules to items and services furnished to ESRD patients in hospital emergency rooms or emergency departments for reasons other than the treatment of ESRD. One commenter supported CMS's recognition that the ESRD PPS consolidated billing rules do not apply to patients in the emergency department. One commenter supported the exclusion of services provided in an emergency room from the definition of renal dialysis services under the ESRD PPS. One commenter appreciated the clarification that”“legitimate” non-ESRD laboratory tests in emergency rooms, hospitals, and ambulatory care centers are not part of the ESRD PPS. Another commenter agreed that hospital emergency department claims are excluded from the ESRD consolidated billing edits. The commenter suggested modeling specific guidance from the skilled nursing facility (SNF) consolidated billing guidance. The commenter believed that that medication administration should not be included in the ESRD PPS consolidated billing stating that the administration of medications other than EPO or Aranesp would be directly related to the emergency condition. The commenter stated that the application of the AY modifier is a huge operational burden for hospitals and often they are unaware that patients have ESRD.
Response: We thank the commenters who supported our clarification of consolidated billing under the ESRD PPS. However, some commenters have misunderstood our clarification. In the proposed rule (76 FR 40517), we explained that we understood that laboratory tests that could be used for dialysis could also be ordered for ESRD Start Printed Page 70254patients in an emergency room or emergency department for reasons other than the treatment of ESRD in order to arrive at a diagnosis. We stated that we recognize that laboratory tests ordered for ESRD patients in emergency room or emergency department that are needed to arrive at a diagnosis would not be considered renal dialysis services under the ESRD PPS and, therefore, would not be subject to consolidated billing. We further explained that the exclusion of laboratory tests that are ordered in an emergency room or emergency department and excluded from consolidated billing edits does not mean that renal dialysis facilities should attempt to circumvent the ESRD PPS bundled payment rate by directing patients to the emergency room or emergency department for ESRD-related laboratory tests.
We have not included drugs or any other renal dialysis item or service in the consolidated billing rule exemptions when furnished in an emergency room or emergency department. In other words, the only services that we have excluded from the consolidated billing edits are laboratory tests that are performed in an emergency room or emergency department to determine a diagnosis. We are not discussing any other outpatient setting other than an emergency room or emergency department. We will consider the inclusion of renal dialysis drugs (that is, drugs used for ESRD-related conditions) furnished in the emergency room or emergency department exemption in future rulemaking.
With regards to the suggestion that we follow the SNF consolidated billing guidelines, we will be issuing guidance on the consolidated billing exemption of laboratory tests ordered in an emergency room or emergency department for the purpose of establishing a diagnosis. Finally, with regard to the comment on the burden of using an AY modifier for non-ESRD-related items and services, we believe it is important that we assure that duplicate payments are not being made for items and services that have been included in the ESRD PPS bundled payment. At the current time, the use of the AY modifier is the only means that can be used in order to clearly identify items and services that are not ESRD-related.
Comment: One commenter expressed disappointment that CMS did not remind ESRD facilities of the November 1, 2011 deadline to elect to be excluded from the transition.
Response: We believe that the decision to receive a blended payment under the transition or to receive payment under the ESRD PPS was a very important business decision for ESRD facilities and that a reminder was not necessary.
Comment: One national association urged CMS to consider the concerns of facilities in the transition and make adjustments to the proposed rule when it may impact their financial viability and ability to provide quality patient care.
Response: We always assess the degree to which our proposed policies negatively impact categories of ESRD facilities such as rural, independent, pediatric, and transitioning ESRD facilities and are committed to developing payment policies that are fair and lead to increased payment accuracy under the ESRD PPS.
Comment: One independent ESRD facility did not believe that ESRD facilities should be held to the one-time election if changes are made annually. The commenter proposed that the one-time election be made on an annual basis or for those facilities that will be “disproportionately negatively impacted” by the proposed changes. The commenter further stated that the ability to rescind decisions made in 2010 should be made available.
Response: Section 1881(b)(14)(E)(ii) of the Act prohibits us from allowing facilities to submit annual elections or to rescind elections. Therefore, we are unable to allow changes to the election under any circumstance. With regard to annual changes to the ESRD PPS, we did not state that CMS would not make any changes to the composite rate portion of the blended payment or to the ESRD PPS. We believe there are changes finalized in this rule (such as eliminating a site of service distinction with regard to separate payment for antibiotics used for access infection and, eliminating the 50 percent rule under the outlier policy) that will result in positive effects to transitioning facilities.
Comment: One patient organization stated that bundling has already negatively impacted patients. The commenter further states that providers have in large part changed prescribed medications to the detriment of patients. The commenter cited changing practices of providing analog vitamin D and iron as examples.
Response: We are concerned about the comments made by this organization. We expect that ESRD facilities through their interdisciplinary teams and through the patient's nephrologist will ensure that patients receive the care that they require. We are monitoring many aspects of the ESRD PPS, including outcomes. We encourage patients to contact their ESRD Network if they are concerned about the care that they are receiving from their ESRD facilities.
Comment: Several commenters requested that the rate-setting and impact files at the provider level be provided to allow for transparency. The commenters indicated that they did not have the data to evaluate the proposed rule and offer suggestions to improve the bundled system. One commenter cited the need for the rate-setting file to allow for evaluating the proposed changes to the low-volume adjuster. The commenter further stated that their findings differed from CMS and expressed concern that CMS may have overestimated the low-volume adjuster in the standardization calculation leading to funds being taken out of the payment system inappropriately. One dialysis organization expressed their concern that small providers may not have the resources to identify outliers and place them on claims. The commenter urged CMS to show data that outlier payments were helping small providers. The commenter further stated that if small providers were not receiving outlier payments, then it may be best for funds allocated for outliers be made part of the base rate. One commenter stated that they remain concerned that some proposed policies continue to result in a loss of funds from the ESRD program that exceeds the Congressionally-mandated two percent for CY 2011.
Response: We do not agree with the assertions that CMS provided inadequate data to evaluate and comment on the proposals described in the proposed rule. We believe that the discussions and explanations in the proposed rule are sufficiently detailed to provide an adequate explanation as to how values were computed. In addition, we posted a provider-level impact file on the ESRD Payment Web site which was used to create the proposed impact analysis. We acknowledge that we may not have provided sufficient notification that the files were available and, therefore, in the future, we plan to provide a listserv notification to inform stakeholders when these files are available on the ESRD Payment Web site. As we did for CY 2011, we will post the provider-level file that will allow further analysis of the impact of the final outlier and wage index changes for CY 2012 on individual providers.
We have not made the rate setting file available because the release of patient identifiable data is not necessary to accomplish the purpose of analyzing our proposals. Applicable Federal privacy laws and regulations, including Start Printed Page 70255the Privacy Act and HIPAA Privacy Rule only permit us to disclose personal identifiable information when it is necessary to administer the program, or for health care operations and payment.
We believe that some of the concerns raised by the commenters are related to the assumptions we made in computing the final base rate for CY 2011 where we standardized the base rate to account for the projected payments for the ESRD PPS adjustments. These concerns are beyond the scope of this final rule.
With regard to the commenters' claims that we had overstated the low-volume adjustment in the standardization calculation leading to funds being inappropriately taken out of the payment system, we explained the low volume methodology in great detail in the CY 2011 ESRD PPS proposed rule (74 FR 49969 through 49978) and in the CY 2011 ESRD PPS final rule (75 FR 49117 through 49125). We did not propose to change or modify the low-volume adjuster methodology for CY 2012. We note that we are monitoring the extent to which the low-volume and other ESRD PPS adjustments are consistent with the assumptions we made in developing the ESRD PPS. We will address this issue in future rulemaking.
We do not understand the comment that suggested that the proposed policies continue to result in a loss of funds from the ESRD program that exceeds the Congressionally-mandated two percent, because the two-percent reduction only applied to CY 2011.
Comment: Some commenters provided comments on issues that were not addressed in the proposed rule. These are summarized as follows. Some commenters suggested that the extra costs associated with patient non-compliance should be addressed. Some commenters advocated for inclusion of their products in the ESRD bundled payment. Other commenters believed that there should be a new technology adjustor and provided suggestions such as including new pharmaceutical agents into the base rate; providing for incremental payments for innovations that improve clinical outcomes, but do not reduce costs to dialysis facilities immediately; and a non-budget-neutral pass-through for new technology. One commenter suggested that we include over-the-counter nutritional support in the PPS as of January 1, 2012. Several commenters maintained that oral drugs for long term residents with ESRD should be dispensed by the Long Term Care pharmacy. Several commenters declared that CMS provide a statement indicating that future updates to items and services in the bundle will be made through rulemaking rather than guidance and, requested that CMS specify how future changes to the system will be handled. One commenter supported a race/ethnicity adjuster and provided their rationale on its inclusion. Another commenter urged CMS to examine time on machine, nutritional services, social work services and nursing services. One commenter requested that CMS explore broader ESRD bundles, such as integrated care models. Several commenters expressed difficulty of documenting co-morbidities and suggested that CMS provide the adjusters to the providers. Finally, some commenters expressed concerns about the ESRD cost report and with the anticipated funding of oral-only drugs.
Response: Because these comments were not in response to any proposals or discussions in the proposed rule, they are beyond the scope of this final rule. However, we refer the commenters to the CY 2011 ESRD PPS final rule where we believe that we addressed many of these issues (75 FR 49030). We also note that we will review all of the comments and may address them in future rulemaking.
Comment: One individual commenter supported the proposed rule. One national association supported the case-mix adjusted PPS. Another national association expressed their pleasure with the way in which CMS has implemented the first year of the ESRD PPS and the agency's willingness to work with the ESRD community.
Response: We thank the commenters for their support and willingness to work with CMS in implementing the ESRD PPS.
For over 30 years, monitoring the quality of care provided to end-stage renal disease (ESRD) patients and provider/facility accountability have been important components of the Medicare ESRD payment system. The ESRD Quality Incentive Program (QIP), required by section 1881(h) of the Social Security Act (the Act), is the next step in the evolution of the ESRD quality program that began more than three decades ago. The first year for which the ESRD QIP payment reduction will be implemented is PY 2012. The PY 2012 ESRD QIP was finalized in two regulations: one that finalized the three performance measures (75 FR 49030, 49182 (August 12, 2010) (hereinafter referred to as the “CY 2011 ESRD PPS final rule”)); and one that finalized other aspects of the 2012 ESRD QIP such as the scoring methodology and payment reduction scale (76 FR 628 through 646) (hereinafter referred to as the “2012 ESRD QIP final rule”). Section 1881(h) of the Act, as added by section 153(c) of MIPPA, generally requires that the Secretary establish an ESRD QIP by (i) Selecting measures; (ii) establishing the performance standards that apply to the individual measures; (iii) specifying a performance period with respect to a year; (iv) developing a methodology for assessing the total performance of each provider/facility based on the performance standards with respect to the measures for a performance period; and (v) applying an appropriate payment reduction to providers and facilities that do not meet or exceed the established Total Performance Score.
As we have stated, the first year for which the ESRD QIP payment reduction will be implemented is PY 2012, and we selected one measure for the PY 2012 ESRD QIP of dialysis adequacy and two measures of anemia management. The following are the three measures (finalized in the CY 2011 ESRD PPS final rule) for the PY 2012 ESRD QIP:
Percentage of Medicare patients with an average hemoglobin less than 10.0 g/dL (Hemoglobin Less Than 10 g/dL measure).
Percentage of Medicare patients with an average hemoglobin greater than 12.0 g/dL (Hemoglobin Greater Than 12 g/dL measure).
Percentage of Medicare patients with an average urea reduction ratio (URR) equal to or greater than 65 percent (URR Hemodialysis Adequacy measure).
A full description of the methodologies used for the calculation of the measures can be reviewed at: http://www.dialysisreports.org/pdf/esrd/public/Guide_to_the_PY_2012_ESRD_QIP_PSR.pdf (see the “Inclusion Criteria” and “Calculation Process” sections of the document).
Other aspects of the 2012 ESRD QIP finalized in the PY 2012 ESRD QIP final rule include the establishment of performance standards for these measures (including applying the special rule under section 1881(h)(4)(E) of the Act) and establishing a scoring methodology for calculating individual Total Performance Scores ranging from 0-30 points based on the three finalized measures. As part of our methodology for calculating the provider/facility Total Performance Score, we weighted the Hemoglobin Less Than 10 g/dL Start Printed Page 70256Measure at 50 percent of the score, while the Hemoglobin Greater Than 12 g/dl measure and the URR Hemodialysis Adequacy measure were each weighted at 25 percent of the score. We also finalized a policy under which providers/facilities that did not meet or exceed a Total Performance Score of 26 points would receive a payment reduction ranging from 0.5 percent to 2.0 percent.
On July 8, 2011, a proposed rule entitled “Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012, End-Stage Renal Disease Quality Incentive Program for PY 2013 and PY 2014; Ambulance Fee Schedule; and Durable Medical Equipment” (76 FR 40498) (the “proposed rule”) appeared in the Federal Register. In the proposed rule, we expanded upon the PY 2012 ESRD QIP framework by proposing to adopt new ESRD QIP requirements for PYs 2013 and 2014.
We received approximately 88 public comments on the proposed rule that were related to the ESRD QIP. Interested parties that submitted comments included dialysis facilities, national organizations representing dialysis facilities, nephrologists, nurses, nutritionists, home health agencies, dialysis corporations, clinical laboratories, pharmaceutical manufacturers, hospitals and their representatives, individual dialysis patients, advocacy groups, and the Medicare Payment Advisory Commission (MedPAC). In this section of the final rule, we provide a summary of each proposed requirement for the PY 2013 and PY 2014 ESRD QIP, a summary of the public comments received on those requirements, our responses to these comments, and the final policies that will apply to the PY 2013 and the PY 2014 ESRD QIP.
In the proposed rule, we outlined the proposed requirements for the two proposed measures for the PY 2013 ESRD QIP. We proposed that ESRD providers and facilities that do not meet these requirements would receive a reduction, based on their Total Performance Score, to the payments otherwise made under section 1881(b)(14) with respect to PY 2013 services, in accordance with section 1881(h)(1)(A) of the Act. We proposed to calculate these payment reductions by assigning each provider/facility a Total Performance Score, ranging from 0-30 points, in accordance with its individual performance on the two proposed measures. We proposed that a provider/facility that does not achieve a Total Performance Score of 30 points would receive a payment reduction in PY 2013 ranging from 1.0 percent to 2.0 percent, depending upon how far below this minimum Total Performance Score its performance falls. Our specific proposals, responses to comments, and finalized policies based on comments, are discussed below.
Section 1881(h)(2)(A) of the Act requires that the measures specified for the ESRD QIP include measures on anemia management that reflect the labeling approved by the FDA for such management; measures on dialysis adequacy; to the extent feasible, a measure or measures on patient satisfaction; and such other measures that the Secretary specifies, including (to the extent feasible) measures on iron management, bone mineral metabolism, and vascular access, including maximizing the placement of arterial venous fistula. In selecting measures for the PY 2013 ESRD QIP, we examined whether it would be feasible to propose to adopt any new measures for the program. In light of our proposal to select CY 2011 as the performance period (discussed more fully below), we determined that it is not feasible to adopt any of the new measures mentioned above until the PY 2014 ESRD QIP. We also carefully reexamined the three measures that we adopted for the PY 2012 ESRD QIP, and for the reasons discussed below, proposed to continue including only two of them, (i) The Hemoglobin Greater Than 12 g/dL measure and (ii) the URR Hemodialysis Adequacy measure, in the PY 2013 ESRD QIP measure set.
We also proposed to retire the Hemoglobin Less Than 10 g/dL measure beginning with the PY 2013 ESRD QIP. As we explained in more detail in the proposed rule (76 FR 40519), we have recently reassessed the evidence for the use of erythropoiesis stimulating agents (ESAs) in patients with kidney disease through a National Coverage Analysis (CAG-00413N) and, while we did not seek to limit the coverage of these agents at this time, we could not identify a specific hemoglobin lower bound level that has been proven safe for all patients treated with ESAs. In addition we believe that retiring the Hemoglobin Less Than 10 g/dL measure is reflective of the new labeling approved by the FDA for the use of ESAs (http://www.fda.gov/Drugs/DrugSafety/ucm259639.htm). We discussed with the FDA our proposal to retire the Hemoglobin Greater Than 10 g/dL measure starting in PY 2013. Because this measure encourages providers/facilities to keep hemoglobin above 10 g/dL, the FDA agreed that retiring this measure is consistent with the new labeling for ESAs approved by the FDA.
We proposed to maintain the Hemoglobin Greater Than 12g/dL measure as a measure of anemia management. As we explained in more detail in the proposed rule (76 FR 40519), the studies continue to show that targeting hemoglobin levels above 12 g/dL through the use of ESAs can contribute to adverse patient outcomes.[1] This measure, consistent with the requirement under section 1881(h)(2)(A)(i) of the Act, also continues to reflect the labeling approved by the FDA for anemia management.
We also proposed to retain the URR Hemodialysis Adequacy measure, which assesses the percentage of Medicare patients with an average URR equal to or greater than 65 percent. Section 1881(h)(2)(A)(i) of the Act states that the measures specified under the ESRD QIP for a payment year shall include measures on dialysis adequacy. We noted that, for the reasons stated in the CY 2011 ESRD PPS final rule (75 FR 49182), we believe that the URR Hemodialysis Adequacy measure is an appropriate and accurate measure of hemodialysis adequacy.
The comments we received on these proposals and our responses are set forth below. The comments on and the responses to the Hemoglobin Greater Than 12 g/dL measure also apply to the proposal to include this measure in the PY 2014 ESRD QIP.
Comment: Many commenters urged CMS to retire the URR Hemodialysis Adequacy measure for PY 2013 in favor of a Kt/V measure because Kt/V is widely accepted, is used extensively by the renal community as a measure of dialysis adequacy, and is the basis for a measure endorsed by the National Quality Forum (NQF). One commenter specifically noted that there are situations in which patients may have a Kt/V within an acceptable range, but not a URR equal to or greater than 65 percent. One commenter suggested that, if CMS does retire the URR dialysis adequacy measure for the PY 2013 Start Printed Page 70257ESRD QIP, the agency should consider allowing facilities to report either URR or Kt/V.
Response: We thank the commenters for their input on this issue. We agree that a Kt/V dialysis adequacy measure would more accurately measure how much urea is removed during dialysis because the calculation takes into account the amount of urea removed with excess fluid. We asked providers/facilities to begin submitting Kt/V data on July 1, 2010, and plan to incorporate measure(s) based on Kt/V as soon as we can to ensure the validity and consistency of these data. In the interim, for the reasons stated in the CY 2011 ESRD PPS final rule (75 FR 49182), we believe that the URR Hemodialysis Adequacy measure is, overall, an appropriate and accurate measure of hemodialysis adequacy.
Comment: Many commenters voiced concern over CMS' proposal to retire the Hemoglobin Less Than 10 g/dL measure. One commenter specifically stated that CMS should consider the effects of retiring this measure on pediatric patients. Commenters noted that without a lower bound for hemoglobin in the ESRD QIP, the bundled payment system financially incentivizes providers/facilities to provide less ESAs, driving hemoglobin down. Commenters argued that decreased hemoglobin will lead to a rise in transfusions, hospitalization, morbidity, and mortality, endanger vascular access due to the need for additional venipuncture, and decrease quality of life, appetite of patients, and consistency of care, shifting care to hospitals and outpatient infusion centers. Further, one commenter argued that dropping the hemoglobin floor will increase the burden of ESRD patients because, as a result of the negative consequences, it will require more appointments and travel to receive transfusions; another commenter stated that retiring the measure will have a “chilling effect” on the ability to pursue innovation in the treatment of patients with chronic kidney disease (CKD). Commenters also noted that a rise in transfusions could result in worse transplant outcomes and a higher likelihood of infection. They also argued that quality of life issues may cause individuals to be less active and eat less nutritious foods, possibly resulting in patients who are less healthy and need more care. Some commenters noted that many of these consequences would be disproportionately suffered by the African-American community and encouraged CMS to collect and analyze data on health disparities.
Response: We thank commenters for their input. As we stated in the proposed rule (76 FR 40519), we have recently reassessed the evidence for the use of ESAs in patients with kidney disease through a National Coverage Analysis (CAG-00413N), and we could not identify a specific hemoglobin lower bound level that has been proven safe for all patients treated with ESAs. We are also not aware of, nor did the comments note, any studies that identify a specific hemoglobin level which should be maintained to increase quality of life or minimize transfusions or hospitalizations. However, if any new evidence or studies emerge, we will take such evidence into consideration in adopting future measures for the ESRD QIP. We have discussed our proposal to retire the Hemoglobin Less Than 10 g/dL measure with the FDA and they concur that retiring the measure is consistent with the new labeling for ESAs. Factors that impact anemia management, including optimal iron stores, dialysis adequacy, avoidance of infections, reduction of inflammation, and other factors should be addressed by the health care team to improve patient health. We urge patients and providers to work together to achieve optimal hemoglobin levels for each individual patient. We will continue to monitor and evaluate practice patterns and outcomes for all segments of the Medicare ESRD population as we develop and refine our measurement of the quality of anemia management. Additionally, we note that pediatric patients are excluded from the anemia management measures we have thus far adopted and are adopting in this final rule for the ESRD QIP, so the retirement of this measure does not directly affect the pediatric population.
Comment: As an alternative to retiring the measure, some commenters argued that CMS should reduce the lower bound from 10 g/dL to 9 g/dL or 8 g/dL or decrease the financial penalty. Commenters also suggested that the measure not be limited to those on ESAs because there are other means of maintaining hemoglobin levels. Other commenters suggested that the root cause of health issues related to high hemoglobin is the overuse of ESAs, and, therefore, CMS should create an anemia management measure monitoring ESA usage or other outcomes such as transfusion avoidance rather than hemoglobin levels. One commenter recommended that CMS set a range for hemoglobin of 10-11 g/dL, and, if a patient's hemoglobin is higher than 11 g/dL, CMS should require the ESA dosage to be decreased and not discontinued. One commenter proposed that, in the event the Hemoglobin Less Than 10 g/dL measure remains in the ESRD QIP, the weighting for this measure be decreased until an accurate baseline is determined reflecting current medical evidence and drug labeling. One commenter suggested that this weighting decrease to zero. Commenters also asked CMS to continue to monitor hemoglobin levels, perhaps through a reporting measure or as a condition for coverage, and publicly report low hemoglobin levels even if the measure is retired from the ESRD QIP.
Response: As we noted above, we did not find scientific evidence to identify an appropriate and safe quality standard for a minimal achieved hemoglobin level. Therefore, in the absence of this evidence, we do not believe it is appropriate to simply decrease the lower bound. Additionally, continuing to employ the measure in the program, but decreasing its weight to zero may signal to beneficiaries that this measure is valid, although less important, and that it is, therefore based in scientific evidence. As noted above, we are actively monitoring trends in anemia management as well as patient outcomes, and we strongly encourage patients and providers to work together to develop anemia management strategies appropriate for individual patient circumstances. We note that the Hemoglobin Less Than 10 g/dL measure results are currently reported on Dialysis Facility Compare, and that we are exploring the options and feasibility of continuing to publicly report anemia management trends.
We agree with commenters that we should consider anemia management measures that apply to patients not on ESAs, and, under 42 CFR 494.180(h), we asked providers/facilities to begin providing data for these patients on January 1, 2012. In addition, we are considering ways to incorporate achieved hemoglobin levels, ESA usage, and other important factors in our anemia measurement strategy for future years of the ESRD QIP; we welcome community input and would like to encourage measure development in this area.
Comment: Some commenters agreed with our proposal to retire the Hemoglobin Less Than 10 g/dL measure. Commenters noted that such a proposal reflects the new labeling approved by the FDA for the use of ESAs, is consistent with the lack of scientific evidence for a lower bound, and will allow providers more latitude, providing room for more patient-centered care. Several commenters also suggested that, while CMS should retire Start Printed Page 70258the measure, the agency should also conduct additional clinical studies to establish optimal dose strategies, targets, and the long term safety of various ESA therapies, and reinstate a lower bound as soon as possible.
Response: We thank commenters for their support. As we noted above, we will continue to monitor practice patterns in the area of anemia management and develop and evaluate additional measures for future years of the ESRD QIP. We will also continue to work with our Federal partners and external stakeholders to advance knowledge in this area.
Comment: One commenter suggested that the agency include text in the ESRD QIP certificates to be posted in December 2011 to acknowledge the changing guidance in anemia management so patients and caregivers are aware that the data are dated and not necessarily relevant in today's environment. Another commenter stated that CMS should develop Performance Score Report (PSR) mechanisms to adjust for unusual patient demographics and dialysis facility census.
Response: The PY 2012 ESRD QIP certificates will clearly state that “the information communicated * * * is based on 2010 data.” Our regulations do not preclude providers/facilities from providing patients with more explanatory detail, and we encourage providers/facilities to engage patients in discussions of this information.
As we have stated, we continue to monitor the effects of the ESRD QIP on all segments of the Medicare ESRD population, and we will continue to evaluate our scoring and public reporting methodology for any necessary modifications.
Comment: Some comments suggested that the Hemoglobin Greater Than 12 g/dL measure should be retired from the PY 2013 and PY 2014 ESRD QIP measure set because some patients may benefit from a higher hemoglobin level and there is a lack of scientific evidence for an upper hemoglobin bound. Commenters argued that, generally, higher hemoglobin leads to better quality of life and patients and doctors should be able to weigh risks and benefits, leading to a more patient-centered definition of quality. These commenters noted that CMS should only be regulating those providers/facilities that are clear outliers. Some commenters requested that, should CMS retain the measure, the bound be raised to Greater Than 12.5 or Greater Than 13 g/dL. Another commenter stated that, given recent clinical practice changes already addressing the concern for high hemoglobin and high ESA doses, it may be reasonable for CMS to decrease the weighting for the Hemoglobin Greater Than 12 g/dL measure.
Response: Studies continue to show that targeting hemoglobin levels above 12 g/dL through the use of ESAs can contribute to adverse patient outcomes including an increased risk of myocardial infarction, stroke, venous thromboembolism, thrombosis of vascular access, and overall mortality, and, in patients with a history of cancer, tumor progression or recurrence. Given the significance of these outcomes, we do not believe it is appropriate either to retire the measure or reduce the weight of the measure. In addition, as explained further below, this measure is consistent with new labeling for ESAs approved by the FDA that directs providers to reduce or interrupt the dose of ESAs if the hemoglobin level approaches or exceeds 11 g/dL.
Comment: Some commenters argued that the only anemia management measure should be Hemoglobin Greater Than 11 g/dL, replicating the FDA guidelines. Commenters suggested that such a measure is consistent with current scientific evidence, provides the best level of care for patients, and lowers Medicare costs.
Response: New labeling approved by the FDA for the use of ESAs addresses targeted hemoglobin levels while we measure achieved hemoglobin levels. The achieved hemoglobin level is a function of the target but also reflects patient factors such as the underlying causes of anemia which determine how sensitive the patient is to ESAs and whether the target is actually achieved. These patient factors can vary unpredictably over time even within an individual patient which means that patients will sometime exceed (or fall short of) the hemoglobin level target despite clinician diligence. The FDA label recognizes this hemoglobin variability and states that, if the hemoglobin approaches or exceeds 11 g/dL, ESA dosing should be reduced or interrupted, but the label does not state that hemoglobin levels should never exceed this value. We believe that the current anemia measure allows for some deviations of the achieved hemoglobin while highlighting that higher hemoglobin targets can result in adverse patient outcomes.
Comment: Some commenters supported the Hemoglobin Greater Than 12 g/dL measure.
Response: We thank commenters for their support.
Comment: One commenter requested clarification on the meaning of “on ESA,” and another commenter requested that CMS explicitly state that the Hemoglobin Greater Than 12 g/dL measure applies only to those patients on ESAs. Specifically, one commenter inquired whether it is applied based on one bill indicating ESA administration after 90 days of dialysis and the submission of four bills for dialysis within a 12 month period for adult patients. In addition, the commenter asked how patients with untreated Hemoglobin Greater Than 12 g/dL will be identified and excluded from the measure calculation.
Response: We assume that the commenters are referring to data extracted from claims. As outlined in the measure specification, “on ESA” means that a patient is receiving ESAs during the month covered by a claim, as identified by the presence of an ESA dose and hemoglobin on the claim. This measure applies only to months for which a patient has received an ESA agent. Patients are attributed to a facility only after they have four months of eligible claims from that facility. To be eligible for the Hemoglobin Greater Than 12 g/dL measure, among other criteria, (i) The beginning date of the claim must have been at least 90 days since the date of first ESRD service for the patient and (ii) the claim must include a line item reporting the administration of an ESA in that month. These inclusion criteria are unchanged from the PY 2012 ESRD QIP. The measures specifications are available at http://www.dialysisreports.org/ESRDMeasures.aspx.
Comment: Some commenters believe that the Hemoglobin Less Than 10 g/dL measure should be retired from the PY 2012 measure set because it would be unfair to penalize dialysis providers/facilities for their nephrologists' interpretation of the medical literature. One commenter argued that CMS knew of published studies in 2006 and 2009 which signaled that no lower bound could be identified and noted that these studies changed behavior in the industry. One commenter also stated its belief that if CMS does not retire the measure for the PY 2012 ESRD QIP, the public may erroneously conclude that the provider's/facility's PY 2012 ESRD QIP total performance score reflects CY 2012 data, as opposed to the data utilized for the performance period. Commenters also argued that the legislative language requiring the Secretary to reflect the FDA labeling applies to the labeling in the payment year rather than the performance year.
Response: Based on the available evidence in 2006 regarding the treatment of anemia in the ESRD population, we developed a consensus-based measure which was endorsed by Start Printed Page 70259the NQF in 2008 (NQF #0370). This measure formed the basis for the Hemoglobin Less Than 10 g/dl measure which was adopted for the ESRD QIP (76 FR 628). This measure remained consistent with clinical practice guidelines and the labeling approved by the FDA for the use of ESAs in effect until June 2011. In June 2011, new labeling for ESAs was approved by the FDA. We will retire the Hemoglobin Less Than 10 mg/dL measure beginning in PY 2013 in accordance with this new labeling.
Although measures are adopted for a specific payment year, we evaluate performance on those measures during a performance period that precedes the payment year so that we can collect and evaluate the data for these measures and allow providers/facilities adequate time to review their scores before payment reductions occur. Therefore, to the extent that the anemia management measures under section 1881(h)(2)(A)(i) reflect the labeling approved by the FDA for such management, we believe that those measures must reflect the labeling and guidance in effect and the care provided during the performance period which, with respect to the PY 2012 program, was CY 2010.
Finally, as we noted above, the PY 2012 ESRD QIP certificates state that “the information communicated * * * is based on 2010 data.”
For the reasons discussed above, for the PY 2013 ESRD QIP, we finalize use of the following two measures previously adopted for the PY 2012 ESRD QIP:
Hemoglobin Greater Than 12g/dL measure
URR Hemodialysis Adequacy measure
Section 1881(h)(4)(D) of the Act requires the Secretary to establish a performance period with respect to a year, and for that performance period to occur prior to the beginning of such year. In the proposed rule, we discussed in detail the factors that we considered in determining what performance period to select for the PY 2013 ESRD QIP (76 FR 40519). We also noted that, in light of the new ESRD PPS, we believe that it is important to assess the quality of care being furnished to ESRD patients and that basing this assessment on a year of data will provide an accurate and fair determination of whether a provider/facility has met or exceeded the proposed performance standards with respect to the proposed measures. Therefore, we proposed to select all of CY 2011 as the performance period for the PY 2013 ESRD QIP.
Consistent with what we finalized for the PY 2012 ESRD QIP, we also proposed to require that providers/facilities have at least 11 cases that meet the reporting criteria for a measure in order to be scored on the measure.
Comment: Several commenters expressed concern that both the PY 2013 and PY 2014 programs will use data more than a year old and penalize facilities that have since improved; commenters encouraged the use of methodologies that recognize changes in performance over time and use the most recently available data as comparison data. Another commenter recommended that CMS establish CY 2012 as the performance year for PY 2013 because it would allow dialysis facilities and providers to gauge their performance using clinically relevant, timelier, and prospective data.
Response: For both PY 2013 and PY 2014, we have determined that data derived from claims is the most appropriate source on which to score providers/facilities. Claims data allows us to implement a variety of measures which can be used to evaluate the greatest number of facilities. In order to assure completeness of this claims data, there is a lag between when the data is generated and when we are able to use it in the ESRD QIP. This time period is lengthened because we believe it is important to allow providers/facilities a period of time to review their scores before the payment period. We are considering how we might be able to shorten this timeline in the future, such as by collecting data through CROWNWeb or by some other method, such as the NHSN or electronic health records, and we will continue to take the commenters concerns into account as we do so.
Comment: Several commenters argued that, under section 1881(h)(4)(C) of the Act, the ESRD QIP performance periods must be prospective, but nearly all of the PY 2013 performance period will have ended by the time the performance standards are finalized. Commenters also argued that finalizing performance standards when the performance period is nearly complete impermissibly creates a retroactive rule. Comments also noted that a retrospective performance period does not allow a provider/facility to change its practices to meet standards, thereby increasing quality of care. Other commenters, however, voiced support for the proposed PY 2013 performance period.
Response: We acknowledge that section 1881(h)(4)(C) of the Act requires the Secretary to establish performance standards under subparagraph (A) prior to the beginning of the performance period for the year involved. However, we are establishing the performance standard that will affect ESRD payments in PY 2013 in accordance with section 1881(h)(4)(E), which does not impose the limitation suggested by the commenters. We believe that setting a CY 2011 performance period for the initial ESRD QIP will ensure that the performance scores are based on a robust set of data, and will allow us sufficient time to analyze that data, determine whether provider/facilities met the performance standards, provide providers/facilities with an opportunity to preview their performance scores and submit related inquiries, and implement the applicable payment reductions for PY 2013. We also note that, beginning with the PY 2014 program, we will set performance standards under section 1881(h)(4)(A) of the Act.
Comment: Commenters voiced concerns about CMS' approach to including low-volume facilities in the program because one patient could significantly affect a score for reasons unrelated to quality of care, such as patient comorbidities, and decrease the ability of a provider/facility to score well on a measure. This scoring could, in turn, affect patient volume if consumers judge facilities based on their scores. Commenters suggested different minimum case thresholds such as 20 cases or 25 cases or that providers with fewer cases be scored differently; some commenters also noted that their studies showed that the sample size rather than overall performance is driving the results for facilities and requested that CMS raise the case minimum to 20. Another commenter urged CMS to research the reliability of a measure to set the minimum number of cases, publish minimum case reliability data, and use this data to set a minimum number of cases for all value-based purchasing programs. One commenter urged CMS to re-consider its scoring methodology to analyze for statistical significance. Another commenter stated its belief that the ESRD QIP methodology does not appropriately account for low patient census, unusual treatment setting, or patient case-mix, and recommended that CMS develop a mechanism to adjust for circumstances in which facilities with an unusual care setting, atypical case-mix, or small patient census may be at high risk of incurring Start Printed Page 70260penalties for failure to meet performance standards.
Response: We appreciate the commenters' concerns regarding the potential impact of patient case mix on smaller providers/facilities. The goal of the ESRD QIP is to accurately assess the quality of care provided by a provider/facility. However, we recognize that a quality measure score could be impacted by one or more factors unrelated to the care furnished by the provider/facility, and that the potential of such factors to greatly skew the calculation decreases as the number of cases included in the measure increases. Similarly, a provider/facility with a small number of patients could find that one patient's outcome determined its score on a quality measure. Thus we proposed that a provider/facility would need to have a minimum of eleven cases that meet the eligibility criteria for a measure in order to be scored on that measure. This eleven case minimum allows as many providers/facilities as possible to participate in the program. This minimum case number is also consistent with the reporting of these measures on Dialysis Facility Compare. We will continue to closely monitor beneficiary access to care, including evaluating the rate of facility closures. We will also continue to assess the impact of the program on facilities of all sizes, and we will change the methodology if we believe it is necessary to ensure that the program adequately measures quality. Additionally, we continue to monitor and evaluate the reliability of all of our value-based purchasing programs; we note, however, that each of these programs has its own set of requirements which must be considered during any assessment of reliability.
Comment: One commenter expressed concern that new facilities without a complete data set available for the measures will be unfairly penalized.
Response: Like all ESRD QIP providers/facilities, new facilities will only be included in the program if they have the requisite amount of data. Any provider/facility must have adequate data to calculate performance rates on both PY 2013 measures to be included in the PY 2013 ESRD QIP. For each of these measures, there must be at least eleven cases each with four claims, regardless of whether the facility is new or established.
Additionally, under the special rule in section 1881(h)(4)(E), we will be setting the initial performance standard as the lesser of the provider's/facility's performance during 2007 or the 2009 national performance rates. If a provider/facility was not in existence in 2007, we will assign a score of zero for purposes of assessing which of the two standards applies to the provider/facility. The provider/facility's performance in 2011 will then be compared against that initial performance standard.
For the reasons discussed above, we are finalizing all of CY 2011 as the performance period for the PY 2013 ESRD QIP.
In the proposed rule, we discussed in detail what performance standards we planned to select for the PY 2013 ESRD QIP. We noted that comparing provider/facility performance over time based on data from successive years would be beneficial as this method would allow the public to most accurately gauge provider/facility improvement. As we discussed above, we also noted that due to operational issues, it is not feasible for us to establish performance standards prior to the beginning of the proposed performance period, as is required if the performance standards are established under section 1881(h)(4)(A). Therefore, we proposed to continue using the performance standard under section 1881(h)(4)(E) of the Act for the PY 2013 ESRD QIP. Under this proposed standard, providers/facilities would be evaluated based on the lesser of (i) the performance of the provider/facility in 2007, which is the year selected by the Secretary under the second section of section 1881(b)(14)(A)(ii), or (ii) a performance standard based on the national performance rates for the measures in a period determined by the Secretary. With respect to the second prong, we proposed selecting CY 2009 because that is the most recent year-long period for which data would be publicly available prior to the beginning of the proposed performance period. At the time we published the proposed rule, the 2009 national performance rates for the Hemoglobin Greater Than 12 g/dL measure and the URR Hemodialysis Adequacy measure were:
For the Hemoglobin Greater Than 12g/dL measure: 16 percent.
For the URR Hemodialysis Adequacy measure: 96 percent.
The comments we received on the proposed selection of this performance standard and our responses are set forth below.
Comment: One commenter recommended rounding the average hemoglobin to one decimal place because this method is the industry standard and more decimal places exaggerates the precision of the laboratory tests. One commenter also stated that CMS should allow rounding to the tenth to address “between instrument variability within a single laboratory.”
Response: For Dialysis Facility Compare (DFC) and Dialysis Facility Reports (DFR), we have traditionally not rounded the average patient hemoglobin values or the values resulting from the hematocrit to hemoglobin conversion. The final rule for the first year of the ESRD QIP stated that we would calculate the hemoglobin measure rates as they have been calculated for purposes of DFC and DFR in order to maintain consistency (76 FR 629). In light of this comment, however, we have concluded that beginning with the PY 2013 program, it is reasonable to round the patient average hemoglobin value to one decimal place to better reflect the precision of the original laboratory data prior to determining performance on the measure. We will also round the hematocrit to hemoglobin conversion to one decimal place. Using this new rounding convention, the 2009 national performance rate for the Hemoglobin Greater Than 12 g/dL measure using this new rounding convention rate is 14 percent.
Comment: One commenter suggested that CMS use a baseline period of 2009 for the Hemoglobin Greater Than 12 g/dL measure because data from 2009 is the most currently available data. This commenter also argued that, because of the change in FDA approved labeling and guidance from the baseline period to the performance period, this measure will cause confusion and not accurately measure quality and improvement.
Response: We proposed to use CY 2009 as the source of data for the national comparative performance standard for scoring the PY 2013 ESRD QIP measures. Although we recognize that the FDA-approved label for ESAs changed in CY 2011, we note that this change did not directly impact this measure. The Hemoglobin Greater Than 12 g/dL measure reflects both the prior and new labels for ESAs.
Comment: One commenter requested that CMS employ the PY 2014 achievement and improvement scoring methodology for PY 2013. One commenter voiced support for the change in methodology to equally weight the measures in PY 2013. One commenter stated that performance standards for PY 2013 should be less stringent to decrease the incentive to game the system.
Response: As explained above, we are using the special rule for PY 2013. Under this standard, providers/facilities would be evaluated based on the lesser Start Printed Page 70261of (1) The performance of the provider/facility in 2007, which is the year selected by the Secretary under the second section of section 1881(b)(14)(A)(ii), or (2) a performance standard based on the national performance rates for the measures in a period determined by the Secretary (for PY 2013, this is CY 2009). We do not believe that the performance standards are too stringent; a provider/facility is scored on the lesser of its own performance or the national performance rate. We will be monitoring providers/facilities to assess any incentives to game the system.
After considering the comments, and for the reasons stated above, we are finalizing following performance standards. For the PY 2013 ESRD QIP, providers/facilities will be evaluated based on the lesser of (i) Their individual performance on the measures in 2007 or (ii) the national performance rates for the measures in 2009. We also finalize that we will round the values obtained when we convert hematocrit values to hemoglobin values and the average patient hemoglobin values used in the Hemoglobin Greater Than 12 g/dL measure to one decimal place.
Based on our new rounding methodology and the most recent 2009 data, the 2009 national performance rates vary slightly from those in the proposed rule. The national performance rate in 2009 for the Hemoglobin Greater Than 12 g/dL measure is 14 percent, and the national performance rate in 2009 for the URR Hemodialysis Adequacy measure is 97 percent.
Section 1881(h)(3)(A)(i) of the Act requires the Secretary to develop a methodology for assessing the total performance of each provider and facility based on performance standards with respect to the measures selected for a performance period. Section 1881(h)(3)(A)(iii) of the Act states that the scoring methodology must include a process to weight the performance scores with respect to individual measures to reflect priorities for quality improvement, such as weighting scores to ensure that providers/facilities have strong incentives to meet or exceed anemia management and dialysis adequacy performance standards, as determined appropriate by the Secretary.
For the PY 2012 ESRD QIP, we finalized a scoring methodology under which we calculated the performance of each provider and facility by assigning 0-10 points for each measure. The full rationale for this scoring methodology is presented in detail in the PY 2012 ESRD QIP final rule (76 FR 629 through 634).
For the PY 2013 ESRD QIP, we proposed to adopt the same methodology for scoring provider/facility performance on each of the measures. We noted that, we believe that it is important to provide a clear-cut method for calculating scores initially while providers and facilities are becoming familiar with the program. We proposed to calculate the performance of each provider/facility on each measure by assigning points based on how well it performed on the measure in CY 2011 relative to the proposed performance standard (discussed above). If a provider or facility meets the performance standard for a measure, then it would receive 10 points for that measure. If a provider/facility does not meet the performance standard for a measure, we would award points for each measure based on a 0 to 10 point scale and would subtract 2 points for every 1 percentage point the provider or facility's performance falls below the performance standard during CY 2011, the performance period for PY 2013.
For the PY 2013 ESRD QIP, we proposed to weight the Total Performance Score for each provider/facility such that 50 percent would reflect the Hemoglobin Greater Than 12g/dL measure and 50 percent would reflect the URR Hemodialysis Adequacy measure. To be consistent with the scoring methodology that we finalized for the PY 2012 ESRD QIP, we proposed to award up to 30 points to a provider/facility based on its performance on the proposed measures. However, because we only proposed to adopt two measures for the PY 2013 ESRD QIP measure set, we proposed to calculate a provider's/facility's Total Performance Score by multiplying each measure score (0-10 points) by 1.5, adding both measure scores together and rounding this number to the nearest integer (with 0.50 rounded-up), resulting in a 0-30 point range.
Section 1881(h)(3)(A)(ii) of the Act requires the Secretary to ensure that the application of the scoring methodology results in an appropriate distribution of reductions in payments among providers and facilities achieving different levels of Total Performance Scores, with providers and facilities achieving the lowest Total Performance Scores receiving the largest reductions.
For the PY 2012 ESRD QIP, we implemented a sliding scale of payment reductions, setting the minimum Total Performance Score that providers/facilities will need to achieve in order to avoid a payment reduction at 26 points (76 FR 634). Providers/facilities that score between 21-25 points will receive a 0.5 percent payment reduction; between 16-20 points, a 1.0 percent payment reduction; between 11-15 points, a 1.5 percent payment reduction; and for a score between 0-10 points, providers/facilities will receive the full 2.0 percent payment reduction (76 FR 634).
To ensure that providers/facilities are properly incentivized to provide quality care, we proposed to implement a more rigorous sliding scale of payment reductions for the PY 2013 ESRD QIP and raise the minimum Total Performance Score that providers/facilities would need to achieve in order to avoid a payment reduction from 26 to 30 points. We noted that providers/facilities that score between 26-29 points would receive a 1.0 percent payment reduction; between 21-25 points, a 1.5 percent payment reduction; and between 0-20 points, providers/facilities would receive the full 2.0 percent payment reduction (see Table 3 below). We believe that applying a payment reduction of 2.0 percent to providers/facilities whose performance falls significantly below the performance standards, coupled with applying two intermediate payment reduction levels to providers/facilities based on lesser degrees of performance deficiencies, will provide proper incentives for all providers/facilities to improve the quality of their care.
The comments we received on this proposed scoring, weighting, and payment methodologies and our responses are set forth below.
Comment: Several commenters expressed concern that the PY 2013 scoring methodology and resulting payment reductions are too aggressive and would overly penalize facilities, draining them of monetary resources and morphing the ESRD QIP into a cost-cutting program. Several commenters suggested either doubling the penalty or requiring more points to avoid a penalty, but not both, stating that it is unreasonable of CMS to expect facilities to improve so rapidly from PY 2012 to PY 2013. Commenters also argued that CMS should reassess its PY 2013 scoring because nearly all of the performance period will have passed before the rule is finalized, not allowing providers/facilities enough time to make the necessary adjustments, and a facility that does not meet the performance standard for one measure may be significantly and unduly penalized because the program only evaluates two measures. Other commenters noted that many other quality programs have a broader sliding scale which gives more incentive for improvement and suggested that the PY 2012 payment scale of 0.5-2.0 percent also be used for PY 2013. This broader range was also suggested because it may take patients a period of time to stabilize or larger penalties might result from outliers, and the penalty structure should be more forgiving of these patients. Other commenters also stated that, because of the change in scoring from PY 2012, patients will be unable to compare facilities' scores and note progress.
Response: We believe that providers/facilities should always be striving to improve the quality of care they provide to patients. Therefore, we believe it is appropriate, in the second year of the program, to set a higher standard to further encourage improvement. Because both of the measures that we adopted for the PY 2013 ESRD QIP were included in the PY 2012 ESRD QIP measure set, we believe that it is reasonable to expect providers/facilities to have implemented practices to improve their performance on these measures. Additionally, because we are using the special rule, providers/facilities will be evaluated based on the lesser of two standards, which should help alleviate the concerns expressed by the commenters.
We designed the scoring based on a scale similar to what we are using for the PY 2012 ESRD QIP to make it easier for Medicare beneficiaries to compare providers'/facilities' performance in PY 2012 and PY 2013. Although we are using one less measure and weighting the measures differently in PY 2013, we believe that Medicare beneficiaries will still be able to compare both the overall quality of provider/facility performance (for example, whether the performance improved as a whole from PY 2012 to PY 2013), and the degree to which provider/facility performance on each of the two PY 2013 measures may have changed (because the certificates will display individual measure scores).
Comment: Some commenters voiced their support for the PY 2013 scoring methodology, including the more rigorous scale and the equal weighting of the PY 2013 measures.
Response: We thank the commenters for their support. For the reasons stated above, we are finalizing the proposed scoring, weighting, and payment methodology for the PY 2013 ESRD QIP.
For the PY 2014 ESRD QIP, we proposed to continue using the Hemoglobin Greater Than 12g/dL measure, adopt seven new measures (Kt/V Dialysis Adequacy, Vascular Access Type (VAT), Vascular Access Infections (VAI), Standard Hospitalization Ration (SHR)-Admissions, National Healthcare and Safety Network (NHSN) Dialysis Event reporting, Patient Experience of Care (ICH CAHPS) reporting, and Mineral Metabolism reporting) and to retire the URR Hemodialysis Adequacy measure. We also proposed to adopt measures under section 1881(h)(2)(A)(iii) of the Act. In specifying such measures, we recognize that section 1881(h)(2)(B)(i) of the Act requires that they must have been endorsed by the entity with a contract under section 1890(a) of the Act (that entity is currently the NQF) unless the exception in clause (ii) applies. That provision provides that in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practicable measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by consensus organizations identified by the Secretary.
Section 1881(h)(2)(A)(i) of the Act requires that the measures specified for the ESRD QIP include measures on anemia management that reflect the labeling approved by the FDA for such management. For the PY 2014 ESRD QIP, we proposed to retain the Hemoglobin Greater Than 12g/dL measure that we adopted for the PY 2012 ESRD QIP and are finalizing in this final rule for the PY 2013 ESRD QIP. We made this proposal for the same reasons that supported our proposal to retain this measure for the PY 2013 ESRD QIP measure set.
The comments we received on this proposed measure are discussed above in the section discussing the PY 2013 ESRD QIP. For the reasons stated above, we finalize the Hemoglobin Greater Than 12 g/dL measure for the PY 2014 ESRD QIP. The specifications for this measure can be found at http://www.dialysisreports.org/pdf/esrd/public-measures/AnemiaManagement-HGB12-2013-2014-FR.pdf.
Section 1881(h)(2)(A)(i) of the Act requires that the ESRD QIP include measures on dialysis adequacy. For the PY 2014 ESRD QIP, we proposed to retire the URR Hemodialysis Adequacy measure we adopted for the PY 2012 Start Printed Page 70263ESRD QIP and are finalizing in this final rule to retain for the PY 2013 ESRD QIP. In its place, we proposed to adopt a measure of dialysis adequacy based on Kt/V (K = dialyzer clearance, t = dialysis time, and V = volume of distribution) for the PY 2014 ESRD QIP. Kt/V has been advocated by the renal community as a more widely accepted measure of dialysis adequacy. Specifically, Kt/V more accurately measures how much urea is removed during dialysis, primarily because the Kt/V calculation also takes into account the amount of urea removed with excess fluid. Further, the proposed measure assesses Kt/V levels in both hemodialysis (HD) patients (in-center and home (HHD)) and peritoneal dialysis (PD) patients, and is based on two Kt/V measures of dialysis adequacy that have been endorsed by the NQF (#0249 [2] and #0318 [3] ). Specifically, the proposed measure assesses the percent of Medicare dialysis patients (PD, HD and HHD) meeting the modality specific Kt/V threshold. For hemodialysis patients (HHD and in-center patients), we proposed to measure the percentage of adult (≥ 18 years old) Medicare patients dialyzing thrice weekly whose average delivered dose of hemodialysis (calculated from the last measurements of the month using the Urea Kinetic Modeling (UKM) or Daugirdas II formula) was a Kt/V of at least 1.2 during the proposed performance period. For PD patients, we proposed to measure the percentage of adult (≥ 18 years old) Medicare patients whose average delivered PD dose was a weekly Kt/V urea of at least 1.7 (dialytic + residual) during the proposed performance period. The specifications for the proposed measures exclude pediatric patients. The NQF has since endorsed a separate pediatric hemodialysis adequacy measure (#1423), and we are considering how to best incorporate this measure into future years of the QIP.
The comments we received on the proposed Kt/V measure and our responses are set forth below.
Comment: Several commenters expressed concern that providers/facilities use different methodologies to calculate Kt/V and asked CMS to indicate which methodology should be used. Several commenters noted that this disparity in formulas and specifications may lead to disparate baseline standards and requested that CMS standardize requirements for Kt/V values for performance standards instead and/or wait until PY 2015 to implement the measure. Some commenters asked CMS to acknowledge that Daugirdas II or UKM formulas should be used for those patients receiving thrice weekly hemodialysis care. One commenter urged CMS to rigorously validate comparison calculation methods to assure that if different equations are used, they provide comparable results for Kt/V. Another commenter suggested that it would be extremely difficult, if not impossible, for the agency to correct the lack of standardization in the base year and asked instead that CMS take this into account in weighting this measure.
Response: Beginning January 1, 2012, we have asked providers and facilities to report Kt/V values on claims using the Daugirdas II or UKM formulas, which are also the formulas specified in the NQF-endorsed hemodialysis adequacy measures based on Kt/V (CR 7460). We have also stated that residual renal function should be included in the peritoneal dialysis Kt/V value but not included in the hemodialysis Kt/V value. We recognize the commenters' concerns and agree that it would be difficult, if not impossible, to create accurate, comparable Kt/V measure scores for providers/facilities that might not have used either the Daugirdas II or UKM formula in their Kt/V reporting or that may have incorporated residual renal function differently. In light of this concern, we are not finalizing our proposal to adopt the Kt/V dialysis adequacy measure for the PY 2014 ESRD QIP. We intend to propose to adopt a Kt/V dialysis adequacy measure for future years of the ESRD QIP and welcome public input as we proceed with this process.
We recognize that we are required under section 1881(h)(2)(A)(i) to include measures on dialysis adequacy in the ESRD QIP. For this reason, we are also not finalizing our proposal to retire the URR Hemodialysis Adequacy measure for the PY 2014 ESRD QIP and will continue to include this measure in the PY 2014 measure set. For the reasons stated in the CY 2011 ESRD PPS final rule (75 FR 49182) we believe that the URR Hemodialysis Adequacy measure continues to be an appropriate and accurate measure of hemodialysis adequacy.
Comment: Many commenters strongly supported CMS' proposal to use Kt/V to measure dialysis adequacy beginning with the PY 2014 ESRD QIP because it is widely accepted, is used extensively by the renal community as a measure of dialysis adequacy, and is the basis for measures endorsed by the NQF. One commenter stated a belief that Kt/V is a substandard measure as it does not adequately reflect the patient's quality of life. One commenter noted that CMS should also promote the understanding that minimal Kt/V levels may not be optimal levels and should develop a method for assessing dialysis adequacy across all modalities; another commenter argued that CMS should use the last Kt/V value of the month for each patient to calculate the measure rate because it is the best clinical indicator of the actual dialysis dose delivered to a patient during the month. Some commenters stated that the measure specifications excluding Kt/V values exceeding 2.5 for patients receiving thrice weekly in-center nocturnal hemodialysis may not be appropriate because many patients achieve such values and asked that this exclusion be removed from the measure. Commenters also suggested that adjustments should be made in the Kt/V measure for short daily, more frequent, and nocturnal treatments. Commenters asked CMS to exclude residual renal function (RRF) because it could result in patients being under dialyzed, and it carries operational burdens such as requiring patients to collect urine during a 48-hour period. Some commenters, however, asked CMS to consider RRF in the calculation so that the Kt/V measure does not cause over-treatment. One commenter asked for clarification of the Kt/V specifications in two areas: (i) For PD patients, (a) does CMS require that facilities report the average of all available values for the year; (b) should the facilities record Kt/V every 3 or 4 months; and (c) when should the RRF be measured; and (ii) for both HD and PD, (a) What are the requirements related to urea clearance; and (b) can facilities use creatinine clearance as an alternative? Although not specific, some commenters noted that some of the measure specifications were not clear or were confusing and asked for clarification. One commenter suggested that the proposed Kt/V dialysis adequacy measure be calculated as the average of twelve months Kt/V values in an index year. One commenter questioned the functionality of CROWNWeb to collect Kt/V measurements in CY 2012.
Response: For the reasons stated above, we will not finalize this measure for the PY 2014 ESRD QIP but we intend to propose to adopt a Kt/V dialysis adequacy measure for the program as soon as possible. We will take the many comments regarding the use of Kt/V and questions regarding the measure Start Printed Page 70264specifications into account as we develop this future proposal.
Comment: Some commenters urged CMS to develop a dialysis adequacy measure for hemodialysis patients who dialyze more or less than three times per week, either at home or in a clinic.
Response: We agree with the commenter that a dialysis adequacy measure for hemodialysis patients who dialyze more or less than three times per week, either at home or in a clinic, is an important quality indicator that should be part of the ESRD QIP. At this time there is no consensus within the ESRD stakeholder community as to what the correct formula or target value should be for this population. We are committed to working with the stakeholder community to achieve consensus on the correct formulas and target values for this population and to developing measures for future years of the ESRD QIP that accurately assesses the adequacy of hemodialysis for this population.
For the reasons stated above, we are not finalizing the proposed Kt/V Dialysis Adequacy measure for the PY 2014 ESRD QIP. We are also not finalizing our proposal to retire the URR Hemodialysis Adequacy measure, but are instead finalizing that this measure will be included in the PY 2014 ESRD QIP. The measure specifications for the URR measure can be found at: http://www.dialysisreports.org/pdf/esrd/public-measures/DialysisAdequacy-URR65-2013-2014-FR.pdf.
Section 1881(h)(2)(A)(iii) of the Act states, in part, that the measures specified for the ESRD QIP shall include other measures as the Secretary specifies, including, to the extent feasible, measures on vascular access, including for maximizing the placement of arterial venous fistula. For the PY 2014 ESRD QIP, we proposed to adopt a VAT measure. We noted that arteriovenous (AV) fistulae are the preferred type of vascular access for patients on maintenance hemodialysis. Because of the lower complication rates (including reduced infections), decreased risk of patient mortality, and greater cost efficiency associated with this type of vascular access for eligible patients,[4, 5] we proposed to adopt a VAT measure, based on two measures that are endorsed by the NQF. These measures assess (i) The percentage of a provider's/facility's patients on hemodialysis using an autogenous AV fistula with two needles during the last HD treatment of the month (NQF #0257); and (ii) the percentage of a provider's/facility's patients on hemodialysis using an intravenous catheter during the last HD treatment of the month that have had an intravenous catheter in use for 90 days or longer (NQF #0256).
While catheter reduction and increased use of AV fistula are both important steps to improve patient care, we recognized that these two events are tightly interrelated and do not want to penalize providers/facilities twice for related outcomes. We therefore proposed to combine these two separate measures into one measure to contribute jointly to the Total Performance Score. Because the rates and goals for each subcomponent measure are very different, we proposed to calculate separate measure rates for each measure, based on a provider's/facility's performance on each subcomponent measure and to adopt a different methodology (discussed below) for purposes of setting performance standards and scoring providers/facilities on this measure.
As explained above, section 1881(h)(2)(B)(i) of the Act requires that, unless the exception set forth in section 1881(h)(2)(B)(ii) of the Act applies, the measures specified for the ESRD QIP under section 1881(h)(2)(A)(iii) of the Act must have been endorsed by the entity with a contract under section 1890(a) of the Act (which is currently the NQF). Under the exception set forth in section 1881(h)(2)(B)(ii), in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. We stated in the proposed rule that we believe that assessing the type of vascular access used in hemodialysis patients is important because clinical evidence has shown that proper vascular access reduces the risk of adverse outcomes such as infections. We also noted that we considered proposing to adopt the two NQF-endorsed measures noted above (#0256 and #0257); however, in order to ensure that these measures fit the purposes of the ESRD QIP, we made modifications to these NQF-endorsed measures. Accordingly, we proposed to adopt this measure under section 1881(h)(2)(B)(ii) of the Act.
We noted in the proposed rule that since July 1, 2010, we have asked dialysis providers/facilities to submit VAT data on ESRD claims (CR 6782). We also proposed that hemodialysis patients with acute renal failure, peritoneal dialysis patients, and patients under 18 years of age would be excluded from this proposed measure. Finally, we stated our belief that adoption of this measure would be consistent with the efforts of the Fistula First initiative, which advances the use of fistulas proven to reduce the risk of infection/morbidity and mortality.[6]
The comments we received on this proposed measure and our responses are set forth below.
Comment: Many commenters supported the proposed VAT measure, noting the benefits of AV fistulas and the problems with catheters. Many commenters also stated that they support CMS' decision to exclude hemodialysis patients with acute renal failure, PD patients, and patients under age 18 from this proposed measure.
Comment: Some commenters applauded CMS for proposing to adopt a VAT measure but noted certain “flaws.” Commenters noted that the measure (i) ignores grafts, which are preferable to catheters and are available to some patients who are not candidates for fistulas; (ii) is limited to Medicare beneficiaries; (iii) could prejudice facilities with new patient populations who do not yet have a permanent access type and those with patients who refuse or are not eligible for fistulas, causing an access to care issue; and (iv) because of the 90 day requirement for the catheter measure, will provide less than a year's worth of data on which facilities will be evaluated.
Response: We thank commenters for their insights and will address each issue in turn. As we have noted previously, VAT is critical to patient care. Catheters are undesirable due to their high rate of complications, such as infections, and we discourage their use through the proposed catheter submeasure. The preferred type of vascular access is an AV fistula due to lower rates of complications, which we promote through the fistula submeasure. Although grafts do decrease the risk of infections and complications when compared to catheters, grafts do not decrease these risks as much as fistulae. We, therefore, do not believe that grafts Start Printed Page 70265are either beneficial enough to be specifically rewarded or harmful enough to be specifically penalized.
We agree that it would be beneficial to measure vascular access type for all ESRD patients, but, at this time, we are unable to collect the needed data through Medicare claims. We believe that when CROWNWeb becomes available as a data collection vehicle for all providers/facilities, we will be able to collect data on all patients, and we anticipate proposing in future rulemaking to change this measure when these events occur. We are actively monitoring access to care and issues associated with “cherry-picking,” and it is our intent to engage the community as we monitor these issues.
Finally, we will be able to measure 1 year of catheter data despite the 90 day pre-requisite. The proposed measure specifications state that the catheter submeasure assesses the percentage of hemodialysis patients in whom (i) A catheter was in use at the last hemodialysis treatment of the month and for each of the prior 90 days; and (ii) a catheter was the only means of vascular access (that is, patient did not have an AV fistula or AV graft reported at any time during the 90 days).[7] The measure specifications state that patients with a catheter for at least 90 days will be counted in this measure. For example, if a patient was treated at a facility for all of October, November, and December of 2011 and has a catheter for these months, this catheter would be counted in January 2012.
Comment: One commenter recommended that CMS: (i) Consider developing adjusters for unusual patient factors, facility census, and overall case-mix to discourage “cherry-picking”; and (ii) develop a mechanism to more effectively engage, and hold accountable, vascular surgeons in creating successful vascular access. Another commenter suggested that the measure be modified to only include patients with catheters for at least 6 months.
Response: We do not agree that only those patients who have catheters 6 months or longer should be included in the measure. We note that the proposed catheter submeasure is based on an NQF-endorsed measure (#0256) which includes patients with a catheter longer than 90 days.[8] It is important to allow facility's some flexibility without underplaying the risks associated with catheter infections. We believe that 90 days allows facilities a window of time to stabilize patients and obtain a functional arteriovenous fistula. We appreciate the role that vascular surgeons play in obtaining vascular access, and we would expect providers/facilities and their staff to work closely together to ensure that proper care is furnished. We note, however, that the ESRD QIP applies only to providers/facilities.
As we noted above, we are actively monitoring access to care and issues associated with “cherry-picking,” and will consider proposing additional policies in future rulemaking should we conclude that they would improve the overall quality of the ESRD QIP.
Comment: One commenter suggested that CMS develop a measure to monitor fistula flow.
Response: We thank the commenter for the suggestion. We continue to work on developing measures appropriate for the ESRD QIP.
Comment: One commenter asked for clarification of the VAT measure specifications, including the following: (i) What are the blood flow requirements through the AV fistula; (ii) when in the month is the access type to be reported; and (iii) are Medicare only patients counted? The commenter also asked for clarification of the following catheter submeasure specifications: (i) Are Medicare only patients counted; (ii) do facilities count catheters even if there is another access in place; and (iii) how should facilities report the “90 day” requirement if the V-codes do not match this criterion? Some commenters generally commented that the measure specifications are unclear and confusing and asked for clarification.
Response: The proposed VAT measure specifications for the AV fistula submeasure do not contain a blood flow requirement but rather require that the dialysis was performed with two needles. We do not require blood flow because we assume that, if a fistula is used for dialysis treatment, the blood flow achieved is adequate to meet treatment goals. Since July 1, 2010, providers/facilities have been asked to report the access that was used for dialysis during the last dialysis session of the month covered by the claim (CR 6782). These instructions were updated, effective January 1, 2012 (CR 7460), to state that, if an AV fistula/AV graft is used (both must be used with two needles to be reported), but the patient still has a catheter in use providers/facilities should report the presence of both the catheter and the AV fistula/AV graft. Accordingly, for purposes of the measure calculation during the performance period, in instances where an AV fistula or AV graft is reported along with a catheter, we will only count the AV fistula or AV graft as the patient's access type. For purposes of the measure calculation during the baseline period, we exclude any claims reporting more than one access type because we assume this was reported in error since the guidance did not indicate that more than one access type should be reported. Only Medicare patients are included in the proposed VAT measure because we will be calculating it using Medicare claims data. The specifications for the catheter submeasure exclude catheters present for less than 90 days during calculation of the catheter measure rate in order to allow time to establish another form of vascular access. All catheters must be reported regardless of duration of use, the 90 day exclusion will be applied at the time of measure rate calculations.
We thank commenters for requesting clarification, and we would clarify in this final rule that, for the catheter submeasure, a patient will only be attributed to a facility if he or she was at that facility for the 90 days during which he or she had a catheter so that providers/facilities have adequate time to facilitate placement of a permanent access and are not penalized for care provided prior to the patient receiving care at the facility. Because claims do not specify the access type for each patient at every dialysis session, we also clarify that, if the last session of a month indicates only a catheter, we consider that patient to have had the catheter for the entirety of that month.
We further clarify that we will use a patient-month methodology calculating the submeasure rates for the VAT measures (i.e. each patient's value for each month will be included in the measure rate [9] ).The NQF measures which we referred to in the proposed rule are calculated for a one month time period; however, our measure specifications stated that the VAT measure can be calculated in a manner similar to the PY 2012 ESRD QIP measures which are calculated as a percent of patients (i.e. each patient's mean or median value is calculated for the year at the facility and then the patient is classified as meeting the Start Printed Page 70266requirement or not). We believe that patient-months would provide a more accurate picture of the care provided to a patient by weighting the VAT by the number of months that access was present. For instance, if a patient had a catheter for seven months out of the year and an AV fistula for 5 months, the patient's “average” access would be a catheter and the facility would get no credit for the presence of an AV fistula. By using patient-months, we can more accurately assess these patients by counting seven of 12 months towards the catheter submeasure and five of 12 months towards the AV fistula submeasure. This would also weight each patient's contribution to the facility measure rate by the amount of time a patient received care in that facility.[10]
After considering the comments, we finalize the VAT measure for the PY 2014 ESRD QIP with the clarifications and changes discussed above. This measure is comprised of two submeasures, one of which measures catheters and one of which measures AV fistulas. The VAT measure specifications can be found at http://www.dialysisreports.org/pdf/esrd/public-measures/VascularAccess-Fistula-2014-FR.pdf and http://www.dialysisreports.org/pdf/esrd/public-measures/VascularAccess-Catheter-2014-FR.pdf.
We proposed to measure dialysis access-related infection rates by assessing the number of months in which a monthly hemodialysis claim reports a dialysis access-related infection using HCPCS modifier V8, and we noted that since July 1, 2010, we have asked dialysis providers/facilities to code all Medicare claims for dialysis access-related infections using this modifier (CR 6782). As discussed more fully in the proposed rule, we proposed to adopt this measure under section 1881(h)(2)(B)(ii) of the Act.
The public comments we received on the VAI measure and our responses are set forth below.
Comment: Many commenters commended CMS for moving towards measuring infections. However, some commenters noted that infections should not be measured through claims because claims data are unable to provide precise identification of healthcare-associated infections (HAIs), nor do they provide information in a timely manner to effectively drive quality improvement. Additionally, several commenters noted or asked for clarification regarding whether claims can result in duplicative counting of a patient with a recurrent infection, penalizing a facility twice (or more) for the same event. Commenters also stated that CMS has not issued specific guidance for uniformity in reporting the V8/V9 modifiers and requested a workable definition of VAI to account for cases where it is difficult to accurately identify the source of infection. One commenter argued that infection measures should not be a composite so that facilities can individualize areas of concern. Some commenters noted the measure's lack of precedent and NQF endorsement, suggesting instead that CMS use the NHSN-endorsed measure (NQF #1460) (which would also prevent redundancy) or change the measure to a reporting measure only.
Response: We agree that reducing vascular access infections is critical to improving quality of care because infections are one of the leading causes of morbidity and mortality among the Medicare ESRD population. Furthermore, many of these infections can be prevented through evidence-based practices. However, in response to these comments, we reassessed our proposal and concluded that the claims-based data that we proposed to use to calculate this measure is not detailed enough and, as a result, could lead to inaccurate assessments and comparisons of quality. In addition, we are also proposing that providers/facilities begin reporting similar information via the CDC NHSN Dialysis Event reporting system and recognize the burden that may result from requiring reporting to two separate systems for purposes of the ESRD QIP. We note that commenters were much more supportive of the CDC infection tracking system and the associated NHSN-based blood stream infection measure which is NQF-endorsed (#1460) and upon which we based the NHSN Dialysis Event reporting measure. Given the overall quality of the data obtained through the NHSN system and the general support expressed by the ESRD community, we believe that patients' needs will be best served if providers/facilities focus efforts on reporting infection data via the CDC NHSN system. We recognize that the proposed PY 2014 NHSN Dialysis Event reporting measure would not be calculated using actual infection data, but we will consider incorporating a measure which is calculated based on the substance of the data collected through the NHSN Dialysis Event reporting system for future years if the data indicates a need for financial incentives to drive improvement.
Comment: One commenter argued that, because of the prevalence and costs associated with catheter related infections, catheter measures should be in the PY 2012 ESRD QIP and, because the ESRD QIP can only penalize a facility by up to two percent, a new program should be implemented to penalize facilities further for catheter infections. Additionally, this commenter stated that ESRD facilities should be required to educate patients on appropriate homecare and supplies to help prevent infection.
Response: We thank the commenter for the input and concern. CMS continues to consider programs within its statutory authority which will lead to an increase in the quality of care provided to Medicare ESRD beneficiaries. The PY 2012 ESRD QIP, however, has been finalized, and we have calculated and will shortly be implementing the resulting payment reductions. We note that the ESRD Conditions for Coverage require that the patient be included as a member of the dialysis multidisciplinary team, and that providers/facilities educate patients and promote appropriate patient care (for example 42 CFR 494.90(d)).[11]
For the reasons discussed above, we are not finalizing the VAI measure for use in the PY 2014 ESRD QIP. We will consider proposing in future rulemaking to adopt a CDC NHSN-based clinical measure that assesses infection rates related to dialysis.
In the proposed rule, we proposed to adopt the SHR-Admissions measure to measure hospitalizations for Medicare dialysis patients. We proposed to adopt this measure under section 1881(h)(2)(A)(iii) of the Act. The proposed SHR-Admissions measure is a risk-adjusted measure of hospitalizations for Medicare dialysis patients. The data needed to calculate the proposed SHR-Admissions measure is based on claims and has been regularly reported to DFR since 1995 (previously known as Unit-Specific Reports). We noted that the measure is an “all-cause” measure, meaning that Start Printed Page 70267hospitalizations related to other medical conditions outside of ESRD are included in the measure. We refer readers to the proposed rule for further information on this proposed measure (76 FR 40524).
The public comments we received on the SHR-Admissions measure and our responses are discussed below.
Comment: Many commenters voiced concern that the SHR-Admissions measure does not reflect issues that dialysis facilities can control, may lead to untimely or inappropriate care, and is not adequately transparent in its calculation. Commenters also stated that the measure may lead to “cherry-picking” of patients based on their risk of hospitalizations, causing access to care issues for patients with more severe illness. Commenters suggested that, instead, CMS measure hospitalizations resulting from the care, or lack of care, provided by ESRD facilities. Other commenters disapproved of the SHR-Admissions measure because there is currently no mechanism either for correcting or updating patient comorbidity data on CMS' Medical Evidence Reporting Form 2728, and these comorbidities affect the calculation of the measure. Another commenter stated that, because patients in nursing homes are more likely to have a greater number and severity of comorbidities, the metrics for independent living patients and nursing home patients should be compared to determine if the established goals place nursing homes at a disadvantage in achieving such goals. Another commenter suggested that, because of the issues mentioned above, if CMS retains the measure, it should weight it less than the other clinical measures. Some commenters suggested that CMS use a longer baseline period, such as four years.
Response: After reviewing these comments, we have decided, for the reasons articulated by commenters, to not finalize our proposal to adopt the SHR-Admissions measure for the PY 2014 ESRD QIP. We recognize concerns that this measure may not promote improved patient care and may not accurately reflect hospitalizations which can be controlled by dialysis facilities, and we are concerned about the potential for “cherry-picking.” We are additionally concerned that we do not yet have the necessary data to more accurately risk-adjust the measure. Therefore, after considering the comments, we agree that the measure as proposed should not be included in the PY 2014 ESRD QIP. We intend, however, to work to develop a measure for future years of the ESRD QIP that does not raise the issues identified by the commenters, and we welcome public input on the composition of such a measure.
Comment: One commenter supported tracking hospitalization rates among dialysis clinic patients. Another commenter suggested that the SHR-Admissions measure could be used as a balancing measure once CMS retires the Hemoglobin Less Than 10 g/dL measure to ensure that patients do not experience hospitalizations due to hemoglobin levels that are too low.
Response: We thank the commenters for their support, but, for the reasons stated above, we will not include this measure in the program at this time. While the SHR-Admissions measure would include hospitalizations due to anemia, the SHR-Admissions is an all-cause measure, and it is uncertain how sensitive it would be in detecting practice changes and patient outcomes related to anemia management alone. As we have stated, we will continue to work with the ESRD community to develop appropriate measures reflecting hospitalizations and will specifically consider measures which account for hospitalizations related to inappropriate anemia management.
For the reasons discussed above, we are not finalizing the SHR-Admissions measure for use in the PY 2014 ESRD QIP. We intend to work with the community to adopt a measure for future years of the program that more accurately measures quality of care in this area.
We proposed that a provider/facility would need to report a minimum number of eleven cases for a proposed clinical performance measure in order to receive a score on that measure (76 FR 40533). As stated above, we believe that this minimum threshold will help reduce the possibility that a small number of poor outcomes artificially, and for reasons unrelated to the quality of care, skew a small provider's/facility's performance score.
The comments we received regarding this proposal and our responses are set forth below. We also address other comments regarding the measures we proposed to adopt for the PY 2014 ESRD QIP below.
Comment: Commenters voiced concerns about CMS' approach to including low-volume facilities in the program because one patient could significantly affect a score for reasons unrelated to quality of care, such as comorbidities. This scoring could, in turn, affect patient volume if patients and their care-givers judge facilities based on their scores. Commenters suggested different minimum case thresholds such as 20 cases or 25 cases, or that providers with fewer cases be scored differently; some commenters also noted that their studies showed that the sample size rather than overall performance is driving the results for facilities and requested that CMS raise the case minimum to 20. Another commenter urged CMS to research the reliability of a measure to set the minimum number of cases, publish minimum case reliability data, and use this data to set a minimum number of cases for all value-based purchasing programs. One commenter urged CMS to re-consider its scoring methodology to analyze for statistical significance. Another commenter stated the belief that the ESRD QIP methodology does not appropriately account for low patient census, unusual treatment setting, or patient case-mix, and recommended that CMS develop a mechanism to adjust for circumstances in which facilities with an unusual care setting, atypical case-mix, or small patient census may be at high risk of incurring penalties for failure to meet performance standards.
Response: We appreciate the commenters' concerns regarding the potential impact of patient case mix on smaller providers/facilities. One goal of the ESRD QIP is to accurately assess the quality of care provided by a provider/facility. However, we recognize that a quality measure score could be impacted by one or more factors unrelated to the care furnished by the provider/facility, and that the potential of such factors to greatly skew the calculation decreases as the number of cases included in the measure increases. Similarly, a provider/facility with a small number of patients could find that one patient's outcome determined its score on a quality measure. Thus we proposed that a provider/facility would need to have a minimum of eleven cases that meet the eligibility criteria for a measure in order to be scored on that measure. This eleven case minimum allows as many providers/facilities as possible to participate in the program. This minimum case number is also consistent with how we have traditionally reported measures on Dialysis Facility Compare. We will continue to closely monitor beneficiary access to care, including evaluating the rate of facility closures.
We recognize, however, that we are introducing new measures and scoring methodologies for the PY 2014 program. As additional data becomes available for these measures, we will conduct additional analysis to assess our case Start Printed Page 70268minimum. If we determine that a different threshold is more appropriate, we will propose an alternative scoring approach in future rulemaking for the ESRD QIP to ensure that smaller or low-volume facilities are not unfairly penalized.
Comment: One commenter urged CMS to use only NQF-endorsed measures for the ESRD QIP because of the NQF's high level of review. Because none of the PY 2014 measures are NQF-endorsed, this commenter does not support their adoption.
Response: We believe that, when evaluating measures for the ESRD QIP, it is important to consider measures endorsed by NQF and other consensus-based entities and we have based our measures on available endorsed measures where possible. We note, however, that under Section 1881(h) of the Act, the Secretary has discretion to adopt measures that are not NQF-endorsed in certain circumstances. We refer readers to our discussions of our rationale for adopting the individual measures, above.
Comment: Commenters noted that the same data sent to multiple laboratories can yield different results from each laboratory. They noted that this variability, rather than the actual care delivered, may affect provider's/facility's rates and, ultimately, their Total Performance Scores. These commenters suggested that CMS incorporate an acceptable standard deviation value into the measure rate calculations in order to mitigate this variability. One commenter also stated that CMS should allow rounding to the tenth to address “between instrument variability within a single laboratory.”
Response: The proposed PY 2014 scoring methodology allows providers/facilities some latitude to account for issues such as laboratory variability. For example, as further explained below, providers/facilities need not score at the performance standard for each measure in order to avoid a payment reduction. We believe that such flexibility mitigates concerns about details such as laboratory variability. We do agree that it is important to account for the precision of the data that we use to calculate rates and scores, and, as explained above with regard to the Hemoglobin Greater Than 12 g/dl measure, we will specify the number of decimal places for measure calculations to reflect the precision of the data submitted by providers/facilities.
Comment: One commenter requested clarification that the PY 2014 measures do not apply to providers/facilities that only treat patients receiving peritoneal dialysis (PD).
Response: Two of the measures apply to PD patients and, therefore, PD-only facilities will be evaluated on these measures. According to the specifications, adult PD patients would be included in the calculations for the following measures: Hemoglobin Greater Than 12 g/dL, and the Mineral Metabolism reporting measure. Pediatric PD patients qualify for the mineral metabolism reporting measure.
For the reasons stated above, we are finalizing our proposal that a provider/facility must have a minimum of eleven cases for a measure, each with four claims, in order to receive a score for that measure.
As we noted in the proposed rule, healthcare-associated infections (HAI) are a leading cause of preventable mortality and morbidity across different settings in the healthcare sector, including dialysis facilities. In a national effort to reduce this outcome, Department of Health and Human Services agencies, including CMS, are partnering with the Centers for Disease Control and Prevention (CDC) to encourage providers to report to the NHSN as a way to track and facilitate action for reducing HAIs.
The NHSN is currently a secure, Internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion at the CDC. NHSN has been operational since 2008 with acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities. We believe that reporting dialysis events to the NHSN by all providers/facilities would support national goals for patient safety, and particularly goals for the reduction of HAIs. Accordingly, for the PY 2014 ESRD QIP we proposed to adopt a measure that would assess whether providers/facilities enroll and report dialysis event data to the NHSN.
We stated our belief that, by measuring only whether providers/facilities report dialysis event data to the NHSN, providers/facilities would be given time to become familiar with the NHSN reporting process. We also noted our intention in the future to propose to adopt a measure that would score providers/facilities based on actual dialysis events reported to the NHSN if necessary. Specifically, we proposed that providers/facilities: (i) Enroll in the NHSN and complete any training required by the CDC; and (ii) submit three or more consecutive months of dialysis event data to the NHSN.
Section 1881(h)(2)(B)(i) of the Act requires that unless the exception set forth in section 1881(h)(2)(B)(ii) applies to the Act, the measures specified for the ESRD QIP under section 1881(h)(2)(A)(iii) of the Act must have been endorsed by the entity with a contract under section 1890(a) of the Act (which is currently the NQF). Section 1881(h)(2)(B)(ii) of the Act states that, in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. Although a measure calculated using NHSN Dialysis Event data is currently endorsed by the NQF, the measure for reporting purposes only has not been NQF-endorsed. We noted that because HAIs are a significant patient safety concern, we intend to propose to adopt one or more measures that assess actual dialysis event rates in the future if necessary.
The public comments we received on the proposed NHSN Dialysis Event reporting measure and our responses are discussed below.
Comment: Many of the commenters voiced general approval of the proposed NHSN reporting measure, but voiced concern that the required training, enrolling, and reporting will unduly burden many facilities, diminishing the amount of time staff can focus on patients. One commenter suggested that CMS more clearly study and define what is needed of staff before moving forward with the measure. Other commenters noted that CROWNWeb will be collecting similar data upon its implementation, leading to redundancy in reporting and further burdening providers/facilities, and requested that CMS delay an infection reporting measure until it can be recorded via CROWNWeb. Commenters also noted that this measure is redundant because it captures data already being captured by other measures. Other commenters expressed concern that the CDC does not have infrastructure to be able to support the high volume of new reports and facilities will not have the necessary reporting mechanisms in place to submit these reports. They suggested that providers/facilities only be scored on enrolling and training for PY 2014, delaying actual reporting of Start Printed Page 70269data to allow providers/facilities to prepare to meet the NHSN requirements and the NHSN to prepare for receiving these reports. One commenter noted that the CDC reporting requires manual entry which can lead to data entry error and suggested the CMS arrange an alternative mechanism for collection; another commenter suggested that this mechanism be CROWNWeb.
Response: The CDC has informed us that it is preparing for the additional volume of new system enrollees and data reporting that will result from the ESRD QIP and is enhancing the NHSN's technical infrastructure. Additionally, our proposal that providers/facilities submit, at a minimum, only three consecutive months of data in CY 2012 is expected to lessen the demand on the NHSN's infrastructure. Thus, we believe that the CDC will be able to accommodate the additional data that will be reported to the NHSN as a result of this measure.
Furthermore, we do not believe that this reporting requirement will unduly burden providers/facilities. For facilities that are currently enrolled in the NHSN, CDC has studied what is required of staff in order to comply with this reporting. In addition, we believe that this reporting requirement will not be burdensome because, reporting this data will only take five to ten minutes per patient, or a total of two hours and ten minutes, of staff time per month for a facility of average size. Although we stated in the proposed rule that we believed that enrolling and training would take a total of 48 hours per facility (76 FR 40540), based on data we have since received from the CDC, we have revised that analysis in the final rule and now believe that both enrolling and training, each a one-time event, will take approximately 8 total hours, spread across a period of several weeks, to complete. Although the NHSN currently requires manual entry of data, CDC is moving towards an electronic system that will further reduce the time required for data entry and reduce the opportunity for error.
Finally, we, as we noted above, we agree with this measure's possible redundancy and we are no longer adopting the VAI measure for PY 2014. Thus, the NHSN measure will be the only measure related to infections. Furthermore, we do not intend to require reporting of the same data elements to both the NHSN and CROWNWeb. It is our intent to require providers/facilities to report dialysis event data to only one system.
Despite our belief that this measure will not unduly burden providers/facilities, to decrease any perceived burden and to further align our reporting requirements with those of NHSN, we will allow all facilities until March 31, 2013 at 11:59 EST to report these data as allowed by the NHSN system.
Comment: One commenter suggested that, if CMS requires this burdensome reporting, CMS should increase its base rate for dialysis care. Another commenter noted that this measure does not increase quality because it only requires reporting.
Response: Section 1881(h) of the Act does not authorize the Secretary to increase the base rate for dialysis care. Furthermore, we do not agree that this measure does not incentivize quality. In order for providers/facilities to successfully report at least 3-consecutive months of data to the NHSN, the provider/facility must either have or must implement processes to record dialysis infection events. This implementation will require providers/facilities to begin monitoring dialysis events and could draw their attention to areas in need of improvement. In future years of the ESRD QIP, we will consider incorporating a measure based on providers'/facilities' infection rates.
For the reasons stated above, we are adopting the NHSN reporting measure for the PY 2014 ESRD QIP.
Section 1881(h)(2)(A)(ii) of the Act states that the measures specified for the ESRD QIP shall include, to the extent feasible, a measure (or measures) of patient satisfaction as the Secretary shall specify. Information on patient experience with care at a facility is an important quality indicator to help providers/facilities improve services to their patients and to assist patients in choosing a provider/facility at which to seek care. We proposed to adopt a measure for the PY 2014 ESRD QIP that assesses provider/facility usage of the In-Center Hemodialysis (ICH) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. The intent of including this reporting measure is to assess the degree to which providers/facilities are providing their patients with a voice in the quality of their hemodialysis care.
We proposed to measure whether a provider/facility administers the survey, but we did not propose to measure a provider's/facility's actual performance based on the survey results. We expect to adopt such a measure for the ESRD QIP in future rulemaking. For purposes of reporting this proposed measure for the ESRD QIP, we stated that we will consider the ICH CAHPS survey to have been administered if the provider/facility administered it in accordance with the current specifications for the survey. These specifications can be accessed at: https://www.cahps.ahrq.gov/content/products/ICH/PROD_ICH_Intro.asp?p=1022&s=222.[12]
We proposed to measure whether a provider/facility has attested that it successfully administered the ICH CAHPS survey during the performance period for the PY 2014 program. We proposed that providers/facilities would be required to submit this attestation through CROWNWeb (which will be implemented nationally in 2012) by January 30, 2013 at 11:59 p.m. EST.
The public comments we received regarding the proposed ICH CAHPS reporting measure and our responses are discussed below.
Comment: Many of the commenters were generally supportive of a patient experience measure, but stated that the ICH CAHPS survey is too burdensome for patients to complete and for providers/facilities to implement. Several of these commenters suggested that, instead, either providers/facilities be allowed to field any type of patient experience survey or CMS adopt a more simplistic patient experience measure. Other commenters suggested that the 57 question survey be split into three independently verified domains, each given to one-third of the patient population and each including a set of core questions, to lessen patient burden and prevent incomplete surveys. One commenter believes the survey should more adequately address the range of care a patient may receive and suggested that CMS develop a process measure to allow patients to voice individual dialysis experiences. Some commenters asked CMS to implement a survey that is validated across all treatment modalities and settings; another commenter asked CMS to clarify whether the survey applies to PD and HHD. One commenter also noted that this measure alone is not sufficient because it requires providers/facilities to attest to administration of the survey, but it does not base payment reductions upon the results of these surveys.
Response: We thank commenters for their support and suggestions. As we noted in the proposed rule (76 FR 40525), we believe empowering patients to voice their concerns is a critical part of quality improvement. Patient surveys can, and should, draw provider/facility Start Printed Page 70270attention to insights that can only be provided by those receiving care. Given the importance of this survey, we do not believe the burden to patients or providers/facilities outweighs the importance of this measure. Many of the concerns the commenters voiced can be mitigated without decreasing the number of questions on the survey or how the survey is administered. For example, as the specifications indicate,[13] patients may take a break during the administration of the survey or take the survey in multiple sittings if they feel that the number of questions is too great to answer at one time. Additionally, the survey requires third-party administration, taking no additional dialysis staff time.
We note that the ICH CAHPS survey was developed through the study of surveys used by dialysis providers. The CAHPS tool went through extensive testing during development including focus groups and one-on-one patient sessions. Thus, we believe that this survey is the best method available at this time to measure patient experience. We also note that we intend to develop a measure that evaluates providers/facilities based on patient responses to the ICH CAHPS survey and use of a uniform survey tool will allow us to more accurately compare providers/facilities in future years of the program.
Furthermore, we disagree that this reporting measure does not improve quality. In order to successfully report the measure, providers/facilities must attest that they have successfully administered the ICH CAHPS survey. The results of these surveys will be reported to the provider/facility by the third-party administrator, and these results can draw providers'/facilities' attention to areas in need of improvement.
Finally, we thank commenters for their suggestions in developing new measures. The ICH CAHPS survey was developed for adult in-center HD patients and this measure therefore does not apply to HHD, PD, or pediatric patients. Further, at this time, we are not aware of a tool which allows patients to rate their experiences for every dialysis experience. We continue to evaluate opportunities to accurately capture patient experience for all modalities.
Comment: Some commenters expressed concern that CROWNWeb will not be available or will be unreliable for submitting the ICH CAHPS survey attestations. These commenters, however, also thought that a paper attestation would be overly burdensome. They encouraged CMS to work with the community to offer an alternative solution.
Response: CROWNWeb is on schedule for national release in CY 2012 which will allow providers/facilities to report their attestations by the January 2013 deadline. We do recognize, however, that unanticipated delays may occur. Therefore, if CROWNWeb will not be available in time for the January 30, 2013 attestation deadline, we will adopt an alternative, electronic mode of attestation and notify providers/facilities of this method through the ESRD Networks.
Comment: One commenter noted discrepancies between the ICH CAHPS specifications and the proposed regulation, including (i) ICH CAHPS requires survey administration to all or a random sample of patients (depending on how many patients the facility serves), whereas the proposed regulation requires surveying in-center hemodialysis patients, and (ii) ICH CAHPS recommends using third-party survey administrators, whereas the proposed regulation seems to expect facilities to survey their own patients. This commenter noted concern that requiring a third-party survey administrator will unequally burden small clinics. Another commenter requested that facilities be allowed to administer their own surveys, provided that those fielding the surveys are not center staff.
Response: As outlined in the specifications,[14] the ICH CAHPS survey was developed for adult, in-center hemodialysis patients and, therefore, this is the population to which it must be administered. Specifically, it must be administered to all patients meeting these criteria or, if a facility cares for over 200 such patients, a random sample of 200. This administration must be completed by a third-party; https://www.cahps.ahrq.gov/content/products/ICH/PROD_ICH_Intro.asp?p=1022&s=222. Even if the surveys were not administered by staff with whom the patient had a direct relationship, a patient could still feel pressure to refrain from responding candidly. It is crucial that patients feel comfortable answering honestly and openly, and, therefore, it is vital that this survey be administered by a third-party. As we noted above, although we are aware of the burden associated with this administration, we do not believe it outweighs the importance of recognizing patients' experience of care. For the reasons discussed above, we are finalizing the use of the ICH CAHPS reporting measure in the PY 2014 ESRD QIP.
Section 1881(h)(2)(A)(iii) of the Act states that the measures specified for the ESRD QIP shall include other measures as the Secretary specifies, including, to the extent feasible, measures of bone mineral metabolism. Abnormalities of bone mineral metabolism are exceedingly common and contribute significantly to morbidity and mortality in patients with advanced CKD. Numerous studies have associated disorders of mineral metabolism with morbidity, including fractures, cardiovascular disease, and mortality. Overt symptoms of these abnormalities often manifest in only the most extreme states of calcium-phosphorus dysregulation, which is why we believe that routine blood testing of calcium and phosphorus is necessary to detect abnormalities.[15]
The Kidney Disease: Improving Global Outcomes (KDIGO) 2009 guideline recommends that the serum phosphorus level in a dialysis patient generally be lowered toward the normal range, but does not recommend a specific target level that would apply to all patients.[16] The guideline also recommends that therapy to correct for abnormal levels be administered based on the health needs of the individual patient. Accordingly, we noted in the proposed rule that we do not feel it is appropriate at this time to propose to adopt a measure that would penalize providers/facilities if they did not achieve a specific target serum phosphorus level in all patients. We also noted that there is currently no NQF-endorsed measure dealing with the achievement of specific target phosphorus levels. In the time since this rule was proposed, the NQF has endorsed a mineral metabolism measure based on calcium levels (NQF #1454) which we will consider proposing for Start Printed Page 70271future years of the ESRD QIP.[17] We also noted that the NQF has previously endorsed phosphorus and calcium monitoring measures (NQF #0261 and NQF #0255) and, in 2008, we adopted serum calcium and serum phosphorus monitoring as CPMs (http://www.dialysisreports.org/ESRDMeasures.aspx). Despite the current lack of consensus on specific target ranges for both phosphorus and calcium levels in dialysis patients, we stated our belief that there is consensus that monthly monitoring of calcium and phosphorus is important for early detection of abnormalities.
Section 1881(h)(2)(B)(i) of the Act requires that unless the exception set forth in section 1881(h)(2)(B)(ii) of the Act applies, the measures specified for the ESRD QIP under section 1881(h)(2)(A)(iii) of the Act must have been endorsed by the entity with a contract under section 1890(a) of the Act (which is currently the NQF). Under the exception set forth in section 1881(h)(2)(B)(ii) of the Act, in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary.
Although we gave due consideration to the NQF-endorsed measures on phosphorus and calcium level monitoring in dialysis patients, we noted that it is not feasible for us to propose to adopt either of them at this time as we do not currently collect data on whether these levels are checked for each patient each month to allow calculation of the measure rates. We are also not aware that any other consensus building entity has endorsed or adopted measures on this topic. Therefore, we proposed to adopt a Mineral Metabolism reporting measure that is based on the two NQF-endorsed measures, but requires providers/facilities to attest to compliance with monthly monitoring, and we proposed to adopt it under section 1881(h)(2)(B)(ii) of the Act.
We proposed that providers/facilities would be required to submit an attestation through CROWNWeb that they have conducted the appropriate monitoring. We further proposed that this reporting must be electronically submitted by January 30, 2013 at 11:59 p.m. E.S.T.
We also noted that we anticipate adopting, for future years of the ESRD QIP, one or more mineral metabolism clinical measures in addition to or in replacement of the proposed Mineral Metabolism reporting measure.
The public comments regarding the proposed Mineral Metabolism reporting measure and our responses are discussed below.
Comment: Several commenters expressed support for this measure, but requested that CMS also develop an outcomes measure for phosphorus for submission to the NQF for endorsement as soon as feasible. Several commenters urged CMS to also adopt a parathyroid hormone (PTH) measure in order to encompass all areas of bone mineral metabolism. One commenter noted the morbidity and mortality risks associated with extreme PTH values and stated that it is important to monitor the number of patients with PTH below 100 pg/mL and above 400 pg/mL who are not on therapy. Another commenter suggested that CMS consider the addition of a statement in the attestation to indicate that a treatment plan is in place for any abnormalities in bone mineral metabolism; one commenter also expressed concern that the reporting measure alone would not improve quality.
Response: We do not agree that this measure does not incentivize quality. In order to successfully report the measure, providers/facilities must attest that they have monitored calcium serum and phosphorous serum at least once a month for each Medicare ESRD patient, and to do that, the provider/facility must either have or implement processes to collect and monitor this data. This monitoring could draw provider/facility attention to areas in need of improvement and mineral metabolism concerns for individual patients.
We continue to explore new measures in the area of bone mineral metabolism; we will consider commenters' suggestions for additional measures for future years of the ESRD QIP, including outcomes-based bone mineral metabolism measures and measures that indicate whether a treatment plan is in place for identified abnormalities.
Comment: One commenter agreed that the Mineral Metabolism measure should be a reporting measure only and discouraged CMS from instituting a clinical measure unless and until studies prove a causal relationship between certain values and morbidity and mortality.
Response: We thank this commenter for the support. We will consider commenters' suggestion as we develop a mineral metabolism measure for future years of the ESRD QIP.
Comment: Some commenters expressed concern that CROWNWeb will not be available or will be unreliable for submitting the Mineral Metabolism attestations. These commenters, however, also thought that a paper attestation would be overly burdensome. They encouraged CMS to work with the community to offer an alternative solution.
Response: CROWNWeb is on schedule for national release in CY 2012 which will allow providers/facilities to report their attestations by the January 2013 deadline. We do recognize, however, that unanticipated delays may occur. Therefore, if CROWNWeb will not be available in time for the January 30, 2013 attestation deadline, we will provide an alternative, electronic mode of attestation and notify providers/facilities of this method through the ESRD Networks.
For the reasons discussed above, we are finalizing the Mineral Metabolism reporting measure for the PY 2014 ESRD QIP. We note that, as we proposed, a provider/facility must attest that it measured the calcium and phosphorous of each Medicare ESRD patient at least once per month.
Having decided to propose to adopt all of CY 2011 as the performance period for the PY 2013 ESRD QIP, we examined what performance period would be most appropriate for the PY 2014 ESRD QIP. We noted that we believe that a 12-month performance period is most appropriate for the ESRD QIP at this point in the program. We also noted that a period of a year accounts for seasonal variations, but also provides a timely incentive and feedback for providers/facilities, as well as timely performance information for Medicare beneficiaries. We have also determined that CY 2012 is the first feasible period during which we can collect sufficient performance period data for all of the proposed measures. Therefore, we proposed to select all of CY 2012 as the performance period for the PY 2014 ESRD QIP.
The comments we received on the proposed selection of CY 2012 as the performance period and on the use of shorter performance periods in future years, and our responses are set forth below.
Comment: Commenters applauded CMS for adopting a prospective Start Printed Page 70272performance period of CY 2012 for the PY 2014 ESRD QIP and noted their disapproval of any performance period of less than a full year.
Response: We thank commenters for their support of the proposed PY 2014 performance period. We also believe that it is most appropriate and helpful for providers/facilities to be scored on a full year of data at this point in the program.
For the reasons stated above, we are finalizing CY 2012 as the performance period for all of the finalized measures for the PY 2014 ESRD QIP.
Section 1881(h)(3)(A)(i) of the Act requires the Secretary to develop a methodology for assessing the total performance of each provider and facility based on the performance standards with respect to the measures selected for the performance period.
The final rule entitled, “Medicare Programs; Hospital Inpatient Value-Based Purchasing Program,” appeared in the Federal Register on May 6, 2011 (76 FR 26490) and set forth our view that value-based purchasing represents an important step in revamping how we pay for care and services, allowing CMS to move increasingly toward rewarding better value, outcomes, and innovations instead of merely paying for volume (76 FR 26491). The final rule also set forth principles guiding the development of performance scoring methodologies, including:
Providers should be scored on their overall achievement relative to national or other appropriate benchmarks. In addition, scoring methodologies should consider improvement as an independent goal.
Measures or measurement domains need not be given equal weight, but over time, scoring methodologies should be more weighted towards outcome, patient experience, and functional status measures.
Scoring methodologies should be reliable, as straightforward as possible, and stable over time and enable consumers, providers, and payers to make meaningful distinctions among providers' performance.
For the PY 2014 ESRD QIP, we proposed to adopt a new performance scoring methodology to replace the methodology we are using for the PY 2012 and are finalizing in this final rule for the PY 2013 ESRD QIP. We believe that this scoring methodology will more accurately reflect a provider's/facility's performance on the measures proposed for the PY 2014 ESRD QIP because it will enable us to differentiate between providers/facilities that simply meet the performance standards, those that exceed the performance standards by varying amounts, and those that fall short of the performance standards. We further believe that the proposed methodology will better incentivize providers and facilities to both achieve high Total Performance Scores and improve the quality of care they provide.
For the PY 2014 ESRD QIP, we proposed to establish performance standards under section 1881(h)(4)(A) of the Act. This section of the Act generally provides that, subject to subparagraph (E), the Secretary shall establish performance standards with respect to measures selected for the ESRD QIP for a performance period with respect to a year. Furthermore, under section 1881(h)(4)(B) of the Act, the performance standards established under subparagraph (A) must include levels of achievement and improvement, as determined appropriate by the Secretary. To establish performance standards under section 1881(h)(4)(A) of the Act, the Secretary must also comply with section 1881(h)(4)(C) of the Act, which requires the Secretary to establish performance standards prior to the beginning of the performance period for the year involved.
With respect to the anemia management and dialysis adequacy measures, we proposed to set the achievement performance standard under section 1881(h)(4)(A) of the Act as the national performance rate on each measure during a proposed baseline period. We proposed that the national performance rate for each measure would be calculated at the national aggregate level as the number of Medicare patients for whom the measure was achieved divided by the total number of Medicare patients eligible for inclusion in the measure. We also proposed to set the improvement performance standard as the national performance rate on each measure during the same proposed baseline period. We noted that our goal is to incentivize providers/facilities to achieve these national performance rates, whether they do so by attaining achievement points or improvement points under our proposed scoring methodology (76 FR 40527). We proposed to use a baseline period from July 1, 2010 to June 30, 2011 to calculate the national performance rate. We stated our belief that this baseline period would enable us to calculate national performance rate values for these proposed clinical measures before the beginning of the performance period. We indicated that we would specify these values in the final rule.
With respect to the proposed VAT measure, we proposed to set performance standards using the same methodology and baseline period that we proposed to use for the other proposed clinical measures; however, we proposed to set performance standards for each of the subcomponent measures rather than for the overall combined measure.
We proposed to establish the achievement performance standard for the proposed NHSN Dialysis Event reporting measure as the successful completion by providers/facilities of: (i) Enrollment in the NHSN and completion of the required training during the performance period (as verified by a digital certificate obtained from CDC), or, in the case of providers/facilities that have previously enrolled, continued enrollment throughout the entirety of the performance period; and (ii) submission to the NHSN of at least three-consecutive months of dialysis event data gathered during the performance period.
We proposed to establish the achievement performance standard for the ICH CAHPS reporting measure as an attestation by the provider/facility that it successfully administered the ICH CHAPS survey during the performance period.
We proposed to establish the achievement performance standard for the proposed Mineral Metabolism reporting measure as whether a provider/facility submitted an attestation stating that it measured the serum calcium and serum phosphorus levels of Medicare patients treated by the provider/facility at least once within the month throughout the duration of the performance period.
As noted above, section 1881(h)(4)(B) of the Act provides that the performance standards established under section 1881(4)(A) of the Act must include levels of achievement and improvement, as determined appropriate by the Secretary. We determined that an improvement performance standard is not appropriate for the proposed reporting measures because it is not feasible to measure improvement on these measures at this time because we do not have any existing data we can use to compare provider/facility performance.
We also noted that we do not interpret section 1881(h)(1)(B) of the Act to require that providers/facilities meet or Start Printed Page 70273exceed the performance standards we establish with respect to each individual ESRD QIP measure. Rather, we proposed to implement a scoring methodology that enables a provider/facility to avoid a payment reduction as long as it achieves a minimum Total Performance Score that, as discussed more fully below, is equal to the Total Performance Score it would have received if it had met the performance standards for all of the proposed measures.
Additionally, we noted that, beginning in PY 2015, we intend to propose to establish floors for performance such that performance standards would never be lower than those set for the previous year, even if provider/facility performance fails to improve, or even declines, over time. We also noted that, although we would consider continuing to set the national performance rate as the achievement and/or improvement performance standard, we would also consider establishing future performance standards that reflect performance goals widely recognized by the ESRD medical community as demonstrating high quality care for ESRD patients, should such a consensus be reached.
Under the proposed scoring methodology for the PY 2014 ESRD QIP, a provider's/facility's performance on each of the finalized clinical measures would be determined based on the higher of (i) an achievement score or (ii) an improvement score. In determining the achievement score, we proposed that providers/facilities would receive points along an achievement range, defined as a scale that runs from the achievement threshold to the benchmark. We proposed to define the achievement threshold for each of these proposed measures as one standard deviation below the achievement performance standard for the measure (which we proposed to set as the national performance rate on the measure during the baseline period). We stated our belief that this achievement threshold will provide an incentive for providers/facilities to continuously improve their performance while not reducing the payments made to providers/facilities that score at or above the national performance rate. We proposed to define the benchmark as the mean of the top decile of provider/facility performance during the baseline period because it represents a demonstrably high but achievable standard of excellence that the best performing providers/facilities reached during the baseline period.
In determining an improvement score for the clinical measures, we proposed that providers/facilities would receive points along an improvement range, defined as a scale running between the provider's/facility's performance on the measure (the improvement threshold) during the twelve-month baseline period and the benchmark. The provider/facility's improvement score would be calculated by comparing its performance on the measure during the performance period (CY 2012) to its performance on the measure during the baseline period (July 1, 2010-June 30, 2011).
We proposed to award between 0 and 10 points for achievement for all of the clinical measures except the VAT measure based on where a provider's/facility's performance falls relative to the achievement threshold and the benchmark for that measure. The following formula is used when the provider's/facility's performance rate is equal to or greater than the achievement threshold (but below the benchmark). Using this formula, a provider/facility would receive a score of 1 to 9 points based on a linear scale disturbing all points proportionately between the achievement threshold and the benchmark so that the interval in performance between the score needed to receive a given number of achievement points and one additional achievement point is the same throughout the range of performance from the achievement threshold to the benchmark.
[9* ((Provider's performance period rate—achievement threshold)/(benchmark—achievement threshold))] + .5.
We proposed that all achievement points would be rounded to the nearest integer, with 0.5 rounded up). If a provider's/facility's score was:
Equal to or greater than the benchmark, the provider/facility would receive 10 points for achievement
Less than the achievement threshold (that is, the lower bound of the achievement range), the provider/facility would receive 0 points for achievement.
We proposed that providers/facilities would earn between 0 and 9 points for all of the clinical measures except the VAT measure based on how much their performance on the measure during the performance period improved from their performance on the measure during the proposed individual facility baseline period. A unique improvement range for each measure would be established for each provider/facility. The following formula is used when the provider's/facility's performance rate is equal to or greater than the improvement threshold (but below the benchmark). Using this formula, the provider/facility would receive a score of 0 to 9 improvement points based on equally spaced intervals between the improvement threshold and the benchmark.
[10 * ((Provider performance period rate—provider baseline period rate)/(Benchmark—provider baseline period rate))]—.5, where the provider performance score falls in the range from the provider's baseline period score to the benchmark.
We proposed that all improvement points be rounded to the nearest integer, with 0.5 rounded up). If a provider's/facility's score on the measure during the performance period was equal to or lower than its baseline period score on the measure, the provider/facility would receive 0 points for improvement.
We proposed to calculate the VAT measure score by first calculating the measure rate according to measure specifications for each of the two measure subcomponents. We proposed that these two rates would then be converted into separate achievement and improvement scores, using the above methodology, for each subcomponent using achievement and improvement ranges specific to each subcomponent measure. The higher of the achievement or improvement score for each measure component would then be averaged to produce one overall score for the VAT measure. We believe that this method of calculating this measure stresses the importance of both vascular access sub-measures without penalizing providers/facilities for two similar measures or unduly weighting a provider's/facility's Total Performance Score in favor of VAT measures.
We proposed to adopt a different scoring methodology for the proposed NHSN Dialysis Event reporting measure, Start Printed Page 70274Patient Experience Survey Usage reporting measure, and Mineral Metabolism reporting measure.
With respect to the proposed NHSN Dialysis Event Reporting measure, we proposed to assign providers/facilities a score of 0, 5, or 10 points as follows:
Providers/facilities that enrolled in the NHSN during or before the performance period, completed the required training, and successfully reported at least three-consecutive months of dialysis event data to the NHSN before January 30, 2013, for the period of January 1, 2012-December 31, 2012 would receive 10 points.
Providers/facilities that enrolled in the NHSN and completed the required training during or before the performance period, but did not report at least 3-consecutive months of dialysis event data to the NHSN before January 30, 2013, for the period January 1, 2012 through December 31, 2012, would receive 5 points.
Providers/facilities that failed to enroll in the NHSN and/or complete the required training during or before the proposed performance period would receive 0 points.
We proposed to assign providers/facilities a score of 10 points if they attest that they successfully administered the ICH CAHPS survey during the performance period according to the specifications referenced above. Providers/facilities that did not provide such an attestation would receive 0 points.
We proposed to assign providers/facilities that measured the serum calcium and serum phosphorus levels of all Medicare ESRD patients treated by the provider/facility at least once within the month throughout the duration of the proposed performance period a score of 10 points, while providers/facilities that did not do so would receive 0 points. We will measure this by requiring a facility to furnish an attestation at the end of the performance period. Those facilities that do not provide this attestation will receive 0 points.
Section 1881(h)(3)(A)(iii) of the Act provides that the methodology for assessing provider/facility total performance must include a process to weight the performance scores with respect to individual measures to reflect priorities for quality improvement, such as weighting scores to ensure that providers and facilities have strong incentives to meet or exceed anemia management and dialysis adequacy performance standards, as determined appropriate by the Secretary.
In determining how to appropriately weight the PY 2014 ESRD QIP measures for purposes of calculating Total Performance Scores, we considered a number of criteria. Specifically, we considered the number of measures we have proposed to include in the PY 2014 ESRD QIP as well as CMS and HHS quality improvement priorities. We stated our belief that weighting the finalized clinical measures equally will incentivize providers/facilities to improve and achieve high levels of performance across all of the measures, resulting in overall improvement in the quality of care provided to ESRD patients. For these reasons, we proposed to assign equal weight to the five proposed clinical measures, with those equal weights adding up to 90 percent of the Total Performance Score. We stated our belief that, while the reporting measures are valuable, the clinical measures measure actual patient outcomes and therefore, justify a combined weight of 90 percent. We proposed that the remaining 10 percent of the Total Performance Score would be comprised of the proposed reporting measures, with each measure weighted equally. We recognize that reporting is an important component in quality improvement, and that this type of measure should also be included in the ESRD QIP, although at a substantially lower weight.
We also considered whether and how we could award a Total Performance Score to providers/facilities that do not report data on at least eleven cases with respect to one or more of the finalized clinical measures. As we stated above, we proposed that this minimum number of cases must be reported with respect to each clinical measure in order for the provider/facility to receive a score on that measure. We stated that because we are proposing to adopt additional measures, we believe that it is appropriate to calculate Total Performance Scores for all providers/facilities. In the case of a provider/facility that has sufficient data from the performance period, but lacks sufficient data from the baseline period, we proposed to only calculate its achievement score, because it would not be possible to calculate its improvement score. We believe that this approach is necessary to ensure that as many providers/facilities receive a score as possible. We proposed that the combined weight of the clinical measures that are scored would still be equal to 90 percent of the Total Performance Score, but only those measures for which providers/facilities report a minimum of eleven cases or more would be included in determining this score, with each such measure being weighted equally. We stated our belief that this approach achieves that goal of including as many providers/facilities as possible, while ensuring the reliability of the measure scores.
Similarly, we proposed to assign equal weight to the proposed NHSN Dialysis Event reporting measure, Patient Experience Survey reporting measure, and Mineral Metabolism reporting measure, with those equal weights adding up to 10 percent of the Total Performance Score. Applying the proposed weighting criteria to a provider/facility that receives a score on all of the proposed measures, we proposed to calculate the provider/facility Total Performance Score using the following formula:
Total Performance Score = [(.18 * Hemoglobin Greater Than 12g/dL Measure) + (.18 * Kt/V Dialysis Adequacy Measure) + (.18 * Vascular Access Type Measure) + (.18 * Vascular Access Infection Measure) + (.18 * SHR-Admissions Measure) + (.0333 * NHSN Reporting Measure) + (.0333 * Patient Experience Survey Reporting Measure) + (.0333 * Mineral Metabolism Reporting Measure)] * 10.
We proposed that the Total Performance Score be rounded-up to the nearest integer (and any individual measure values ending in .5 would be rounded-up).
We solicited public comment on the proposed performance scoring methodology as detailed above. The comments we received and our responses are summarized below.
Comment: One commenter urged that CMS should give greater weight to those measures over which facilities have the greatest control and asked for clarification of the process that will be used to weight measures in future years of the ESRD QIP. Another commenter suggested that CMS weight measures that detect underutilization of services more than those that detect overutilization. Another commenter suggested that CMS weight each measure based on its potential to improve quality.
Response: We believe, at this time, that it is appropriate to weight all of the clinical measures equally and all of the reporting measures equally in order to equally incentivize quality in all of these areas of care. Additionally, we believe that providers/facilities can, overall, impact the outcomes of these measures by providing high-quality, Start Printed Page 70275patient-centered care in accordance with the specified measures. Finally, we do not believe it is appropriate to penalize underutilization more than overutilization. Whether care is substandard due to underutilization or overutilization, it is still substandard care and should be recognized as such. We seek to be as transparent as possible in all aspects of the ESRD QIP, and we will outline the weighting methodology for future years of the program through rulemaking.
Comment: Several commenters argued that the clinical measures should not be weighted equally. Some commenters suggested that the VAT catheter submeasure comprise a larger weight in the final VAT measure score because of the literature suggesting that a reduction in catheters will also reduce infections and mortality. One commenter voiced support for CMS' proposal that the clinical measures compose 90 percent of the Total Performance Score, but argued that, because of the importance of vascular access to overall health and cost reduction, the VAT measure should be weighted at 50 percent with the other clinical measures comprising the equally weighted remainder of the clinical measure score. One commenter suggested that CMS weight the VAT measure less than the other clinical measures. Other commenters suggested that, if CMS retains the VAT measure, the catheter submeasure be weighted greater than the fistula submeasure, perhaps at a 2:1 ratio. Some commenters also suggested that the Patient Experience Survey measure be weighted half as much as the other reporting measures because of the greater clinical impact of the Mineral Metabolism and NHSN reporting measures.
Response: We believe that all of the clinical measures improve care and are important to the program. For the measures finalized for PY 2014, we do not believe any one area of care should be promoted over another, and we believe that providers/facilities should be equally incentivized to achieve high standards in all of the areas evaluated by the clinical measures. Thus, although we have finalized only three of the five proposed clinical measures, we still believe that is appropriate to evenly weight the clinical measures. Additionally, we continue to believe that the clinical measures are vital to improving care and should be weighted more substantially than those measures which to not score providers/facilities based upon actual outcomes. We also believe that appropriate VAT is critical to ensuring optimal patient outcomes. Thus, we do not agree that we should weight this measure less than the other clinical measures. Furthermore, we do not believe it is in the best interest of patients to weight the fistula VAT submeasure more than the catheter VAT submeasure because of our goal to promote fistula use. Although we agree that catheters pose a greater risk to patients, we do not believe this necessitates weighting the catheter subcomponent measure twice as much as the AV fistula subcomponent measure as both are equally important in promoting the best clinical practices with respect to VAT. Therefore, as stated below, we finalize that the three clinical measures will be weighted equally to comprise 90 percent of a providers/facilities Total Performance Score.
As we have also stated, we believe that the Patient Experience Survey is one of the most important tools in impacting clinical practices because it is the only measure that gives patients a voice that may otherwise go unrecognized. Therefore, we do not believe the ICH CAHPS measure should have a lesser weight than the other reporting measures.
Response: Like all ESRD QIP providers/facilities, new facilities will only be included in the program if they have the requisite amount of data. For each of the clinical measures, there must be at least eleven cases each with four claims, regardless of whether the facility is new or established, in order for such measure to be included in the Total Performance Score. For the reporting measures, however, we acknowledge that we did not specify any data requirements, and we recognize that new facilities may be unfairly penalized if they do not have a sufficient amount of time to fulfill the requirements for the reporting measure.
Accordingly, we finalize that a provider/facility that receives a new CCN on or after July 1, 2012 will have the option to not be scored on the reporting measures. We believe that these new providers/facilities need a reasonable amount of time to put the necessary infrastrucure into place in order to be able to satisfy these measures. For example, with respect to the ICH CAHPS patient survey experience measure, a new facility would need to, at a minimum, hire a third party vendor, treat at least one in-center hemodialysis patient for 3 months, and field the survey (which, depending on the responsiveness of the patient, could take an additional period of months). For these new providers/facilities, that do not successfully satisfy the requirements for the reporting measures, their Total Performance Score will be calculated based solely on the applicable clinical measures that apply to them.
However, we also recognize that under our scoring methodology, a provider/facility's score on a reporting measure could help it achieve the minimum Total Performance Score needed to avoid a payment reduction that it would otherwise receive based solely on its clinical measure score(s). In order to balance these competing concerns, we will allow a new provider/facility (defined above as one that receives a new CCN on or after July 1, 2012) the option to report one or more of the reporting measures. If the new provider/facility chooses to take advantage of this option by successfully satisfying the reporting requirement for one or more of these measures, we will score the new provider/facility on those measures and include those scores in the calculation of that provider/facility's Total Performance Score.
We believe that we should include as many providers/facilities in the program as possible. In the proposed rule, we proposed to calculate Total Performance Scores for all providers/facilities and did not specifically state any minimum number of clinical and reporting measures a provider/facility would need to receive a Total Performance Score. Thus, we clarify in this final rule that a provider/facility will receive a Total Performance Score for PY 2014 if it is eligible for at least one measure. We finalize that, if a provider/facility is eligible for at least one clinical measure and at least one reporting measure, the clinical measures will be equally weighted to sum 90 percent of the Total Performance Score, and the reporting measures will be equally weighted to sum 10 percent of the Total Performance Score. If a provider/facility is only eligible for clinical but not reporting measures or vice versa, we will compute its Total Performance Score based solely on the measures for which it is eligible.
Comment: Some commenters commended CMS for proposing measures, proposing timeframes, and proposing the weight each measure would have in the PY 2014 program within one regulation.
Comment: Commenters noted that establishing the achievement threshold as one standard deviation below the national performance rate might lead to inappropriate achievement thresholds as a result of skewed performance distributions. Some commenters Start Printed Page 70276suggested that, instead, CMS base performance standards on the median performance of providers/facilities, with the achievement threshold being at the 15th percentile. Other commenters urged CMS to establish the achievement threshold as the mean performance of facilities performing in the lowest third.
Response: In the proposed rule, we defined the performance standards as the national performance rate, the achievement threshold as one standard deviation below the achievement threshold, and the benchmark as the mean of the top decile of providers/facilities. After receiving public comment, we have found that the distribution of facility performance on several measures is skewed, we have determined that the median is a better measure of central tendency, which was our original intent for these standards. If the measures had had a more even distribution, one standard deviation below the mean would have been calculated to be at approximately 35 percentage points below the mean or the 15th percentile. Thus, we agree with the commenters who suggested that the performance standard should be set at the median performance of providers/facilities during the baseline period. In order to more accurately access the achievement threshold, we will set the performance standards (both achievement and improvement) as the median of facility/provider performance and establish the achievement threshold at the 15th percentile because the 15th percentile represents approximately one standard deviation below the median had the distributions been even.
Comment: Several commenters argued that the performance standards must be published and commenters must be allowed to comment on these standards and the related scoring methodology before the beginning of the performance period.
Response: Our proposal set forth the performance standards that would apply to the PY 2014 clinical measures and assigned example numerical values to each of those proposed measures using data from July 1, 2010 through November 30, 2010, which was the most current data that was available at the time that overlapped with the proposed performance period. Because of data limitations related to the claims verification process which allows providers/facilities a period of time to review and contest claims, we are able in this final rule to finalize the performance standards that will apply to the PY 2014 ESRD QIP but cannot yet assign actual numbers to those finalized standards based on a full year of data. However, we will post these numbers on the following Web site: http://www.dialysisreports.org/pdf/esrd/public-measures/UpdatedBaseline-2014-FR.pdf. We are publishing in this final rule numbers based on data from July 1, 2010 through March 30, 2011, or nine of the 12 months of baseline data. We will publish numbers based on 12 months, July 1, 2010 through June 30, 2011, on or before January 31, 2012 at the following Web site: http://www.dialysisreports.org/pdf/esrd/public-measures/UpdatedBaseline-2014-FR.pdf. We do not anticipate that the final numbers will differ substantially from these numbers.
We believe that this approach complies with section 1881(h)(4) of the Act, including the requirement in subparagraph (C) that the Secretary establish performance standards under subparagraph (A) prior to the beginning of the performance period. However, we recognize that providers/facilities are very interested in these numbers and have a legitimate need to learn what they will be with respect to a payment year as soon as possible. Although we are not able to provide them in this final rule for the reasons discussed above, we anticipate that beginning with the PY 2015 ESRD QIP, we will be able to select a baseline period that ends early enough to make these numbers available in the final rule that applies to that program. The estimated actual values that apply to the PY 2014 performance standards, based on nine of the twelve months of baseline data, are shown in Table 5 below.
Comment: One commenter suggested that CMS modify the payment reduction scale to encourage providers to perform well on all of the measures.
Response: As we noted in the proposed rule, we do not interpret section 1881(h)(1)(B) of the Act to require that providers/facilities meet or exceed the performance standards we establish with respect to each individual ESRD QIP measure. Rather, we believe that our proposed approach best balances the goal of incentivizing providers/facilities to provide quality care across all of the measures while still recognizing the higher quality of care provided by those providers/facilities that exceed the performance standards on certain measures. Additionally, we believe that this approach will give providers/facilities the flexibility they need to become familiar with the new scoring methodology.
Comment: Several commenters commended CMS for recognizing both achievement and improvement in its scoring methodology. Some commenters suggested that CMS implement a methodology to ensure that improvement standards do not diminish incentives for achievement (for example, facilities should be required to meet minimum thresholds prior to having improvement rewarded). Commenters noted that CMS should adjust its scoring methodology to ensure that facilities performing consistently above the achievement threshold are not penalized. Under the proposed scoring system, these facilities would not be eligible for improvement points and could perform worse in the long run than those who performed less well in baseline years. These commenters suggested that CMS establish a consistency multiplier. Another commenter proposed that CMS set a fixed achievement threshold in order to prevent penalizing facilities that have improved (that is, improvement will raise the standard which will cause the achievement threshold to rise which will cause the provider to have to improve more). One commenter stated that the performance standards for both PY 2013 and PY 2014 should be less stringent to decrease the incentive to game the system.
Response: We believe that the scoring methodology we are finalizing for the PY 2014 ESRD QIP provides appropriate incentives to providers/facilities to both achieve and improve. We acknowledge that under the methodology, it might be possible for a provider/facility to attain a lower measure rate on one or more measures than the measure rate attained by other providers/facilities but receive more points overall in the form of improvement points. However, we believe it is appropriate to incentivize lower-achieving facilities to continue to improve, even if their measure rates do not meet the achievement threshold and even if their improvement points would be higher than their achievement points. For these providers/facilities, our scoring methodology allows us to reduce the amount of a payment reduction that they might otherwise receive because they have improved over their baseline rates. Additionally, because providers/facilities can score 1-10 points for achievement and only 0-9 points for improvement, providers/facilities can always be rewarded more for achieving at higher levels. We agree with the commenters that the performance standard will likely continue to rise if we continue to utilize this scoring methodology in future years, and we will take these comments into consideration as we gain experience with the ESRD QIP.
Additionally, we do not believe that the performance standards for PY 2013 or PY 2014 are too stringent. For PY Start Printed Page 702772014, the performance standard is at the midpoint of providers'/facilities' performance. Thus, this standard has been achieved by half of all facilities. To begin scoring achievement points, providers/facilities need only be at or above the 15th percentile. Thus, we believe that the performance standards have been and will continue to be attainable. We will be monitoring outcomes and practice patterns in the ESRD setting to determine whether any ESRD QIP policies might be encouraging activities that could be described as “gaming,” and, to the extent necessary, we will make changes to the ESRD QIP to lessen the potential that such activities occur.
Comment: Some commenters suggested that there was an error in CMS' proposed scoring methodology because, if a facility does not improve at all, it is possible for that facility to receive a negative improvement score; these commenters asked CMS to clarify that facilities with the same or lower improvement score compared to their baseline score will have an improvement score of zero.
Response: Under the proposed scoring methodology, scores would be rounded to the nearest integer, with a score of 0.5 rounded up to the next highest integer. Accordingly, the lowest improvement score a provider/facility could receive is (−) 0.5, and this score would be rounded to zero. The commenter is correct in that the lowest score a facility can receive for both improvement or achievement is zero.
Comment: One commenter expressed concern that, by setting the benchmark score at the mean of the top decile of provider/facility performance, many facilities will be unfairly penalized and requested that CMS set a benchmark closer to the national performance rate.
Response: As noted, one of the goals of the ESRD QIP is to incentivize the highest quality care. However, we agree that the benchmark should be lowered to reflect a more attainable standard, and because we are changing the achievement threshold to a fixed point, we also believe it is appropriate to modify our methodology for calculating the benchmark. To more accurately represent the top of all performers, we will calculate the benchmark at the 90th percentile instead of as the mean of the top decile of performers; while the mean of the top decile will vary depending upon the rates of the top ten percent of performers for each measure, the 90th percentile is a fixed place on all measure performance distributions, thus allowing a more consistent calculation throughout various distributions for all measures. We believe that this change conforms the benchmark to the new performance standards and achievement threshold while still accomplishing the benchmark's intent to incentivize providers/facilities to provide the highest achievable level of care.
For the reasons discussed above, we are finalizing the PY 2014 ESRD QIP scoring methodology to score each clinical measure rate as the higher of the measure's achievement or improvement score, as explained above. We are also finalizing the proposed scoring methodology for calculating the reporting measure scores and the requirement that a provider/facility must have received a CCN on or before July 1, 2012 in order to automatically be scored on the reporting measures. We note that, as discussed above, for the NHSN Dialysis Event measure, we will now allow providers/facilities until March 31, 2013 at 11:59 EST to report the required three consecutive months of data from the performance period. We are also finalizing our proposal to calculate the VAT measure score as the average of the submeasure scores.
Based on public comments, we are not finalizing the proposed definition of performance standards, achievement thresholds, or benchmarks which were based on means and standard deviations. Due to skewed distributions of facility performance, we are finalizing the performance standards (both achievement and improvement) as the median (50th percentile), the achievement threshold as the 15th percentile, and the benchmark as the 90th percentile. We agree with commenters that this better reflects the central tendency and spread of these performance distributions.
We are finalizing the proposed baseline period of July 1, 2010-June 30, 2011. We are also finalizing our proposal that providers/facilities that do not have enough data in the baseline period to calculate a rate for a measure but do have enough data to calculate a measure rate in the performance period will receive a score on that measure based solely on achievement. We also finalize that the clinical measures for which a provider/facility is eligible will be equally weighted to comprise 90 percent of its Total Performance Score, and the reporting measures for which a provider/facility is eligible will be equally weighted to comprise 10 percent of its Total Performance Score. If a provider/facility is only eligible for one type of measure, the provider's/facility's Total Performance Score will be calculated based on that measure(s) alone.
Because of the data limitations explained above, we are unable at this time to assign final numbers to the performance standards, achievement thresholds, and benchmarks. We will publish these numbers at the following Web site: http://www.dialysisreports.org/pdf/esrd/public-measures/UpdatedBaseline-2014-FR.pdf on or before January 31, 2012. Below, in Table 4 and 5, we have provided estimates based upon data from July 1, 2010 through March 30, 2011. We do not believe that these estimates will vary significantly from our finalized numbers.
Below, we provide examples to illustrate the performance scoring model. Figures 1-4 illustrate the scoring for a clinical measure. Figure 1 shows Facility A's performance on the URR measure. The example benchmark (90th percentile) calculated for this measure in this case is 100 percent, while the example achievement threshold (15th percentile) is 91 percent. Facility A's performance rate of 100 percent during the performance period meets or exceeds the benchmark, so Facility A would earn 10 points (the maximum) for achievement for this measure. (Because, in this example, Facility A has earned the maximum number of points possible for this measure, its improvement score is irrelevant.)
Figure 2 and 3 show the scoring for another facility, Facility B. As illustrated below, the facility's performance on the URR measure went from 80 percent in the baseline period to 95 percent during the performance period.
Applying the achievement scale, Facility B would earn 5 points for achievement, calculated as follows:
9 * [(95 − 91)/(100 − 91)] + .5 = 4.5, which is rounded to 5 points.
However, because Facility B's performance during the performance period is also greater than its baseline period performance (but Facility B's performance period score is less than the benchmark), it would be scored based on improvement as well, as shown by Figure 3, below.
Applying the improvement scale, based on Facility B's period-to-period improvement, from 80 percent to 95 percent, Facility B would earn 7 improvement points, calculated as follows:
10 * [(95 − 80)/(100 − 80)] − .5 = 7.5 − .5 = 7.0, which would be rounded to 7 points.
Because the higher of the two scores is used for determining the measure score, Facility B would receive 7 points for this measure.
In Figure 4 below, Facility C's performance on the URR measure drops from 80 percent in the baseline period to 75 percent in the performance period, a decline of 5 percent.
Because Facility C's performance during the performance period falls below the achievement threshold of 91 percent, it would receive zero points for achievement. Facility C would also receive zero points for improvement because its performance during the performance period was lower than its performance during the baseline period. In this example, Facility C would receive zero points for the URR Measure.
The method illustrated above would be applied to each clinical measure in order to obtain a score for each measure. Scores for reporting measures are calculated based upon the methodology as proposed.
Applying the weighting criteria to a provider/facility that receives a score on all finalized measures, we calculate the provider's/facility's Total Performance Score using the following formula:
Total Performance Score = [(.300 * Hemoglobin Greater Than 12g/dL Measure) + (.300 * URR Hemodialysis Adequacy Measure) + (.300 * Vascular Access Type Measure) + (.0333 * NHSN Reporting Measure) + (.0333 * Patient Experience Survey Reporting Measure) + (.0333 * Mineral Metabolism Reporting Measure)] * 10.
The Total Performance Score be rounded to the nearest integer (and any individual measure values ending in .5 would be rounded to the next higher integer)).
However, if, for example, a provider/facility did not receive a score on the proposed VAT measure, the provider's/facility's Total Performance Score would be calculated as follows:
Total Performance Score = [(.4500 * Hemoglobin Greater Than 12g/dL Measure) + (.4500 * URR Hemodialysis Adequacy Measure) + (.0333 * NHSN Reporting Measure) + (.0333 * Patient Experience Survey Reporting Measure) + (.0333 * Mineral Metabolism Reporting Measure)] * 10, (the Total Performance Score will be rounded to the nearest integer (and any values ending in .5 would be rounded to the next higher integer)).
Finally, if, for example, a provider/facility qualified for two of the reporting measures,[18] the provider's/facility's Total Performance Score would be calculated as follows:
Total Performance Score = [(.300 * Hemoglobin Greater Than 12g/dL Measure) + (.300 * URR Hemodialysis Adequacy Measure) + (.300 * Vascular Access Type Measure) + (.05 * NHSN Reporting Measure) + (.05 * Mineral Metabolism Reporting Measure)] * 10.
Section 1881(h)(3)(A)(ii) of the Act requires the Secretary to ensure that the application of the scoring methodology results in an appropriate distribution of payment reductions across providers and facilities such that providers and facilities achieving the lowest Total Performance Scores receive the largest payment reductions. We have adopted a sliding scale of payment reductions for the PY 2012 ESRD QIP (76 FR 634) and have finalized a sliding scale in this final rule for PY 2013 ESRD QIP. In developing a payment reduction scale for the PY 2014 ESRD QIP, we sought to create an approach that would retain aspects of the tiered sliding scale selected for the PY 2012 ESRD QIP, but also reflect the change in provider/facility scores under the new scoring methodology. Under the proposed approach, a provider/facility would not be required to meet or exceed the performance standards with respect to each of the finalized measures in order to avoid receiving a payment reduction under the ESRD QIP. Rather, even if a provider/facility failed to meet or exceed the performance standards with respect to one or more of these measures, the provider/facility could avoid a payment reduction if it achieved a minimum Total Performance Score that is equal to or greater than the minimum Total Performance Score it would receive if it had met the performance standards for each finalized measure, or, in the case of the VAT measure, for the two subcomponent measures. At the time we issued the proposed rule, we were unable to calculate the minimum Total Performance Score because we did not have the data for the baseline period. We estimated, however, that the minimum Total Performance Score that a provider/facility would have to achieve to avoid a payment reduction would be 60 points, and we stated that we would specify the exact number in the final rule. We proposed to implement at least a 1.0 percent payment reduction for all providers/facilities that fail to meet or exceed this minimum Total Performance Score.
To ensure that the proposed payment reduction methodology complies with the section 1881(h)(3)(A)(ii) requirement that providers and facilities achieving the lowest Total Performance Scores receive the largest payment reductions, we proposed to increase the payment reduction from 1.0 percent to 1.5 percent for all providers/facilities that fail to achieve a Total Performance Score that is 10 points below the minimum Total Performance Score (described above). Additionally, we proposed to increase the payment reduction to 2.0 percent for all providers/facilities that fail to achieve a Total Performance Score that is 20 points below the minimum Total Performance Score (described above). We stated our belief that such a sliding scale will incentivize providers/facilities to meet the performance standards and continue to improve their performance because even if a provider/facility fails to achieve the minimum Total Performance Score, such provider/facility will still be incentivized to strive for, and attain, better performance in order to reduce the amount of its payment reduction.
The comments we received on the proposed payment reductions are set forth below.
Comment: One commenter opposed the elimination of the 0.5% payment reduction level and suggested that there be at least five tiers in the payment reduction scale because, in addition to allowing comparisons between years, five-tiers in the payment reduction scale is more consistent with the literature supporting value-based purchasing programs.
Response: We agree with the commenter's concern and will include the 0.5 percent payment reduction level as an additional level in the PY 2014 ESRD QIP payment reduction scale. Thus, the payment reductions for PY 2014 will range on a sliding scale from 0.5 percent to 2.0 percent with the provider/facility moving down a tier for every ten points its Total Performance Score falls below the minimum Total Performance Score. We are finalizing new measures, a new scoring methodology, and rigorous performance standards which are not familiar to the community. We believe that including this additional payment reduction level will allow time for us as well as providers/facilities to become familiar with this new structure.
Comment: One commenter disapproved of setting 10 points as a threshold for each reduction in payment for PY 2014 when CMS cannot yet estimate the minimum Total Performance Score because the distribution in payment reductions is not yet known and will not be known until the performance period has ended. Instead, the commenter suggested that CMS allow for a sufficient period of Start Printed Page 70282time for the quality measure scores to be made publicly available and data to be collected to assess the potential impact of the QIP on the facilities. Another commenter suggested that CMS score the PY 2014 measures on a 30 point scale consistent with PY 2012 so that facilities and consumers can meaningfully compare performance from year to year.
Response: We appreciate the commenter's concern regarding how we establish the minimum Total Performance Score and each successive payment reduction level. Although we will not know the distribution of payment reductions based on the minimum Total Performance Score until we have the data at the end of the performance period, given our current estimates of the data, we believe that, the payment reductions will be appropriate to incentivize providers/facilities to improve patient care. We have calculated these estimates based on the data currently available to us, as further explained in the Regulatory Impact Statement, and they are similar to the reductions for PY 2012 and our estimates for PY 2013. However, in light of the commenter's concern, we will further adjust how we set the minimum Total Performance Score. Rather than set the minimum Total Performance Score as the score a provider/facility would receive if it had met the performance standards for each finalized measure, we will define the minimum Total Performance Score as the score a provider/facility would receive if it had met the performance standards for each of the finalized clinical measures. Recognizing many commenters' concerns regarding the new reporting measures, and our lack of data on which to approximate likely provider/facility performance, we will exclude them from the calculation of the minimum Total Performance Score. We believe this policy will balance our desire to appropriately incentivize improvements in clinical quality while ensuring that providers/facilities are not unduly penalized.
Based on our analysis of the data from July 1, 2010 through March 30, 2011, we estimate that the PY 2014 minimum Total Performance Score will be 56 points. We will publish the final minimum Total Performance Score at the following Web site: http://www.dialysisreports.org/pdf/esrd/public-measures/UpdatedBaseline-2014-FR.pdf on or before January 31, 2012.
Additionally, although we generally believe that the ESRD QIP should provide a means for patients to evaluate their providers/facilities over time, we do not believe that, even if we set performance on a 30 point scale, PY 2014 would be comparable to previous years of the ESRD QIP because of the significant changes to scoring methodology and measures. We believe a 100 point scale will accommodate a growing number of measures that may be adopted in future years of the QIP and plan to consistently use the 100 point scale going forward.
Based on the public comments we received, we are finalizing most of the payment reduction methodology that we proposed; however, we are adding an additional payment reduction level of 0.5 percent, with the scale now ranging from 0.5 percent to 2.0 percent. For every ten points a provider/facility's Total Performance Score falls below the minimum Total Performance Score, it will receive an additional 0.5 percent reduction. We are modifying our definition of the minimum Total Performance Score to be equal to the score a provider/facility would receive if it performed at the performance standards for each of the clinical measures.
As noted above, we are unable to publish a finalized minimum Total Performance Score until we assign a final number to each finalized performance standard. We will publish a finalized minimum Total Performance Score at the following Web site: http://www.dialysisreports.org/pdf/esrd/public-measures/UpdatedBaseline-2014-FR.pdf on or before January 31, 2012. Based upon the performance standard examples we provided above, we estimate that the minimum Total Performance Score will be 56. We do not anticipate that this estimate will substantially change. Using this estimation, the payment reduction scale would be as detailed below in
Section 1881(h)(6)(A) of the Act requires the Secretary to establish procedures for making information regarding performance under the ESRD QIP available to the public, including information on the Total Performance Score (as well as appropriate comparisons of providers and facilities to the national average with respect to such scores) and performance scores for individual measures achieved by each provider and facility. Section 1881(h)(6)(B) of the Act further requires that a provider or facility have an opportunity to review the information to be made public with respect to that provider/facility prior to such information's publication.
In addition, section 1881(h)(6)(C) of the Act requires the Secretary to provide each provider and facility with a certificate containing its Total Performance Score to post in patient areas within the facility. Finally, section 1881(h)(6)(D) of the Act requires the Secretary to post a list of providers/facilities and performance-score data on a CMS-maintained Web site.
For both the PY 2013 and PY 2014 ESRD QIP, we proposed no change in the implementation of these statutory provisions (section 1881(h)(6)(A) through section 1881(h)(6)(D) of the Act) from the proposals finalized in the 2012 ESRD QIP final rule (76 FR 636 through 639), wherein we finalized the establishment of procedures for providers/facilities to review the information to be made public and the procedures for informing the public through facility-posted certificates.Start Printed Page 70283
The comments we received on the public reporting proposals are set forth below.
Comment: Some commenters noted that information reported to the public should be meaningful and requested that CMS include language on the ESRD QIP certificates stating (i) The date range of the performance period; (ii) the date ranges used to compute the performance standards; and (iii) a statement that the data may not reflect current medical standards or facility/provider performance.
Response: The certificates for PY 2012 will indicate the year of the performance period. We will monitor whether beneficiaries find the certificates to be effective in conveying performance, and we will continue to evaluate the information they should include for PY 2013 and PY 2014. We believe that the intent of the certificates is to convey information about facility performance in an understandable, clear, and concise manner. We do not believe that details about the baseline data used to compute the performance standards, or disclaimers about the limitations of the data, are required to convey this basic message, but we encourage providers/facilities to discuss these certificates with their patients and provide any further explanatory information they feel is necessary.
Comment: Several comments requested that CMS address procedural issues related to facility Performance Score Reports.
Response: Performance Score Reports (PSRs) are distributed to providers/facilities for their review after the end of the performance period but before payment reductions are assessed. For PY 2012, PSRs were sent to providers/facilities in July 2011, and provider/facilities were permitted to preview the reports and ask us any questions. We are currently reviewing our PSR process, and we will consider commenters' suggestions as we develop the PSRs for PY 2013 and PY 2014.
For the reasons set forth above, we are finalizing the public reporting requirements as proposed.
As part of our effort to continuously improve the ESRD QIP, we are working to adopt additional robust measures that provide valid assessments of the quality of care delivered to ESRD beneficiaries. To that end, we are developing measures that apply to all modalities (including home and in-center dialysis) and the pediatric population. We also sought public comment on the inclusion of iron management measures, serum calcium management measures, and serum phosphorus management measures for future years of the ESRD QIP. Specifically, we sought public comment on:
Measurement of Serum Calcium Concentration.
Measurement of Serum Phosphorus Concentration.
Assessment of Iron Stores.
These measures are currently collected through CROWNWeb as part of the CPM set. The full specifications for these measures may be accessed at: http://www.dialysisreports.org/ESRDMeasures.aspx.
The comments we received on future measures are set forth below.
Comment: Many commenters suggested measures and/or domains for future ESRD QIP payment years. These suggestions included (i) Iron measures, perhaps measuring trends in ferritin; (ii) upper serum phosphorus limit measures; (iii) hypercalcemia measures (e.g. NQF #1454); (iv) PTH measures; (iv) albumin measures; (v) immunization measures; (vi) fluid management measures; (vii) quality of life measures; (x) measures focusing upon the nurse-patient relationship; (viii) measures assessing the number of HHD and PD patients; (ix) blood pressure measures; and (x) standardized mortality rate measures. Other commenters suggested that we make the reporting measures clinical measures as soon as feasible. Commenters also encouraged us to consider domains and measures in which the pediatric community, HHD patients, and PD patients can more actively participate.
Response: We thank commenters for these suggestions. We continue to monitor measure development and valid and available data sources and look forward to working with the ESRD community to choose future measures which drive quality of care.
Comment: One commenter stated a belief that that CMS should not adopt any current or future measures that do not indicate a causal relationship between the measure and morbidity and mortality and requested that CMS conduct more scientific tests on these measures. Therefore, this commenter believes that an iron stores measure should be a reporting measure only until further scientific evidence can be obtained. This commenter also expressed concern that a “one size fits all” system will lead to “cherry-picking.”
Response: We thank the commenter for the input. We continue to analyze and develop measures that we believe best reflect quality in care. We also continue to monitor access to care issues and will adjust the ESRD QIP to address these issues in future rulemaking, as needed.
Comment: One commenter suggested that the ESRD QIP should focus more on mitigating patient non-compliance.
Response: We thank the commenter for the suggestion and will consider it as we further develop measures and policies for the ESRD QIP. We also note that there are mechanisms currently in place under the ESRD Conditions for Coverage that require that providers/facilities educate patients and promote appropriate patient care (e.g. 42 CFR 494.90(d)).
Comment: Some commenters urged CMS to require reporting of the ESRD QIP measures for all applicable patient populations, including both Medicare and non-Medicare populations, because providers will then have a better understanding of their overall performance.
Response: We intend to propose to require reporting of measure data on all ESRD patient populations after the launch of CROWNWeb. We have thus far not required reporting on all patient populations because our measures have been claims-based and have thus been restricted to Medicare patients. We adopted claims-based measures to reduce the burden of reporting for providers/facilities in the initial years of the program.
Comment: Some commenters requested that we clearly provide the criteria which we will use to select future measures and their weight and suggested that measures be “phased-in.” Commenters also suggested the CMS use criteria similar to that used by the NQF to adopt measures and employ the feedback of the Measure Applications Partnership in selecting measures appropriate for the program.
Response: We believe that we have outlined the criteria we used to select measures and their weights for the ESRD QIP, and we will continue to do so in the future. We will also consider NQF criteria, as well as feedback of other consensus-based entities, such as the Measures Application Partnership, as we select measures for the ESRD QIP. We also believe that, in some cases, it might be appropriate to “phase-in” measures, and we will continue to consider the best methods of introducing measures to the program.
Comment: One commenter suggested that CMS impose a method for ensuring that the data provided by facilities/providers is accurate.
Response: We currently have the ability to cross check the accuracy of some of the data reported via CROWNWeb. If a provider/facility reports information via CROWNWeb, Start Printed Page 70284we can see if this information reflects that submitted for the ESRD QIP. We will continue to monitor provider/facility compliance with the ESRD QIP reporting requirements, and we will propose to implement a validation methodology in future rulemaking if we conclude that this would be appropriate for the program.
Comment: Some commenters encouraged CMS to implement a program or conduct demonstration programs for incentive bonus payments rather than payment reductions. These commenters suggested that these bonuses could be funded by the money saved in payment reductions under the ESRD QIP. Another commenter suggested that CMS make more of the payment amount contingent upon quality, and one commenter urged CMS to encourage innovation in the ESRD field.
Response: Section 1881(h) does not provide us with the authority to issue bonus payments to providers/facilities based on their performance under the ESRD QIP or to make reductions of more than 2.0 percent. We have conducted quality incentive ESRD demonstration projects in the past, and we intend to do so in the future; we will consider commenters' suggestions as we develop future projects. We believe that the ESRD QIP will encourage innovation in the ESRD field as providers/facilities seek to reach the highest quality standards through better and more efficient methods of care.
Section 1881(h)(2)(C) of the Act enables the Secretary to establish a process for updating the measures specified under subparagraph (A) in consultation with interested parties. Occasionally there are changes in science or new issues arise related to patient safety that may impact the measures that have been adopted through the rulemaking process. Therefore, for such cases where new information is available that specifically relates to patient safety concerns, we proposed that we would post a notice of the updates we intend to make to the measure(s) in the Federal Register. We proposed to specify in the notice a time period during which we would accept comments from the public. We also proposed to consider these comments and post a notice in the Federal Register finalizing any updates that we make to the measure(s). We stated our belief that this process will enable us to make necessary updates to the ESRD QIP measures to ensure that the measures are based on the best available scientific data.
Comment: Some commenters requested that CMS use the rulemaking process to update and/or modify measures.
Response: We believe that the measure updating process that the Secretary establishes under section 1881(h)(2)(B) can be a subregulatory process, as long as it is established in consultation with interested parties. We also believe that we have met this statutory requirement by proposing in rulemaking to implement a process to update measures. Generally, we will use the rulemaking process as often as possible to updated and/or modify measures. But the process we proposed to adopt balances our need, in some circumstances, to expeditiously update measures to address changes in science or issues related to patient safety while still allowing the public to express its critiques, concerns, and approval of such updates.
After considering the comments, we are finalizing our process for updating measures as proposed.
In the CY 2012 ESRD PPS proposed rule (76 FR 40535 through 40536), we proposed to revise the regulations at § 414.610 to conform with section 106 of the Medicare and Medicaid Extenders Act of 2010 (MMEA), and to incorporate a technical correction.
Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 (Pub. L. 110-275) (MIPPA) amended section 1834(l)(13)(A) of the Act to specify that, effective for ground ambulance services furnished on or after July 1, 2008 and before January 1, 2010, the ambulance fee schedule amounts for ground ambulance services shall be increased as follows:
For covered ground ambulance transports which originate in a rural area or in a rural census tract of a metropolitan statistical area, the fee schedule amounts shall be increased by 3 percent.
For covered ground ambulance transports which do not originate in a rural area or in a rural census tract of a metropolitan statistical area, the fee schedule amounts shall be increased by 2 percent.
Sections 3105(a) and 10311(a) of the Affordable Care Act further amended section 1834(l)(13)(A) of the Act to extend the payment add-ons described above for an additional year, such that these add-ons also applied to covered ground ambulance transports furnished on or after January 1, 2010 and before January 1, 2011. In the CY 2011 physician fee schedule final rule (75 FR 73385 and 73386, 73625), we revised § 414.610(c)(1)(ii) to conform the regulations to this statutory requirement.
Subsequently, section 106(a) of the MMEA again amended section 1834(l)(13)(A) of the Act to extend the payment add-ons described above for an additional year, such that these add-ons also apply to covered ground ambulance transports furnished on or after January 1, 2011 and before January 1, 2012. In the CY 2012 ESRD PPS proposed rule (76 FR 40535), we proposed to revise § 414.610(c)(1)(ii) to conform the regulations to this statutory requirement. This statutory requirement is self-implementing. A plain reading of the statute requires only a ministerial application of the mandated rate increase, and does not require any substantive exercise of discretion on the part of the Secretary. For further information regarding the extension of these payment add-ons, please see Transmittal 706 (Change Request 6972) dated May 21, 2010 and the CMS Web site, http://www.cms.gov/AmbulanceFeeSchedule/02_afspuf.asp.
Section 146(b)(1) of the MIPPA amended the designation of rural areas for payment of air ambulance services. This section specified that any area that was designated as a rural area for purposes of making payments under the ambulance fee schedule for air ambulance services furnished on December 31, 2006, shall continue to be treated as a rural area for purposes of making payments under the ambulance fee schedule for air ambulance services furnished during the period July 1, 2008 through December 31, 2009.
Sections 3105(b) and 10311(b) of the Affordable Care Act amended section 146(b)(1) of MIPPA to extend this provision for an additional year, through December 31, 2010. In the CY 2011 physician fee schedule final rule (75 FR 73385 through 86, 73625 through 26), we revised § 414.610(h) to conform the regulations to this statutory requirement. Subsequently, section 106(b) of the MMEA amended section 146(b)(1) of MIPPA to extend this provision again through December 31, 2011. Therefore, in the CY 2012 ESRD PPS proposed rule (76 FR 40536), we Start Printed Page 70285proposed to revise § 414.610(h) to conform the regulations to this statutory requirement. This statutory requirement is self-implementing. A plain reading of the statute requires only a ministerial application of a rural indicator, and does not require any substantive exercise of discretion on the part of the Secretary. Accordingly, for areas that were designated as rural on December 31, 2006, and were subsequently re-designated as urban, we have re-established the “rural” indicator on the ZIP Code file for air ambulance services through December 31, 2011.
For further information regarding the extension of this MIPPA provision, please see Transmittal 706 (Change Request 6972) dated May 21, 2010 and the CMS Web site, http://www.cms.gov/AmbulanceFeeSchedule/02_afspuf.asp.
Section 414 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) added paragraph (12) to section 1834(l) of the Act, which specified that in the case of ground ambulance services furnished on or after July 1, 2004, and before January 1, 2010, for which transportation originates in a qualified rural area (as described in the statute), the Secretary shall provide for a percent increase in the base rate of the fee schedule for such transports. The statute requires this percent increase to be based on the Secretary's estimate of the average cost per trip for such services (not taking into account mileage) in the lowest quartile of all rural county populations as compared to the average cost per trip for such services (not taking into account mileage) in the highest quartile of rural county populations. Using the methodology specified in the July 1, 2004 interim final rule (69 FR 40288), we determined that this percent increase was equal to 22.6 percent. As required by the MMA, this payment increase was applied to ground ambulance transports that originated in a “qualified rural area”; that is, to transports that originated in a rural area included in those areas comprising the lowest 25th percentile of all rural populations arrayed by population density. For this purpose, rural areas included Goldsmith areas (a type of rural census tract).
Sections 3105(c) and 10311(c) of the Affordable Care Act amended section 1834(l)(12)(A) of the Act to extend this rural bonus for an additional year through December 31, 2010. In the CY 2011 physician fee schedule final rule (75 FR 73385 through 73386 and 73625), we revised § 414.610(c)(5)(ii) to conform the regulations to this statutory requirement.
Subsequently, section 106(c) of the MMEA again amended section 1834(l)(12)(A) of the Act to extend the rural bonus described above for an additional year, through December 31, 2011. Therefore, as directed by the MMEA, we are continuing to apply the rural bonus described above (in the same manner as in previous years), to ground ambulance services with dates of service on or after January 1, 2011 and before January 1, 2012 where transportation originates in a qualified rural area.
This rural bonus is sometimes referred to as the “Super Rural Bonus” and the qualified rural areas (also known as “super rural” areas) are identified during the claims adjudicative process via the use of a data field included on the CMS supplied ZIP Code File.
In the CY 2012 ESRD PPS proposed rule (76 FR 40536), we proposed to revise § 414.610(c)(5)(ii) to conform the regulations to the statutory requirement set forth at section 106(c) of the MMEA. This statutory requirement is self-implementing. The statute requires a one-year extension of the rural bonus (which was previously established by the Secretary), and does not require any substantive exercise of discretion on the part of the Secretary. For further information regarding the extension of this rural bonus, please see Transmittal 706 (Change Request 6972) dated May 21, 2010 and the CMS Web site, http://www.cms.gov/AmbulanceFeeSchedule/02_afspuf.asp.
In the CY 2011 physician fee schedule final rule (75 FR 73386, 73625), CMS made technical changes to reformat § 414.610(c)(1). However, in making these revisions, language related to the ambulance fee schedule conversion factor (CF) was inadvertently left out of this regulation. Specifically, the following sentence was inadvertently omitted from revised § 414.610(c)(l): “The CF is multiplied by the applicable RVUs for each level of service to produce a service-level base rate.” Prior to the changes made in the CY 2011 physician fee schedule final rule, this was the first sentence under § 414.610(c)(l)(i). We did not intend to delete this language in making the CY 2011 formatting changes. Therefore, in the CY 2012 ESRD PPS proposed rule (76 FR 40536), we proposed to revise § 414.610(c)(1) to reinstate this sentence which was inadvertently deleted in the CY 2011 physician fee schedule final rule.
We did not receive any comments regarding the proposed revisions to § 414.610 discussed above. (We received one ambulance-related comment during the comment period which was beyond the scope of the proposed rule, and thus, it is not addressed in the final rule). Therefore, we are finalizing the revisions to § 414.610 as proposed.
Title XVIII of the Social Security Act (the Act) governs the administration of the Medicare Program. The statute provides coverage for broad categories of benefits, including inpatient and outpatient hospital care, skilled nursing facility care, home health care, physician services, and durable medical equipment (DME). DME is covered by Medicare based, in part, upon section 1832(a) of the Act, which describes the scope of benefits under the supplementary medical insurance program (Medicare Part B). Section 1861(s)(6) of the Act defines “medical and other health services” to include DME as a separate benefit for which payment is authorized by section 1832 of the Act. Section 1861(m)(5) of the Act specifically includes DME in the definition of the term “home health services.”
In accordance with section 1861(n) of the Act, the term “durable medical equipment” includes iron lungs, oxygen tents, hospital beds, and wheelchairs used in the patient's home whether furnished on a rental basis or purchased. The patient's home includes an institution used as his or her home other than an institution that meets the requirements of section 1861(e)(1) or section 1819(a)(1) of the Act. Besides being subject to this provision, the coverage of DME must also meet the requirements of section 1862(a)(1)(A) of the Act, which in general excludes from payment any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and section 1862(a)(6) of the Act, which (except for certain specified exceptions) precludes payment for personal comfort items.
Section 1834(a) of the Act, as added by section 4062 of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), Public Law 100-203, sets forth the payment rules for most DME furnished on or after January 1, 1989. Historically, the Medicare payment amount for a DME item is generally equal to 80 Start Printed Page 70286percent of the lesser of the actual charge or the fee schedule amount for the item, less any unmet Part B deductible. The beneficiary coinsurance for such items is generally equal to 20 percent of the lesser of the actual charge or the fee schedule amount for the item once the deductible is met. The fee schedule amounts are generally calculated using average allowed charges from a base period and then updated by annual update factors. Sections 1834(a)(2) through (a)(7) of the Act set forth six separate classes of DME and separate payment rules for each class. The six classes of items are: inexpensive and other routinely purchased DME; items requiring frequent and substantial servicing; customized items; oxygen and oxygen equipment; other covered items (other than DME); and capped rental items. For DME in general, § 414.210(f) specifies that payment can be made for replacement of DME that is lost, stolen, irreparably damaged, or has been in continuous use for the equipment's reasonable useful lifetime (RUL). In general, the RUL for DME is established as 5 years. Computation of the RUL is based on when the equipment is delivered to the beneficiary, not the age of the equipment. The 5-year standard is set forth in section 1834(a)(7)(C)(iii) of the Act for capped rental DME, but was applied to all DME through the regulations. The RUL is used to determine how often it is reasonable to pay for replacement of DME under the program and is not specifically set forth as a minimum lifetime standard. Therefore, we are using our discretion to establish a rule regarding how long equipment must withstand repeated use to be considered DME.
Payment for inexpensive or routinely purchased DME is made on a purchase or rental basis, with total payments being limited to the purchase fee schedule amount for the item. The regulation at 42 CFR 414.220 provides that inexpensive DME have an average purchase price of $150 or less and routinely purchased DME are items that have historically been acquired on a purchase basis 75 percent of the time or more. Accessories used with DME are also included in the inexpensive or routinely purchased DME class. Payment is generally made on a monthly rental basis with no cap on the number of rental payments made for items such as ventilators that require frequent and substantial servicing. Payment for items meeting the definition of customized DME set forth at § 414.224 is made on a lump sum purchase basis in an amount established based on the Medicare claims processing contractor's individual consideration and judgment of a reasonable payment amount for each item. Payment for oxygen equipment set forth at § 414.226 is made on a monthly basis for up to 36 months of continuous use. The supplier retains ownership of the oxygen equipment following the 36-month cap, but must continue to furnish the equipment for the remainder of the equipment's 5-year RUL, at which point the beneficiary can elect to obtain new equipment. Payment for capped rental items set forth at § 414.229(f) is made on a monthly rental basis for up to 13 months of continuous use. The supplier must transfer title to the equipment to the beneficiary on the first day following the 13th month of continuous use.
In establishing regulations for the purpose of implementing the payment rules mandated by OBRA 87, 42 CFR 414.202 sets forth the basic definition of DME that was originally established and elaborated upon in program instructions discussed below. Section 414.202 defines DME as equipment furnished by a supplier or a home health agency that—
Can withstand repeated use;
Is primarily and customarily used to serve a medical purpose;
Generally is not useful to an individual in the absence of an illness or injury; and
Is appropriate for use in the home.
The benefit for DME as it was initially defined at section 1861(s)(6) of the Act was a benefit for “rental of durable medical equipment.” The owner of rented equipment is paid for the use of the equipment. When the equipment is no longer needed, it is returned to the owner and can then be rented by another customer. Items that are disposable cannot be rented and items that last for short periods of time are not likely to be items that would be rented. The Act was amended by section 16 of the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 (Pub. L. 95-142) to allow for purchase of DME in cases where purchase is less costly or more practical than rental. In 1978, program instructions were added to the Medicare Part B Carriers Manual (HCFA-Pub. 14-3, Rev. 3-669) to further define DME and durability of an item, that is, when an item is considered durable. The instructions are now included in section 110.1 of chapter 15 of the Medicare Benefit Policy Manual (CMS-Pub. 100-02). In specifying which items satisfy the durability criteria, these program instructions provide that “an item is considered durable if it can withstand repeated use, that is, the type of item which could normally be rented” and excludes items that are “of an expendable nature.” The instructions do not specify exactly how long an item must last to be considered a durable item that would normally be rented as opposed to a disposable item or an item that would not normally be rented.
CMS has provided program instructions for coverage of supplies and accessories at Section 110.3 in Chapter 15 of the Medicare Benefit Policy Manual. The instructions provide that payment may be made for supplies that are necessary for the effective use of DME, such as lancets used to draw blood for use with a home blood glucose monitor. The lancet itself is disposable and would not be covered as DME, but it is a covered item that falls under the general DME benefit because it is necessary for the effective use of DME—the home blood glucose monitor. Supplies necessary for the effective use of DME also include oxygen and those drugs and biologicals which must be inserted directly into the equipment for the effective use of DME.
The Healthcare Common Procedure Coding System (HCPCS) is a standardized coding system used to process claims submitted to Medicare, Medicaid, and other health insurance programs by providers, physicians, and other suppliers. The HCPCS Code Set is divided into two principal subsystems, referred to as level I and level II of the HCPCS:
Level I of the HCPCS codes is comprised of Current Procedural Terminology (CPT) codes, which are copyrighted by the American Medical Association (AMA), and are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals that are billed to public or private health insurance programs.
Level II of HCPCS is a standardized coding system used primarily to identify products and supplies that are not included in the CPT codes, such as DME, orthotics, prosthetics, and supplies when used outside a physician's office. Assignment of a HCPCS code is not a coverage determination and does not imply that any payer will cover the items in the code category. In October 2003, the Secretary delegated authority under the Health Insurance and Portability Act of 1996 to CMS to maintain and distribute HCPCS Level II codes.
The regulation and program instructions do not lend guidance regarding the specific period of time that equipment must function in order Start Printed Page 70287to be considered “durable.” In addition, the regulation does not provide specific guidance or criteria regarding how to determine if new devices consisting of a system of durable and non durable components that together serve a medical purpose fall within the DME benefit category. Therefore, we believe it is necessary to revise the regulation at this time to include a definition of DME that uses more specific language to define the term “durable” for the purpose of determining whether equipment is DME. The issue of linking durability to the lifetime of equipment and where to draw the line has come to our attention in light of the recent technology and engineering in the field of medical devices and equipment. Establishing a minimum lifetime requirement (MLR) would help facilitate the benefit category determination process for items that clearly last longer or shorter than the minimum lifetime threshold.
In cases where it is not clear that the equipment can function for the specified minimum period of time, we proposed that reviewing additional information and evidence consistent with the present benefit category determination process would be necessary to determine the expected life of the equipment. CMS and CMS contractors would base the decision on various sources of information including but not limited to the HCPCS request form, pre-market clearance documents from the Food and Drug Administration (FDA), product warranty documents, product Web site, product marketing materials, product user guides, product operating manuals, consumer product reviews, subject matter expert reviews, industry product standards data, and product data created as a result of clinical studies or standardized test results. A minimum lifetime standard for DME may also help facilitate the HCPCS process. The current application form used to request new HCPCS codes for items includes the question regarding whether equipment is durable and, if so, instructs the applicant to provide an explanation of how the item can withstand repeated use. We have received requests from several entities including DME stakeholders for additional clarification regarding the durability standard for DME. Comments from some of these entities indicate that there is limited direction on what is required for an item to be considered “durable” in the current regulation. Additional clarification of the term “durable” would be helpful to industry stakeholders such as manufacturers in anticipating how their products would be treated under coding classification and benefit category determinations.
On July 8, 2011, we published in the Federal Register a proposed rule entitled, “Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012, End-Stage Renal Disease Quality Incentive Program for PY 2013 and PY 2014; Ambulance Fee Schedule; and Durable Medical Equipment” (76 FR 40498). In that rule, we proposed revising the definition of DME by adding a 3-year MLR that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME.
We received approximately 35 comments on our proposal. Interested parties that submitted comments included several medical device and equipment manufacturers, a healthcare provider, RESNA (Rehabilitation Assistive Technology Standards Board) and national organizations for HCPCS coding, disability, medical technology innovators and beneficiaries. In this final rule we provide a summary of each proposed provision, a summary of the public comments received, and our responses to them.
We proposed making changes to the definition of DME at 42 CFR 414.202 in order to clarify the meaning of the term “durable” in order to reflect our current interpretation of the statutory provisions discussed above consistent with the DME payment provisions. Specifically, we proposed establishing a 3-year MLR that equipment will be expected to meet in order to be considered DME. Based upon the statute and current regulations, equipment would not qualify as DME if it could not withstand repeated use. Although the capacity for reuse is in itself a fundamental characteristic of durability, it is not clear how many months or years an item must withstand repeated use in order to be considered durable.
The Merriam Webster dictionary defines “durable” as the ability to exist for a long time without significant deterioration. The United States Department of Commerce uses a durability standard of 3 years for consumer durable goods for National Income and Accounts estimates.[19] Furthermore, economics dictionaries,[20] various encyclopedias,[21] and economics textbooks [22] define durable goods as goods that are expected to last longer than 3 years.
In addition, information gathered from various sources such as Rehabilitative Engineering and Assistive Technology Society of North America (RESNA),[23] product catalogs, product warranty documents, and consumer product reviews indicate that conventional DME items such as wheelchairs, hospital beds, and ventilators specified in section 1861(n) of the Act typically have a useful life of 3 or more years before they need to be replaced or need major repairs. Therefore, we proposed establishing a 3-year MLR for items to meet the durability criterion for DME.
The 3-year MLR was proposed to increase the clarity of the current definition and give regulatory weight to a reasonable benchmark for a minimum period of durability or repeated use that an item would be expected to meet in order for the equipment to be considered DME. In addition, the rule was proposed to provide clear guidance to CMS and other stakeholders for making consistent informal benefit category determinations and national coverage determinations for DME. It was also proposed to assist manufacturers in designing and developing new medical equipment to have a better understanding of how long an item must be able to withstand repeated use in order to be considered DME for Medicare purposes. It is important to note that the 3-year MLR does not replace the RUL standard established by section 1834(a)(7)(C) of the Act for payment purposes. The RUL rules are used to determine how often payment can be made for replacement items and is not a MLR for DME. Although the proposed 3-year MLR is a requirement for determining whether an item will be considered durable, it is not an indication of the typical or average lifespan of DME, which in many cases may last for much longer than 3 years.Start Printed Page 70288
We proposed that the 3-year MLR be prospective only and not apply to equipment classified as DME before the proposed rule is implemented. Based on our experience with the program, we believe that most items that are currently classified as DME function for 3 or more years. We also proposed not to apply the standard to supplies and accessories used with DME that are paid for under the DME benefit or blood glucose monitors and blood testing strips to allow for continued coverage of such items, supplies and accessories that are necessary for the effective use of DME. In the proposed rule we also solicited public comments on methods for determining when multi-component devices are durable. We requested comments only and did not propose any regulation changes regarding this issue. The comments received on this issue will be taken into consideration in determining whether changes on this issue should be proposed in future rulemaking.
Comment: Several commenters acknowledged that it is necessary to establish a MLR for use in determining if medical equipment is durable for purposes of Medicare payment.
Response: We agree and thank the commenters for their support and feedback that it is necessary to establish a MLR for use in determining if medical equipment is durable.
Comment: Several commenters argued that the proposed rule is unnecessary and the current criteria for determining whether equipment is durable are clear, with one commenter stating that Medicare payment rules and manufacturer warranties already provide beneficiaries with appropriate protection. Two commenters suggested that CMS should publish a MLR for DME through subregulatory guidance.
Response: We appreciate the comments; however, we believe there is a need to make changes to the definition of DME at 42 CFR 414.202 to clarify the meaning of the term “durable” to reflect our current interpretation of the statute, consistent with the DME payment rules previously discussed. Manufacturers of new technology medical devices have specifically asked how long an item must withstand repeated use in order to be considered durable equipment, and therefore our objective is to establish a clear expected MLR for equipment in order to facilitate consistent benefit category determinations. We also wanted to publish the 3-year MLR through rule making rather than providing this clarification through Manual provisions and program instructions to provide an opportunity for input given that the definition of DME is set forth in regulations.
Comment: Several commenters stated that the proposed 3-year MLR was arbitrary and inappropriate.
Response: We disagree. As discussed previously, the 3-year MLR for durability reflects the standard used by various Federal agencies to define durable consumer goods such as cars, refrigerators, air conditioning units, as well as hospital beds, walkers, crutches, scooters, wheelchairs, oxygen equipment, etc. Federal agencies such as the Department of Commerce and the Department of Labor have been applying this standard to durable goods including DME. Furthermore, the 3-year durability standard is widely supported in the industry. See for example, Simon Kuznet's “National Income and Capital Formation” published by the National Bureau of Economic Research (1937), defining durable commodities as those whose period of utilization is more than 3 years, and references in a wide variety of more recent literature, textbooks, dictionaries and encyclopedias, which specifically reference a 3-year period of time in defining or classifying items as durable.[24] We see no reason why a different standard for durability should be used for the equipment covered as DME under the Medicare program. Therefore, we believe it is reasonable for the Department of Health and Human Services to apply this 3-year standard to DME.
Additionally, in light of the statutory 5-year RUL requirement and the DME payment rules, which support the fact that equipment paid for under the DME benefit is intended to be used over many years, we believe that it is reasonable to require that such equipment be functional or capable of withstanding repeated use for at least 3 years. As we discussed in our equipment replacement payment rule, we expect that equipment furnished by suppliers will function for a reasonable period of time. See 71 FR 65884, 65920 (Nov. 9, 2006). We believe that a 3-year MLR would provide sufficient flexibility to cover new technology items that could be considered durable, but that may not last for 5 years before having to be replaced. As noted previously, the Congress, in drafting section 4152(c)(2)(F) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508), selected 5 years as the default RUL for capped rental DME. The RUL was specified to be 5 years for each capped rental DME item unless prior experience in making payment for the item resulted in the establishment of an alternative RUL for the item. As part of the interim final rule (57 FR 57675) implementing this provision on December 7, 1992, we extended the RUL provision to other items of DME and specified that, in the absence of program instructions, the carrier may determine that the RUL of equipment is greater than, but not less than, 5 years. See 57 FR 57675, 57686 (Dec. 7, 1992). Furthermore, such standards are consistent with the DME payment methodology, mandated by Section 4062(b) of the Omnibus Budget Reconciliation Act of 1987, Public Law 100-203, and section 5101(b) of the Deficit Reduction Act of 2005, Public Law 109-171, which authorized the changes in the payment for oxygen equipment and mandated a cap on payments for all rented equipment other than a few frequently serviced items such as ventilators. The following are some examples of changes in payment rules that were made to avoid excessive payments for durable items needed and used by patients for extended periods of time lasting for several years.
The rental payments for inexpensive equipment such as canes and crutches that the beneficiary elects to rent rather than purchase is capped at the purchase fee for the equipment.
The payment for oxygen equipment is currently capped at 3 years and suppliers are mandated to continue furnishing the equipment after the cap for up to 2 additional years.
Title to other expensive equipment such as wheelchairs and hospital beds is transferred to the beneficiary after 13 continuous rental payments.
The 5-year RUL and payment rules apply to durable equipment that can be used for many years. See 71 FR at 65920, (regarding the expectation that suppliers furnish a quality item that will last over a 5-year period). CMS continues to expect that in light of these Start Printed Page 70289RUL provisions, equipment covered under the DME benefit should be capable of withstanding repeated use for a minimum time period. Consistent with these standards, we believe that a 3-year durability threshold is reasonable, especially given our history with the program and the vast majority of categories of DME that already last for at least a 3-year period.
Comment: One commenter suggested that CMS should refrain from adding a 3-year MLR and instead define what is meant by repeated use.
Response: We appreciate the comment; however, we believe it is necessary to establish a reasonable expectation regarding durability by adding a 3-year MLR to the definition of DME. Manufacturers of new technology medical devices have specifically asked how long an item must withstand repeated use in order to be considered durable equipment, and therefore we believe it is necessary to establish a clear expected MLR for equipment in order to assure payment for quality items of DME, and facilitate consistent benefit category and national coverage determinations.
Comment: One commenter suggested establishing 6 months as the MLR for DME.
Response: We appreciate the comment, however, as discussed earlier, 3 years is a standard used by Federal agencies and the industry for classifying durable goods, which include equipment typically covered under the DME benefit. Therefore, we believe that adopting a standard of 3 years for purposes of the Medicare program would be reasonable and assure payment for equipment consistent with industry standards. Furthermore, as noted previously, in light of the statutory 5-year RUL requirement we do not believe it is reasonable to establish a 6-month standard. As discussed earlier, consistent with the statute, the payment rules support the fact that equipment included in the DME benefit is intended to be used over many years. For all the reasons stated above, we do not believe that a 6-month MLR for DME is a reasonable option.
Comment: Several commenters added that using a universal 3-year MLR for all types of products is inflexible and nonfeasible. One commentator indicated that engineering a device for a guaranteed lifetime is virtually impossible.
Response: We do not believe that establishing an expected 3-year MLR is inflexible and nonfeasible. As noted earlier, the regulations already provide a requirement for repeated use and a 5-year RUL standard. We proposed to establish an expected 3-year threshold standard consistent with these requirements and other Federal agencies and industry standards. In addition, while we understand that exact periods of longevity will vary, the purpose of the rule is to establish a MLR in order for the equipment to be considered durable for purposes of Medicare payment determinations. The 3-year MLR is intended to be a minimum threshold that equipment will be expected to meet in order to be considered durable under Medicare regulations We expect that equipment furnished under the benefit will be quality items that will function consistent with industry standards for a 3 year threshold period.
Furthermore, a vast majority of the categories of DME last for 3 years or longer. Therefore, consistent with these RUL and payment provisions, we believe that a 3-year MLR would continue to provide the flexibility to cover new technology items.
We also appreciate the comment that engineering a device for a guaranteed lifetime is virtually impossible; however, given the industry standards, we expect that equipment should function for a minimum threshold period of time. Based on our experience in making benefit category determinations and analyzing the types of equipment that are covered under the DME benefit over the years; we believe that the 3-year MLR is a reasonable threshold standard for the types of equipment paid for under the DME benefit. Therefore, we believe that for purposes of Medicare payment, it is reasonable to establish a threshold of 3 years which is consistent with other Federal agencies and industry standards.
Comment: Two commenters suggested that the MLR should be based upon a specific code set, natural therapeutic requirements, and normal length of needs and medical necessity as dictated by the prescriber, rather than a universally applied standard.
Response: We thank the commenters for their input that the MLR should be based upon a specific code set, natural therapeutic requirements, and normal length of needs and medical necessity as dictated by the prescriber, rather than a universally applied standard. However, we have established a standard applicable to the Medicare benefit that is designed to be consistent with criteria established in the statute and payment provisions. We have interpreted the benefit consistent with the standards in the statute, Medicare payment regulations, industry standards, and Federal agency standards. Furthermore, based on our experience in making benefit category determinations and analyzing the types of equipment that are covered under the DME benefit over the years, the majority of the categories of DME items already last for 3 years or longer. As noted earlier, we already expect items will function consistent with the 5-year RUL and DME payment rules. For all the reasons discussed, we believe that it is appropriate to apply the 3-year MLR as a threshold for defining durability for equipment under the program.
Comment: One commenter recommended that CMS create a rebuttable presumption that a DME item should last for 3 years but provide that a manufacturer can rebut that presumption with convincing evidence that the 3-year MLR should not be applied automatically in a particular instance.
Response: We disagree with the commenter's recommendation for creating a rebuttable presumption that a DME item should last for 3 years. As stated earlier, manufacturers of new technology medical devices have specifically asked how long an item must withstand repeated use in order to be considered durable equipment, and therefore our objective is to establish an expected MLR for equipment in order to assure payment for quality items and facilitate consistent benefit category and national coverage determinations. The issue of linking durability to the lifetime of equipment and where to draw the line has come to our attention in light of the recent technology and engineering in the field of medical devices and equipment. We are establishing a MLR for DME to clarify our expectation regarding durability. An option to rebut the 3-year MLR in some instances would undermine this objective.
Comment: Several commenters recommended that CMS collaborate with industry stakeholders to develop additional requirements related to determining durability of items.
Response: We appreciate the comment. The current processes including Benefit Category Determination (BCD), National Coverage Determination (NCD), Local Coverage Determinations (LCD), and Healthcare Common Procedure Coding System (HCPCS) include meetings with manufacturers in addition to the public where we seek input from the stakeholders. We will continue to receive input from stakeholders consistent with the BCD and NCD process when determining whether an item is durable. See 68 FR 55634, (September 26, 2003); and http://www.Start Printed Page 70290cms.gov/DeterminationProcess/Downloads/FR09262003.pdf.
See also, information on the HCPCS Level II coding process at: http://www.cms.gov/MedHCPCSGenInfo/Downloads/2013_HCPCS_Application.pdf. http://www.cms.gov/MedHCPCSGenInfo/08_HCPCSPublicMeetings.asp#TopOfPage.
Comment: Several commenters stated that the rule would create burdensome testing requirements to verify the 3-year MLR for a device. One commenter stated that testing standards cannot validate the lifetime of a device and it is unclear how a manufacturer would prove an item meets the 3-year MLR. One commenter noted that added testing for durability will increase the cost for manufacturers in addition to designing new 3-year versions of DME products that currently function for a shorter period of time.
Response: We did not intend to create burdensome testing requirements. As noted previously, our objective is to establish a reasonable minimum lifetime standard for DME for purposes of Medicare payment, consistent with other Federal agencies and industry practice. As stated in the proposed regulation, in cases where it is not clear that the equipment can function for the specified minimum period of time, we will review information and evidence consistent with the current benefit category determination process to determine the expected life of the equipment. As discussed previously, the benefit category determination process typically involves reviewing information from various sources including but not limited to information related to Food and Drug Administration (FDA) pre-market clearance, product manuals, operating guides, warranty documents, and standardized test results. The NCD process is available at http://www.cms.gov/DeterminationProcess/Downloads/FR09262003.pdf. See also, 68 FR 55638 (September 23, 2003).
Additionally, we routinely collect information regarding durability of new products as part of the HCPCS editorial process in order to identify categories of new DME subject to the procedures established in accordance with the mandate of section 531(b) of the Medicare, Medicaid and SCHIP Benefit Improvement and Protection Act of 2000 (BIPA 2000), Public Law 106-554. Based on our experience with the program, this information has been readily available from the manufacturers of these items and other entities submitting requests for changes to the HCPCS. Information on the HCPCS Level II coding process is available at: http://www.cms.gov/MedHCPCSGenInfo/Downloads/2013_HCPCS_Application.pdf and http://www.cms.gov/MedHCPCSGenInfo/08_HCPCSPublicMeetings.asp#TopOfPage.
Furthermore, the 3-year MLR will be prospective and will not be applied on a retroactive basis; it will be used for making benefit category decisions for new items. As noted previously, we believe that a vast majority of the categories of DME already last for at least 3 years, consistent with the RUL and payment provisions. The 3-year MLR is designed to be a minimum threshold for determining if an item is considered durable and we expect that new DME products in general will continue to meet or exceed this MLR. For reasons discussed above, we have no reason to believe that the 3-year MLR will increase the cost for manufacturers.
Comment: One commenter supported the grandfathering provision.
Response: We thank the commenter for the input and support.
Comment: Several commenters voiced concerns that the new requirement will stifle innovation and prevent the entry of new devices in the market. Several commenters stated that the grandfathering provision would create disparities among manufacturers and be disadvantageous to new product manufacturers and advantageous to existing DME product manufacturers. Some commenters stated that applying the rule prospectively and not applying the rule to items currently classified as DME makes the rule unclear and nontransparent.
Response: We did not intend to create disparities. As noted in the proposed regulation and a response to an earlier comment, we are making changes to the definition of DME to reflect our current interpretation of the statute consistent with the RUL and general DME payment provisions. The 3-year MLR is designed to be applied on a prospective basis and would represent a minimum threshold for determinations regarding equipment durability. As noted earlier, in light of the statutory 5-year RUL requirement and DME payment rules which support the fact that DME items should be able to withstand repeated use for many years; we believe that it is reasonable to require that equipment be capable of withstanding repeated use consistent with the industry 3 year standard. We believe that a 3-year MLR would provide the flexibility to cover new technology items that can be considered durable, but may not last for 5 years before having to be replaced.
We also believe that the 3-year MLR is reasonable given the general payment and RUL requirements. As discussed previously, the 5-year RUL is well established since 1992 and we have not found that the RUL standard has stifled innovation or prevented entry of new devices in the market. Therefore, in light of these provisions, we believe that 3 years is a reasonable threshold consistent with Medicare payment rules, industry standards and Federal agency standards. However, while we expect that equipment will meet our 3 year standard, we will continue to monitor the issue and undertake additional rulemaking if necessary.
Comment: One commenter requested clarification on the applicability and scope of the rule. Some commenters requested clarification on how the MLR would be applied to new generations of products that are currently classified as DME or how the standard would apply to an existing DME item that is modified in the future to improve functionality. One commenter recommended that the new rule not apply if an existing DME item is just upgraded. Some commenters questioned if the rule would be applicable to only products that apply for a new HCPCS code. Some commenters questioned if the new rule would apply to items that are billed using existing HCPCS codes or any item that fits into an existing product category or existing HCPCS codes and how miscellaneous codes would be handled.
Response: We will apply the revised definition for DME on a prospective basis. That is, we will not redetermine for payment as DME any product that is currently paid under the DME benefit. The revised definition would only apply to new products. To the extent that a modified product is not a new product (including an item that has been upgraded), the 3-year MLR will not be applicable. We will consider issuing additional guidance to provide further clarification if necessary.
Comment: One commenter questioned how CMS would validate that a device lasts fewer than 3 years. One commenter requested clarification on whether the MLR would be calculated from the date the manufacturer sells the item to the provider or date first provided to the patient.
Response: We are not proposing a new process and as noted previously, we will continue to follow the current benefit category determination process to determine whether a product meets the standards for DME set forth in the rule. As noted earlier, the expected life of an item will be estimated based upon information gathered from various sources consistent with the current benefit category determination process Start Printed Page 70291and will be calculated based upon use, not when it is sold to a supplier.
Comment: One commenter voiced concern that there would be no process for appealing decisions that items are not durable.
Response: A manufacturer or supplier can request a reconsideration of an informal BCD determination or a reconsideration of a formal NCD consistent with the statute. See (68FR 55638, September 26, 2003) available at: http://www.cms.gov/DeterminationProcess/Downloads/FR09262003.pdf.
Comment: One commenter stated that the current testing standards for certain types of equipment that are currently classified as DME require a much shorter lifespan than 3 years.
Response: We appreciate the comment; however, as stated previously, the 3-year MLR would not apply to any items currently classified as DME. In addition, the 3-year MLR would not apply to blood testing strips, accessories and supplies used with DME that are necessary for the effective use of the DME item. For example: A blood glucose monitor and lancets used to obtain blood samples for use in a blood glucose monitor are covered under the DME benefit. The blood glucose monitor is covered as DME and the lancets are covered as supplies necessary for the effective use of the DME item.
After reviewing all the comments, we are finalizing the regulation to revise the definition of durable medical equipment at § 414.202 by adding a 3-year MLR that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME. This will be effective with respect to items classified as DME after January 1, 2012.
In some cases, a device may be a system consisting of durable and non-durable components that together serve a medical purpose. Currently, a multi-component device consisting of durable and non-durable components is considered non-durable if the component that performs the medically necessary function of the device is non-durable, even if other components that are part of the device are durable. Therefore, if the proposed regulation to establish a minimum 3-year MLR for DME is applied to these devices, the component(s) of a multi-component device that performs the medically necessary function of the device would need to meet the 3-year MLR. Although, we did not propose to change our policy with regard to these types of systems at this point, we solicited public comments on this topic. Specifically, we solicited public comments on various ways we might consider applying the 3-year MLR to multi-component devices consisting of both durable and non-durable components. Various options might include the following:
1. Apply the 3-year MLR to the component(s) that performs the entire medically necessary function of the device.
2. Apply the 3-year MLR to the component(s) that performs a vital part of the medically necessary function of the device.
3. Consider a device/system to be durable only if the cost of the durable component(s) over a period of time (for example, 5 years) makes up greater than 50 percent of the overall cost of the device/system over the same period.
In the proposed rule we solicited public comments on the application of various options to multi-component devices to determine whether the device is durable. We received approximately 20 comments pertaining to the topic of applying the 3-year MLR to multi-component devices consisting of both durable and non-durable components. One commenter disagreed with option one because this option requires that the whole device meet the MLR as many devices will not be able to function without even minor elements, such as accessories and supplies. This commenter noted that for the option two, it is not clear what is meant by “performs a vital part of the medically necessary function.” This commenter further stated that for option three it is unclear what is meant by “cost.” The commenter noted that option 3 could be considered if the Medicare reimbursement rate for the durable and non-durable components is used as the “cost” for calculating the ratio of the cost for durable and non-durable components. One commenter supported the 3-year MLR and endorsed option 2 which applies the 3-year MLR to the component(s) that performs a vital part of the medically necessary function for multi-component devices.
Several commenters endorsed the coverage of a specific multi-component device for Medicare beneficiaries. One commenter stated that medical equipment comprised of durable and non-durable components should be considered durable if any one component of the equipment is able to meet the MLR as determined in the HCPCS application process and CMS should evaluate the medically necessary function performed by the device in its totality rather than basing durability on the component that performs the medically necessary function of the device.
We requested comments only and did not propose any regulation changes. Therefore, the comments received will be taken into consideration for future proposed rulemaking.
Section 1847 of the Act, as amended by section 302(b)(1) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)(Pub. L. 108-173), requires the Secretary to establish and implement a Medicare DMEPOS Competitive Acquisition Program (“competitive bidding program” or “program”). Under the competitive bidding program, Medicare sets payment amounts for selected DMEPOS items and services furnished to beneficiaries in competitive bidding areas (CBAs) based on bids submitted by qualified suppliers and accepted by Medicare. For competitively bid items, the payment amounts, referred to as “single payment amounts”, replace the fee schedule payment methodology set forth in section 1834 of the Social Security Act (the Act) and 42 CFR part 414, Subpart D of our regulations.
The competitive bidding program guarantees savings to both the Medicare program and beneficiaries under the program. The program also includes provisions to ensure beneficiary access to quality DMEPOS items and services. Section 1847 of the Act limits participation in the program to suppliers who have met applicable quality and financial standards and requires the Secretary to maintain beneficiary access to multiple suppliers.
On May 1, 2006, we issued a proposed rule (72 FR 25654) in the Federal Register that would implement the competitive bidding program for certain DMEPOS items and services and solicited public comment on our proposals. On April 10, 2007, we issued a final rule (72 FR 17992) in the Federal Register addressing the comments on the proposed rule and establishing the regulatory framework for the Medicare DMEPOS competitive bidding program in accordance with section 1847 of the Act.
Consistent with the requirements of section 1847 of the Act and the Start Printed Page 70292competitive bidding regulations, we began implementing the program by conducting the first Round of competition in 2007 in 10 of the largest metropolitan statistical areas (MSAs) for 10 product categories and implemented the competitive bidding program on July 1, 2008.
On July 15, 2008, section 154 of the Medicare Improvements for Patients and Providers Act (MIPPA) amended section 1847 of the Act to make certain limited changes to the Medicare DMEPOS competitive bidding program. Section 154(a) of the MIPPA delayed competition under the program and terminated the competitive bidding contracts effective June 30, 2008.
The MIPPA required the Secretary to conduct a second competition for Round 1 in 2009 (“Round 1 rebid”) that included the “same items and services” in the “same areas” as the 2007 Round 1 competition, with certain limited exceptions. Specifically, the Round 1 rebid excluded negative pressure wound therapy (NPWT) items and services and excluded Puerto Rico. In addition, section 154(a) of the MIPPA permanently excluded group 3 complex rehabilitative wheelchairs from the competitive bidding program by amending the definition of “items and services” in section 1847(a)(2) of the Act. Suppliers, including suppliers that previously were awarded a competitive bidding contract, had to resubmit bids to be considered for a contract under the Round 1 rebid.
Section 154(a) of the MIPPA also delayed competition for Round 2 of the competitive bidding program from 2009 to 2011 and subsequent competition under the program from 2009 until after 2011. A competition for a national mail order competitive bidding program may occur after 2010 as a result of the MIPPA.
The MIPPA mandated certain changes to the bidding process, starting with the Round 1 rebid. Section 154(a) of the MIPPA added a new paragraph (F) to section 1847(a)(1) of the Act, which sets forth a process for supplier feedback on missing financial documents. Pursuant to this requirement, we notify suppliers that submit their bids within a specific time period if their bid submission is missing any of the required financial documents. We allow suppliers to submit missing financial documents within 10 business days after this notice.
Section 154(b) of the MIPPA amended section 1847(b)(3) of the Act to require contract suppliers to notify us of subcontracting relationships they have entered into for the purpose of furnishing items and services under the competitive bidding program. Contract suppliers must also inform CMS whether each subcontractor meets the accreditation requirement set forth in section 1834(a)(20)(F)(i) of the Act, if applicable to the subcontractor.
Section 154(d) of the MIPPA excludes from the competitive bidding program certain DME furnished by a hospital to the hospital's patients during an admission or on the date of discharge.
On January 16, 2009, we published in the Federal Register (74 FR 2873) an interim final rule with comment period to incorporate into regulations at 42 CFR 414 Subpart F the MIPPA provisions discussed above.
In addition to the changes implemented through the interim final rule, section 154 of the MIPPA made other changes to the competitive bidding program which included:
Exclusions of certain areas in subsequent rounds that are not already selected under Rounds 1 and 2;
Extension of the Program Advisory and Oversight Committee;
Exemption for Off-the-Shelf Orthotics from Competitive Bidding when provided by Certain Providers; and
Evaluation of certain Healthcare Common Procedure Coding System (HCPCS) codes.
These provisions have been addressed through subsequent rulemaking or subregulatory guidance, as appropriate. For additional information about exclusions of certain areas in subsequent rounds that are not already selected under Rounds 1 and 2 and the exemption for off-the-shelf orthotics from competitive bidding when provided by certain providers, please refer to the November 29, 2010, Federal Register (75 FR 73574).
The following administrative requirements were also not addressed in the interim final rule:
A post-award audit by the Office of Inspector General;
Establishment of a Competitive Acquisition Ombudsman; and
A Government Accountability Office report on the results of the competitive bidding program.
The MIPPA mandated a nationwide 9.5 percent reduction in the fee schedule payment amounts for all items and services that were competitively bid during the prior round of competition regardless of any exclusion such as group 3 complex rehabilitative wheelchairs. This provision was not addressed in the interim final rule because it was administered through the standard process for updating fee schedule amounts.
On February 10, 2009, we published a notice (74 FR 6557) in the Federal Register proposing to delay the effective date of the interim final rule by 60 days to allow Department officials the opportunity for further review of the issues of law and policy raised by the interim final rule. On February 19, 2009, we published another notice (74 FR 7653) in the Federal Register that implemented the temporary delay proposed on February 10, 2009. As specified by the February 19, 2009 notice, the interim final rule became effective on April 18, 2009.
On January 16, 2009, we published in the Federal Register an interim final rule (74 FR 2873 through 2881) entitled “Changes to the Competitive Acquisition of Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) by Certain Provisions of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)”. In the interim final rule, we revised current provisions at 42 CFR part 414, Subpart F, to incorporate certain self-implementing MIPPA provisions. The interim final rule addressed the following changes made by the MIPPA:
General Changes to the DMEPOS Competitive Bidding Program:
Temporary Delay of the Medicare DMEPOS Competitive Bidding Program.
Supplier Feedback on Missing Covered Documents.
Disclosure of Subcontractors and their Accreditation Status under the Competitive Bidding Program.
Exemption from Competitive Bidding for Certain DMEPOS.
Exclusion of Group 3 Complex Rehabilitative Wheelchairs.
Round 1 Changes of the Competitive Bidding Program:
Rebidding of the “same areas” as the previous Round 1, unless otherwise specified.
Rebidding of the “same items and services” as the previous Round 1, unless otherwise specified.
The interim final rule was published in the Federal Register on January 16, 2009 with a comment period that ended Start Printed Page 70293on March 17, 2009. We received approximately 793 timely pieces of comments from the interim final rule. Various parties submitted comments including DMEPOS manufacturers, suppliers, national associations representing the supplier community, and pharmacies.
We note that we received many comments on a wide range of issues that were not addressed in the interim final rule. We thank commenters for sharing their views on these issues; however, because these comments were outside the scope of the interim final rule, we do not address those comments in this final rule. In this final rule we provide a summary of each proposed provision, a summary of the public comments received, our responses to them, and any changes to the interim final rule we are implementing in this final rule as a result of comments received.
Section 154(a) of the MIPPA amended section 1847(a)(1) of the Act to delay competition under Rounds 1 and 2 of the Competitive Bidding Program from 2007 and 2009 to 2009 and 2011, respectively. It also delayed competition for a national mail order program until after 2010 and competition in additional areas, other than mail order, until after 2011.
We revised § 414.410(a)(1) and (2) to indicate that competition under Round 1 of the competitive bidding program occurred in 2009 and competition under Round 2 of the program would occur in 2011. In addition, we have revised § 414.410(a)(3) to indicate that competition in additional MSAs will occur after 2011 (or, in the case of national mail order for items and services, after 2010).
The comments we received on Temporary Delay of the Medicare DMEPOS Competitive Bidding Program and our responses are set forth below.
Comment: Several commenters disagreed with starting competition for the Round 1 rebid in 2009 and wanted CMS to delay the program further. Some commenters suggested that CMS spend more time determining the impact and improving the quality of the DMEPOS Competitive Bidding Program for suppliers and beneficiaries by considering comments received on the interim final rule and evaluating the effects from Round 1 of the competitive bidding program before starting the Round 1 rebid.
Response: Section 154(a) of the MIPPA 2009 required the supplier competition for the Round 1 rebid to occur in 2009; therefore, we could not delay the program further. We note that we made numerous process improvements to the competitive bidding program for the Round 1 rebid. For example, we implemented an upgraded on-line bid submission system, early bidder education, and increased oversight of bidders that are new to product categories or competitive bidding areas to ensure they meet our requirements. These improvements, combined with the MIPPA reforms discussed in this final rule, resulted in a smoother experience for bidders and contributed to the successful implementation of the Round 1 rebid contracts and prices on January 1, 2011.
Consistent with our expectations, the Round 1 rebid results so far have been very positive. The program is fulfilling its promise as an effective tool to help Medicare set appropriate payment rates for DMEPOS items and services: payment amounts from the supplier competition for the Round 1 rebid of the program resulted in average savings of 35 percent as compared to the current fee schedule prices. The program is expected to save more than $17 billion in Medicare expenditures over 10 years. In addition to this positive impact on the Medicare Part B trust fund balance, the program is expected to save beneficiaries more than $11 billion over the next ten years as a result of lower coinsurance payments and the downward effect on monthly premium payments. The overall combined savings to Medicare and beneficiaries is therefore expected to total more than $28 billion over the first ten years of the program.
As anticipated, beneficiaries are receiving quality products from contract suppliers in their CBAs. 76 percent of contracts were awarded to suppliers already furnishing contract items in the local area. Additional contract suppliers have furnished other items in the local area or furnished contract items in other areas: fully 97 percent of contracts were awarded to suppliers already established in the competitive bidding area, the product category, or both. Also, CMS exceeded the the 30 percent small supplier target. For the Round 1 rebid, small suppliers, those with gross revenues of $3.5 million or less as defined for the program, make up about 51 percent of the contract suppliers. As discussed later in this preamble, our comprehensive monitoring program has shown a very smooth effective implementation with few inquiries and complaints and no changes in beneficiary health status outcomes.
After consideration of the public comments received, we are finalizing this provision without modification.
Section 1847(b)(2)(A) of the Act prohibits the Secretary from awarding a contract under the program to a supplier unless the supplier meets applicable financial standards specified by the Secretary, taking into account the needs of small providers. We have implemented this requirement at § 414.414(d) of the competitive bidding regulations, which requires suppliers to submit, as part of their bids, financial documents specified in the request for bids (RFB).
The RFB issued for the Round 1 rebid required suppliers to submit the same categories of financial documents as we requested for the previous Round 1 competition. In the previous round of competition, we required suppliers to submit financial documents from the most recent 3 years. As stated in 42 CFR 414.414(d), the required financial documents have been specified in the RFB. Based on experience from the previous round of competition, we modified the required financial documents to lessen the burden on suppliers; instead of 3 years of documentation, we required only 1 year. We believe that we can determine whether a supplier demonstrates financial soundness by reviewing one year of documentation.
Section 154(a) of the MIPPA added a new paragraph (F) to section 1847(a)(1) of the Act, which established a detailed process by which we must notify suppliers of missing “covered documents”—defined by MIPPA as financial, tax or other documents required to be submitted by a bidder as part of an original bid submission in order to meet required financial standards—if such documents are submitted within a specified time period. The MIPPA details the specific steps of this process and provides a timeline for each stage of this covered document submission review. We have implemented this provision of the MIPPA consistent with its detailed requirements.
Consistent with section 1847(a)(1)(F) of the Act, in the case of a bid in which one or more covered documents in connection with such a bid has been submitted not later than the covered document review date, we would notify suppliers of each covered document that is missing from the bidder's submission as of the covered document review date. As set out in the Act the “covered document review date” is the later of— Start Printed Page 70294(1) The date that is 30 days before the final date specified by the Secretary for submission of bids; or (2) the date that is 30 days after the first date specified by the Secretary for submission of bids. For example, if a bid window opens on January 1st and closes on April 30th, the “covered document review date” would be the later of: (1) March 31st (30 days before the final date specified by the Secretary); or (2) January 31st (30 days after the first date specified by the Secretary). Therefore, in this case, the “covered document review date” would be March 31st. Suppliers that submit their financial documents after the covered document review date would not receive notice of any missing financial documents.
Section 1847(a)(1)(F)(i) of the Act requires that we notify bidders of any missing covered documents within 45 days after the covered document review date for the Round 1 rebid. In subsequent rounds of competition, we have 90 days after the covered document review date to provide such notice. For all rounds of competition, bidders that are notified of the missing covered document(s) have 10 business days after the date of notice to submit the missing covered document(s). If a supplier submits the missing covered document(s) within this time period, we may not reject the supplier's bid on the basis that any covered document is missing or has not been submitted on a timely basis.
Section 1847(a)(1)(F)(iii) of the Act places certain limitations on the covered document review process. First, the covered document review process applies only to the timely submission (prior to the covered document review date) of covered documents. Second, the process does not apply to any determination as to the accuracy or completeness of the covered documents submitted or whether such documents meet applicable financial requirements. Third, the process does not prevent us from rejecting a bid for reasons other than those not described in section 1847(a)(1)(F)(i)(II) of the Act. Fourth, the covered document review process shall not be construed as permitting a bidder to change bidding amounts or to make other changes in a bid submission.
We have amended § 414.414 by adding paragraphs (d)(2)(i) through (iii) to set forth the required covered document review process. These paragraphs identify the timeframes established by the MIPPA for—
Suppliers to submit covered documents in order to be eligible to receive notice of any missing covered documents;
CMS to review the submitted covered documents and notify bidders of any missing covered documents; and
Suppliers to submit the missing covered documents.
We also added a definition for “covered document” and “covered document review date” to § 414.402.
Comment: Several commenters suggested that the decision to change financial document requirements from 3 years to 1 year should have been subjected to notice and comment rulemaking. Commenters believed that this would ensure that quality suppliers are selected as contract suppliers, taking into consideration historical demonstrated financial stability. Some commenters also believed that it would be easier to falsify 1 year worth of financial documents as opposed to 3 years.
Response: As noted in the interim final rule, regulations at 42 CFR 414.414(d) state that required financial documents will be specified in the RFB. Based on our experience from the initial Round 1 competition, we determined that one year of financial documents provides sufficient information for determining whether suppliers meet the required financial standards. In the interest of lessoning the burden on suppliers and ensuring compliance with program requirements, we therefore decided to revise the financial documentation requirements from three years to one year. We also sought public comment on the RFB for the Round 1 rebid through the Paperwork Reduction Act (PRA) process, and the Office of Management and Budget (OMB) approved the RFB (OMB Control Number 0938-1016).
Comment: One commenter reflected that, in Round 1 of the competitive bidding program, many bidders lost because they did not have the required documents and CMS did not allow suppliers to resend the documents after the close of the bid window.
Response: The MIPPA-mandated covered document review process was incorporated into our regulations through the interim final rule addressed this issue. Many Round 1 rebid bidders took advantage of this process, and we believe it greatly helped these bidders ensure that they submitted all required financial documents.
Comment: One commenter suggested that the rule needs to address not only missing documents but missing and incorrect contents in documents.
Response: We appreciate this comment; however, the statute specifically indicates that the covered document review process does not apply to the accuracy or completeness of individual documents.
Section 154(b)(2) of the MIPPA added a new paragraph (C) to section 1847 (b)(3) of the Act. This new paragraph requires contract suppliers to disclose information on: (1) Each subcontracting arrangement the supplier has in furnishing items and services under the contract; and (2) whether each such subcontractor meets the accreditation requirement of section 1834(a)(20)(F)(i) of the Act, if applicable to such subcontractor. The contract supplier must make this disclosure not later than 10 days after the date a supplier enters into a contract with CMS. If the contract supplier subsequently enters into a subcontracting relationship, the supplier must disclose this information to CMS no later than 10 days after entering into the subcontracting relationship.
Section 154(b) of the MIPPA added section 1834(a)(20)(F)(i) to the Act, which mandates that the Secretary require suppliers furnishing items and services under a competitive bidding program on or after October 1, 2009, directly or as a subcontractor for another entity, to submit evidence of accreditation by a CMS-designated accreditation organization. Both contract suppliers and their subcontractors that furnish items and services under the competitive bidding program must do so in accordance with the applicable supplier standards found in Part 424, subpart D and other Federal regulations.
We have amended § 414.422, by revising paragraph (f) to set forth these requirements for disclosing subcontracting arrangements. We have also addressed subcontracting relationships and the method for disclosure of the subcontracting relationships in subregulatory guidance.
Comment: Some commenters stated that subcontracting relationships should not be allowed after contract suppliers have been selected. Commenters believed that companies that did not win a contract would contact the contract supplier and form an arrangement in which the contract supplier would bill for an item furnished by a non-contract supplier. Several commenters also mentioned that adding subcontractors after contract suppliers have been selected could mean that the contract suppliers are not Start Printed Page 70295able to furnish items to beneficiaries in the CBA and that they need subcontractors to provide items for the contract supplier.
Response: The MIPPA specifically indicates that contract suppliers must disclose subcontracting relationships they establish after contract award; therefore, we do not have discretion to prohibit subcontracting after contract suppliers have been selected. Under the competitive bidding program, contract suppliers are permitted to subcontract under the same rules that apply to all DMEPOS suppliers. Thus, the extent to which contract suppliers subcontract is not a valid measure of contract suppliers' ability to furnish items.
We note that we have implemented a robust monitoring program to track and resolve any issues that might occur with program implementation and have not identified any concerns about contract suppliers' ability to furnish items. To date, the data show that Round 1 rebid implementation is going very smoothly with very few inquiries or complaints. For example, the competitive bidding call volume at the 1-800-MEDICARE call center for the first calendar quarter of 2011was less than 0.9 percent of 1-800-MEDICARE's total call volume. Most inquiries were about routine matters like selecting a contract supplier. Also, no changes in beneficiary health outcomes resulting from the competitive bidding program have been observed to date. The monitoring program includes:
Local, on-the-ground presence in each competitive bidding area through the CMS regional offices and local ombudsmen;
A complaint process for beneficiaries, caregivers, providers and suppliers to use for reporting concerns about contract suppliers or other competitive bidding implementation issues;
Contract supplier quarterly reports identifying the brands of products they furnish;
Real-time claims analysis to identify utilization trends, monitor health outcomes and beneficiary access, address aberrancies in services, and target potential fraud and abuse;
A CMS Competitive Acquisition Ombudsman who will respond to complaints and inquiries from beneficiaries and suppliers about the application of the program and will issue an annual Report to Congress;
Secret shopping; and
Beneficiary surveys.
Comment: Some commenters recommended that CMS obtain and verify disclosures of both accreditation and licensing status of contract suppliers and subcontractors prior to awarding contracts.
Response: Regulations at § 414.414 specify that suppliers must be licensed and accredited to be selected for contract award. We carefully check all bidders during bid evaluation and reject any bidders that are not fully licensed and accredited. As specified by MIPPA, contract suppliers must disclose any subcontractors within set time frames after contract award; disclosures must indicate if the subcontractors meet applicable accreditation requirements. We check all subcontractor disclosures and verify that all applicable accreditation requirements have been met. If we find that a contract supplier has subcontracted with an entity that does not meet applicable accreditation requirements, we will take appropriate action to ensure that the contract supplier stops using the subcontractor until the subcontractor becomes properly accredited. Although MIPPA does not require specific disclosure of subcontractors' licensure status, contract suppliers, like all suppliers, must comply with all State regulatory and licensure requirements (see § 424.57(c)(1)((ii)). This would include any State regulatory requirements regarding applicable subcontractor licensure.
Comment: Many commenters wanted CMS to clarify what is considered to be a subcontracting relationship between the contract supplier and a subcontractor with respect to accreditation. One commenter wanted CMS to provide the industry with a framework for entering into subcontracts.
Response: Contract suppliers may subcontract to the same extent as any other DMEPOS suppliers. The supplier standards at § 424.57 set forth requirements regarding subcontracting arrangements for purchase of inventory, delivery and instruction on the use of Medicare-covered items, and maintenance and repair of rented equipment. The quality standards are a helpful reference tool in distinguishing the role of a primary supplier versus the role of a subcontractor as described in the supplier standards. We note that guidance about subcontracting, including guidance about accreditation of subcontractors, may be found on the National Supplier Clearinghouse Web site, http://www.palmettogba.com/nsc and the Competitive Bidding Implementation Contractor Web site at http://www.dmecompetitivebid.com.
Comment: One commenter believed that the accreditation status of a subcontractor is irrelevant to the contract supplier's relationship with the subcontractor. One commenter did not believe that disclosing the subcontractor was a part of the MIPPA statute.
Response: MIPPA sections 154(b)(1) and (2) explicitly require subcontractors to meet applicable accreditation requirements and require contract suppliers to disclose their subcontracting arrangements within specific time frames. We do not have the authority to eliminate this requirement.
Section 414.404(b) previously exempted from competitive bidding certain DME items when furnished by a physician or treating practitioner to his or her own patients as part of his or her professional services. This exception is limited to crutches, canes, walkers, folding manual wheelchairs, blood glucose monitors, and infusion pumps that are considered DME. Section 154(d) of MIPPA amended section 1847(a) of the Act to exclude from the competitive bidding program these same items when they are furnished by hospitals to the hospital's own patients during an admission or on the date of discharge. We interpreted this exclusion to include only DMEPOS paid for under Part B of the Medicare program because section 1847 does not apply to items that are paid for under Part A. As discussed in the April 10, 2007 final rule, in accordance with § 414.404(b)(3) payment for items furnished under the exceptions in § 414.404(b) will be made in accordance with § 414.408(a).
We have revised § 414.402 to include a definition for hospitals and have revised § 414.404(b)(1) to incorporate the mandated exemption from the competitive bidding program for hospitals that furnish certain types of competitively bid DME to their own patients during an admission or on the date of discharge. In addition, we amended subparagraph (b)(1)(iii) to address the billing requirements for hospitals under this exemption.
Comment: Some commenters expressed concern that the MIPPA hospital exemption was not more expansive. Several commenters suggested that CMS reconsider including hospital-based suppliers in the competitive bidding program. One commenter suggested that although there is a hospital exemption, hospitals may have trouble finding DME equipment, such as oxygen, for snowbird beneficiaries. A few commenters believed that quality of care and efficient operations of hospitals Start Printed Page 70296would be impacted if they were allowed to furnish some items directly to their patients while having to arrange with contract suppliers for furnishing other items not covered by the exemption. One commenter suggested that a separate competitive bidding process should be established for hospital-based DME suppliers.
Response: Section 154(d) of MIPPA explicitly described the scope of the hospital exemption, so we do not believe we have discretion to provide a broader exemption. We do not believe that separate competitions for suppliers that only furnish items to patients in hospitals is necessary or would result in efficient implementation of the requirements of section 1847 of the Act.
Section 1847(a)(2) of the Act defines the items and services subject to competitive bidding. Section 1847(a)(2)(A) of the Act includes DME and supplies as items and services subject to competitive bidding. Section 154(a) of the MIPPA amended this definition to exclude group 3 complex rehabilitative power wheelchairs (and related accessories when furnished in connection with such wheelchairs) from competitive bidding. For Medicare coding, coverage, and payment purposes, power wheelchairs are classified under several groups based on performance and durability test results, patient weight capacity, and equipment handling capabilities. For a description of the components, performance requirements and coding guidelines for group 3 power wheelchairs, see https://www.dmepdac.com/resources/articles/2006/08_14_06.pdf. Group 2 complex rehabilitative power wheelchairs were included in Round 1 rebid of the competitive bidding program because they were not excluded by the MIPPA.
We amended § 414.402 to revise the definition of “item” to exclude group 3 complex rehabilitative wheelchairs from the competitive bidding program.
Comment: One commenter agreed that the exclusion was good policy because the equipment needs to be properly designed or it would result in additional costs for the government. Another commenter believed that the exclusion should not be implemented because having some power wheelchair equipment options subject to competitive bidding while others are not would promote Medicare fraud.
Response: The statute explicitly excludes Group 3 complex rehabilitative power wheelchairs from the competitive bidding program, and therefore, we do not believe we have any discretion to include these items in the program.
Comment: Some commenters suggest that Group 2 complex rehabilitative power wheelchairs be excluded from the competitive bidding program for several reasons. One commenter suggested that, if the Group 2 complex rehabilitative power wheelchairs are not excluded, suppliers should be able to bid above the fee schedule amount. Another commenter stated that the inclusion of Group 2 complex rehabilitative power wheelchairs in the Round 1 rebid is not envisioned by the statute; this commenter did not believe that this product category has the potential for significant savings.
Response: The MIPPA excludes Group 3 complex rehabilitative power wheelchairs from the competitive bidding program but also mandates rebidding of the “same items and services” as the previous Round 1. Therefore, we had no discretion to exclude 2 complex rehabilitative power wheelchairs from the Round 1 rebid because these wheelchairs were included in the Round 1 competition.
Section 1847(a)(1)(D)(i)(II) of the Act, as amended by section 154(a) of the MIPPA, required us to conduct the supplier competition for the Round 1 rebid in 2009. Pursuant to section 1847(a)(1)(D)(i)(II) of the Act, we conducted the competition for the Round 1 rebid in a manner “so that it occurs in 2009 with respect to the same items and services and the same areas” as the first Round 1 competition, except as provided by section 1847(a)(1)(D)(i)(III) and (IV) of the Act. Under section 1847(a)(1)(D)(i)(III), as amended by the MIPPA, we excluded Puerto Rico so that the Round 1 rebid of the competitive bidding program occurred in 9 of the largest MSAs. Therefore, the Round 1 rebid occurred in the following MSAs:
Cincinnati—Middletown (Ohio, Kentucky and Indiana)
Cleveland—Elyria—Mentor (Ohio)
Charlotte—Gastonia—Concord (North Carolina and South Carolina)
Dallas—Fort Worth—Arlington (Texas)
Kansas City (Missouri and Kansas)
Miami—Fort Lauderdale—Miami Beach (Florida)
Orlando (Florida)
Pittsburgh (Pennsylvania)
Riverside—San Bernardino—Ontario (California)
Section 154(a) of MIPPA mandated that we conduct the Round 1 “rebid” in the “same areas”—except for Puerto Rico—as the previous competition in 2007. As stated in the Federal Register (72 FR 18016), we identified CBAs in the 2007 Round 1 competition by counties and zip codes to clearly identify the boundaries of a CBA. Therefore, we believe it is reasonable to implement the “same areas” mandate by conducting the Round 1 rebid in those same zip codes. Certain zip codes changed since the first competition. We therefore reviewed zip code changes made since 2007 and incorporated applicable updates to the zip codes for the Round 1 rebid. For example, if a particular zip code had been split into two new zip codes, we included the new zip codes in the CBA. We did not add any new zip codes that expanded the geographic area of the CBAs.
Accordingly, we have amended § 414.410(a)(1) to reflect the areas for competition set forth in section 1847(a)(1) of the Act, as amended by the MIPPA.
Comment: Several commenters recommended various changes to the areas for the Round 1 rebid competition. For example, several commenters suggested that a few MSAs have rural areas and should be excluded from the program to prevent patient access and quality issues. Some also felt that small suppliers would not be able to provide items to the rural parts of the MSAs, especially with lower reimbursements. One commenter suggested that the Dallas MSA is too large and should be split into two separate CBAs. One commenter recommended that CBAs should be limited to large cities and not divided at a county level. One commenter suggested that CMS choose different MSAs for the Round 1 rebid competition because the original MSAs' suppliers have been affected financially from Round 1 and because the suppliers that bid in the first round know the single payment amounts that were selected for those areas and may cause bids to be skewed.
Response: MIPPA explicitly required the Round 1 rebid competition to occur in the same areas as in the initial Round 1 competition except for Puerto Rico, therefore we do not have any discretion to change the areas for the Round 1 rebid.Start Printed Page 70297
Section 1847(a)(1)(D)(i)(II) of the Act, as amended by the MIPPA, required that we conduct the Round 1 rebid competitive bidding program with respect to the “same items and services” as were previously bid in Round 1 except as provided in section 1847(a)(1)(D)(i)(IV) of the Act, which excludes negative pressure wound therapy. The Round 1 rebid also excludes group 3 complex rehabilitative power wheelchairs as noted previously. Therefore, the Round 1 rebid included the following categories of items and services:
Oxygen Supplies and Equipment.
Standard Power Wheelchairs, Scooters, and Related Accessories.
Complex Rehabilitative Power Wheelchairs and Related Accessories (Group 2).
Mail-Order Diabetic Supplies.
Enteral Nutrients, Equipment and Supplies.
Continuous Positive Airway Pressure (CPAP), Respiratory Assist Devices (RADs), and Related Supplies and Accessories.
Hospital Beds and Related Accessories.
Walkers and Related Accessories.
Support Surfaces (Group 2 mattresses and overlays) in Miami.
In the April 10, 2007 Federal Register (72 FR 18084), we define an item, in part, as a product included in a competitive bidding program that is identified by a HCPCS code.
Therefore, consistent with our understanding of the MIPPA and the mandate that bidding in the Round 1 rebid occur with respect to the “same items and services” as the previous round of competition, we conducted the competition for the Round 1 rebid for essentially the same codes for which we bid in 2007. We have made certain adjustments to reflect changes in the HCPCS codes consistent with 42 CFR 414.426. We excluded obsolete codes and codes which, in light of the MIPPA amendments, are no longer separately payable. For example, under the MIPPA, the transfer of title provision was deleted, thus oxygen accessories are no longer separately payable because the supplier maintains ownership of the equipment. The final list of HCPCS codes for the Round 1 rebid was published on the Competitive Bidding Implementation Contractor (CBIC) Web site at http://www.dmecompetitivebidcom. prior to opening of the bid window.
Comment: Some commenters suggested that several items should be excluded from competitive bidding for a variety of reasons.
Response: The MIPPA specifically required us to conduct the Round 1 rebid competitive bidding program for the “same items and services” as were previously bid in Round 1 except negative pressure wound therapy and group 3 complex rehabilitative power wheelchairs, and therefore, we had no discretion to exclude these items from the Round 1 rebid.
Comment: One commenter agreed with the statutory exclusion of negative pressure wound therapy (NPWT) for the Round 1 rebid and suggested that it be excluded entirely from competitive bidding.
Response: Although MIPPA excluded NPWT from the Round 1 rebid, it did not provide a permanent exclusion from the competitive bidding program. The statute mandates competitive bidding for most items of DME, including NPWT equipment and supplies. CMS has decided to utilize the flexibility provided by the statute to phase in items under the program beginning with high cost or high volume items. The average monthly rental fee schedule amount for the NPWT pump is currently $1,558, meaning the beneficiary pays at least $312 per month on average for rental of this device. By comparison, the average monthly fee and corresponding coinsurance amount for a respiratory suction pump is $46 (monthly fee) and $9 (monthly coinsurance). A study conducted in 2009 by the Office of Inspector General for the Department of Health and Human Services found that suppliers purchase these pumps for significantly less, $3,604 on average, than Medicare pays over 13 months, currently $16,359. The savings potential for the Medicare program and beneficiary for this item is therefore very significant. Medicare allowed charges for NPWT equipment and supplies were approximately $178 million in 2010, making this a high volume and high cost item as well.
We note that section 154 (c) (3) of MIPPA required the Secretary of the Department of Health and Human Services (DHHS) to perform an evaluation of the Healthcare Common Procedure Coding System (HCPCS) coding decisions for NPWT devices. CMS requested this report from The Technology Assessment Program (TAP) at the Agency for Healthcare Research and Quality (AHRQ). AHRQ determined that there are no significant therapeutic distinctions among NPWT devices. Because there are no significant differences among NPWT products, the current HCPCS codes are adequate and do not need to be updated or changed. The study results are available on the AHRQ Web site at: http://www.ahrq.gov/clinic/ta/negpresswtd/npwtd01.htm.
We ordinarily publish a notice of proposed rulemaking in the Federal Register to provide for public comment before the provisions of a rule take effect in accordance with section 553(b) of the Administrative Procedure Act (APA) and section 1871 of the Act. This process may be waived, however, if an agency finds good cause that a notice and comment procedure is impracticable, unnecessary, or contrary to the public interest. We found good cause to waive notice and comment rulemaking because we simply conformed the competitive bidding regulations to specific, detailed, and proscriptive statutory provisions.
The comments we received on the waiver of proposed rulemaking and our responses are set forth below.
Comment: Several commenters believed that CMS should have engaged in notice and comment rulemaking to implement MIPPA provisions rather than issuing an interim final rule with comment period for several reasons. One reason was so that stakeholders would have sufficient time and opportunity to give input on the program. The second reason was because commenters wanted to ensure that comments received during the comment period would be taken into account before any final rule was published. The third reason commenters wanted CMS to conduct a notice and comment rulemaking was because commenters felt that important issues were left unaddressed in the interim final rule such as how the program would be impacted by the changes that were made by MIPPA, lessons learned from Round 1, and supplier and beneficiary concerns and suggestions from Round 1. Commenters felt that CMS should address major issues in notice and comment rulemaking instead of using of subregulatory guidance and Web site postings.
Response: As we explained in the interim final rule, under the waiver of proposed rulemaking, we ordinarily publish a notice of proposed rulemaking to provide for public comment before provisions of a rule take effect, but the Start Printed Page 70298process may be waived if the agency finds good cause that a notice and comment procedure is impracticable, unnecessary, or contrary to public interest. Because CMS issued the rule to conform to the specific statutory requirements contained in section 154 of the MIPPA it was impractical, unnecessary, and contrary to public interest to use notice and comment rulemaking to incorporate these provisions into regulations. As indicated earlier in this preamble, we also made process improvements to ensure compliance with the statute that did not require notice and comment rulemaking before we conducted the Round 1 rebid. Finally, we agree that substantive issues should be addressed through notice and comment rulemaking consistent with the Administrative Procedure Act and note that we used notice and comment rulemaking to implement non-self-implementing provisions of MIPPA (see 75 FR 73170 (November 29, 2010).
Comment: A few commenters disagreed with the statement in the interim final rule that MIPPA “did not alter fundamental requirements * * * used by us in * * * selecting suppliers under the program”. Some of the commenters believed that the interim final rule is not self-implementing and was not clear or understandable.
Response: We continue to believe as discussed in the interim final rule that the provisions of MIPPA included in the interim final rule were self-implementing. The language in these provisions was highly detailed and proscriptive and did not provide options for discretionary revisions.
Under the Paperwork Reduction Act of 1995, we are required to provide 60-day notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection burden.
The quality, utility, and clarity of the information to be collected.
Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.
Because we did not receive any comments for the ESRD PPS, we are finalizing the collection of information section as proposed.
We solicited public comment on the issues below for the following sections of this document that contain information collection requirements (ICRs):
As discussed in section I.B.3 of this final rule, to receive the low-volume adjustment, an ESRD facility would need to provide an attestation to their Fiscal Intermediary or Medicare Administrative Contractor (FI/MAC) that it has met the criteria to qualify as a low-volume facility no later than November 1st of each year preceding the applicable low-volume adjustment payment year (except for the 2012 low-volume payment year, which has an attestation submission deadline of January 3, 2012). The FI/MAC would verify the ESRD facility's attestation of their low-volume status for the 3-consecutive years immediately preceding the payment year, using the ESRD facility's most recent final-settled or as-filed 12-month cost reports.
The burden associated with the requirement is the time and effort necessary for an ESRD facility attesting as a low-volume facility to develop an attestation and submit it to their FI/MAC. In the proposed rule, we estimated that it would require an administrative staff member from each low-volume facility 10 minutes to obtain the total number of treatments in the cost reports necessary for eligibility determination, develop the attestation, and submit it to their FI/MAC. For this final rule, using 2010 claims our contractor, UM-KECC, identified 963 ESRD facilities as providing treatments below the low-volume threshold of 4,000 treatments in 2010. Of these 963 facilities, we estimated that 378 met the additional low-volume criteria as specified in § 413.232. Further, due to the historical trend of increase in the number of small dialysis facilities, we believe that several dozen additional ESRD facilities may meet the criteria of a low-volume facility prior to the CY 2012 payment year. To take these facilities into account, we have rounded the total number of estimated low-volume facilities to 400. Therefore, for CY 2012, we estimate that the total initial ESRD facility burden would be 67 hours. The estimated cost associated with compliance with this requirement is $2.61 per ESRD facility and a total of $1,044 for all 400 facilities. These costs are estimated using the 2010 estimate for the occupational code 43-0000 Office and Administrative Support Occupation mean hourly wage of $15.66 as stated by the U.S. Bureau of Labor Statistics.
This final rule imposes collection of information requirements as outlined in the regulation text and specified above. However, this final rule also makes reference to several associated information collections that are not discussed in the regulation text contained in this document. The following is a discussion of these information collections, some of which have already received OMB approval.
Section II.B of this rule discusses a disclosure requirement for both the PY 2013 and the PY 2014 ESRD QIP. As stated earlier in this final rule, section 1881(h)(6)(C) of the Act requires the Secretary to provide certificates to dialysis care providers and facilities about their total performance scores under the ESRD QIP. This section also requires each provider and facility that receives a QIP certificate to display it prominently in patient areas.
To comply with this requirement, we proposed to issue a PY 2013 and PY 2014 ESRD QIP certificate to providers and facilities via a generally accessible electronic file format. We proposed that each provider and facility would be required to prominently display the applicable ESRD QIP certificate in patient areas. In addition, we proposed that each provider and facility would take the necessary measures to ensure the security of the certificate in the patient areas. Finally, we proposed that each provider/facility would be required to have staff available to answer questions about the certificate in an understandable manner, taking into account that some patients might have limited English proficiency. These proposals represent no change from the policy finalized for the PY 2012 ESRD QIP, and we are finalizing them in this final rule.
The burden associated with the aforementioned requirements is the time and effort necessary for providers and facilities to print the applicable ESRD QIP certificate, display the certificate prominently in patient areas, ensure the safety of the certificate, and respond to patient inquiries in reference to the certificates. We estimate that Start Printed Page 70299approximately 5,503 providers and facilities will receive an ESRD QIP certificate in PY 2013 and PY 2014 and will be required to display it. We also estimate that it will take each provider/facility 10 minutes per year to print, prominently display, and secure the ESRD QIP certificate, for a total estimated annual burden of 917 hours [(10/60) hours × 5503 facilities] at a cost of $31, 755 [917 hours × $34.63 per hour]. We estimate that approximately one-third of ESRD patients (estimated to be 119,686 out of 395,058) will ask a question about the ESRD QIP certificate. We further estimate that it will take each provider/facility approximately 5 minutes to answer each patient question about the applicable ESRD QIP certificate, or 1.8 hours per provider or facility each year. The total estimated annual burden associated with this requirement is 9,905 hours [1.8 hours × 5503 providers]. The total estimated annual burden for both displaying the ESRD QIP certificates and answering patient questions about the certificates is 10,822 hours [10,822 hours + 9,905 hours] (for each of PY 2013 and PY 2014). While the total estimated annual burden associated with both of these requirements as discussed is 10,822 hours, we do not believe that there will be a significant cost associated with these requirements because we are not proposing to require providers/facilities to complete new forms. As discussed in section A.1.3 of this final rule, we estimate that the total cost for all ESRD providers/facilities to comply with the collection of information requirements associated with the certificate each year would be less than $400,000.
We did not receive any public comments regarding our analysis of the economic impact of the collection of information requirement for this proposal.
As stated above in section II.B.2.b.vi of this final rule, we are finalizing a proposal to include reporting dialysis events to the National Healthcare Safety Network (NHSN) as a reporting measure for the PY 2014 ESRD QIP. Specifically, we are requiring providers/facilities to: (1) Enroll in the NHSN and complete required training as verified by a digital certificate obtained from CDC; and (2) submit at least 3-consecutive months of dialysis event data to the NHSN.
The burden associated with these requirements is the time and effort necessary for providers and facilities to enroll in the NHSN and conduct the required training and submit 3 months of data. We estimated in the proposed rule that approximately 5,503 providers and facilities will enroll in the NHSN and submit the necessary data. We also estimated that it would take each provider or facility 48 hours per year to enroll in the NHSN and complete the required training, for a total estimated annual burden of 264,144 hours [5,503 providers × 48 hours]. Upon further consultation with the CDC, we have now revised this estimate. We now believe that it will take each provider/facility approximately 8 hours to enroll in the NHSN and complete the required training, for a total estimated burden of 44,024 hours (8 hours × 5,503 facilities). Based on the Bureau of Labor Statistics we estimate the average salary to be $34.63 per hour. Thus, average cost for each provider/facility will be $277.04 (8 hours × $34.63 per hour). Across all 5,503 providers/facilities, this will equal approximately $1.5 million ($277.04 × 5,503 facilities). However, we further estimate that the number of dialysis events in a 3-month period will be 125,680 for the 2014 ESRD population. We estimate it will require 2 hours of staff time per month to collect and submit data on these events and the estimated burden for submitting 3 months of data will be 33,018 hours (6 hours times 5,503 facilities). If the dialysis events are distributed evenly across all 5,503 providers/facilities, that will result in an additional 6-hour burden ($218.58 (6 hours times $36.43)) for each provider/facility. Based upon our updated analysis, the total estimated annual burden for enrolling in the NHSN, conducting the required training, and submitting 3-consecutive months of data is 77,042 hours (44,024 + 33,018). We estimate that the total cost for all ESRD providers/facilities to comply with the collection of information requirements associated with NHSN reporting requirement each year will be less than $2.8 million (77,042 × $36.43), with the total average cost per provider/facility approximately $508.80 ($2.8 million/5,503 facilities).
We did not receive any public comments regarding our proposed analysis of the economic impact of the collection of information requirements related to the adoption of an NHSN reporting measure for the PY 2014 ESRD QIP.
As stated above in section B.A.2. of this final rule, we are finalizing our proposal to include a measure that assesses provider/facility usage of the In-Center Hemodialysis (ICH) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey as a reporting measure for the PY 2014 ESRD QIP. The burden associated with this requirement is the time and effort necessary for providers and facilities to administer the ICH CAHPS survey and submit an attestation to CMS that they successfully administered the survey.
We estimate that approximately 5,503 providers and facilities will administer the ICH CAHPS survey and submit an attestation to that affect. We estimate that it will take each provider or facility 16 hours per year to be trained on the survey features. We further estimate that it will take each provider/facility approximately 5 minutes to submit the attestation each year. The estimated total annual burden on providers/facilities is estimated to be 88,507 hours [(5,503 providers × 16 hours) + (5,503 providers × (5/60) hours)] which is valued at $3 million [88,507 hours × $34.63 per hour], or $556.97 per provider/facility [$3 million/5,503 providers]. We estimate that administering the survey would take a third-party entity 45 minutes per patient (to account for variability in education levels) and 200 surveys per year which equals 150 hours [(45/60) hours × 200 surveys] or $2,707.32 [150 hours × $17.58 per hour] per facility-year to administer the ICH CAHPS survey for an estimated annual burden of 825,450 hours (150 hours × 5,503 providers) which is valued at $14.5 million ($2,637.00 × 5,503 providers). As discussed in section A. of this final rule, we estimate that the total cost for ESRD providers/facilities to comply with the collection of information requirements associated with administering the ICH CAHPS survey each year will be approximately $3,193.97 [$556.97 + $2,637.00] or $17.5 million [$3 million + $14.5 million] across all ESRD providers/facilities.
We did not receive any public comments regarding the proposed collection of information requirements associated with our adoption of this measure for the PY 2014 ESRD QIP.
As stated above in section B.A.2 of this final rule, we are finalizing our proposal to include a Mineral Metabolism reporting measure as part of the PY 2014 ESRD QIP. The burden associated with this requirement is the time and effort necessary for providers and facilities to review their records and submit an attestation to CMS that they had monitored on a monthly basis the serum calcium and serum phosphorus levels of all patients each month.
We estimate that approximately 5,503 providers and facilities will submit the Start Printed Page 70300attestation. We estimate that it will take each provider or facility approximately 18 hours to review its records and submit the attestation each year. The estimated total annual burden on providers/facilities is estimated to be 99,054 hours [18 hours × 5,503 providers] which is valued at $3.43 million [99,054 hours × $34.63 per hour], or $623 per provider/facility [$3.43 million/5,503 providers].
We did not receive any public comments regarding our proposed collection of information requirements associated with the adoption of a mineral metabolism reporting measure for the PY 2014 ESRD QIP.
We solicited public comment on the following information collection requirements (ICRs):
We previously estimated that the burden associated with Round 1 would be 1,086,164 hours (68 hours × 15,973 bids). Our estimate was that on average it would take a supplier 68 hours to complete and submit a bid and that we would receive 15,973 bids. Although we expect the amount of hours to generally remain the same (68 hours) for the Round 1 rebid, based on our Round 1 experience we anticipated fewer bids. For the 2007 Round 1 of the competitive bidding program, we received approximately 6,500 bids. Therefore, the total estimated burden associated with the Round 1 rebid was approximately 442,000 hours (68 hours × 6,500).
Section 414.422(f) states that suppliers entering into a contract with CMS must disclose information on each subcontracting arrangement that the supplier has to furnish items and services under the contract and whether each subcontractor meets the accreditation requirements in section 424.57, if applicable. Section 414.422(f) also requires that the required disclosure be made no later than 10 days after the date a supplier enters into a contract with CMS or 10 days after a supplier enters into a subcontracting arrangement after entering into a contract with CMS.
The burden associated with the requirements in § 414.422(f) is the time and effort necessary to disclose the information to CMS. In the 2007 Round 1 competition, there were 329 winning suppliers. Therefore, we approximated fewer than 400 winning suppliers for the Round 1 rebid. Also, we estimated it will take each of the winning suppliers that use subcontractors on average approximately 1.5 hours to submit information on each subcontracting arrangement to furnish items and services under the contract and whether each subcontractor meets the accreditation requirements in § 424.57, if applicable. Those that do not use subcontractors will not have a reporting burden. The total estimated burden associated with these requirements is approximately 600 hours (1.5 hours × 400 winning suppliers).
We did not receive any comments on the information collection requirements of the interim final rule. We sought comments on these information collection requirements again in the May 19, 2009 Federal Register (74 FR 23415), and the Office of Management and Budget (OMB) approved the collection (OMB Control Number 0938-1016).
We examined the impacts of this final rule as required by Executive Orders 12866 (September 30, 1993, Regulatory Planning and Review) and Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011). Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). Executive Order 13563 emphasizes the importance of quantifying both costs and benefits, of reducing costs, of harmonizing rules, and of promoting flexibility. This rule has been designated an “economically” significant rule, under section 3(f)(1) of Executive Order 12866. Accordingly, the rule has been reviewed by the Office of Management and Budget. We have prepared a Regulatory Impact Analysis that to the best of our ability presents the costs and benefits of the final rule. We solicited comments on the regulatory impact analysis provided.
This rule finalizes a number of routine updates for renal dialysis services in CY 2012, implementing the second year of the transition, and makes several policy and technical changes to the CY 2011 ESRD PPS final rule. This includes updates to the ESRD PPS and composite rate base rates, wage index values, wage index budget-neutrality adjustment factors, outlier payment policy, low-volume adjustment and transition budget-neutrality adjustment. Failure to publish this final rule would result in ESRD facilities not receiving appropriate payments in CY 2012.
In addition, this rule will implement a QIP for Medicare ESRD dialysis providers and facilities with payment reductions beginning January 1, 2013. Under section 1881(h) of the Act, after selecting measures, establishing performance standards that apply to each of the measures, specifying a performance period, and developing a methodology for assessing the total performance of each provider and facility based on the specified performance standards, the Secretary is required to apply an appropriate reduction to ESRD providers and facilities that do not meet or exceed the established total performance score. Our vision is to continue to implement a robust, comprehensive ESRD QIP that builds on the foundation that has already been established in providing incentives to providers/facilities to improve the quality of care they provide to Medicare beneficiaries.
Also, this final rule will revise the ambulance fee schedule regulations to conform to the requirements of section 106 of the Medicare and Medicaid Extenders Act of 2010 Public Law 111-309 (MMEA). This final rule also revises the definition of durable medical equipment. The revision adds a 3-year MLR that must be met by an item or device in order to be considered durable for the purpose of classifying the item under the Medicare benefit category for DME. The proposed rule would not impact items classified and covered as DME before the new rule takes effect or supplies and accessories used with covered DME. Finally, this final rule incorporates into regulations certain self-implementing provisions of section 154 of MIPPA that affect the DMEPOS Competitive Bidding Program.
We estimate that the final revisions to the ESRD PPS will result in an increase of approximately $240 million in payments to ESRD facilities in CY 2012. Furthermore, as a result of implementing the ESRD QIP for Medicare outpatient ESRD dialysis providers and facilities, we estimate aggregate payment reductions in payment years 2013 and 2014 would be $23.7 million and $22.1 million, Start Printed Page 70301respectively. However, given the lack of data for several measures, the actual impact of the PY 2014 ESRD QIP may vary significantly from the values provided herein. Lastly, the aggregate costs associated with the QIP collection of information requirements described in section III.1 of this final rule (Display of Certificates for the 2013 ESRD QIP) are estimated to be $400,000 for all ESRD providers/facilities in PY 2013. The additional estimated aggregate costs associated with the collection of information requirements described in sections III.1. (Display of Certificates for the PY 2013 and PY 2014 ESRD QIP), III.2 (NHSN Reporting Requirement for the PY 2014 ESRD QIP), III.3 (Patient Experience Survey Usage Requirement for the PY 2014 ESRD QIP) and III.4 (Mineral Metabolism Reporting Requirement for the PY 2014 ESRD QIP) in this final rule are expected to be approximately less than $24 million for all participating ESRD facilities.
The impact of section 106 of the MMEA, requiring the extension of certain add-on payments for ground ambulance services, and the extension of certain rural area designations for purposes of air ambulance payment, through CY 2011, is estimated to be $20 million (for CY 2011).
The fiscal impact of the proposed 3-year MLR cannot be estimated because it is difficult to predict how many different types of devices will be introduced in the market in the future that may or may not qualify as DME items as a result of the new rule. We would expect that this final rule would have a small, if any, savings impact on the program.
Finally, we believe that the changes to the Medicare DMEPOS Competitive Bidding Program have a minimal fiscal impact because they are very limited and do not change fundamental program requirements.
As explained in the proposed rule (76 FR 40542), to understand the impact of the changes affecting payments to different categories of ESRD facilities, it is necessary to compare estimated payments (that is, payments made under the 100 percent ESRD PPS and those under the blended payment during the transition) in CY 2012 to estimated payments (that is, payments made under the 100 percent ESRD PPS and those under the ESRD PPS blended payment during the transition) in CY 2011. To estimate the impact among various classes of ESRD facilities, it is imperative that the estimates of payments in CY 2011 and CY 2012 contain similar inputs. Therefore, we simulated payments only for those ESRD facilities that we are able to calculate both current payments and new payments.
For this final rule, we used the June 2011 update of CY 2010 National Claims History file as a basis for Medicare dialysis treatments and payments under the ESRD PPS. We updated the 2010 claims to 2011 and 2012 using various updates. The updates to the ESRD PPS base rate and the base composite rate portion of the blended rate during the transition are described in section I.B of this final rule. In addition, in order to prepare an impact analysis, since some providers opted to be paid the blended payment amount during the transition, we made various assumptions about price growth for the formerly separately billable drugs and laboratory tests with regard to the composite portion of the ESRD PPS blended payment during the transition. These rates of price growth are briefly outlined below, and are described in more detail in the CY 2011 ESRD PPS final rule (75 FR 49078 through 49080).
We used the CY 2010 amounts for the CY 2011 and CY 2012 amounts for Supplies and Other Services, since this category primarily includes the $0.50 administration fee for separately billable part B drugs and this fee is not increased; thus we used no price update. Because some ESRD facilities will receive blended payments during the transition and receive payment for ESRD drugs and biologicals based on their average sales price plus 6 percent (ASP+6), we estimated price growth for these drugs and biologicals based on ASP+6 percent. We updated the last available quarter of actual ASP data for the top twelve drugs (the fourth quarter of 2011) thru 2012 by using the quarterly growth in the Producer Price Index (PPI) for Drugs, consistent with the method for addressing price growth in the ESRDB market basket. This resulted in 1.7 percent, 1.4 percent, 1.1 percent, and 0.8 percent increase, respectively, for the first thru the fourth quarter of 2012. Since the top twelve drugs account for over 99 percent of total former separately billable Part B drug payments, we used a weighted average growth of the top twelve drugs, for the remainder. Table 7 below shows the updates used for the drugs.
We updated payments for laboratory tests paid under the laboratory fee schedule to 2011 and 2012 using the statutory required update of the CPI-U increase with any legislative adjustments. For this final rule, the growth from 2010 to 2011 is −1.8 percent and the growth from 2010 to 2012 is −1.2 percent.
Table 8 shows the impact of the estimated CY 2012 ESRD payments compared to estimated payments to ESRD facilities in CY 2011.
Column A of the impact table indicates the number of ESRD facilities for each impact category and column B indicates the number of dialysis treatments (in millions). The overall effect of the final changes to outlier payment policy and the final changes for the BSA national average described in section I.C.10 and section .I.C.9, respectively, of this final rule, are shown in column C. For CY 2012, the impact on all facilities as a result of the changes to outlier payment policy and the BSA national average would be a 0.3 percent increase in estimated payments. The estimated impact of the changes to outlier payment policy and the BSA national average ranges from −0.1 percent decrease to a 0.5 percent increase. Most ESRD facilities are anticipated to experience a positive effect in their estimated CY 2012 payments as a result of the outlier policy and BSA national average changes being finalized.
Column D shows the effect of the wage index on ESRD facilities and reflects the CY 2012 wage index values for the composite rate portion of the blended payment during the transition and the ESRD PPS payments. Facilities located in the census region of Puerto Rico and the Virgin Islands would receive a 2.4 percent decrease in estimated payments in CY 2012. Since most of the facilities in this category are located in Puerto Rico, the decrease is primarily due to the reduction in the wage index floor (which only affects facilities in Puerto Rico in CY 2012). Renal dialysis facilities outside of Puerto Rico would experience changes in estimated payments ranging from a 0.4 percent decrease to a 0.9 percent increase due to the update of the wage index.
Column E reflects the overall impact (that is the effects of the outlier policy and BSA national average changes, the wage index, the effect of the ESRDB market basket increase minus productivity adjustment, and the effect of the change in the blended payment percentage from 75 percent of payments based on the composite rate system and 25 percent based on the ESRD PPS in 2011, to 50/50, respectively, for 2012, for those facilities that opted to be paid under the transition). We expect that overall, ESRD facilities will experience a 2.5 percent increase in estimated payments in 2012. ESRD facilities in Puerto Rico are expected to receive a 0.3 percent increase in their estimated payments in CY 2012. This negligible increase is primarily due to the negative impact of the wage index. The remainder of ESRD facilities are expected to be positively impacted ranging from an increase of 1.7 percent to 3.6 percent in their 2012 estimated payments.
Under the ESRD PPS, ESRD facilities are paid directly for the renal dialysis bundle and other provider types such as laboratories, DME suppliers, and pharmacies, may no longer bill Medicare directly for renal dialysis services. Rather, effective January, 1, 2011, such other providers can only furnish renal dialysis services under arrangements with ESRD facilities and must seek payment from ESRD facilities rather than Medicare. Under the ESRD PPS, Medicare pays ESRD facilities one payment for renal dialysis services, which may have been separately paid to suppliers by Medicare prior to the implementation of the ESRD PPS. Therefore, in CY 2012, the second year of the ESRD PPS, we estimate that the ESRD PPS will have zero impact on these other providers.
We estimate that Medicare spending (total Medicare program payments) for ESRD facilities in 2012 will be approximately $8.2 billion. This estimate is based on various price update factors discussed in section VII.B in this final rule. In addition, we estimate that there will be an increase in fee-for-service Medicare beneficiary enrollment of 4.3 percent in CY 2012.
Under the ESRD PPS, beneficiaries are responsible for paying 20 percent of the ESRD PPS payment amount or blended payment amount for patients treated in facilities going through the ESRD PPS transition. As a result of the projected 2.5 percent overall increase in the ESRD PPS payment amounts in CY 2012, we estimate that there will be an increase in beneficiary co-insurance payments of 2.5 percent in CY 2012, which translates to approximately $50 million.
As we explained in the proposed rule (76 FR 40544), we considered eliminating all laboratory tests from the outlier policy, but instead we proposed to eliminate only the Automated Multi-Channel Chemistry (AMCC) panel tests. We indicated that we believed this approach would continue to recognize expensive laboratory tests in the outlier policy while reducing the burden associated with the 50 percent rule. We also considered alternatives for applying the wage index budget-neutrality adjustment factor under the ESRD PPS for purposes of the full ESRD PPS payments and ESRD PPS portion of the blended payment during the transition, such as applying the wage index budget-neutrality adjustment factor to the ESRD PPS wage index values. We chose to apply the wage index budget-neutrality adjustment factor to the ESRD PPS base Start Printed Page 70305rate and ESRD PPS portions of the transition blended payment to be consistent with how these adjustments are applied in other Medicare payment systems. Finally, we considered retaining the current BSA adjustment under the composite rate potion of the blended payment amount.
This final rule is intended to mitigate possible reductions in the quality of ESRD dialysis facility services provided to beneficiaries as a result of payment changes under the ESRD PPS by implementing an ESRD QIP that would reduce ESRD payments by up to 2 percent to dialysis providers/facilities that fail to meet or exceed a Total Performance Score with respect to performance standards established by the Secretary with respect to certain specified measures.
The methodology that we are finalizing to determine a provider/facility's Total Performance Score is described in section IV.A.3 (Methodology for Calculating the Total Performance Score for the PY 2013 ESRD QIP) and section IV.A.2.e (Methodology for Calculating the Total Performance Score for the PY 2014 ESRD QIP) of this final rule. Any reductions in ESRD payment would begin on January 1, 2013 for services furnished on or after January 1, 2013 for the PY 2013 ESRD QIP and any reductions in ESRD payment would begin on January 1, 2014 for services furnished on or after January 1, 2014 for the PY 2014 ESRD QIP.
As a result, based on the ESRD QIP outlined in this final rule, we estimate that approximately 19 percent or 1,014 of total ESRD dialysis providers/facilities would likely receive a payment reduction for PY 2013. In PY 2014, we estimate that approximately 30.3 percent or 1,665 of total ESRD facilities would likely receive some type of payment reduction. We note that these estimates differ significantly from the estimates that were included in the proposed rule. We believe that the difference in our PY 2013 estimates is attributable to two changes. First, we determined that our previous estimates for PY 2013 had mistakenly included the Hemoglobin Less Than 10 g/dL measure, which resulted in lower provider/facility scores and greater payment reductions. Second, we are now able to update our PY 2013 estimates using newly available data, such that we are now using 2009 data as the baseline period and 2010 data as the performance period. We believe that the difference in our PY 2014 estimates is attributable to four changes that were made to how we calculated the estimate. First, as previously mentioned, we are now able to update our estimates using newly available data, such that we are now using 2009 data as the baseline period and 2010 data as the performance period. Second, our estimates no longer include performance on the proposed SHR measures, because we are not finalizing its inclusion in the PY 2014 program. Third, our estimate now uses data from the Fistula First Breakthrough Initiative to approximate provider/facility performance on the Vascular Access Type (VAT) measure proposed for the 2014 QIP. The 2014 QIP will use data from Medicare claims based on HCPCS modifier V-codes that indicate fistula or catheter use. Because sufficient historical data are not yet available from Medicare claims for the fistula and catheter rates that will be used to calculate the VAT, historical data regarding fistula and catheter use were obtained from the Fistula First Breakthrough Initiative dataset for use in this impact analysis. For more information on the Fistula First Dataset, please see http://www.fistulafirst.org.. Lastly, our estimates incorporate the changes to the proposed payment reduction methodology that have been finalized in this final rule.
The ESRD QIP impact assessment assumes an initial count of 5,596 dialysis providers/facilities with paid Medicare dialysis claims in 2010. The PPS analysis, presented earlier, excludes 93 facilities for PPS-specific reasons thereby narrowing the final analytic sample to 5,503. The most common reason for exclusion was that facilities closed during 2010. As a result, Table 9 shows the overall estimated distribution of payment reductions resulting from the PY 2013 ESRD QIP. Table 10 shows the overall estimated distribution of payment reductions resulting from the PY 2014 ESRD QIP.
To estimate the total payment reductions in PY 2013 and PY 2014 for each provider/facility resulting from this final rule, we multiplied the total Medicare payments to the facility in 2010 by the provider's/facility's estimated payment reduction percentage expected under the ESRD QIP, yielding a total payment reduction amount for each provider/facility: (Total ESRD payment in 2010 × estimated payment reduction percentage).
The PY 2014 payment reduction levels will include the 0.5 percent payment reduction level as an additional level within the payment reduction scale. We are finalizing new measures, a new scoring methodology, and rigorous performance standards which are not familiar to the community. We believe that including this additional payment reduction level will allow time for providers/facilities to become familiar with this new structure and for CMS to acquire additional data on the impact of these changes. The inclusion of the 0.5 percent payment reduction level creates a more gradual payment reduction scale, and therefore benefits providers by lessening the reduction impacts that would have been received under the original proposed scale.
For PY 2013, totaling all of the payment reductions for each of the 1,014 providers/facilities expected to receive a reduction leads to a total payment reduction of approximately $23.7 million. Further, we estimate that the total costs associated with the collection of information requirements described in section III.1, of this final rule (Display of Certificates for the PY 2013 ESRD QIP) would be less than $400,000 for all ESRD providers/facilities in PY 2013.
For PY 2014, totaling all of the payment reductions for each of the 1,665 facilities expected to receive a reduction leads to a total payment reduction of approximately $22.1 million. Further, we estimate that the total costs associated with the collection of information requirements described in sections III.1. (Display of Certificates for the PY 2013 and PY 2014 ESRD QIP), III.2 (NHSN Reporting Requirement for the PY 2014 ESRD QIP), III.3 (Patient Experience Survey Usage Reporting Requirement for the PY 2014 ESRD QIP) and III.4 (Mineral Metabolism Reporting Requirement for the PY 2014 ESRD QIP) of this final rule would be less than $25 million for all ESRD providers/facilities.
As a result, we estimate that ESRD providers/facilities will experience an aggregate impact of $24.1 million for PY 2013 and $47.1 million for PY 2014.
Table 11 below shows the estimated impact of the finalized ESRD QIP payment reductions to all ESRD facilities for PY 2013. The table details the distribution of ESRD providers/facilities by facility size (both among facilities considered to be small entities and by number of treatments per facility), geography (both urban/rural and by region), and by facility type (hospital based/freestanding facilities).
We note that for the PY 2014 ESRD QIP we lack performance data on the Vascular Access Type measure to conduct an analysis at this time. We conducted a simulation using the latest available performance data on the Hemoglobin Greater Than 12 g/dL measure, and the Dialysis Adequacy (URR) measure and fistula and catheter rates based on Fistula First data to estimate the impact of this final rule as accurately as possible. These simulated analyses were performed using 2010 claims data as the performance year and 2009 claims data as the baseline year for the Hemoglobin Greater Than 12g/dL measure and the Dialysis Adequacy Measure (URR).
Using these conditions, we calculated estimated national achievement threshold and benchmark values for the Hemoglobin Greater Than 12 g/dL, URR Hemodilaysis Adequacy, and VAT measures using all facilities present in the data set. Equal weighting was applied in calculating Total Performance Scores. Facilities were required to have data on at least one of the measures. Given the lack of data for the reporting measures, and the use of Fistula First data, the actual impact of the PY 2014 ESRD QIP may vary significantly from the values provided here.
Using the above assumptions, Table 12 below shows the estimated impact of the ESRD QIP payment reductions to all ESRD facilities for PY 2014. The table details the distribution of ESRD providers/facilities by facility size (both among facilities considered to be small entities and by number of treatments per facility), geography (both urban/rural and by region), and by facility type (hospital based/freestanding facilities).
In developing the final PY 2013 ESRD QIP, we carefully considered the size of the incentive to providers and facilities to provide high-quality care. We also selected the measures adopted for the PY 2013 ESRD QIP because these measures are important indicators of patient outcomes and quality of care. For example, inadequate dialysis can lead to avoidable hospitalizations, decreased quality of life, and death. Thus, we believe the measures selected will allow CMS to continue focusing on improving the quality of care that Medicare beneficiaries receive from ESRD dialysis providers and facilities.
Additionally, for PY 2013 we considered whether to leave the Hemoglobin Measure Less Than 10g/dL in the program. Ultimately we decided that the clinical evidence shows that this measure is not conducive to improving the patient quality of care for which the ESRD QIP strives. The ESA labeling approved by the FDA on June 24, 2011 states that no trial has identified a hemoglobin target level that does not increase risks, and that “in controlled trials, patients experienced greater risks for death, serious adverse cardiovascular reactions, and stroke when administered ESAs to target a hemoglobin level of greater than 11 g/dL.” We decided to retire the Hemoglobin Less Than 10g/dL measure from the program and are finalizing that proposal in this final rule.
This final rule implements an ESRD QIP for Medicare ESRD dialysis providers and facilities with payment reductions beginning January 1, 2013 and January 1, 2014. Under section 1881(h) of the Act, after selecting measures, establishing performance standards that apply to each of the measures, specifying a performance period, and developing a methodology for assessing the total performance of each provider and facility based on the specified performance standards, the Secretary is required to apply an appropriate reduction to ESRD providers and facilities that do not meet or exceed the established Total Performance Score. In developing the final ESRD QIP, we carefully considered the size of the incentive to providers and facilities to provide high-quality care. We also considered finalizing all of the measures proposed for the PY 2014 ESRD QIP because these measures are important indicators of patient outcomes and quality of care. Poor management of anemia and inadequate dialysis, for example, can lead to avoidable hospitalizations, decreased quality of life, and death. Infections are also a leading cause of death and hospitalization among hemodialysis patients, but there are proven infection control methods that have been shown effective in reducing morbidity and mortality. However, after considering public comments, we decided not to finalize all the measures we proposed. While we intend to adopt additional measures in future payment years, we believe that the measures finalized will allow us to continue focusing on improving the quality of care that Medicare beneficiaries receive from ESRD dialysis providers and facilities.
In finalizing the scoring methodology for the PY 2014 ESRD QIP, we considered a number of alternatives, including continuing to use the existing scoring model. In proposing to move to a new scoring approach for the PY 2014 ESRD QIP, we aimed to design a scoring methodology that was straightforward and transparent to providers/facilities, patients, and other stakeholders. During the public comment period, we received comments on the Total Performance Score as proposed, and in light of those concerns, we have adjusted how we set the minimum Total Performance Score. Rather than set the minimum Total Performance Score as the score a provider/facility would receive if it had met the performance standards for each finalized measure, we will define the minimum Total Performance Score as the score a provider/facility would receive if it had met the performance standards for each of the finalized clinical measures. In recognition of commenter concerns regarding the proposed reporting measures, and our lack of data on which to approximate likely provider/facility performance, we will exclude these measures from the calculation of the minimum Total Performance Score. We believe this policy balances our desire to appropriately incentivize improvements to clinical quality of care while ensuring that providers/facilities are not unduly penalized.
Furthermore, although we believe that the ESRD QIP should provide a means for patients to evaluate their providers/facilities over time, we do not believe that PY 2014 will be comparable to previous years of the ESRD QIP because of the significant changes to the scoring methodology and measures. We believe the 100 point scale will accommodate the growing number of measures that may be adopted in future years of the ESRD QIP and plan to consistently use the 100 point scale going forward.Start Printed Page 70311
Additionally, we believe that all scoring methodologies for Medicare Value-Based Purchasing programs should be aligned as appropriate given their specific statutory requirements, and that the changes made to the proposed methodology in this final rule are in keeping with this approach.
The comments we received on this analysis and our responses are set forth below.
Comment: One commenter asked CMS to explain why rural and urban facilities will be affected differently by the PY 2013 and PY 2014 ESRD QIP. This commenter specifically asked why those providers/facilities not receiving scores because of, for example, inadequate data varied from PY 2013 to PY 2014. This commenter urged CMS to change its methodology to encompass as many facilities as possible in the ESRD QIP. This commenter also requested the CMS explain why more payment reductions will likely result from PY 2014.
Response: The estimates of the impact for both PY 2013 and PY 2014 of the proposed rule we developed were created by modeling how providers/facilities would have scored on the ESRD QIP using data from 2008 and 2009. While these estimates did show a slight difference in the average payment reduction between urban and rural facilities for PY 2013 and PY 2014, we believe that these differences are relatively minor. While these estimates have changed since we used more recent data (2009 and 2010) and adjusted the model to account for changes to the program in this final rule, we still believe that the differences will be relatively minor. We expect all facilities to provide quality care, particularly in the important areas of anemia management and dialysis adequacy, regardless of size or geographic location. We will continue to monitor and evaluate the impact of the ESRD QIP on access to and quality to care and the quality of care received by Medicare ESRD beneficiaries, including indicators of facility financial health, to identify any disruptions or to make future improvements in the program. In light of our finalized proposal that every provider/facility will receive a Total Performance Score as long as at least one measure applies to it, we believe that nearly all providers/facilities will be included in the ESRD QIP. Lastly, we do not believe that payment reductions will be significantly greater in PY 2014. As seen from the estimates above, we believe that payment reductions will be $23.7 million for PY 2013 and $22.1 million for PY 2014. To the extent that this number decreases somewhat in PY 2014, we believe this is appropriate given that providers/facilities will be adjusting to a dramatically different program with new measures.
As discussed in section III of this final rule, section 106 of the MMEA requires the extension of certain add-on payments for ground ambulance services, and the extension of certain rural area designations for purposes of air ambulance payment, through CY 2011. As further discussed in section III of this final rule, we are amending the Medicare program regulations to conform the regulations to this section of the MMEA. This MMEA section is essentially prescriptive and does not allow for discretionary alternatives on the part of the Secretary.
As discussed in the July 1, 2004 interim final rule (69 FR 40288), in determining the super-rural bonus amount under section 1834(l)(12) of the Act, we followed the statutory guidance of using the data from the Comptroller General (GAO) of the U.S. We obtained the same data that were used in the GAO's September 2003 Report titled, “Ambulance Services: Medicare Payments Can Be Better Targeted to Trips in Less Densely Populated Rural Areas” (GAO report number GAO-03-986) and used the same general methodology in a regression analysis as was used in that report. The result was that the average cost per trip in the lowest quartile of rural county populations was 22.6 percent higher than the average cost per trip in the highest quartile. As required by section 1834(l)(12) of the Act, this percent increase is applied to the base rate for ground ambulance transports that originate in qualified rural areas, which were identified using the methodology set forth in the statute. Payments for ambulance services under Medicare are determined by the point of pick-up (by zip code area) where the beneficiary is loaded on board the ambulance.
We determined that ground ambulance transports originating in 7,842 zip code areas (which were determined to be in “qualified rural areas”) out of 42,879 zip code areas, according to the July 2010 zip code file, will realize increased base rate payments under section 106(c) of the MMEA for CY 2011; however, the number and level of services that might occur in these areas for CY 2011 is unknown at this time. Similarly, for purposes of assessing the impact of MMEA section 106(a) and (b), the number and level of services that might occur during CY 2011 in rural and urban areas generally is unknown at this time. While many elements may factor into the final impact of section 106 of the MMEA, our Office of the Actuary (OACT) estimates the impact of this section to be $20 million for CY 2011.
The fiscal impact of the final 3-year MLR for DME will be minimal because we believe that this standard is consistent with our current interpretation of the payment and repeated use provisions for DME. It is difficult to predict how many different types of new devices will be introduced in the market in the future that may or may not meet the 3-year MLR. However, even absent the final rule, it is likely that new products which do not meet the 3-year MLR will not qualify as DME based upon our current interpretation of the criteria for DME. It is possible that with the clarification of the 3-year MLR, we will limit what can be covered as DME compared to what we would have covered as DME absent this regulatory clarification. To the extent the regulatory change is binding to some new products, there may be reduced program cost. Also, the final revised regulation does not apply to items that were classified as DME before the effective date of the amended regulation, which tends to lessen the overall impact to the program. In general, we expect that this final will have a small, if any, savings impact on the program. We are finalizing the rule with no modifications.
As discussed in section V of this final rule, section 154 of MIPPA amended section 1847 of the Act to make limited changes to the Medicare DMEPOS Competitive Bidding Program. These changes were incorporated into regulations through an interim final rule with comment period published in the Federal Register on January 16, 2009 (74 FR 2873). The interim final rule merely incorporated limited statutory changes to the Medicare DMEPOS Competitive Bidding Program and did not change the fundamental requirements of the program. Specifically, this final rule cites the new timeframes for competition under the program. In addition, the rule implements the MIPPA provisions that mandated limited changes that affected Start Printed Page 70312competition under the program including a process for providing feedback to suppliers regarding missing financial documentation, requiring contractors to disclose to CMS information regarding subcontracting relationships, and exempting from competitive bidding certain items and services. These changes are not economically significant. Furthermore, because the regulation simply codifies the MIPPA provisions, we do not have the authority to consider alternatives.
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars_a004_a-4), in Table 13 below, we have prepared an accounting statement showing the classification of the transfers and costs associated with the various provisions of this final rule.
The Regulatory Flexibility Act (September 19, 1980, Pub. L. 96-354)(RFA) requires agencies to analyze options for regulatory relief of small entities, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Approximately 20 percent of ESRD dialysis facilities are considered small entities according to the Small Business Administration's size standards, which classifies small businesses as those dialysis facilities having total revenues of less than $34.5 million in any 1 year. Individuals and States are not included in the definitions of a small entity and 17 percent of dialysis facilities are nonprofit organizations. For more information on SBA's size standards, see the Small Business Administration's Web site at http://sba.gov/idc/groups/public/documents/sba_homepage/serv_sstd_tablepdf.pdf (Kidney Dialysis Start Printed Page 70313Centers are listed as 621492 with a size standard of $34.5 million).
The claims data used to estimate payments to ESRD facilities in this RFA and RIA do not identify which dialysis facilities are part of a large dialysis organization (LDO), regional chain, or other type of ownership. Each individual dialysis facility has its own provider number and bills Medicare using this number. Therefore, in previous RFAs and RIAs presented in proposed and final rules that updated the basic case-mix adjusted composite payment system, we considered each ESRD to be a small entity for purposes of the RFA. However, we conducted a special analysis for this final rule that enabled us to identify the ESRD facilities that are part of an LDO or regional chain and therefore, were able to identify individual ESRD facilities, regardless of ownership, that would be considered small entities.
We do not believe ESRD facilities are operated by small government entities such as counties or towns with populations 50,000 or less and therefore, they are not enumerated or included in this estimated RFA. Individuals and States are not included in the definition of a small entity.
For purposes of the RFA, we estimate that approximately 20 percent of ESRD facilities are small entities as that term is used in the RFA (which includes small businesses, nonprofit organizations, and small governmental jurisdictions). This amount is based on the number of ESRD facilities shown in the ownership category in the impact Table 12. Using the definitions in this ownership category, we consider the 663 facilities that are independent and the 437 facilities that are shown as hospital-based to be small entities. The ESRD facilities that are owned and operated by LDOs and regional chains would have total revenues more than $34.5 million in any year when the total revenues for all locations are combined for each business (individual LDO or regional chain) are not included as small entities.
For the ESRD PPS updates finalized in this rule, a hospital-based ESRD facility (as defined by ownership type) is estimated to receive a 2.3 percent increase in payments for CY 2012. An independent facility (as defined by ownership type) is estimated to receive a 2.3 percent increase in payments for 2012.
Based on the finalized QIP payment reduction impacts to ESRD facilities for PY 2013, we estimate that of the 2,059 ESRD facilities expected to receive a payment reduction, 385 ESRD small entity facilities would experience a payment reduction (ranging from 0.5 percent up to 2.0 of total payments), as presented in Table 11 above. We anticipate the payment reductions to average approximately $22,934 per facility, with an average of $23,807 per small entity. Using our projections of provider/facility performance, we then estimated the impact of anticipated payment reductions on ESRD small entities, by comparing the total payment reductions for the 385 small entities expected to receive a payment reduction, with the aggregate ESRD payments to all small entities. For the entire group of 1,054 ESRD small entity facilities, a decrease of 0.57 percent in aggregate ESRD payments is observed.
Furthermore, based on the finalized QIP payment reduction impacts to ESRD facilities for PY 2014, we estimate that of the 737 ESRD entity facilities expected to receive a payment reduction, 132 small entities are expected to experience a payment reduction (ranging from 1.0 percent up to 2.0 of total payments), as presented in Table 11 above. We anticipate the payment reductions to average approximately $18,820 per facility, with an average of $20,436 per small entity facility. Using our projections of provider/facility performance, we then estimated the impact of anticipated payment reductions on small entities, by comparing the total payment reductions for the 132 small entities expected to receive a payment reduction, with the aggregate ESRD payments to all small entities. For the entire group of 1,054 small entity facilities, a decrease of 0.16 percent in aggregate ESRD payments is observed.
Therefore, the Secretary has determined that this final rule will not have a significant economic impact on a substantial number of small entities. We solicit comment on the RFA analysis provided.
Finally, based on data from the Small Business Administration (SBA), we estimate that 85 percent of the suppliers of the items and services affected by the changes to the Medicare DMEPOS Competitive Bidding Program would be defined as small entities with total revenues of $6.5 million or less in any 1 year. This final rule merely codifies MIPPA provisions, so there are no options for regulatory relief for small suppliers. The RFA therefore does not require that we analyze regulatory options in this instance.
In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. Any such regulatory impact analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. We do not believe this final rule will have a significant impact on operations of a substantial number of small rural hospitals because most dialysis facilities are freestanding. While there are 178 rural hospital-based dialysis facilities, we do not know how many of them are based at hospitals with fewer than 100 beds. However, overall, the 178 rural hospital-based dialysis facilities will experience an estimated 2.3 percent increase in payments. As a result, this final rule is estimated to not have a significant impact on small rural hospitals. Therefore, the Secretary has determined that this proposed rule will not have a significant impact on the operations of a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year $100 million in 1995 dollars, updated annually for inflation. In 2011, that threshold is approximately $136 million. This final rule does not include any mandates that would impose spending costs on State, local, or Tribal governments in the aggregate, or by the private sector, of $136 million.
Executive Order 13132 on Federalism (August 4, 1999) establishes certain requirements that an agency must meet when it promulgates a final rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this final rule under the threshold criteria of Executive Order 13132, Federalism, and have determined that it will not have substantial direct effects on the rights, roles, and responsibilities of States, local or Tribal governments.
This section lists the Addenda referred to in the preamble of this final. Beginning in CY 2012, the Addenda for the annual ESRD PPS proposed and final rulemakings will no longer appear in the Federal Register. Instead, the Start Printed Page 70314Addenda will be available only through the Internet. We will continue to post the Addenda through the Internet.
Readers who experience any problems accessing the Addenda that are posted on the CMS Web site at http://www.cms.gov/ESRDPayment/PAY/list.asp, should contact Lisa Hubbard at (410) 786-4533.
Start List of Subjects
Reporting and recordkeeping requirements
Proposed Rule to revise the definition of durable medical equipment (DME) to incorporate a minimum lifetime standard of 3 years and further refine the meaning of the term durable
For the reasons set forth in the preamble, under the authority at 42 U.S.C. 1395hh section 1871 of the Act, the Centers for Medicare & Medicaid Services confirms as final, the interim final rules published on January 16, 2009 (74 FR 2873), and April 6, 2011 (76 FR 18930), and further amends 42 CFR chapter IV as set forth below:
Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395(g), 1395I(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Public Law 106-113 (133 stat. 1501A-332).
2. Section 413.232 is amended by revising paragraphs (b)(1), (b)(2), and (f) to read as follows:
§ 413.232
Low-volume adjustment.
(a) * * *
(b) * * *
(1) Furnished less than 4,000 treatments in each of the 3 cost reporting years (based on as-filed or final settled 12-consecutive month cost reports, whichever is most recent) preceding the payment year; and
(2) Has not opened, closed, or received a new provider number due to a change in ownership in the 3 cost reporting years (based on as-filed or final settled 12-consecutive month cost reports, whichever is most recent) preceding the payment year.
(f) Except as provided below, to receive the low-volume adjustment an ESRD facility must provide an attestation statement, by November 1st of each year preceding the payment year, to its Medicare administrative contractor that the facility has met all the criteria established in paragraphs (a), (b), (c), and (d) of this section. For calendar year 2012, the attestation must be provided by January 3, 2012.
Start Amendment Part
3. Section 413.237 is amended by adding a new paragraph (a)(1)(v) to read as follows:
Outliers.
(1) * * *
(v) As of January 1, 2012, the laboratory tests that comprise the Automated Multi-Channel Chemistry panel are excluded from the definition of outlier services.
Authority: Secs. 1102, 1871, and 1881(b)(l) of the Social Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(l)).
End Authority
5. Section 414.202 is amended by revising the definition of “durable medical equipment” to read as follows:
Durable medical equipment means equipment, furnished by a supplier or a home health agency that meets the following conditions:
(1) Can withstand repeated use.
(2) Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years.
(3) Is primarily and customarily used to serve a medical purpose.
(4) Generally is not useful to an individual in the absence of an illness or injury.
(5) Is appropriate for use in the home.
6. Section 414.402 is amended by—
End Amendment Part Start Amendment Part
A. Revising the definitions of “covered document” and “covered document review date” and “hospital”.
B. Revising the introductory text of paragraph (1) of the definition of “item”.
Covered document means a financial, tax, or other document required to be submitted by a bidder as part of an original bid submission under a competitive acquisition program in order to meet the required financial standards.
Covered document review date means the later of—
(1) The date that is 30 days before the final date for the closing of the bid window; or
(2) The date that is 30 days after the opening of the bid window.
Hospital has the same meaning as in section 1861(e) of the Act.
Item * * *
(1) Durable medical equipment (DME) other than class III devices under the Federal Food, Drug and Cosmetic Act, as defined in § 414.202 of this part and group 3 complex rehabilitative wheelchairs and further classified into the following categories:
7. Section 414.404 is amended by revising paragraphs (b)(1) introductory text, (b)(1)(ii), and (b)(1)(iii) to read as follows:
Scope and applicability.
(1) Physicians, treating practitioners, and hospitals may furnish certain types of competitively bid durable medical equipment without submitting a bid and being awarded a contract under this subpart, provided that all of the following conditions are satisfied:
(ii) The items are furnished by the physician or treating practitioner to his or her own patients as part of his or her professional service or by a hospital to its own patients during an admission or on the date of discharge.
(iii) The items are billed under a billing number assigned to the hospital, physician, the treating practitioner (if possible), or a group practice to which the physician or treating practitioner Start Printed Page 70315has reassigned the right to receive Medicare payment.
8. Section 414.408 is amended by revising paragraph (e)(2)(iv) to read as follows:
Payment rules.
(e) * * *
(iv) A physician, treating practitioner, physical therapist in private practice, occupational therapist in private practice, or hospital may furnish an item in accordance with § 414.404(b) of this subpart.
9. Section 414.410 is amended by revising paragraphs (a)(1) through (3) to read as follows:
Phased-in implementation of competitive bidding programs.
(a) Phase-in of competitive bidding programs. CMS phases in competitive bidding programs so that competition under the programs occurs—
(1) In CY 2009, in Cincinnati—Middletown (Ohio, Kentucky and Indiana), Cleveland—Elyria—Mentor (Ohio), Charlotte—Gastonia—Concord (North Carolina and South Carolina), Dallas—Fort Worth—Arlington (Texas), Kansas City (Missouri and Kansas), Miami—Fort Lauderdale—Miami Beach (Florida), Orlando (Florida), Pittsburgh (Pennsylvania), and Riverside—San Bernardino—Ontario (California).
(2) In CY 2011, in an additional 91 MSAs (the additional 70 MSAs selected by CMS as of June 1, 2008, and the next 21 largest MSAs by total population based on 2009 population estimates, and not already phased in as of June 1, 2008). CMS may subdivide any of the 91 MSAs with a population of greater than 8,000,000 into separate CBAs, thereby resulting in more than 91 CBAs.
(3) After CY 2011, additional CBAs (or, in the case of national mail order for items and services, after CY 2010).
10. Section 414.414 is amended by revising paragraph (c) and (d) as follows:
Conditions for awarding contracts.
(c) Quality standards and accreditation. Each supplier furnishing items and services directly or as a subcontractor must meet applicable quality standards developed by CMS in accordance with section 1834(a)(20) of the Act and be accredited by a CMS-approved organization that meets the requirements of § 424.58 of this subchapter, unless a grace period is specified by CMS.
(d) Financial standards. (1) General rule. Each supplier must submit along with its bid the applicable covered documents (as defined in § 414.402) specified in the request for bids.
(2) Process for reviewing covered documents. (i) Submission of covered documents for CMS review. To receive notification of whether there are missing covered documents, the supplier must submit its applicable covered documents by the later of the following covered document review dates:
(A) The date that is 30 days before the final date for the closing of the bid window; or
(B) The date that is 30 days after the opening of the bid window.
(ii) CMS feedback to a supplier with missing covered documents. (A) For Round 1 bids. CMS has up to 45 days after the covered document review date to review the covered documents and to notify suppliers of any missing documents.
(B) For subsequent Round bids. CMS has 90 days after the covered document review date to notify suppliers of any missing covered documents.
(iii) Submission of missing covered documents. Suppliers notified by CMS of missing covered documents have 10 business days after the date of such notice to submit the missing documents. CMS does not reject the supplier's bid on the basis that the covered documents are late or missing if all the applicable missing covered documents identified in the notice are submitted to CMS not later than 10 business days after the date of such notice.
11. Section 414.422 is amended by revising paragraph (f) to read as follows:
Terms of contracts.
(f) Disclosure of subcontracting arrangements. (1) Initial disclosure. Not later than 10 days after the date a supplier enters into a contract under this section the supplier must disclose information on both of the following:
(i) Each subcontracting arrangement that the supplier has in furnishing items and services under the contract.
(ii) Whether each subcontractor meets the requirement of section 1834(a)(20)(F)(i) of the Act if applicable to such subcontractor.
(2) Subsequent disclosure. Not later than 10 days after the date a supplier enters into a subcontracting arrangement subsequent to contract award with CMS, the supplier must disclose information on both of the following:
(i) The subcontracting arrangement that the supplier has in furnishing items and services under the contract.
(ii) Whether the subcontractor meets the requirement of section 1834(a)(20)(F)(i) of the Act, if applicable to such subcontractor.
12. Section 414.610 is amended by revising paragraphs (c)(1) introductory text, (c)(1)(ii), (c)(5)(ii), and (h) to read as follows:
Basis of payments.
(c) * * *
(1) Ground ambulance service levels. The CF is multiplied by the applicable RVUs for each level of service to produce a service-level base rate.
(ii) For services furnished during the period July 1, 2008 through December 31, 2011, ambulance services originating in—
(ii) For services furnished during the period July 1, 2004 through December 31, 2011, the payment amount for the ground ambulance base rate is increased by 22.6 percent where the point of pickup is in a rural area determined to be in the lowest 25 percent of rural population arrayed by population density. The amount of this increase is based on CMS's estimate of the ratio of the average cost per trip for the rural areas in the lowest quartile of population compared to the average cost per trip for the rural areas in the highest quartile of population. In making this estimate, CMS may use data provided by the GAO.
(h) Treatment of certain areas for payment for air ambulance services. Any area that was designated as a rural area for purposes of making payments under the ambulance fee schedule for air ambulance services furnished on December 31, 2006, must be treated as a rural area for purposes of making payments under the ambulance fee schedule for air ambulance services furnished during the period July 1, 2008, through December 31, 2011.
(Catalog of Federal Domestic Assistance Program No. 93.773, Medicare—Hospital Insurance; and Program No. 93.774, Medicare—Supplementary Medical Insurance Program)
Dated: October 26, 2011.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
Approved: October 31, 2011.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
1. KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease: 2007 Update of Hemoglobin Target, American Journal of Kidney Diseases, 50(3): Pages 471-530 (September 2007).
Back to Citation
2. Note that in the proposed rule, we mistakenly referred to this measure as #0250.
4. http://www.kidney.org/professionals/kdoqi/guideline_uphd_pd_va/va_guide2.htm.
5. http://www.fistulafirst.org/AboutAVFistulaFirst/History.aspx.
6. See http://www.fistulafirst.org/ for further information regarding this initiative.
7. See http://www.dialysisreports.org/pdf/esrd/public-measures/VascularAccess-Fistula-2014-FR.pdf and http://www.dialysisreports.org/pdf/esrd/public-measures/VascularAccess-Catheter-2014-FR.pdf.
8. See http://www.kidney.org/professionals/kdoqi/pdf/12-50-0210_JAG_DCP_Guidelines-VA_Oct06_SectionC_ofC.pdf; http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id...67692.
9. For example, if one patient was treated every month, his/her claim inputs would account for twelve, individual inputs for calculating the measure rate. Whereas a patient that is only seen for four months would be counted as four inputs.
10. For example, if one patient was treated every month, his/her claim inputs would account for twelve, individual inputs for calculating the measure rate. Whereas a patient that is only seen for four months would be counted as four inputs.
11. We also encourage providers/facilities to utilize other clinical practice guidelines regarding patient education. See, for example, http://www.kidney.org/professionals/kdoqi/pdf/12-50-0210_JAG_DCP_Guidelines-VA_Oct06_SectionC_ofC.pdf.
12. In order to successfully field the survey, the facility/provider must follow the recommendations found at: https://www.cahps.ahrq.gov/CAHPSkit/files/53_Fielding_the_ICH_Survey.pdf.
13. See https://www.cahps.ahrq.gov/content/products/ICH/PROD_ICH_Intro.asp?p=1022&s=222.
14. https://www.cahps.ahrq.gov/content/products/ICH/PROD_ICH_Intro.asp?p=1022&s=222.
15. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney International 2009; 76 (Suppl 113): S1-S130.
16. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney International 2009; 76 (Suppl 113): S1-S130.)
17. See http://www.qualityforum.org/Projects/e-g/End_Stage_Renal_Disease_2010/End_Stage_Renal_Disease_2010.aspx for more information regarding the National Voluntary Consensus Standards for ESRD.
18. This could occur, for example, if a provider/facility is a pediatric and/or peritoneal facility only.
19. The NIPA Handbook (Concepts and Methods of the U.S National Income and Product Accounts, Chapter 5-Personal Care Expenditures. The handbook is available at http://www.bea.gov/national/pdf/NIPAhandbookch5.pdf.
20. The McGraw Hill Dictionary of Modern Economics by Douglas Greenwald & Associates, Economics dictionary by Donald Moffat, Dictionary of Business and Economics by Christine Ammer and Dean Ammer.
21. Encyclopedia of Business, Britannica Encyclopedia and Gale Encyclopedia.
22. A Lexicon of Economics by Kenyon A. Knopf.
23. http://resna.org/.
24. The NIPA Handbook (Concepts and Methods of the U.S National Income and Product Accounts, Chapter 5—Personal Care Expenditures,The handbook is available at http://www.bea.gov/national/pdf/NIPAhandbookch5.pdf, U.S. Department of Labor/Bureau of Labor Statistics. http://www.bls.gov/ppi/ppiwholesale.htm, The McGraw Hill Dictionary of Modern Economics by Douglas Greenwald & Associates, Economics dictionary by Donald Moffat, Dictionary of Business and Economics by Christine Ammer and Dean Ammer, Encyclopedia of Business, Britannica Encyclopedia and Gale Encyclopedia, Lexicon of Economics by Kenyon A. Knopf, Fiscal Policy and Business Cycles by Alvin H. Hansen, Economics: Principles in Action by Steven M. Sheffrin, Durability of Output and Expected Stock Returns by Joao F. Gomes, Leonid Kogan, & Motohiro Yogo, Economics Fluctuations and Forecasting by Vincent Su, Macroeconomics by Roger A. Arnold, and National Income and Capital Formation by Simon Kuznet.
25. PY 2014 QIP Scores estimated using the Hemoglobin > 12 g/dl and Urea Reduction Ratio ≥ 65 percent measures, as well as data from the Fistula First initiative as a proxy for the VAT measure.
BILLING CODE 4120-01-C
BILLING CODE 4120-C
[FR Doc. 2011-28606 Filed 11-1-11; 4:15 pm]
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Published by Film at Lincoln Center
Short Takes: Big Bad Wolves
By Chris Chang in the January-February 2014 Issue
Near the midpoint of this finely crafted serial-killer flick, two of the leads—a pair of policemen gone rogue—have a strategic tête-à-tête. Are we going to play this “good cop, bad cop”? Brief consideration. Nope. The perp is a pedophile-rapist/ killer. As it happens, among his victims is the daughter of one of the cops. It’s an ugly scenario that demands commensurate action. “Bad cop, bad cop?” Agreed. But what if the mild-mannered teacher of religious studies is actually, as he adamantly maintains, innocent?
The problems begin in the first scene. The teacher is brought to an abandoned warehouse, bound to a chair, and then all but pulverized with a phonebook. He’s not the only one with problems. The beating is captured on a cellphone; when it goes viral on YouTube, the officer most responsible for the deed is busted down to traffic duty. Nevertheless the “investigation” will continue at an even more remote location.
Co-directors Aharon Keshales and Navot Papushado are Israeli. The film is in Hebrew—which may mean it will get less attention from the genre crowd. (Although Tarantino has already proclaimed it “the best film of the year.”) In addition to its accomplished visual style and pacing, and its excellent cast, special mention should be made of the writing, particularly the way in which it manages to inject all sorts of comedy into the gaps between the mayhem—and sometimes directly into the nail-pulling brutality itself.
From the January-February 2014 Issue
State of the Art By Film Comment
Dream Lovers By Jonathan Romney
Just Short of Forever By Beverly Walker
Article from the January-February 2020 issue
Letter to an Unknown Decade
By Devika Girish
Article from the March-April 1995 issue
Sundance Kids
By Gavin Smith
News to Me: Terence Davies, Spike Lee, and more Safdies
By James Wham
Film of the Week: I Wish I Knew
By Jonathan Romney
Becoming a critic in an era of burgeoning possibility and unsettling futures
A report from the 1995 festival, where pushing the envelope was the name of the game
Get money: trailblazing black actors, year-end complaints, and festival madness
Be here now: Jia Zhangke’s documentary looks back at Shanghai’s history and offers a picture of drastic, often violent change
Current Issue Issue Archive Web Only Subscribe Store
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Monday, January 20, 2020 5:55 PM
Snow showers this evening. Becoming partly cloudy later. Low 17F. Winds light and variable. Chance of snow 40%..
Snow showers this evening. Becoming partly cloudy later. Low 17F. Winds light and variable. Chance of snow 40%.
Mark Hofmann | Herald-Standard
Jeffery Ranker, 53, of Connellsville is escorted through the Fayette County Courthouse on Tuesday after pleading guilty to third-degree murder and being sentenced to 11 to 22 years in prison in a crash that took the life of John Canada of Dunbar last year.
Connellsville man sentenced up to 22 years in 2018 fatal collision
By Mark Hofmann mhofmann@heraldstandard.com
A Connellsville man was sentenced up to 22 years behind bars after pleading guilty to causing the crash that killed a Dunbar man last year.
On Tuesday, Jeffery R. Ranker, 53, pleaded guilty in Fayette County Court to third-degree murder, homicide by vehicle while DUI, homicide by vehicle, accidents involving death, DUI, recklessly endangering another person and other summary traffic citations.
District Attorney Rich Bower said the plea agreement was for 11 to 22 years of incarceration, with 8 to 16 years for the third-degree-murder charge and 3 to 6 years for the homicide-by-vehicle charge.
Police said Ranker was driving a Chevrolet Silverado while under the influence of multiple drugs when he hit John Anthony Canada of Dunbar as Canada was stopped in the turning lane at a red light at the intersection of University Drive and Industrial Park Drive at about 6 a.m. Oct. 10, 2018.
Canada was pronounced dead at the scene.
Bower said members of Canada’s family, who were in attendance on Tuesday, agreed with the plea. He read a victim impact statement on behalf of Canada’s family in court.
The statement read that Canada married his high-school sweetheart and had been with her for 50 years; together, they raised two girls—one who became a doctor and the other, a nurse—and was a grandfather of four grandchildren.
Canada’s son-in-law, Jaison Keeney, said in the statement that Ranker had no regard for the consequences of his actions, took the life of a hard-working man who loved being with his family. Keeney noted Canada’s grandchildren will miss all the lessons he could pass on to them, and he will miss all of the important moments in their lives.
“Our family is forever broken,” Bower read from Keeney’s statement.
Ranker expressed his sorrow for the Canada family, adding that he prays and thinks about the crash every day. He said he would trade placed with Canada if he could.
Kory Crowley, who said he’s Ranker’s future son-in-law, spoke on behalf of their family, extending sympathies to the Canada family.
He added that while a good man’s life was taken, Ranker is also a good man who will miss time with his family, too.
“I wish you knew him like the way I know him,” Crowley said, adding that the Ranker family is also hurting. “Don’t think of Jeff as a bad man, because he’s not.”
Following the hearing, Bower said Crowley’s statement to the Canada family was a travesty.
“He (Ranker) was the one who caused the harm to his own family,” Bower said, adding that Ranker was the one who ingested multiple drugs and killed a bystander with his truck.
President Judge John F. Wagner Jr. accepted the plea offer and sentenced Ranker to 11 to 22 years in a state correctional prison with credit for time served from March 19 to April 1 and also from May 8 to Tuesday.
Local legislators back hand-held phone ban
Uniontown police office dismissed from lawsuit over homicide acquittal
Pechin supermarket closing, as company focuses on Connellsville, Dunbar locations
Impact fee revenue predicted to drop
Uniontown woman recognized for advocacy, support of daughter with rare blood cancer
Ringgold selects Evans, Wyvratt as Winter Scholar-Athletes
Uprooted from Uniontown, Harris starred for F-G hoops team
LH graduate Sankovich to play for Marshall University
Rust, Johnson help Pittsburgh rally past Bruins 4-3
EF's Michaels wins 2nd straight Allegheny County title, earns 100th career victory
Albert Gallatin to seek quotes for overlay roof at Smithfield
Local Orthodox churches gather to bless Monongahela River
Another Democratic bombshell 'bombs'
There may be lots of jobs, but many of them don't pay well
We need to change our thinking on drug addiction treatment
County tax increase a huge burden on residents
MLK Day more than just a day off
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Arguments About Videogame Sexism Dumb Down Discussion
In some arguments, nobody wins and everyone loses
So in the news this week is the “controversy” surrounding The Chinese Room tweeting out that a promotional image for CD Projekt’s upcoming title Cyberpunk 2087 suggests it is “just as sexist” as Witcher 3.
But just as sexist if that image is anything to go by… https://t.co/jlLW0lWP6z
— The Chinese Room (@ChineseRoom) April 29, 2016
Now, you might think: “hang on there, Chinese Room, you’re jumping to conclusions a bit based on one image”. You’d be right too. One image of a robotic woman attired in lingerie doesn’t necessarily mean CD Projekt want to urinate on Emiline Pankhust’s grave while wearing “This is the Patriarchy” t-shirts. Sadly, one of the first responses to Chinese Room’s presumptuousness was not a well-reasoned criticism, but an image of the same woman with a bhurka photo-shopped over her.
@ChineseRoom happy? pic.twitter.com/IEQEA1fWkO — Kristian Thörnblom (@Lordwarpgun) April 29, 2016
Of course, that’s obviously what The Chinese Room really want, isn’t it? Clearly, based on one sentence in a tweet, it’s perfectly reasonable to assume that they’re a bunch of neo-puritans who want women to be ashamed of their bodies, right? Criticism of the Chinese Room continued in an equally petty way with Nercubed snarkily mentioning that The Chinese Room are just jealous because they can’t render a human character model… or write a story.
I think they’re just jealous they haven’t worked out how to model a human character yet.
Or write a story.
— Daniel Hardcastle (@DanNerdCubed) April 29, 2016
Gosh, sick burn, eh? The usual suspects on Twitter and YouTube continued to round on Chinese Room with insults aplenty. What seemed oddly absent though, was anyone asking The Chinese Room: “can you elaborate on your opinion a little so we can talk about it?”
This latest bit of twitter drama isn’t really “news” because it’s nothing new – this is now a rote weekly event like taking out the garbage. It’s not really a controversy, because it’s not controversial – it’s a dogwhistle for the Twitterati to call eachother “sexists” or “SJWs”. It’s not really a debate, because sure as hell, no-one involved is even attempting that. What it can safely be described as is an enormous waste of time. No-one involved is going to change their opinions or learn anything new. These twitter slapfights will yield no learned intellectual tete-a-tetes like Lincoln-Douglas or Frost-Nixon that will fascinate and inform future generations. It wouldn’t be a problem if this dumbed-down bickering was just background noise. Now though, time-wasting feces-flinging like this has dominated gaming discussion for the past two years, and looks set to continue to do so.
Fourscore and seven years ago… we didn’t have twitter and actually knew how to debate.
I remember when the various gaming websites were focused on discussions about whether games were art. Sure, it wasn’t a great topic to be debating. Obviously, art is subjective and anything can be art. But hey, it was good sign that gaming was becoming open to the same type of critical opinion that TV and film had been for decades.
In the heady days when New Games Journalism was on the rise; Tim Rogers used to write vaugely narccisstic 10,000 word reviews of games where he would talk about everything from who he was text messaging while playing, to heating himself up a burrito while he waited for the game to load. To him, the idea of evaluating a game as anything other than a completely personal experience was old hat. I remember reading Maoist essays on Fallout 2 about how the protagonist could be a force for liberating the enslaved tribal proletariat from the post-apocalyptic bourgeoisie. I also fondly recall a treatise about Stracraft 2 with a Freudian analysis about the Xel’naga artifact as a phallic symbol to subvert Kerrigan with its psychic ejaculations of energy. Sure, I didn’t agree with everything I read from these people, but they all provided a fresh perspective for me to consider and enjoy! At least no-one was organizing hate campaigns against them.
This is… a thing people care about?
Now, every single week I have to struggle with the burden of having a nuanced opinion in a social media environment determined to encourage hateful stupidity. In Metal Gear Solid V, I think Kojima could’ve done better representing women than having a single mute female character in a cage who has orgasmic showers in a bikini. Does that make me a “social justice warrior” determined to destroy video games and human sexuality? I think Senran Kagura is a bit of harmless fun as long as you view it as escapism, and don’t think real women are like that. Does that make me a basement-dwelling mysognist? Am I a bad games journalist because I think #bootygate is a pretty ridiculous thing to even be discussing? I mean, as long as a games developer isn’t being harrassed or otherwise coerced, it’s up to them whether they want to listen to fan feedback – whether it’s the stat balancing on a gun, a breathtakingly awful ending, or a slightly posterior-emphasizing pose. Why should we yell at eachother over it? When we have games that include more complex political and intellectual themes than ever before, the fact that there even is a #bootygate at all just reveals how utterly trivial and nasty gaming discussion has become.
It’s hard to participate in any debate about events of the day anymore, because I don’t really want to put myself on either side of a crushingly tedious culture war, manufactured to give the self-appointed commentariat more ad money. However, even if you don’t pick sides, someone will twist the facts and ignore your actual views and opinions so they can feel self-righteously angry at you. I feel pretty dumb writing paragraph after paragraph to people I will never meet, thinking I’m perhaps getting through to them on some level, just to be called a “feminazi cuck”. I’m not really bothered about being insulted by random internetlings, but I do feel stupid for wasting my time.
Anyone reading this article, please do me a favour. Don’t try and have discussions about serious, multi-faceted issues on twitter. The character limit doesn’t really lend itself to more than cheeky one-liners. If you’ve got a point to make, maybe write an article about it on medium.com or respond to another essay written there.
Are you outraged or outraged about people being outraged? Either way, more money for the clickbait merchants!
If someone starts demonising you, or calling you names, just ignore them and have discussions with people who actually want to listen as well as reply. Treat whatever internet person you’re talking to as a rational individual with complex opinions, and maybe you’ll be treated the same way. There are plenty of e-celebs with a financial stake in stirring up drama, or feeding into it by making the same childish insults and tiresomely redundant points. If we stop giving them views, clicks and attention – and stop being part of the inanity they feed off – they’ll have to either think of something new and refreshing to say, or fade into obscurity.
If we can do all this, then maybe gaming discussion will be about compelling issues again – with the overriding aim being mutual enlightenment, not brain-dead partisan bickering.
Or at least, you’ll have a bit more spare time because you’re not arguing about stupid shit on the internet.
Tagged OpinionsexismSocial Justice
Jonathan Trussler
Jonathan is HeyPoorPlayer's token British person, so expect him to thoroughly exploit this by quoting Monty Python and saying things like "Pip, pip, toodly-whotsit!" for the delight of American readers. He likes artsy-fartsy games, RPGs and RPG-Hybrids (which means pretty much everything at this point). He used to write for Sumonix.com. He's also just realised how much fun it is to refer to himself in the third person like he's The Rock or something.
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Tightening the reins on case management
In-house counsel will need to be aware of this latest decision of the High Court which requires legal advisers to think carefully before launching interlocutory applications.
Expense Reduction and Analysis Group Pty Ltd v Armstrong Strategic Management and Marketing Pty Ltd1
This case was ostensibly all about the inadvertent waiver of the client’s legal professional privilege attaching to discovered documents. No doubt there are many practitioners who can tell tales of cases where privileged solicitor and client advice was mistakenly sent to the other side, but the lawyer on the other side had the good manners and good judgment to return the document unread.
In very large cases, involving tens of thousands, or even hundreds of thousands of documents, mistakes can happen despite care and attention being taken by the practitioners responsible for disclosure. This is the result of the sheer volume of documents involved in large and complex cases.
In this case, there were somewhere in the region of 60,000 documents to be discovered by the ERA parties. By the time the litigation about the inadvertent disclosure of some of these documents reached the Court of Appeal of New South Wales, only 13 documents were in issue.
The ERA parties decided to agitate the issue by seeking injunctions and other relief in the Supreme Court of New South Wales. The result of those proceedings was that nine of the 13 documents were found to have been disclosed inadvertently.
The Armstrong parties appealed that decision on the basis that the mistakes in disclosure of the documents would not have been obvious to a reasonable solicitor. In short, the High Court observed (at [6] and [7]) that the litigation on this single issue was substantial, occupying several days hearing and the production of lengthy reasons by the Court of Appeal. In the words of the High Court, “proceedings of this kind and length concerning a tangential issue should have been averted.” However, the High Court did not rest there. It proceeded to consider the issue of waiver in the context of inadvertent disclosure of privileged discovered documents, but it also took the opportunity to remind practitioners of their paramount duty to the Court.
In NSW, the Civil Procedure Act 2005 (the CPA) sets out the powers and obligations of the court with respect to case management in proceedings. In the present case, the High Court highlighted the overriding purpose of the CPA, which requires that the court “facilitate the just, quick and cheap resolution of the real issue in the dispute or proceedings” (s 56(1)).
In view of these objectives, the High Court advocated a more robust and proactive approach to the court’s case management powers. Upon hearing the application, the Supreme Court should have allowed ERA to amend the list of documents and ordered for the return of the disks, allowing the privileged material to be deleted. These directions would have diffused the dispute and obviated the need for further court time, resources and expense.
The High Court emphasised that this case management obligation applies equally to the parties in civil proceedings and in particular to the lawyers representing those parties. In such circumstances as these, solicitors have a responsibility to determine not only whether there is any real, substantive benefit in disputing the return of inadvertently disclosed documents, but also to facilitate the overriding purposes of the CPA. These case management obligations will apply equally to in-house counsel who will have an equivalent duty to their internal clients to ensure that these obligations are not contravened. They will also apply equally in the context of arbitration which, of itself is designed to ensure efficiency and reduce expense.
The Court explained in strong terms, that bringing proceedings which went no way towards resolving a real issue in dispute could not be consistent with the solicitors’ duties under those provisions. This conclusion is consistent with the view taken in AON Risk Services Australia Ltd v Australian National University2, which described the vicious cycle of inefficiency that arises when the objectives of the duty to the court are forgotten. This approach accords with a solicitors’ paramount duty to the court. Such a duty requires solicitors not to act in a way which is contrary to the proper administration of justice, even to the extent of priority over the interests and instructions of their client.
The Court further drew attention to Rule 31 of the Australian Solicitors’ Conduct Rules, under which a solicitor must return material which is known or reasonably suspected to be confidential, where that solicitor is aware that the disclosure was inadvertent. While this provision is not yet in force in NSW, the rule reflects a common sense position which avoids complications and the need for unnecessary and costly interlocutory applications. The New Solicitors Rules, which will take effect from 1 January 2014, will codify this provision into NSW law and place a formal obligation on legal advisers. These new rules also demonstrate the increasing recognition occurring, at both at state and federal level, that case management is now the benchmark for the behaviour of litigants and their legal representatives throughout proceedings.
The courts have broad powers regarding the breach of these overarching obligations. Most commonly, and as illustrated in the present case, failure to observe these duties will be taken into account when making orders in the course of proceedings. In this instance, the contravention resulted in costs orders against the Armstrong parties in respect of each level of appeal. This kind of outcome could subsequently expose legal representatives to actions against them in negligence.
This case is ultimately a salutary reminder to practitioners that case management is not merely one of the number of factors to be addressed when acting for parties on one or other side of an interlocutory application. It is critically important that solicitors have regard to these professional and ethical obligations throughout proceedings, and that they conduct themselves in a way which will assist the court to facilitate the overriding purposes of the CPA.
(2009) 239 CLR 175
For more information, please contact Julian Sher, Partner on +61 (0)8 9422 4701, or julian.sher@hfw.com, or your usual contact at HFW. Research by Orla Isaacson, Trainee.
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First Year & Common Reading
Faces at the Bottom of the Well
The Permanence of Racism
by Derrick Bell
Foreword by Michelle Alexander
The classic work on American racism and the struggle for racial justice, now with a new foreword by Michelle Alexander
In Faces at the Bottom of the Well, civil rights activist and legal scholar Derrick Bell uses allegory and historical example to argue that racism is an integral and permanent part of American society. African American struggles for equality are doomed to fail so long as the majority of whites do not see their own well-being threatened by the status quo. Bell calls on African Americans to face up to this unhappy truth and abandon a misplaced faith in inevitable progress. Only then will blacks, and those whites who join with them, be in a position to create viable strategies to alleviate the burdens of racism. “Freed of the stifling rigidity of relying unthinkingly on the slogan ‘we shall overcome,'” he writes, “we are impelled both to live each day more fully and to examine critically the actual effectiveness of traditional civil rights remedies.”
With a new foreword by Michelle Alexander, Faces at the Bottom of the Well is urgent and essential reading on the problem of racism in America.
Genre: Nonfiction / Law / Civil Rights
On Sale: October 30th 2018
Basic Books Logo
Trade Paperback Arrow Icon
"Eerily prophetic, almost haunting, and yet at the same time oddly reassuring."—Michelle Alexander, from the Foreword
"Effective...chilling."—New York Times Book Review
"A disturbing but ultimately inspiring book."—San Francisco Chronicle
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Index •
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January 02 Issue •
"I need a scapegoat for what doesn’t work out in my life, and I hurt people doing it."
It was like they had some government support network for ex-girlfriends to spread dirt on you the minute you did something wrong.
Ever slap two thawed pork chops against the hood of a Cadillac on a frosty, February morning? This was the sound Cameron’s feet made every day when he dropped them from the sanctity of sleep to the resounding sobriety of a cold, wooden floor, glimmering in barren purity, stretching impeccably across his entire studio. And so it seemed that with the rise and fall of the sun, every new day was yet one more through which Cameron must suffer the annoyance of not being dead. It seemed that way every day until today.
The telephone, a coiled viper of venomous verbalization, is a brutal way to shake one from slumber. Yet, at the deafening surreal existence of twelve thirty on a Saturday morning, this was precisely what plucked Cameron from his blissful dip from consciousness.
"Hello?" Cameron spoke in an irritated whisper, rattling the phone against his head in the black, cloudy stupor that accompanies the unexpected raping of one’s dreams.
"Hi." It was Steff. She spoke with a vulnerable, nasal tone, like a voice on those 911 phone recordings on TV emergency shows.
"Yeah?" Cameron asked with a yawn, hoping she would get to the point, a practice of futility. "What is it?"
"Oh, well you left your James Thurber thing over here. You need to pick it up today so we can finally get all this over with." All this? That didn’t sound right.
"W-w-wait a minute," Cameron stammered, a reddening wave of dominance cascading like a hormonal avalanche to the ends of his extremities, "what do you mean by all this? Are you insinuating that there is the need for a label to the mild amount of effort involved in transferring my few possessions that I may have accidentally left at your apartment on the few occasions I even stayed overnight?"
"Cameron, does everything have to be so horribly difficult?" An even weaker twinge had taken over Steff’s battered vocal chords. "You are the one who always talks about scapegoats; I can’t believe how you can turn on me!" Her words held so much worth with those who hadn’t dated her.
"As I recall," Cameron began, pull-starting his little gasoline generator of witty argumentative rebuttals, "it was you who was a fucking cunt and cheated on me in your hometown, and don’t try that different area code exemption rule on me; you’re the woman, you are supposed to be the virtuous one."
"Oh now we are playing role games, Cam? Fuck that. I am just going to toss the fucking Thurber w-whatever it is to the curb and—"
"IT’S A PORTRAIT," Cameron shot forth with the angst of a Smashing Pumpkins groupie. "It’s not a thing, its not a w-w-whatever; it’s a fucking portrait, its lines on a page and can be recreated so don’t twist it around on me. Jeezus, what are they teaching you business majors anyway?"
Silence. Not the silence of anger, but the silence of shock, a shock that someone could hurt you so easily.
"Goodbye, Cameron, I hope you feel better about yourself now that you have taken control of the conversation. You just always need to be right." Click.
Cameron, a self-imprisoned holocaust victim, laid still as a corpse in his foldout coffin. He stared at a faded Jamaican flag tacked to the ceiling for eons, (actually, only forty-five minutes) contemplating what he saw to be the end of any contact with Steff indefinitely. His pining had been fairly successful. It was only this morning that everything had become clear; the origin to it all had finally been made visible. Cameron had to put Steff and her insistence on prolonging the inevitable behind him. The past is the foundation and destruction of a revolution; I want evolution.
The evolution of a breakfast: in the beginning there were eggs and milk; a great heat emerged and the two life forces emulsified, only to meet the ultimate boon of melted feta cheese and the almighty mushroom; the birth of an omelet.
This was now the plague of Cameron at a shadowy one thirty in the afternoon, as he stumbled over Nietzsche and Foucault while attempting to clothe himself, his shivering package embracing the newfound warmth of boxer briefs in the frigid chill of his cold, wooden studio. Sitting alone, in his voluntarily dark and malnourished studio, he was happiest. Reading slowly yet astutely, Cameron studied the works of Chekhov and Dostoevsky; crime and punishment; pain and redemption.
Cameron marveled in the reliability of his food co-op. On the outside, his smoke-stained, crème-colored refrigerator looked like some run-down, fifties import out of a David Fincher movie, yet was housing to a sanitary, well kept assortment of fresh foods for cooking a variety of pallet-pleasing, gourmet entrees, even tofu for those eccentric wok occasions. "Eating well, no more TV dinners…" And it was only a seventy-dollar charge per month for nutritional enlightenment.
The evolution of an upright citizen: in the waters of a hot shower a man can wash his sin away, covering up the funk of impurity with the sharp, angelic scent of Irish Spring soap; a shave to show an honest face; a comb to straighten what roams free; roll-on, antiperspirant godliness. I wonder how many times a day the Pope brushes his teeth. Cameron emerged from the shower, slender, sinewy limbs dripping in the glistening humidity clinging also to the walls and mirror in his cramped bathroom. At least it is a private bathroom; no more TP seat covers… Staring at himself naked, he was not ashamed of his thin, barren physique, but marveled in its nihilistic refusal to die. Fuck the gym; that is so artificial. Embracing your healthiness in a cement compound that destroyed wildlife areas and farmland... Everyone is so in tune with their Chi. He chuckled to himself in his cynicism.
Despite his rampant trashing of the mainstream, Cameron knew it was a good sign. At least I feel something. With the speed of time-lapse photography, his mental conversation had ended and he was now completely dressed and ready to venture out into the labyrinth of drum shops, lattes and video games that a large city had to offer. Like many other days, Cameron had assembled the apparel of a sophisticated stoner: polished leather shoes, soft jeans or corduroy pants, multiple, non-matching shirts and of course, dark sunglasses. His brown hair fell just over his glasses and dangled loosely by his temples, but thanks to the lard-heap of gel Cameron insisted upon using, it wouldn’t be free to move for long. In his red pleather jacket rested a stash tin, a bic lighter and a pinchie—the bare minimum. Into his CD player went Sweep the Leg Johnny’s new release, and out the studio Cameron strolled, leaving a slouchy kitten dubbed William the Conqueror yawning in his wicker basket.
Cheeks had been up since ten thirty, when he revived his girlfriend, Elena to the taste of "serene" chamomile tea and toast. Elena adored that nurturing aspect in Cheeks, and they loved to vegetate within the warmth of Cheek’s plush, cozy apartment for hours on end. A good many weekend nights had been ended with a four-hour movie marathon from within Cheek’s abode, frequenting such films as Fight Club, Run Lola Run, and anything directed by Kevin Smith.
Cheeks was the type of trusting, romantic dolt that could devote himself on end and not think twice about it. This made him a very good friend, but an easy tool to manipulate. Cameron had looked out for Cheeks, warding off the party whores who would latch onto Cheeks for some various, selfish agenda, like prick teasing him to death to make themselves feel prettier. Elena made Cameron’s job a lot easier.
Elena was a girl that Cheeks had met in one of his classes. Elena, for a long time, didn’t know Cameron. Cameron used to have contempt for the girl; she had stolen his friend, but upon actually meeting her and becoming aware of her sharp wit and hilarious ability to prod the honesty out of most situations, Cameron gave Cheeks an official "toke of approval on the girl situation." Elena, she was a good woman too, she looked out for Cheeks the same way he did for her. She valued him like a lock of Fabio’s hair, and in that resided the respect in which their relationship was founded--a mutual concern for and reliance upon each other.
Three o’ clock in the afternoon; three knocks at the door, spaced out like that of a detective on a drug bust. In response, Cheeks fumbled a pipe out of his shaking hand and into his lap, spilling ash everywhere. Meanwhile, Elena wailed without sympathy from the bed in response, laughter echoing expansively through the thin walls of the apartment. She rolled off the flip-n-fuck giggling, and swayed in slow, heavy steps across the dark blue carpet (which somehow was supposed to match the tan wallpaper) and finally to the door. A peephole is a marvelous evolution, an instantaneous, Louis and Clark-style exploration into the outside world. Residing outside, chai in hand, was Cameron.
"Open the door you fuckin’ dyke," Cameron demanded with a smirk from the street, shaking the moisture of a misty day off his jacket. Elena, a golem in response to Cameron’s "joke," unlatched the chain and invited inside the vampirish terror that was one Cameron Renfield.
"That’s the thanks I get for feeding your cat last week?" Elena asked as she quickly cut off the crisp, winter wind’s intrusion into the apartment, slamming the door and chaining it shut. "You need to take better care of William, Cam," Elena cautioned with the know-how that accompanies a veterinary degree, "or he won’t attach to you." Cameron bowed in monk-like attrition from behind the chai and sealed the lie with a warm hug; a hug that had gotten him out of many a shit storm before; girls loved that hug.
"CHEEKY!" Cameron called across the room, causing Cheeks to again fumble the bowl out of his fingers, this time while cleaning it. Cheeks could clean a piece better than anyone; once this steamroller saw so much action, it was completely clogged with resin. Twenty minutes later, Cheeks had the thing cleaner than the china in cabinets that your grandparents never use.
Cheeks and Cameron had both picked cotton at the same plantation of a high school, and upon finding similar interests in music, humor and recreational tendencies, became far better friends upon escaping to the same college. They shared rides home and smoked the whole way.
Upon locating Cheeks, scrubbing away from the sanitation of the kitchen at some glassware in a yellowed, porcelain sink, Cameron began with the dramatics of a General Hospital rerun, like he usually did.
"What up compadre, yo I got some shit to tell you man," Cameron declared, forewarning of the rant to come. "So guess who calls me at like nine in the fucking morning?" Cameron began, asking rhetorically. He didn’t have time to answer his own question.
"Actually," Elena cut in, "it was more like twelve thirty." She had the inside story. Shit. Cameron was amazed how fast word traveled. It was like they had some government support network for ex-girlfriends to spread dirt on you the minute you did something wrong. "I talked to Steff this morning right before she called you. She wanted me to pick up your stuff for you, but I insisted you would pay her at least that much respect." That was the assumption of a foolish carpenter.
"Heh, think again ‘E’; I stuck it to her cheatin’ heart like any self-respecting person should’ve done." Cameron felt guilty about the way things had turned out, preferring to savor the drunkenness and not the vomit of his relationship gone awry. The pair had long been unhinging, however; like most things, if you weren’t growing, you were dying. The evolution of a failed relationship…
In the beginning there was courtship. Not the hokey, flowerful sense of courtship, but the realistic, considerate and expressive sense of courtship; the type of courtship that exists when you care about someone so much (or at least you tell yourself that you do), you just can’t fuck around. Sure, there was romantic sentiment; it was the icing on the cake, sweet with the taste of Cameron’s cooking and exploration of the arts. The humanities, it seemed, possessed a similar passion for indulgence that one can find in an interesting, attractive woman. Cameron’s quick wit and Steff’s infatuation with beauty mixed like vermooth and gin, and things grew.
Things grew into comfort. This comfort grew into laziness, a laziness of rented videos and repeated sexual indulgences. This was the basement life—the hybrid of life that kills most young relationships; it’s so much easier to sit alone in your basement and piece it up all night than it is to go out on the town and eventually make it home, like back when you were trying to win her over. This was the beginning of the end.
"So you gave her shit," Elena scolded, brow wrenched at a torqued, obtuse angle. "You are the most egotistical—"
"We can make false accusations all day," Cameron interrupted, taking the bull of reason by the horns, "or we can cut the fat off this big ball of lard to find the one, ultimate chunk of truthitude at the core of this bundle of illogical nonsense." He was on a roll; their attention was his. "May I continue," Cameron asked with an emerging smirk.
Cheeks was starting to get nervous about the overly sarcastic argument. He didn’t understand the terms of Cameron and Elena’s friendship; it was forged on sincere respect for the other, and thus all bullshit was eliminated. Sometimes toes got stepped on, but it was never either of their intentions; calling each other off-sides showed a hell of a lot more consideration than just standing by like every other idiot that was too lacking in confidence to stand up for what was right. The evolution of dignity.
"Cameron, lets just smoke a bowl and relax in the kitchen," Cheeks pleaded, trying to break things up like the chubby little barkeep he was deep down. His efforts were timed like a NSA assassination, as Cameron’s eyes lit up like fireflies behind his shades for all to see. Thankfully for Cameron, he didn’t have time to escalate the argument to something more damaging.
"Uhh… now you’re speaking my language, Cheekster," Cameron reported, marking his change in attitude with his distinguishing grin, "pack it up; I’ll hit you back later." Later being never.
One nugget of marijuana quickly shuffled loose its mortal coil, and two nineteen-year-old guys now fell victim to the paralysis of the munchies. Elena hadn’t smoked yet; she was considering it, if by "considering" you mean tempted at every turn to join in the love parade exclusive to only those who burned the root.
"Elena, my dear," Cameron trumpeted, addressing her grandly with a Turkish Gold trumpeting from the corner of his mouth, "take me to a party tonight and introduce me to women." Such a quick counter from being a parasite under the microscope only moments ago. Cameron: 1; Elena: 0.
"Why? Why should I Cam," she reasoned almost too logically, "what’s to say you aren’t going to shit on this one because she is… how would it go? ‘Too nice?’" That was a good question. Cameron, surprisingly enough, had found the answer just this morning.
"Well after my conversation with the queen of monogamy this morning, that is after she woke me up at the ass crack of dawn to bitch about my meager belongings…" Cameron again was cut off.
"It was twelve thirty!!" Elena steamed, amazed at Cameron’s ability to bend the truth like a wad of play-doh to fit his argument.
"No matter the specifics," Cameron countered, again dodging the bullet of logic by millimeters, "I came to the revelation that being angry is easy. I can’t just lie on my ass and expect things to come my way. I have to act, not react. So, take me to a party tonight and I will demonstrate my newfound admiration for the natural habits of some fine, young ‘lay-days’".
"Natural habits??" Elena was dumbfounded by Cameron’s soliloquy; it was so distant from his usual attitude, like he was reading his opinions out of a book of cliff notes.
"Yeah," Cameron quickly replied, losing himself in a wave of virtuosity, rising like driftwood on its crest, "I had a TA last semester that has been coaching me along in my writing, but solely by definition what he says seems to go beyond school." Such admiration, I hope this doesn’t sound sexual. "He seems to know the answers to questions I cant even begin to form with language." Breathe in.
"What he told me," Cameron stated as softly as a secret, "was that the frustration I have been experiencing comes with intellect." This made good enough sense to Cameron; he was a clever guy. "So when I enter a public setting and my little social sex antenna clicks on, I compare everyone in the room by my own standards for cleverness. Yet, in doing this, I ignore the possibility for a completely different type of intellect." Breathe in. Cheeks had a look on his face like a calculus book just hit him in the forehead at mach three. Cameron continued on.
"None of it really hit home until this morning," Cameron explained, taking note of the glare on Elena’s face saying, "Just bitch about Steff again." "Steff and I got in an argument, she and I both were very brutal to each other." Cameron felt the guilt brewing inside of him, a churning vat of whispers for only him to know. "And after it was all over," Cameron continued, his own voice now bending in its harsh tone, "I saw that nothing had been accomplished." Cameron turned his back to his friends under the shame of his own tears, like condensation on a teakettle ready to scream. "And this anger," Cameron stammered in a shudder of release to an empty corner, "all of this that I carry with me, it doesn’t solve anything." Pant; wheeze. "I need a scapegoat for what doesn’t work out in my life, and I hurt people doing it." A rip in the wallpaper now occupied Cameron’s attention, his fingers nervously inspecting its edges.
"I can’t do this anymore," he reassured himself, the wallpaper and his friends, "because as my TA says, ‘everyone is clever in their own fucked up way,’ and the key to finding happiness in others is not to get stuck on finding someone to blame when your intellects don’t match, it’s in accepting the mismatches as part of the relationship pseudo-lottery and holding out for your quasi-‘jackpot.’" Cameron wheezed in emotional exhaustion. Cheeks had a smirk on his face and nodded in agreement with Cameron’s words, but had the hint of his "just a little too fucking abstract for me" face peeking out from his raised eyebrows.
Elena sat there for a moment wrapped in a bedspread and silently considered the stunning, humble honesty to Cameron’s revelation. She also wondered if pseudo and quasi were muppet babies, but her mind couldn’t wander for long.
"So here I stand," Cameron declared, quickly emancipating himself from the threat of being identified as sensitive, "knowing how to deal with what lies ahead of me; all I have to do is be real and meet people. You, Elena, must make it happen."
"Well," Elena bided, while thinking over her evening’s plans, "I am going to a house party with some girls from my floor tonight. You two could come with." Elena lived in a dorm. Cameron had his own thoughts on the life support of disconnected dorm life, but it was not like he was complaining about the situation; it was a good deal that Cheeks and Elena had worked out—she spent the night at Cheeks’ on certain occasions and her residency in a dorm meant possible inlets for Cameron to explore within her circle of friends. By accomplishing this, Cheeks and Cameron could once again hang out at their previous, obnoxiously inseparable rate, now while simultaneously juggling the girlfriend factor.
Ask Cheeks about this strategy and he would deny it. Cameron, as usual, had a contrary belief about their tactics and saw no shame in chasing girls Elena knew; it was a good window through which Cameron could escape his first impressions, which were usually his falling point with women because holding his tongue was a habit seldom practiced, not to mention his tendencies to spew projectile bullshit as if it were vomit and he Linda Blair.
There were many advantages to rummaging through girls of Elena’s acquaintance, but the best aspect in Cameron’s eyes was the simple fact that the friends with whom women surround themselves often share similar ethics and ideals, and Elena was a pretty cool chick.
Nine thirty rolled around quickly, if by quickly you mean, "after a large amount of weed cached in various pipes and washed down with a pizza." Cheeks threw on a sweater and some cologne. Cameron was dressed to depress, thwarting any attempt at a tradition or pattern to his dressing habits; he wore what pleased his fingers as they browsed through the closet. The evolution of a fashion-oriented culture.
In the beginning, there were the conformists. Sociologically, it is human nature to conform, and rebellion is the result of extended intellectual development and the sense of criticism by which it is accompanied. When everyone conformed, there was much joy; the trendsetters felt important and influential, and the weak lackeys thereafter found confidence in their ability to follow suit.
Then, a great revolution befouled this harmony with a demand for ethics and intellectual representation in opposition to materialist indulgences. With this came the emergence of an angry subculture, swearing off the materialist ties of the social conformists plaguing society with their blissful ignorance. Instead, they turned to an alternative fashion and music scene, constructing a bitter rivalry within the socially elite to see who can win the race to enlightenment. Apparently, via dyeing one’s hair black and wearing second or even third-hand clothing, this quintessential subversion will lead ultimately to nirvana. Literally.
Obvious enough to Cameron in the wake of his recent mental remapping, this "reverse-structuralism" would lead inevitably to failure in its demand for an institution to replace the one prior; the evolution of a failed revolution; certainty and assumption the tragic flaw. It’s all straight from the mouth of Paulo Freire.
Cameron’s own course of action seemed obvious—don’t be certain. By building up expectations and reliance upon assumption you segregate yourself from your ultimate range of potential. The night ahead was a blank chalkboard. Cameron, despite the seriousness of his past relationships, was virgin to a lot of things.
"I know a few girls who are single, Cam," Elena mouthed to the hollow chasm of Cameron’s consciousness as she threw on her jacket, bringing him screaming from his vacuous explorations and back into the blaring illumination of reality.
"Great," Cameron replied in an uplifting manner that fit him like a Doberman in a tutu. "I am up for meeting anyone you deem cool shit." Such trust Cameron displayed in Elena’s judgment. Yes, that’s right, I said YOU could pick out girls for me! So it was decided, and was done.
It seemed like an instant and they were in the dorms. Ahh, the familiar smell of social isolation in the evening. Herein lie row upon row of students who lean on the crutch of drug abuse and beer binging to combat their lack of social ties. Foreign and exempt from the culture of the city (and yes, there is one) surrounding their university, these students have no ties to their surroundings and will seldom reach out to take in what exists beyond the streets of the college and surrounding housing.
Faster than stereotypically imaginable, the girls on the floor had been rounded up and crammed into the only working, stuffy, ghetto-fabulous elevator that smelled like three days’ worth of malt liquor and vomit had been somehow implanted into the hard, plastic interior of the dimly lit deathtrap. Fourteen bodies each weighing on average one hundred forty pounds. Maximum weight… Where do they post that anyway???
Cameron had previously engaged in the usual "beer and circus" antics of college life, clinging to the coattails of his former dorm mates a couple of times his freshman year. He found the party scene to be one ephemeral, draining cycle. In terms of intellect, the women he met seldom had more to offer than a night of Cartoon Network at home, and none of the innocence. He could see their own selfish agendas wofting about them like the sorrowful stench of a djambe drum circle, dread-locked, deodorant-opposing hippies banging away. Why else would they need alcohol to get them laid, that is if men in fact are as horny as all the man-hating lesbians want us to think? To Cameron, it seemed like feminism had somehow changed ideologies from "up with women" in the sixties to its current motto, "down with men." Cameron, oppositely, was amused with the puppet show people enjoyed forcing upon one another, oblivious to the significance of their own actions.
Cameron, Elena and Cheeks brought up the rear of the caravan, the group walking briskly to avoid the chill of the February air, quickly wrapping itself around the frail frames of the scantily clad women leading the pack. The party bumped on only a few blocks from the dormitory, and soon enough the cavalry had reached the fort, each shaking off the breath of a deathly winter wind as they entered the sanctity of a house sweating from the inside, coughing forth bellows of hot, sticky warmth. The evolution of a fire code violation.
In the beginning there was a house. Not your typical, occupied, cluttered house, but the shell of a house; a house stripped down to its barest minimums, anything of value locked safely away from where "guests" could interfere.
Then, the word was spread, indigenous peoples leaking out word of the gathering. And then, once the slightest hint of a party slithered its way down the streets of private housing and into the nearby dorms, the students came like masses to worship, idolaters to metallic kegs stacked higher than God himself. Statistically, more than half of these masses were women.
"The mix is warm," Cheeks warned as he dipped his five-dollar plastic cup into the cooler full of whop. Elena was off in search of mixed drinks. Cameron didn’t mind the temperature, as long as the mix called for an ass load of liquor. He was a camel at an oasis, sucking in as much as he could before venturing out into the desolation of the dance floor. The fruit juices masked the liquor almost completely, but Cam could still feel it, burning below. Nine drinks and now I’m good. Thirteen? Ehh, even better.
Yet, instead of dancing, Cameron had found his way into the sweaty, back corner of the crowded basement to toke a pinchie-full of mid-grade Buddha, adding a calm, relaxed attitude to his drunk that was so vividly consuming him. Yet, despite his best-laid plans, Cameron remained in the shadows, not interacting with many of the girls to whom Elena had already introduced him. This isn’t where I need to look. Why can’t I follow through with my intentions? I talk so much and do so little.
"Excuse me," a red-haired girl said to Cameron, grabbing him by the arm. She had that "snotty ‘till I give you head" aura to her, and one of those fancy, petticoat jackets in her arm. Something I can do? Let me rephrase that… What can I do to get you to be perfect? "Are you taking coats," she asked. Wait a minute…
"Heh… What?" Cameron was astounded by the fire-crotch’s ignorance; he stood there, jaw agape.
"I asked you if you were taking coats," the fire crotch repeated, "you are standing in front of the coat racks. Don’t you live here?" Cameron whirled around to find the eyes of forty or so silhouettes, stacked neatly in rows, staring him down from the shadows. I am such a moron. Of course she would assume… No matter, just get out of this.
"Uhh, no but for you I can make an exception," Cameron said, managing to stamp "HORNY DRUNK RETARD" square on his forehead.
"Actually," the fox said, shaking her fluffy tail in rejection, "my friends and I have to leave now. Sorry." Why can’t she just be honest? There is so much more respect in honesty. Cameron slid away from in front of the coat racks and to an even darker corner near the stairs.
The dagger of drunken depression plunged into Cameron’s side, sweeping the strength from his legs and sending him crumpling back against the wall and then onto his ass. No one had yet to notice, Cameron was already hidden in the shadows of the stairwell. He clenched his fists and squinted his eyes to hold back the tears of an internal collapse in his chest. So this is vertigo. It felt as if all strength, both physical and emotional, had been suspended from him, and now only Cameron and his thoughts lay in symposium. The veil of confusion was pulled away, and from deep inside of himself, Cameron discovered an answer: himself. With all this circular bullshit he kept reintroducing to himself, he was only drifting further away from the warm shores of contentment. There were no reasons, only questions. You can only dredge through the same possibilities for so long. Fresh blood was needed.
At that moment, Cameron emerged from his shivering fetus of intoxication and arose to the tall, slender sophistication that originated in his very marrow. He swallowed back one more splash of lukewarm whop from his crumpled, semi-transparent cup, pitched it into the darkness and looked out among the masses. The shepherd and his flock.
Then, just as he had come to terms with the indecipherable complexity of the circumstances containing him at present, a beautiful girl emerged from the crowd like a savior in the Nile. Yet, instead of beginning with verbal communication, she proceeded to immediately rub her ass against Cameron’s genitals to the beat of Sir Mix-a-Lot. And your name is?
Cameron, gelatinous as a rotting squid on a spike, continued to lean motionlessly against a support beam until the girl lost interest and retreated in confusion. A smile meandered its way across Cameron’s face, dripping in subversive stubbornness, as every other guy in the room shook their head in confusion. At least she won’t remember it tomorrow; now everyone probably thinks I’m a flamer. These clothes aren’t helping me out in that department either. No matter, this is all just acting anyway…
Soon enough the man of the hour had his homophobia under control and he again remained at rest, his back to the pillar; potential energy. So this is what it feels like to have a backbone. His amazement with the plethora of beauty surrounding him had changed more quickly than the seasons in a calendar, to a horrid aftertaste of dissatisfaction. Cameron saw Cheeks and Elena nestled away by the keg, so content and so at home. From this sight Cameron could feel only envy. He wanted so much to find what they had discovered long ago, but compromise himself? Nonsense. What did Elena say to me? Lose all hope…
Cameron buttoned up his jacket and lit a cigarette he had bummed off a B-string football player earlier that evening, his own full pack resting snugly in his jacket pocket. Cheeks noticed the preparations across the room, but Cameron faked a smile and waved, soothing Cheek’s sense of obligation for the time being. A smile is the easiest thing to fake. Cheeks would call tomorrow to catch up on what he missed, a whole lot of nothing. As Cameron ascended the stairwell, fleeing the dungeon, he felt only remorse, a remorse that he had fooled himself into thinking he could be strung along by his cock like every other guy in the basement he had just bid adieu. Perfume drenched his nasal passages in the imagery of French whores smoking long, stuffy cigarettes as he scooted through a circle of girls crowding the entry way. A few of them gave him cock-eyed glances that Cameron couldn’t differentiate between wanting his body and solemn disapproval of his perceived independence. He took his chances with the latter.
Deep down, Cameron cared more about the imaginary pimples on his ass than he did about going home with some tramp that, with a little help from her trashy friends, could assemble the colors of a bag of Easter M&M’s with their collective tank tops. He exhaled one big lungful of smoke in the face of the haughtiest-looking girl of all, her breasts as characteristically overplayed as her condescending brow. As her eyes winced and she coughed amidst the opaque, twisting decay that he had summoned forth, Cameron could only grin in the defiance of a puppy shitting on an oriental rug instead of on a nearby newspaper.
And with that, a whirl of red pleather marked the Sexual Avenger’s exit from the party as he stumbled out the busted screen door and into the night alone. For once, Cameron thought, being alone is okay. He didn’t know whom or what he would encounter tomorrow, but he found a little peace in that. Finally, Cameron had done some evolving of his own.
© Nathan West 2002
Previously by Nathan West The Bone Whittler
< Reply to this Article
© Hackwriters 2002
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Vulkan 1.0 is now official, a low-level API that boosts performance across platforms
By Koh Wanzi - on 19 Feb 2016, 10:30am
Page 1 of 1 - Vulkan 1.0 is now official, a low-level API that boosts performance across platforms
The Khronos Group has released Vulkan 1.0, the first publically available version of the open-source Vulkan API specification and the next-generation iteration of OpenGL. Originally based on AMD’s proprietary Mantle API, Vulkan 1.0 promises large performance gains in games and other 3D applications by giving developers low-level control of graphics and CPU hardware, essentially allowing them to work “closer to the metal”.
Like DirectX 12, Microsoft’s low-level graphics API, Vulkan 1.0 offers additional performance by enabling applications to take better advantage of multi-threaded CPUs. In addition, it gives developers explicit control over the GPU and memory allocation.
Traditional graphics drivers that have been designed for APIs like OpenGL and DirectX 11 include a layer of significant context, memory and error management (handled by the graphics driver) between the application and the GPU. Because the application developer has no idea how the data is managed, it cannot fully account for unpredictable scenarios, which could potentially affect performance when the unexpected happens.
On the other hand, Vulkan allows the application to take control of things like memory allocation and CPU thread management, while the driver itself offers direct control of the GPU. This means simpler drivers that are more efficient and translates into a much-reduced API overhead, which is the amount of background work a CPU or GPU must do to interpret what a game is demanding from the hardware.
However, unlike DirectX 12, Vulkan will actually work across platforms, supporting Windows 7, Windows 8.1, Windows 10, Linux, and even Android. In fact, Valve – one of the biggest names in game development and distribution – has even gone so far as to recommend that developers choose Vulkan over DirectX 12 because of its cross-platform nature.
Still, there are certain drawbacks to adopting Vulkan. Because certain elements of hardware management are left to application developers, the language is more difficult to work with and using it would require a higher skill level and increase development costs. As a result, Vulkan is intended to complement rather than replace OpenGL, which is still being developed and improved.
Nevertheless, Vulkan will prove invaluable in situations where performance is a priority. For instance, when an application is suffering a CPU bottleneck, or when the absolute best performance is necessary. Developers might also turn to Vulkan if they want to create the smoothest experience possible. One clear application is in the development of VR applications, where fluid gameplay is integral to an immersive experience.
Developers like Unity, Epic, Valve, and Dice have said that they will support Vulkan, although none currently have games that take advantage of the API. On the GPU manufacturer front, both NVIDIA and AMD have released beta drivers that support Vulkan, although only NVIDIA’s driver has passed the Khronos Group’s conformance tests.
Source: Khronos Group
Tags: khronos vulkan
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arkansas razorback football history
The Hogs Reach the Century Mark
Join us on the 6th of each month for the newest blog in our series on hawg-tales.com. Feel free to make comments and suggestions for subjects that you would enjoy seeing. Be sure and tell your friends about us, so they can also take part. Thanks for your support. Be sure and Like us on Facebook at hawg-tales.
Keep the history alive!
Finally in 1908 the University had selected a head football coach that would last for more than three years. Having been born in Prague, Bohemia this 24 year old coach came to Fayetteville after a successful college career as a fullback for the famous Amos Alonzo Stagg at the University of Chicago. However in 1909, Hugo Francis Bezdek would become known for providing the incentive needed to change the former mascot name of Cardinals to the new name of Razorbacks. This season would also provide Arkansas' first undefeated season which would not happen again until the 1964 national championship season. Bezdek would go on to coach for a total of five seasons (1908-1912) before returning to the University of Oregon where he had started his coaching career in 1906.
In the next to his last season, the Hogs would record their largest score in Razorback football history. During the 1911 season the Hogs, as an Independent team, would post a record of 6-2-1 (loss to Texas, of course, 0-12 at Texas, and Kansas State 0-3 at Kansas, while a tie with Southwestern Texas 0-0 at Texas).
To everyone's surprise, this season would provide the historical game which would come in the initial meeting between Arkansas and the Missouri State Bears. As the season opener, the fans in Fayetteville were in for a real treat as they intently watched their Hogs put together the high scoring game that ended with a complete dismantling 100-0 shutout of Missouri State played on September 11. Arkansas' score sounds more like a present day basketball score, however this would prove to be the game that would go down as the one which would prove to be the Hogs' highest score and have no other to ever top in Razorback football history.
Since this historical meeting, the two teams have battled it out on the gridiron six other times. Arkansas has always come out on top in all of these meetings with the last one being played on September 3, 2011. Over the years the Hogs have put up a total of 345 points against 40 for Missouri State (of course, 100 of these are from the initial game in 1911).
Bezdek truly laid the cornerstone of the program when he came in as a Cardinal and left as a Razorback. Along the way, he would go on to lead the team to their first undefeated season and raise the bar for scoring all the way up to the century mark.
Join us next month, as we once again recall tales of the games, players, and coaches from the past.
Send us your name and e-mail address to receive a reminder of "hawg-tales" each month plus a FREE copy of the 1960's 45-rpm records in mp3 format to play on your computer, tablet, or smart phone. They make a great gift for any Razorback football history buff. Don't forget to let us know where you are from. WPS!
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Check if human
Glenn Short authors this blog. He is shown here with his daughter, although he didn't notice the orange and white outfit on her at the time. It would soon be burned.
1947 Cotton Bowl
1951 Ark. Vs Texas
1963 Texas Tech
1965 Texas Vs. Ark.
1971 Liberty Bowl
1982 Ark. Vs.SMU
1988 Ark. Vs UH
1998 Ark. Vs Tennessee
2001 Ark. Vs. Ole Miss
2003 Independence Bowl
22 Straight
7 Overtimes
Bill Burnett
Bill Montgomery
Bobby Burnett
Brandon Burlsworth
Buddy Bob Benson
Callin' The Razorbacks
Damn Texas Refs
Dennis Winston
Dickey Morton
First Bowl Game
First Conference Champs
Francis A. Schmidt
Hogs First Bowl Game
Hogs Vs. #1
Hugo Bezdek
Jack Mitchell
Jim Lindsey
John Clinton Futrall
Ken Hatfield
Lee Roy Campbell
"Lighthorse" Harry Jones
Light Hoss Harry
Powder River Pass Play
Preston Carpenter
Quarterbackin Man
Quinn Grovey
Razorback Red
Short Squashed Texan
The Big Red
The Ice Bowl
"Tommy" Thomsen
http://www.hawg-tales.com
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Nature Health Care
Human Health Care
Men Health Care
Women Health Care
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15 Everyday Habits to Boost Your Libido
By Celia Shatzman
Easy lifestyle tweaks that will crank up your sex drive.
The lowdown on lust
There are a couple of things that could be to blame if you're suffering from lagging libido, but luckily there's plenty you can do to turn it around. Watch this video for seven ways that you can improve your sex life.
Plan more date nights
If a fun Saturday night with your partner means streaming Netflix in sweatpants, it could be killing your sex drive. Rekindle your romance by getting out of the house for an old-fashioned date. Your dates don't need to be grand romantic evenings; just going to the movies or out to dinner can reignite the spark you felt when you first met. "If it's too expensive to hire a nanny, ask your friends with kids to watch yours for the night and offer to return the favor," says Leah Millheiser, MD, director of the Female Sexual Medicine Program at Stanford Hospital & Clinics. Chances are, they'll need a night out at some point too.
RELATED: 7 Quiet Sex Positions You Need When You're a Guest in Someone's House
Pop a different birth control pill
Elizabeth Renstrom for TIME
Hormonal changes take a big toll on your sex drive. Birth control pills can be one of the biggest perpetrators: they can reduce your body's production of testosterone, and in turn, your desire to get down. Certain varieties may even cause pain during sex.
Even if you're not on birth control, being aware of your hormonal status can help you dial in your libido. Prolactin, the nursing hormone, decreases estrogen and testosterone in breastfeeding women, which can wreak hormonal havoc. Additionally, Dr. Millheiser warns that menopause can bring a decrease in testosterone and estradiol, a type of estrogen.
RELATED: A Lot of What You've Been Told About the Side Effects of Birth Control Pill Is Probably False
Check other meds, too
Take a look at your medicine cabinet—your prescriptions could be behind your lower libido. Aside from birth control pills, common offenders include drugs for high blood pressure, gastroesophageal reflux disease (GERD), anxiety, and depression. "If a medication is the most likely culprit, discuss your concern with the prescribing doctor," says Dr. Millheiser. "It's possible that another treatment may be used with fewer side effects."
RELATED: The Truth About What Happens to Your Vagina When You Haven't Had Sex in a While
Divide household chores equally
After a long day of work, you might head home for your other full-time job: being a parent. "After the kids go to bed, there's often cleanup followed by work that you've brought home," says Dr. Millheiser. "As a result, intimacy gets pushed to the background." If you and your partner are both working full-time, keeping the division of household labor equal and ensuring one partner doesn't shoulder the whole burden will make both of you happier in the bedroom and out.
RELATED: What to Do if Your Sex Drive Is Higher Than His
Set your room up for romance
It's easy to get in the habit of letting your kids crawl into bed with you after they've had a bad dream, or sharing cuddle time with your cat or dog. These are major mood killers, says Dr. Millheiser, who suggests keeping the kiddos and pets out by simply locking the bedroom door at night. It may take some time to break these habits, but making the bed sexy again will make you more relaxed and ready for romance.
RELATED: What to Do if Your Sex Drive Doesn't Match Your Partner's
Add sex to your to-dos
Photo by Cathryn Lavery on Unsplash
We schedule doctor's appointments, work meetings, and drinks with friends—so why not sex? It's not the most romantic approach, but setting aside a specific time with your significant other means you're making a commitment to having an active sex life. This way, you'll feel compelled to keep the appointment and be less likely to make excuses.
RELATED: This Is How Often Most Couples Have Sex, According to Science
Use a lubricant
Getting in the mood can be almost impossible if sex is painful for you—but it doesn't have to be. One of the leading causes is dryness. "If vaginal dryness is causing pain during intercourse, try using a silicone-based sexual lubricant or a vaginal moisturizer," suggests Dr. Millheiser. "Silicone lubricants are longer-lasting and more moisturizing than the water-based alternatives. If this doesn't improve the situation, you may want to check with a gynecologist to see if vaginal estrogen therapy is appropriate."
RELATED: How to Use Lube to Make Sex So Much Better
De-stress before sex
Everyday stressors—your job, the leaky bathroom faucet—have a more powerful effect on your sex life than you may realize. Being stressed causes your body to produce more of the "fight or flight" hormone cortisol, which you need in small doses but can suppress the libido when your system produces an excess. Before you hit the sheets, find an easy way to clear your mind, whether it's taking a long bath or curling up with a good book.
RELATED: As if Having Depression Isn't Enough, It Can Also Ruin Your Sex Life. Here's How to Deal
Following a heart-healthy diet could help you turn up the heat between the sheets. A study published in the Journal of Sexual Medicine found a link between high cholesterol and women who have difficulty with arousal and orgasm. When cholesterol builds up in the arteries, it makes it harder for blood to flow; in the pelvic area, that can lead to less sensation, making it harder to achieve orgasm. Slash your cholesterol levels by loading up on fruits and veggies and cutting down on animal fats and whole-milk products.
RELATED: The Best and Worst Foods for His Penis
Eat aphrodisiacs
A growing body of research shows that certain vitamins and components can enhance sexual function and desire. Avocados, almonds, strawberries, and oysters are just a few foods that may set the mood. Here's the full list of foods for better sex.
RELATED: These Are the Aphrodisiacs That Might Actually Work
Examine your relationship
A slow sex drive may be a sign of broader relationship problems outside the bedroom. It could be bottled-up resentment over lots of minor issues (he left his toothbrush on the counter again?) or something bigger, like a lack of communication. "If the relationship quality needs professional help, find a licensed marriage and family therapist in your area," advises Dr. Millheiser. "If the relationship issue pertains only to sex, look for a certified sex therapist."
RELATED: These Are the Moves That Really Make Women Orgasm, According to Science
Go for a hike together
Or a run, gym class, cooking seminar—any hobby or interest that you and your partner can do together, suggests Dr. Millheiser. "This can strengthen your emotional connection, and feelings of support boost desire." In one study published in the Journal of Personality and Social Psychology, couples that engaged in new and exciting activities had greater satisfaction in their relationships. "New and exciting" is all relative, so depending on how adventurous you are, that could mean anything from trying out mountain biking to skydiving.
RELATED: 21 Signs You’ve Found Your Fitness Swole Mate
Exercise often
Less stress, an improved mood, and higher self-esteem are all health benefits of exercise—and together they can rev up your sex drive. In fact, a recent study found that women who were taking antidepressants and were experiencing a dulled libido (a common side effect) improved sexual satisfaction by doing three 30-minute sweat sessions per week.
RELATED: These Are the 5 Sex Positions That Burn the Most Calories
Sometimes, a slow sex drive winds up being one symptom of a larger medical problem. So if along with your low libido you begin noticing weight gain, dry skin, hair loss, and fatigue, don't ignore it—you may be among the 15 million Americans unknowingly suffering from a thyroid problem. A simple blood test will confirm a diagnosis, and it can be treated with medication. Dr. Millheiser warns that low libido is also linked to other medical disorders, including depression and chronic fatigue.
RELATED: 19 Signs Your Thyroid Isn't Working Right
No dice? Visit your doc
If your engine's still stalled after these lifestyle tweaks, prescription drugs may help. "Certain medications, such as testosterone or Wellbutrin, can be used on an off-label basis for the treatment of low libido and are only available with a prescription," Dr. Millheiser says.
RELATED: The Controversial 'Female Viagra' Drug Is Back–Here's What You Need to Know
To get our top stories delivered to your inbox, sign up for the The Hookup newsletter
1 of 16 The lowdown on lust
2 of 16 Plan more date nights
3 of 16 Pop a different birth control pill
4 of 16 Check other meds, too
5 of 16 Divide household chores equally
6 of 16 Set your room up for romance
7 of 16 Add sex to your to-dos
8 of 16 Use a lubricant
9 of 16 De-stress before sex
10 of 16 Eat clean
11 of 16 Eat aphrodisiacs
12 of 16 Examine your relationship
13 of 16 Go for a hike together
14 of 16 Exercise often
15 of 16 Listen to your body
16 of 16 No dice? Visit your doc
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Mar 04, 2019 More on Accountable Care
Providers await drop-out numbers for BPCI Advanced
There's pent-up demand to get into the model but first providers want to see if other participants are staying in.
Susan Morse, Senior Editor
Friday, March 1, was the deadline for providers in the bundled payments for care improvement advanced model to drop-out of the voluntary program.
The Centers for Medicare and Medicaid Services allowed providers to drop-out retroactively, if they found they were not meeting financial targets since starting the program on October 1, 2018.
CMS is expected to release an updated list of BPCI Advanced participants this spring.
Dave Terry, co-founder and CEO of convener Archway Health in Boston, said he expected about 25 percent to a third of his BPCI advanced clients to drop-out. Of the three-quarters staying in the program, about half will drop some bundles, he said.
The company is a convener for a mix of hospital and health systems, cardiology practices, orthopedics and oncology.
One factor that may help is that on Wednesday, CMS came out with a amendments to the BPCI Advanced participation agreement that make the program more attractive, he said.
The change most attractive to providers is the removal of the 50 percent cap on NPRA shared payments and partner distribution payments.
Participants that choose to execute the amendment will be bound by all of its terms and conditions effective on the date it is signed by CMS. Participants that choose not to execute the amendment will not bound by it or receive the benefits, CMS said in an email. The amendment will also be made available at a later time.
"Overall CMS has been good about responding to the market," Terry said. "They think about modifying the pricing and the use of trend factors."
BPCI Advanced counts as an advanced alternative payment model under MACRA. This is one reason for the robust interest by providers. An estimated 1,299 are in the program.
Meeting targets gives providers the incentive to invest in value-based initiatives.
But once a provider drops out, that incentive is diminished, Terry said.
"We're tracking closely what kind of participation there is," Terry said. "We expect to see a good number drop, especially orthopedic practices. The pricing for those episodes are tight."
The program is designed for providers which have room for improvement. The high-performing practices may decide to get out because there's little room to improve and meet their targets, he said.
"I think people generally like the model, but there's concerns about the pricing and the pace folks need to make decisions," he said.
Providers can choose from 32 clinical episodes, including 29 inpatient and three, outpatient. Payments are based on performance during a 90-day episode of care that continues after discharge or the outpatient procedure.
The average number of bundles per provider is about 10, or about 15,000 total bundles in the program, according to Terry, who expects to see less of a drop in cardiology and pulmonology than in orthopedics.
The BPCI Advanced Model was announced in January and runs from October 1 through December 31, 2023. CMS set a deadline of August 8, 2018, for organizations to decide whether to participate in the bundled payment model. But providers were given the opportunity to reassess their decision in March.
CMS is providing a second application opportunity. The next step will be another open enrollment period in the spring of this year for a January 1, 2020 start date.
Terry believes many providers will decide to get into the program then, but first they want to see how many were successful in the first advanced model, based on the number of dropouts.
"We talked to a lot of providers who thought about getting in but felt they didn't have time. We know there's a lot of pent up demand," Terry said. "I think what happens out of this March 1 drop period, if you see a lot of providers dropping out, it puts negative pressure on these folks unless (CMS) modifies the rules."
Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com
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Home / Columns / Terrorism and communal violence must carry same stigma and punishment
Terrorism and communal violence must carry same stigma and punishment
Stigma and law must apply equally to those who participate in terror crimes and to those who target people for their religious or caste identity
columns Updated: Mar 16, 2016 01:16 IST
Harsh Mander
Among the survivors of these crimes — many of whom fight epic and hopeless battles for justice like the widows of the 1984 Sikh massacre or the survivors of the 2002 Gujarat massacre — there is little popular outrage that these crimes go unpunished (Mohd Zakir/HT )
Three men have been marched to the gallows in recent years in India. All three were convicted of terror crimes. By contrast, I cannot recall a single person awarded the death penalty for communal violence since Independence.
Yakub Memon, convicted for complicity in the 1993 Bombay terror blasts, spent 21 years in prison without a day’s parole before his hanging. Maya Kodnani, convicted for being what the trial court described as the ‘kingpin’ in the 2002 massacre in Naroda Patiya which left 97 people dead — including 35 women and 36 children who were burnt alive, stabbed and dismembered — was awarded imprisonment for life. But she was granted three months’ bail in November 2013 for medical treatment, and the Gujarat High Court confirmed her bail for ill-health from July 2014, which continues until the time of writing.
In both popular, social common sense and the ways in which the laws are designed and implemented in India, there is an implied hierarchy of crimes, in which gravest crimes are seen to be those connected with terror and violence, meriting harsh laws, criminal procedures that severely curtail human rights of the accused, and stricter penalties including death. However, communal violence is akin to terror crimes because it is also driven by hate ideologies and target innocent populations with death and destruction. It is remarkable that these do not carry the same censure and disgrace as terror crimes, both in popular morality and in the framing and implementation of the law.
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This hierarchy of crimes was accepted in the Law Commission report, chaired by progressive Justice AP Shah, which recommended the abolition of the death penalty in all crimes except terror-related ones and waging war against the State. This same idea — that crimes of terror fall into a different category from other crimes, including those that target people for their religious and caste identities — is the rationale for special terror laws in India (as in many parts of the world). These laws dilute accepted standards of human rights protection of the accused. They permit statements before police officials as evidence admissible in courts, ignoring that such statements may have been coercively obtained by torture. They delay the period for communicating charges and submitting charge-sheets, and discourage bail.
There are some who argue that these human costs are regrettable but inevitable when the country battles the ever-looming perils of terror attacks; the costs of possible injustice to a small number are morally acceptable to protect the majority from terror violence. This is a deeply problematic position because justice is indivisible and injustice to some cannot result in authentic justice for the many. However, even in a practical sense, officially sanctioned and effected injustice can only breed fear and discontent that would further imperil the social order.
Remarkably, the same arguments are not applied to communal hate crimes. We have studied the aftermath of many communal massacres since Independence, and what binds them all is the pattern that few, if any, are punished for these crimes. This is the outcome of the communal bias or apathy of all arms of the criminal justice system: The police, prosecution, and courts; and the political, social and economic powerlessness of the victims of communal crimes. Among the survivors of these crimes — many of whom fight epic and hopeless battles for justice like the widows of the 1984 Sikh massacre or the survivors of the 2002 Gujarat massacre — there is little popular outrage that these crimes go unpunished. Unlike for terror crimes, there is no demand for special laws and procedures to ensure different standards of gathering evidence, issuing bail and punishment for those who commit hate crimes against persons of a particular religion or caste. We wish to see those responsible for the 1993 Mumbai blasts hang, but we are indifferent when those named guilty by the judicial commission for the Mumbai communal killings in 1992-93 continue to walk free.
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I am neither making a case for death penalty for perpetrators of communal violence, nor for the dilution of their basic human rights. What I am arguing is that both popular stigma and the imperative of law should apply equally to those who are alleged to participate in terror crimes as those who are charged with hate crimes targeting persons for their religious or caste identity. The selectivity of or popular outrage and the application of the majesty of the legal system reveals a very troubling underlying majoritarian bias in society and law. A majority of those charged with terror crimes are religious minorities. While a majority of those charged with communal crimes are from the majority Hindu community, its victims are mostly religious minorities.
If law and social outrage apply so differently when the minority is charged with hate crimes from when they are the paramount victims of mass hate crimes, then the promises of a secular Constitution — of equal treatment of all before the law — stands exposed, in tatters.
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Influenza of 1918 (Spanish Flu) and the US Navy
Influenza on a Naval Transport
Influenza-Related Medical Terms
The Pandemic of Influenza in 1918-1919
Philadelphia, Nurses, and the Spanish Influenza Pandemic of 1918
A Winding Sheet and a Wooden Box
Information in Relation to the Naval Protection Afforded to The Commerce of the United States in the West India Islands, &c. &c.
Information Operations, Electronic Warfare, and Cyberwar
Injury and Destruction of Navy Vessels by Earthquakes, Dec. 1868
Inquiry Into Occupation and Administration of Haiti and the Dominican Republic
Instances of Use of US Armed Forces Abroad, 1798 - 2004
Instructional Material for the Fight Against Enemy Propaganda
Instructions for the examination and entry into United States Ports in time of war
Instructions on Reception, Care and Training of Homing Pigeons
Inter-Allied Naval Relations and the Birth of NATO
Interrogation of General Alfred Jodl
Interrogations of Japanese Officials - Vol. I & II
Invasion of Sicily
The Invasion of Southern France: Aerology and Amphibious Warfare
Iran, Gulf Security, and U.S. Policy
Iran Hostage - Rescue Mission Report
Iran's Foreign and Defense Policies
Iran's Nuclear Program: Recent Developments
Irregular Enemies and the Essence of Strategy
Irregular Warfare Special Study
Islam: A Primer - Congressional Research Service Report for Congress
Islamic State and US Policy
Islamic Terrorism and the Balkans
Japan's Struggle to End the War - 1946
Japanese Interrogation Of Prisoners Of War
Japanese Naval and Merchant Shipping Losses - WWII
Japanese Naval Ground Forces
Japanese Naval Shipbuilding
Japanese Operational Aircraft CinCPOA 105-45
Japanese Operational Aircraft CinCPOA 105-45 Revised
Japanese Radio Communications and Radio Intelligence CinCPOA 5-45
Japanese - Smithsonian War Background Study
Japanese Story of the Battle of Midway
Action of AA Units
Enemy Action and Damage Suffered By Us
Part II - Plans
Part III - 7 Movement and Action Charts
Part V - Results
SUPPLEMENTARY TABLE NO. 3
Java Sea Campaign
Journal of the Disasters in Afghanistan, 1841-2
Kite Balloons in Escorts
Kosovo Naval Lessons Learned During Operation Allied Force
Korean War Chronology
June-December 1950
January-June 1951
July-December 1951
May-August 1952
January - April 1953
May-July 1953
Korean War Interim Evaluation No 1
Lost of Flight 19 Official Accident Reports
Landing Operations Doctrine, USN, FTP-167
Law of Naval Warfare: NWIP 10-2, 1955
Law of Naval Warfare: Chapters 1 - 6
Appendix A: Convention For the Adaption to Maritime War of the Principles of the Geneva Convention - X Hague, 1907
Appendix B: Convention Concerning the Rights and Duties of Neutral Powers in Maritime War - XIII Hague, 1907
Appendix C: Amelioration of the Condition of the Wounded and Sick
Appendix D: Geneva Convention for the Amelioration of the Condition of the Wounded, Sick, and Shipwrecked Members of Armed Forces at Sea of August 12, 1949
Appendix E: Geneva Convention Relative to the Treatment of Prisoners of War of August 12, 1949
Appendix F: Geneva Convention Relative to the Protection of Civilian Persons in Time of War of August 12, 1949
Appendix G-I
Lend Lease Act, 11 March 1941
Letter from President Harry S. Truman to Secretary of the Navy James V. Forrestal regarding the Five-Star Rank
Lengthy Deployment: The Jeannette Expedition In Arctic Waters
Library Regulations - USS Pittsburgh
Limited Duty Officer
List of Authorized Abbreviations for Use in Bureau of Naval Personnel Messages (1958)
List of Expeditions 1901-1929
List of Patrol Squadron Deployments to Korea During the War
Living Conditions in the 19th Century US Navy
Log of the trip of the president to the Casablanca Conference 9-31 January, 1943
The Logistics of Advance Bases
Look at YOU in the United States NAVY
Lookout Manual 1943
Loss of Flight 19 Official Accident Reports
LSU Squadron Two Thanksgiving Dinner November 22 1951
Magic Background of Pearl Harbor
Magic Background of Pearl Harbor Vol. 2
Magic Background of Pearl Harbor Vol. 2 Appendix
Main Navy Building: Its Construction and Original Occupants
Manual for Buglers, US Navy
Manual of Commands and Orders, 1945
Manual of Information Concerning Employments for the Panama Canal Service
Marine Amphibious Landing in Korea, 1871
Market Time (U) CRC 280
Master File Drawings of German Naval Vessels
Matthew Fontaine Maury: Benefactor of Mankind
Menu Thanksgiving Day November 27, 1913
Merchant Ship Shapes
Mers-el-Kebir Port Instructions for Merchant Vessels [1942]
Mess Night Manual
Midway in Retrospect: The Still Under Appreciated Victory
Midway’s Operational Lesson: The Need For More Carriers
Midway: Sheer Luck or Better Doctrine?
Midway's Strategic Lessons
Midway Plan of the Day Notes
Military Base Closures: Role and Costs of Environmental Cleanup
Military Service Records and Unit Histories
Mine Sweeping Manual 1917
Mine Warfare
Mine Warfare in South Vietnam
Miracle Harbor
Miracle Harbor 1
Miracle Harbor 10
Miscellaneous Actions in the South Pacific
Missile Defense: The Current Debate
More Bang for the Buck: U.S. Nuclear Strategy and Missile Development 1945-1965
My days aboard U.S.S. Santa Fe
Naming of Streets, Facilities and Areas On Naval Installations
Narrative of Captain W.S. Cunningham, US Navy Relative to events on Wake Island in December 1941, and subsequent related events
Narrative of Joshua Davis an American Citizen 1811
Narrative of the Capture, Sufferings and Escape of Capt. Barnabas Lincoln
Narrative of the March and Operations of the Army of the Indus
Narrative of the United States' Expedition to the River Jordan and the Dead Sea
Navajo Code Talker Dictionary
Navajo Code Talkers: World War II Fact Sheet
Naval Anecdotes Relating to HMS Leopard Versus USS Chesapeake, 24 June 1807.
Naval Armed Guard Service in World War II
Russian Convoys
German Surface Raiders
Naval Armed Guard at Bari, Italy
Japanese Atrocities
Normandy Invasion
Research about the Naval Armed Guard
Action at Okinawa
Battle of the Philippines
The Naval Bombing Experiments
An Account of the Bombing
Minutes of the Pre-Bombing Conferences
Naval District Manual 1927
Naval Districts
Naval Gun Factory (Washington Navy Yard) Facilities Data: World War II
Naval Guns at Normandy
Naval Memorial Service, Casting Flowers on the Sea in Honor of the Naval Dead
The Naval Quarantine of Cuba
Quarantine 22 - 26 Oct
Naval Transformation: Background and Issues for Congress
Naval Yarns by Captain Bartlett [manuscript]
The Navy by Michael A. Palmer
Navy Aegis Ballistic Missile Defense (BMD) Program
Navy Aegis Cruiser and Destroyer Modernization: Background and Issues for Congress
Navy and Defense Reform: A Short History and Reference Chronology
Navy and Marine Corps Awards Manual [Rev. 1953]
Pt. 1 - Personal Decorations
Pt. 2 - Unit Awards
Pt. 3 - Special and Commemorative Medals
Pt. 4 - Campaign and Service Medals
Pt. 5 - Decorations Awarded By Foreign Governments
Pt. 6 - Other Federal Decorations (non-military)
Memo - Changes
Ships & Other Units Eligible for the Korean Service Medal
Navy at a Tipping Point - 2010
Navy Civil War Chronology
Navy Columbia Class Ballistic Missile Submarine
Navy CVN-21 Aircraft Carrier Program
Navy DD(X) and CG(X) Programs
The Navy Department A brief history until 1945
Navy Department Communiques 1-300 and Pertinent Press Releases
Navy Department Communiques 301 to 600
Navy F/A-18E/F Super Hornet & EA-18G Growler Aircraft
Navy Filing Manual 1941
Navy Force Structure A Bigger Fleet
Navy Force Structure and Shipbuilding Plans - 2016
The Navy in the Cold War Era, 1945-1991
Navy Interdiction Korea Vol. II
Navy Irregular Warfare and Counterterrorism Operations 2011
Navy John Lewis (TAO-205) Class Oiler Shipbuilding Program
Navy Lasers, Railgun, and Hypervelocity Projectiles
Navy Littoral Combat Ship (LCS)/Frigate Program
Navy LX(R) Amphibious Ship Program
Navy Network-Centric Warfare
Navy Nurse Corps General Uniform Instructions 1917
The Navy of the Republic of Vietnam
Navy Records and [Navy Department] Library (E Branch)
Navy Regulations, 1814
Navy Ship Names - Sept 2016
Navy Ship Names - Jan 2016
Navy Ship Procurement: Alternative Funding Approaches
Navy Ship Propulsion Technologies - 2006
Navy Shipboard Lasers for Surface, Air, and Missile Defense
Navy Trident Submarine Conversion (SSGN) Program: Background and Issues for Congress
Navy Virginia (SSN-774) Class Attack
Navy-Yard, Washington, History by Hibben
The Navy's World War II-era Fleet Admirals
Forward Presence in the Modern Navy: From the Cold War to a Future Tailored Force
Historiography of Programming and Acquisition Management since 1950 - Hone
Historiography of Technology Since 1950
Naval Personnel since 1945: Areas for Historical Research
Navy, Science, and Professional History
The Social History of the U.S. Navy, 1945–Present
U.S. Navy’s Role in National Strategy
Writing U.S. Naval Operational History 1980–2010
Negro in the Navy - 1947
Negro in the Navy by Miller
Neutrality Instructions US Navy 1940
New Equation: Chinese Intervention into the Korean War
A New Look at the Cuban Missile Crisis
Nixon's Trident: Naval Power in Southeast Asia, 1968-1972 by John D. Sherwood
Nomenclature of Decks
Nomenclature of Naval Vessels
Non-Discrimination in V-12 Program
North Korea's Nuclear Weapons Program
North Korea's Second Nuclear Test [2009]
North Korean Ballistic Missile Threat to the United States
Northern Barrage and Other Mining Activities
Northern Barrage: Taking Up Mines
Northern Formosa, Pescadores
Notes on Anti-submarine Defenses ONI Publication No. 8
Notes on Writing Naval (not Navy) English
Nuclear Arms Control: The U.S.-Russian Agenda
Nuclear Weapons: Comprehensive Test Ban Treaty
Occupation of Kiska
Occupation of the Gilbert Islands
The Offensive Navy Since World War II: How Big and Why, A Brief Summary
Office of Naval Records and Library 1882-1946
Officers and Key Personnel Attached to the Office of Naval Records and Library 1882-1946
Officers of the Continental Navy and Marine Corps
Officers of Navy Yards, Shore Stations, and Vessels, 1 January 1865
Officers of the Continental and U.S. Navy and Marine Corps 1775-1900
Marine Corps Officers: 1798-1900
Continental Navy Officers: 1775-1785
Continental Marine Corps Officers: 1775-1785
Navy Officers: 1798-1900 (A)
Navy Officers: 1798-1900 (B)
Navy Officers: 1798-1900 (C)
Navy Officers: 1798-1900 (D)
Navy Officers: 1798-1900 (E)
Navy Officers: 1798-1900 (F)
Navy Officers: 1798-1900 (G)
Navy Officers: 1798-1900 (H)
Navy Officers: 1798-1900 (I)
Navy Officers: 1798-1900 (J)
Navy Officers: 1798-1900 (K)
Navy Officers: 1798-1900 (L)
Navy Officers: 1798-1900 (M)
Navy Officers: 1798-1900 (N)
Navy Officers: 1798-1900 (O)
Navy Officers: 1798-1900 (P)
Navy Officers: 1798-1900 (Q)
Navy Officers: 1798-1900 (R)
Navy Officers: 1798-1900 (S)
Navy Officers: 1798-1900 (T)
Navy Officers: 1798-1900 (U)
Navy Officers: 1798-1900 (V)
Navy Officers: 1798-1900 (W)
Navy Officers: 1798-1900 (Y)
Navy Officers: 1798-1900 (Z)
"Official" USS Missouri Survival Guide
Operation Crossroads
Composition of Joint Task Force One
Target Ships Sunk During Test Able 1 July 1946
Target Ships Sunk During Test Baker 25 July 1946
Disposition of Target Vessels
Operation NEPTUNE - The Invasion of Normandy
Table of Contents - Operation NEPTUNE
Editor's Note - Operation Neptune
Chapter 1: THE STRATEGIC BACKGROUND OF OVERLORD
Chapter 2: PLANNING AND PREPARATION FOR CROSS-CHANNEL (OVERLORD) OPERATIONS
Chapter 4: NEPTUNE OPERATIONS PLANS
Chapter 5: Naval Preparations for Cross-Channel Operations
Chapter 6: The Operation Begins
Chapter 7: Defensive Measures - NEPTUNE Operation
Chapter 8: Bombardment and Other Defensive Operations Against Enemy Land Forces
Chapter 9: The NEPTUNE Assaults
Chapter 10: The Build-up for the Battle of France
Operation NEPTUNE - Index
Operation NEPTUNE Administrative History's Table of Contents
Operation Neptune
Sunk and Damaged Ships and Craft
Operations of the Navy and Marine Corps in the Philippine Archipelago
Operations of the Seventh Amphibious Force
Operations of USS Don Juan de Austria
OPNAV [Office of the Chief of Naval Operations] Acronyms
Origin of Navy Terminology
Our Vanishing History and Traditions - Knox
Operation of the Admiral Scheer
Our Navy at War
Pacific Typhoon, 18 December 1944
Admiral Nimitz's Pacific Fleet Confidential Letter on Lessons of Damage in Typhoon
List of Commands and Ships Involved
Personnel Casualties Suffered by Third Fleet, 17-18 December 1944, Compiled from Official Sources
Aircraft Losses Suffered by Third Fleet, 17-18 December 1944, Compiled From Official Sources
Extracts Relating to the Typhoon from Commander in Chief, Pacific Fleet Report
Pacific Typhoon, June 1945 - Reports
Extracts from Commander Carrier Division Six Report
Extract from Report of Task Group Thirty-eight point one
Extract from Third Fleet Report
Pacific Typhoon October 1945 - Okinawa
Peacekeeping and Related Stability Operations: Issues of U.S. Military Involvement
The Pearl Harbor Attack, 7 December 1941 - Overview
Pearl Harbor Navy Medical Activities
"Pearl Harbor Revisited: USN Communications Intelligence"
Part-1
Notes on Sources
Pearl Harbor Salvage Report 1944
Pearl Harbor Submarine Base 1918-1945
Pearl Harbor: Survivor Reports
USS Arizona - Reports by Survivors of Pearl Harbor Attack
USS California- Reports by Survivors of Pearl Harbor Attack
USS Maryland - Reports by Survivors of Pearl Harbor Attack
USS Oklahoma - Reports by Survivors of Pearl Harbor Attack
USS Tennessee - Report by Survivor of Pearl Harbor Attack
USS West Virginia - Reports by Survivors of Pearl Harbor Attack
Pearl Harbor: Why, How, Fleet Salvage and Final Appraisal
Pentagon 9/11
Personal Identification Tags or "Dog Tags"
BUREAU OF NAVIGATION CIRCULAR LETTER NO. 57-41
BUREAU OF NAVIGATION CIRCULAR LETTER NO. 152-41
Perspectives on Enhanced Interrogation Techniques
Philadelphia Experiment
Philadelphia Experiment: ONR Information Sheet
Phonetic Alphabet and Signal Flags
Piracy Off the Horn of Africa
The Pivot Upon Which Everything Turned
Plea in Favor of Maintaining Flogging in the Navy
Pocket Guide to Hawaii
Pocket Guide to Japan
Pocket Guide to Netherlands East Indies
Pocket Guide to New Guinea and the Solomons
Port Chicago, CA, Explosion
Posse Comitatus Act and Related Matters: A Sketch
Post Mortem CIC [Combat Information Center] Notes
Post Mortems on Enemy Ships
Potato Famine of 1847
Precisely Appropriate for the Purpose
Preserving an Honored Past
Priceless Advantage by FD Parker
Propaganda Foreign Military Studies 1952
Public Law 333, 79th Congress
Q-ships during World War II
Radio Intelligence Appreciations Concerning German U-Boat Activity in the Far East
Radio Proximty (VT) Fuzes
Ready Seapower: A History of the US Seventh Fleet by Edward J. Marolda [pdf]
Recollections of Capture by the Germans, Imprisonment, and Escape of Lieutenant Edouard Victor Isaacs, U.S.N.
Recollections of Ensign Leonard W. Tate
Recollections of Lieutenant Commander William Leide
Recollections of Lieutenant Wilton Wenker and Lieutenant Elby Concerning the Crossing of the Rhine River in 1945
Recollections of USS Pampanito's rescue of prison ship survivors by Lieutenant Commander Landon Davis
Recollections of Vice Admiral Alan G. Kirk Concerning the Crossing of the Rhine River in 1945
Reestablishment of the Marine Corps
Registers of the Navy
Register of the Navy, 1812
Register of Patients at Naval Hospital Washington DC 1814
Register of USN & USMC Officer Personnel 1801-1807 [pdf]
Regulation, December 7, 1841
Regulations for the Information of Officers On Neutrality Duty in Connection With the Visits of Belligerent Vessels of War [1916]
Regulations For Powder Magazines and Shell Houses 1874
Regulations Governing the Uniform of Commissioned Officers 1897
Reincarnation of John Paul Jones The Navy Discovers Its Professional Roots
Religions of Vietnam
Remarks on Protection of a Convoy by Extended Patrols
Remarks on Submarine Tactics Against Convoys
Reminiscences of Seattle Washington Territory and the U. S. Sloop-of-War Decatur
Report by the Special Subcommittee on Disciplinary Problems in the US Navy
Reports of Arica, Peru Earthquake from USS Powhatan and USS Wateree
Republic of Korea Navy
Resolution of the Continental Congress, 11 December 1775
Resolution of the Continental Congress, 25 November 1775
Resolution of the Continental Congress establishing the Marine Corps - 10 November 1775
Hyman G. Rickover's Promotion to Admiral [H.A.S.C. 93-16]
Ringle Report on Japanese Internment
Riverine Warfare Manual [1971]
Riverine Warfare: The US Navy's Operations on Inland Waters
Rocks and Shoals: Articles for the Government of the U.S. Navy
The Recruitment of African Americans in the US Navy 1839
The Role of COMINT in the Battle of Midway
The Role of the United States Navy in the Formation and Development of the Federal German Navy, 1945-1970
Rommel and the Atlantic Wall
Royal Works USS Lexington [Crossing the Line 1936]
Rules for the Regulation of the Navy - 1775
The Russian Navy Visits the United States
Sailors as Infantry in the US Navy
Sailors as Infantry Appendices
The Sailors Creed
Samoan Hurricane
A Sampling of U.S. Naval Humanitarian Operations
Seabee History
Seabee History - Introduction
Seabee History - World War II
Seabee History - 1946-1960
Seabee History - Vietnam
Seabee History - After Vietnam
Seabee History - Desert Shield/Desert Storm
Secretary of the Navy's Report for 1900 on the China Relief Expedition
Selected Documents of the Spanish American War
Battle of Manila Bay
Battle of Manila Bay: Miscellaneous Documents
Olympia in Battle of Manila Bay
Raleigh in Battle of Manila Bay
Concord in Battle of Manila Bay
Baltimore in Battle of Manila Bay
Petrel in Battle of Manila Bay
Boston in Battle of Manila Bay
McCulloch in Battle of Manila Bay
U.S. Consul at Manila
Official Spanish Report on Battle of Manila Bay
Selected Groups in the Republic of Vietnam
Selected Groups/Republic Vietnam - The Binh Xuyen
Selected Groups/Republic Vietnam - The Cao Dai
Selected Groups/Republic Vietnam - The Cham
Selected Groups/Republic Vietnam - The Chinese
Selected Groups/Republic Vietnam - The Khmer
Seventh Amphibious Force - Command History 1945
Shelling of the Alaskan Native American Village of Angoon, October 1882
Ship to Shore Movement
Ship Shapes Anatomy and types of Naval Vessels
Shipboard Ettiquette [Naval R. O. T. C. Pamphlet No. 16]
Shiploading - A Picture Dictionary
Ships named for Individual Sailors
Ships named for Individual Sailors - Citations
Ships Present at Pearl Harbor
Ships Sunk and Damaged in Action during the Korean Conflict
A Short Account of the Several General Duties of Officers, of Ships of War: From an Admiral, Down to the Most Inferior Officer
Short Guide to Iraq
The Sicilian Campaign, Operation 'Husky'
Signals for the Use of the Navy of the Confederate States
Sinking of C.S.S. Alabama by U.S.S. Kearsarge - 19 Jun 1864
Sinking of the Bismarck
Bismarck: The Cruise of the Bismarck
British/American Cooperation
The Scouting and Search for Bismarck
Selected Sources on the German Battleship Bismarck
The Sinking of the German Battleship Bismarck as Described in the B.d.U. [Commander U-boats] War Log, 24-31 May 1941
Sinking of the USS Guitarro
The Sinking of the USS Housatonic by the Submarine CSS H.L. Hunley
Sinking of USS Indianapolis - Press Releases & Related Sources
Memorandum to Press on Scheduled Testimony
Narrative of the Circumstances
Navy Department Press Release
Skill in the Surf: A Landing Boat Manual
Chapter I. Landing Boats Are Important!
Chapter II. Landing Craft From Troy to Tokio
Chapter III. Know Your Boat!
Chapter IV. Know Your Job!
Chapter V. Keep It Running!
Chapter VI. The Coxswain Takes Over
Chapter VII. Learning the Ropes
Chapter VIII. The Salvage Boat
Chapter IX. Where Sea Meets Land
Chapter X. Hit That Beach!
Chapter XI. Information, Please!
Skunks, Bogies, Silent Hounds, and the Flying Fish
Slapton Sands: The Cover-up That Never Was
Small Wars Their Principles and Practice
Smith, Melancton Rear Admiral USN A Memoir
Smoker Sat., July 27, 1918 U.S.S. Arizona
So You are Going to the South Pacific?
Soldier's Guide Bosnia-Herzegovina
Solomon Islands Campaign: I The Landing in the Solomons
Solomon Islands Campaign: II Savo Island & III Eastern Solomons
Solomon Islands Campaign: IV Battle of Cape Esperance
Solomon Islands Campaign: X Operations in the New Georgia Area 21 June-5 August 1943
Some Experiences Reported by the Crew of the USS Pueblo and American Prisoners of War from Vietnam
Some Memorandums Construction of Ships Frederick Tudor
Somers, essay on legal aspects of Somers Affair
Sources on US Naval History by State
Report of the Secretary of the Navy, 1898 Part 1
Report of the Secretary of the Navy, 1898 Part 10
Spanish-American War; War Plans and Impact on U.S. Navy
Special Order 1865 April 17 Assemblage of Officers to Attend
Special Order 1865 April 17 Navy Department Closure
Special Order 1865 April 17 Officers to Attend Funeral
Special Order 1865 April 20 List of Officers to Accompany Remains
Special Order No. 73 - 1905 April 18 Travel Pay
Specifications for Ship and Motor Boat Bells
Composition and Acoustic Properties
Bell Clapper
Sports in the Navy: 1775 to 1963
Stalin's Cold War Military Machine: A New Evaluation
Statement Regarding Winds Message
The Story Of The Confederate States' Ship Virginia
Strait Comparison: Lessons Learned from the 1915 Dardanelles Campaign
Strategic Concepts of the U.S. Navy (NWP 1 A)
Striking the Flag
Structural Repairs in Forward Areas During WWII
Study of the General Board of the U.S. Navy, 1929-1933
Submarine Activities Connected with Guerrilla Organizations
Submarine Sighting Guide ONI 31-2A
ONI 31-2A PDF
Submarine Sighting Guide ONI 31SS-Rev. 1
Submarine Silhouette Book No. 1
Submarine Turtle Naval Documents
Surprised at Tet: U.S. Naval Forces in Vietnam, 1968
Survey of the Amazon- Selfridge
Survival of the Collection of the Navy Department Library
Syria's Chemical Weapons: Issues for Congress
Tactical Lessons of Midway
Target Information From CIC [Combat Information Center]
Terminology and Nomenclature
Terrorism in Southeast Asia
Terrorism: Some Legal Restrictions on Military Assistance
Terrorist Attack on USS Cole: Background and Issues for Congress
This is Ann - Malaria
Time of Change: National Strategy in the Early Postwar Era
Titanic Disaster: Report of Navy Hydrographic Office
Tokyo a Study in Jap Flak Defense
Tokyo Bay: The Formal Surrender of the Empire of Japan
Tonkin Gulf Crisis
Tonkin Gulf Crisis, August 1964 - Summary
Formerly Classified Documents from 2 August - 4 August 1964
Formerly Classified Documents Subsequent to 4 August 1964
Publicly Released Information
Gulf of Tonkin the 1964 Incidents
Gulf of Tonkin the 1964 Incidents [Part II]
Acronyms, Abbreviations, and Code Words
Tonkin Gulf Crisis Select Bibliography
Torpedo War - Rodgers - Fulton
Training Ships
The Trial of Admiral Doenitz
Tsunami (Tidal Wave) Disasters
20th Century Warriors: Native American Participation in the United States Military
Typhoons and Hurricanes: The Effects of Cyclonic Winds on US Naval Operations
Typhoons and Hurricanes: The Storm at Apia, Samoa, 15-16 March 1889
U-94 Sunk By USN PBY Plane and HMCS Oakville 8-27-42
U-162 Sunk By HM Ships Pathfinder, Vimy, and Quentin 9-3-42
U-210 Sunk By HMCS Assiniboine 7-6-42
U-352 Sunk By U.S.C.G. Icarus 5-9-42
U-505 Sinking
U-571, World War II German Submarine
U-595 Scuttled and Sunk Off Cape Khamis, Algeria 11-14-42
U-701 Sunk By US Army Attack Bomber No. 9-29-322, Unit 296 B.S. 7-7-42
U-Boat War in the Caribbean: Opportunities Lost
Ultra and the Campaign Against U-boats in World War II
Underwater earthquake disasters and the U.S. Navy
Uniform Regulations, 1797
General Regulations: Full Dress, Undress, Service Dress
Coats, Overcoats, Jackets
Cuff and Sleeve Ornaments
Pantaloons, Vests
Part 1: Rear Admiral to Ensign
Part 2: Engineer Corps
Part 3: Professors, Secretaries
Part 4: Medical Corps
Part 5: Chaplains, Paymasters
Part 6: Naval Constructors
Part 7: Regulations for Wearing Shoulder Straps
Cap and Cap Ornaments
Straw Hats, Sword and Scabbard, Sword-Belt, Sword-Knot, Buttons, Cravat
Dress for Petty Officers and Crew
Uniform Regulations, Women's Reserve, USNR, 1943
Uniforms of the US Navy
Uniform-Buttons
Chief Petty Officers' Uniforms U.S. Navy
Cold-Weather/Foul-Weather Wear
Gas Masks and Breathing Apparatus U.S. Navy Uniform
Hats/Caps
Uniform and Dress of the Navy of the Confederate States
Insignias U.S. Navy Uniform
Maintenance/Care of Uniforms
Men's Uniforms
Pants/Bell-Bottoms
Seabags
Navy Seabags
Shirts/Jumpers
Naval Uniforms, misc.
Women's Uniforms
Petty Officer Rating Badge Locations and Eagle Designs
Uniform Changes
Historical Surveys of the Evolution of US Navy Uniforms
History of US Navy Uniforms, 1776-1981
Identification Tags ("Dog Tags")
United States Atlantic Fleet Organization 1942
United States Pacific Fleet Organization, 1 May 1945
United States Naval Hospital Ships
United States Naval Railway Batteries in France
United States Navy and the Persian Gulf
United States Navy and World War I: 1914–1922
United States Navy's World of Work
United States Submarine Losses World War II
Notes to US Submarine Losses in World War II
Albacore (SS 218)
Amberjack (SS 219)
Argonaut (SS 166)
Barbel (SS 316)
Bonefish (SS 223)
Bullhead (SS 332)
Capelin (SS 289)
Cisco (SS 290)
Corvina (SS 226)
Darter (SS 227)
Dorado (SS 248)
Escolar (SS 294)
Flier (SS 250)
Golet (SS 361)
Grampus (SS 207)
Grayback (SS 208)
Grayling (SS 209)
Grenadier (SS 210)
Growler (SS 215)
Grunion (SS 216)
Gudgeon (SS 211)
Harder (SS 257)
Herring (SS 233)
Kete (SS 369)
Lagarto (SS 371)
Perch (SS 176)
Pickerel (SS 177)
Pompano (SS 181)
R-12 (SS 89)
Robalo (SS 273)
Runner (SS 275)
S-26 (SS 131)
Scamp (SS 277)
Scorpion (SS 278)
Sculpin (SS 191)
Sealion (SS 195)
Seawolf (SS 197)
Shark I* (SS 174)
Shark 2* (SS 314)
Snook (SS 279)
Swordfish (SS 193)
Tang (SS 306)
Trigger (SS 237)
Triton (SS 201)
Trout (SS 202)
Tullibee (SS 284)
Wahoo (SS 238)
German U-Boat Casualties in World War Two
Italian Submarine Casualties in World War Two
Japanese Submarine Casualties in World War Two (I and RO Boats)
Unmanned Vehicles for U.S. Naval Forces: Background and Issues for Congress
US Democracy Promotion Policy in the Middle East
US-Greek Naval Relations Begin
US Marines at Pearl Harbor
US Mining and Mine Clearance in North Vietnam
US Naval Detachment in Turkish Waters, 1919-1924
US Naval Forces in Northern Russia 1918-1919
US Naval Plans for War with the United Kingdom in the 1890s
US Naval Port Officers in the Bordeaux Region, 1917-1919
US Navy Abbreviations of World War II
Navy Numbers
US Navy and Hawaii-A Historical Summary
Pearl Harbor: Its Origin and Administrative History Through World War II
Development of the Naval Establishment in Hawaii
The World War II Years
US Navy at War Second Official Report
US Navy at War Final Official Report
US Navy Capstone Strategies and Concepts (1970-1980)
US Navy Capstone Strategy, Policy, Vision and Concept Documents
US Navy Code Words of World War II
US Navy Congo River Expedition of 1885
US Navy Forward Deployment 1801-2001
US Navy in Desert Shield/Desert Storm
Overview: Desert Storm - The Role of the Navy
The Gathering Storm
A Common Goal - Joint Ops
Bullets, Bandages and Beans - Logistic Ops
Thunder and Lightning - The war with Iraq
Appendix B: Participating Naval Units
Appendix A: Chronology - August 1990
Appendix A: Chronology - September 1990
Appendix A: Chronology - October 1990
Appendix A: Chronology - November 1990
Appendix A: Chronology - December 1990
Appendix A: Chronology - January 1991
Appendix A: Chronology - January 1991 cont.
Appendix A: Chronology - February 1991
Appendix A: Chronology - March 1991
Appendix A: Chronology - April 1991
Appendix C: Allied Participation and Contributions
Appendix D: Aircraft Sortie Count
Appendix E: Aircraft Readiness Rates
Appendix F: Aircraft and Personnel Losses
Appendix G: Naval Gunfire Support
Appendix H: Surface Warfare
Appendix I: Unmanned Aerial Vehicles
Appendix K: Sealift
Appendix L: Airlift
US Navy in the World (2001-2010)
US Navy instruction for the destruction of signal books, 1863
Truxtun Signal Book
1813 Signal Book
US Navy Interviewer's Classification Guide
US Navy Libraries
US Navy Libraries: Historic Documents
US Navy Motor Torpedo Boat Operational Losses
US Navy Nurse Corps General Uniform Instructions, 1917
US Navy in Operation Enduring Freedom, 2001-2002
US Navy Personnel in World War II: Service and Casualty Statistics
US Navy Personnel Strength, 1775 to Present
US Navy Sailors Operating Ashore as Artillerymen Roth
US Navy Ships Lost in Selected Storm/Weather Related Incidents
US Navy Special Operations in the Korean War
US Navy Submarines Losses, Selected Accidents, and Selected Incidents of Damage Resulting from Enemy Action, Chronological
US Occupation Assistance: Iraq, Germany and Japan Compared
US Occupation of Haiti, 1915-1934
US Periods of War and Dates of Recent Conflicts
US Prisoners of War and Civilian American Citizens Captured
US Radar: Operational Characteristics of Radar Classified by Tactical Application
US Special Operations Forces (SOF): Background and Issues for Congress
Use of Naval Forces in the Post-War Era
U.S.S. Colorado BB-45 Diary
U.S.S. Searaven S.S. 196 4 July 1945
USS Constitution's Battle Record
Cutting Out Expedition, 1800
Bombardment of Tripoli, 1804
Escape from an Enemy Squadron, 1812
Engagement with HMS Guerriere
USS Constitution vs. HMS Java, 1812
USS Constitution, Capture of Cyane and Levant
Seizing a Slaver, 1853
USS John S. McCain (DDG 56) Memorial Ceremony
USS Kearsarge Rescues Soviet Soldiers, 1960
USS Monitor Versus CSS Virginia and the Battle for Hampton Roads
USS Pirate; Selected documents on the Salvage of USS Pirate and USS Pledge
USS Vega, Report of Pearl Harbor Attack
USS West Virgina, Report of Salvage, Pearl Harbor
The U.S. Navy Enlistment, Instruction, Pay and Advancement
V-22 Osprey Tilt-Rotor Aircraft
Vessels Lost and Salvaged, Report of the Secretary of the Navy, 1916
Vessels of the Continental Navy
Vieques, Puerto Rico Naval Training Range: Background and Issues for Congress
Viet-Nam Free-World Challenge in Southeast Asia
Viet-Nam: The Struggle for Freedom
Viet-Nam: The Third Face of the War
Voyage of the Jamestown on Her Errand of Mercy
Vietnamese Naval Intelligence
Walking Tour of Leutze Park
Journal of Captain Edward Preble
Report of Ensign Fredrick Pearson
Report of Commodore D.B. Ridgely
War Damage Reports
Destroyer Report - Gunfire, Bomb and Kamikaze Damage
Destroyer Report - Torpedo and Mine Damage and Loss in Action
Submarine Report - Vol. 1, War Damage Report No. 58
Summary of War Damage to U. S. Battleships, Carriers, Cruisers and Destroyers 17 October, 1941 to 7 December, 1942
USS Birmingham CL62 War Damage Report No. 48
USS Boise CL47 War Damage Report No. 24
USS Canberra CA70 War Damage Report No. 54
USS Capella AK13 & USS Alhena AKA9 War Damage Report No. 27
USS Chincoteague AVP24 War Damage Report No. 47
USS Enterprise CV6 War History 1941 - 1945
USS Franklin CV-13 War Damage Report No. 56
USS Helena CL50 War Damage Report No. 43
USS Honolulu CL48 War Damge Report No. 1
USS Houston CL81 War Damage Report No. 53
USS Independence CVL22 & USS Denver CL58 War Damage Report No. 52
[USS] Joseph Hewes APA22 War Damage Report No. 32
USS Lexington CV2 War Damage Report No. 16
USS Liscome Bay CVE56 War Damage Report No. 45
USS New Orleans CA32 War Damage Report No. 38
USS North Carolina BB55 War Damage Report No. 61
USS Northampton CA26 War Damage Report No. 41
USS O'Brien DD415 War Damage Report No. 28
USS Princeton CVL23 War Damage Report No. 62
USS Quincy CA39, Astoria CA34 & Vincennes CA44 War Damage Report No. 29
USS San Francisco CA38 War Damage Report No. 26
USS Saratoga CV3 War Damage Report No. 19
USS South Dakota BB57 War Damage Report No. 57
War Instructions United States Navy 1944
Wardroom NavPers 10002-A
Wartime Diversion of US Navy Forces in Response to Public Demands for Augmented Coastal Defense-CNA
Wartime Instructions for United States Merchant Vessels 1942
Washington Navy Yard: History of the Naval Gun Factory, 1883-1939
Washington Navy Yard - Pay Roll of Mechanics and Labourers, c1819-1820
WAVE QUARTERS D STATION RULES FOR LIFE AT D
WAVE QTRS. D
[UPDATED] Washington Navy Yard Station Log November 1822 - December 1889
Washington Navy Yard Station Log Images
We Will Stand in Viet-Nam
Who Will Do What With What
Why is the Colonel Called "Kernal"?
Enlisted Ranks
The Story Behind Names of Different Ranks
History of Warrant Officers in the US Navy
With a View to Publication
Women in the Navy
Women's Uniform Regulations, Yeoman (F), US Naval Reserve Force, 1918
Women's Winter Uniform Regulations, Yeoman (F), US Naval Reserve Force, 1919
World War I British and German Naval Messages (1918)
World War II Casualties
World War II Invasion of Normandy 1944 Interrogation of Generalleutnant Rudolf Schmetzer
What is CORDS
Yangtze River Patrol and Other US Navy Asiatic Fleet Activities in China
Yemen: Civil War and Regional Intervention
List of Z-grams
Z-Gram 1
Z-Gram 10
Z-Gram 100
Vietnam Conflict 1962-1975
Colloquium on Contemporary History September 29, 1998 No. 11
Opening Remarks - Dr. Edward J. Marolda
Duty, Duplicity, and Design: The Army's Reaction to Tet - Colonel Harry G. Summers, USA (Ret.)
Creating a Main Line of Resistance: Tet and the Genesis of Operation Sea Lords - Dr. Leslie J. Cullen
The Impact of Tet on the U.S. Air Force - Bernard C. Nalty
Speakers' Biographies
by Dr. Edward J. Marolda
Senior Historian
Naval Historical Center
I am Ed Marolda, Senior Historian of the Naval Historical Center, located here in the historic Washington Navy Yard.
On behalf of the Director of Naval History, Dr. William S. Dudley, who unfortunately could not be with us this morning, I welcome you to the Naval Historical Center's Colloquium on Contemporary History. Today's conference is the eleventh in this series of morning gatherings that focus on issues affecting the U.S. Armed Forces in the modern era. We provide a forum for the exchange of new interpretations, approaches, and information. We also hope to nourish lasting professional contacts among those of us interested in national and international security issues. Past conferences have dealt with such topics as the birth of NATO, joint operations in Korea, women in combat, and ballistic missile development.
Today's colloquium is entitled Tet: The Turning Point in Vietnam. Many Americans remember the Communist Tet Offensive of 1968 as an unmitigated disaster for the U.S. armed forces. They have images of dead GIs and Viet Cong sappers scattered around the grounds of the U.S. Embassy in Saigon; of bandaged and bloody Marines clinging on top of a tank in the devastated old Imperial Capital of Hue; of aircraft burning on the tarmac at Tan Son Nhut air base; and Navy river patrol boats firing into their own overrun bases ashore in the Mekong Delta. One can visualize Walter Kronkite, "Uncle Walty," suggesting in his deep, sonorous voice on the CBS Evening News that the war is lost; and a sad-faced, exhausted Lyndon Johnson announcing to the American people that he was halting the bombing in most of North Vietnam and that he would not seek reelection in November 1968. This was a clear admission that his war leadership and his strategy for Southeast Asia, such as it was, had failed. Shocked by this turn of events and pessimistic about the future, after Tet an increasing number of Americans pressed for the withdrawal of U.S. forces from Vietnam.
What was the real impact of Tet and the enemy's post-Tet offensives on American arms? Were our forces bloodied and beaten in the field, compelled to withdraw to more secure enclaves, to avoid casualties, to surrender the countryside to the Communists, and to cease bombing enemy supply lines in North Vietnam? That may be the image that many Americans have, but as we will learn today the reality was quite different.
The U.S. military developed new strategies and tactics for fighting the war that were anything but retrenchments or retirements. U.S. Army, U.S. Marine, and ARVN (Army of the Republic of Vietnam) troops aggressively attacked North Vietnamese and Viet Cong forces the length and breadth of the country; the Navy pushed its units right up to the border with Cambodia and into the deepest reaches of the Mekong Delta; and Air Force and Navy aircraft squadrons redoubled their interdiction efforts in southern North Vietnam and Laos. We hope to learn much more today about the innovative strategic, tactical, and technological approaches adopted by the American military in the period after Tet.
A common complaint many of us have is that Stanley Karnow, Neil Sheehan, and other writers routinely give short shrift to the five years of battle after Tet. Clearly, they consider the period anticlimactic and irrelevant to the outcome of the war. Some historians, especially Ron Spector in his book After Tet have begun to reverse that trend, and I am confident that the papers and discussion we hear today, the result of serious scholarship and thoughtful analysis, will take us even further along that bearing.
Duty, Duplicity, and Design the Army's Reaction to TET
Colonel Harry G. Summers Jr., USA (Ret.)
"You know you never beat us on the battlefield," I said to my North Vietnamese Army (NVA) counterpart in Hanoi a week before the fall of Saigon. "That may be so," he replied, "but it is also irrelevant." His words applied not only to the war as a whole but to the 1968 Tet Offensive in particular. For the American military that offensive was a grand paradox. At the battlefield tactical level, the enemy was defeated and turned back at every turn without achieving any territorial gain. At the theater-of-war operational level, their Tong Cong Kich/Tong Khoi Ngia (General Offensive/General Uprising) campaign was an absolute failure. Not only did the South Vietnamese people fail to flock to their banners, the South Vietnamese military stood firm and their own Viet Cong guerrilla forces were so decimated that they ceased to be an effective fighting force for the remaining seven years of the war.1
But at the strategic level, the Tet Offensive was an unmitigated disaster for the United States. The American people saw it as a defeat and were confirmed in their belief, arrived at the previous October, that sending troops to Vietnam had been a mistake.2 Many believed that the media was responsible for turning a tactical and operational military victory into a strategic political defeat. But as the late Peter Braestrup argued in his classic account of media reporting on the Tet Offensive, that blame was misplaced. While some of the media reporting was distorted, the real reason for the debacle was the void created by President Lyndon Johnson's "psychological defeat." His two months of inaction after Tet allowed critics to define the terms of this perceived disaster.3
Deception and Design
A major reason for President Johnson's psychological defeat was that he had been ill served by his senior civilian and military advisors, including Secretaries of Defense Robert S. McNamara and Clark Clifford and General Earle Wheeler, the Chairman of the Joint Chiefs of Staff. Particularly duplicitous was Defense Secretary Robert McNamara. By law the Secretary of Defense, not the Chairman of the Joint Chiefs of Staff as most civilians assume, is the military's "general-in-chief." As such he is in direct command of all U.S. armed forces in the field.
That command places an enormous demand on his will and his strength of character. As the great military philosopher Carl von Clausewitz emphasized in 1832, anyone can lead when all is going well. But when disaster strikes, everything "comes to rest on the will of the commander alone." It is his spirit that "must rekindle the flame of purpose in all others." If he cannot, "the mass will drag him down to the brutish world where danger is shirked and shame is unknown." As Clausewitz concludes, "the higher the position, the greater the strength of character he needs to bear the mounting load."4
But McNamara proved to be a man of no character whatsoever. Although President Johnson had charged him with winning the war, McNamara betrayed him and the soldiers, sailors, airmen and marines under his command from the outset. During his testimony in the 1984 CBS-Westmoreland libel trial, McNamara said that he had come to the belief as early as 1965 or 1966 that the war "could not be won militarily."5 That belief, however, did not prevent him from sending thousands of American men and women-myself included-into harms way in Vietnam and getting many of them killed in a war that he did not believe was winnable. To add insult to injury, in an August 3, 1992 Newsweek article he bragged that while he was sending the troops into battle he was schmoozing with the leaders of the anti-war movement to show what a sensitive and politically correct guy he had been.
The magnitude of McNamara's failings is revealed by comparing him with his counterpart, North Vietnam's Defense Secretary Vo Nguyen Giap. Where McNamara admits that his will to win was broken before the war even started, Giap's long-range strategy "was to continue to bleed the Americans until they agreed to a settlement that satisfied the Hanoi regime. . . . For him, "the Tet Offensive was not intended to be a decisive operation but one episode in a protracted war that might last 'five, ten, or twenty years'."6 While the United States was far superior to North Vietnam in the quantifiable physical dimensions of war so beloved by McNamara and his number-crunching "whiz kids," because of his lack of will we were outclassed completely in war's more important moral dimension that was not susceptible to their computer analysis.
In his 1995 apologia, In Retrospect: The Tragedy and Lessons of the Vietnam War, McNamara made what former Senator Eugene McCarthy called a "Presbyterian confession" (i.e., absolving himself while blaming everyone else) for his sins in Vietnam. But this time his schmoozing fell on deaf ears. "His regret cannot be huge enough to balance the books for our dead soldiers," editorialized the New York Times on April 12, 1995. "The ghosts of those unlived lives circle around Mr. McNamara. Surely he must in every quiet and prosperous moment hear the ceaseless whispers of those poor boys in the infantry, dying in the tall grass, platoon by platoon, for no purpose. What he took from them cannot be repaid by prime-time apology and stale tears, three decades later."
A month after the Tet Offensive began, McNamara resigned as secretary of defense. Unfortunately his successor, Washington lobbyist Clark Clifford, was no improvement. Although a longtime Johnson crony, he too betrayed the president. In his 1991 memoir, Counsel to the President, Clifford admits that he was brought in because Johnson wanted "a secretary of defense who supported his policy." As retired Colonel Lewis Sorely noted in his review of Clifford's book in the September 1991 issue of Army, "Clifford set about ensuring that . . . American involvement in the war and American support for the South Vietnamese would be progressively and inexorably eroded. What is more significant he did this not in furtherance of his president's policy and direction but in defiance of it, forcing the president into one untenable position after another and ultimately usurping the role of commander-in-chief."
As Sorely concludes, "It is one thing to seek to influence the formulation of policy, quite another to faithlessly undermine that policy once formulated. Clifford represents himself as being very proud in doing the latter."
Sadly, the advice and support the president received from the Joint Chiefs of Staff (JCS) was no better. As I related earlier in my "Turning Point of the War," in a February 1993 piece in Vietnam, "While the chiefs of staff did not consciously betray their commander-in-chief, neither did they provide him with the kind of straight-forward military advice to which he was rightfully entitled."
As then Army Vice Chief of Staff General Bruce Palmer wrote, "The JCS seemed to be unable to articulate an effective military strategy that they could persuade the commander-in-chief and secretary of defense to adopt." As he goes on to say, "There was one glaring omission in the advice the JCS provided. Not once during the war did the JCS advise . . . that the strategy being pursued most probably would fail and the United States would be unable to achieve its objectives.
The only explanation of this failure," Palmer concludes, "is that the chiefs were imbued with the 'can do' spirit and could not bring themselves to make such a negative statement or to appear to be disloyal."7
Far from rallying to the president's support at Tet, the Joint Chiefs further undermined his will and resolve. Instead of convincing LBJ that things were not as bad as they seemed, they used the enemy attack as a pretext for pushing for mobilization of the reserves to shore up America's depleted strategic reserves. From their perspective, the deception appeared justified. As General Palmer noted, the JCS had earlier "lost control of the overall strategic direction of the American armed forces as the burgeoning force demands of Southeast Asia quickly consumed the strategic reserve of forces in the United States previously earmarked for the reinforcement of Europe or Korea, or for an unforeseen contingency elsewhere."8
With the Tet crisis coinciding with the North Korean seizure of the USS Pueblo and with intelligence reports indicating a developing crisis in Berlin, "the administration could not be certain," wrote retired Colonel Herbert Y. Schandler, that these events did not represent a concerted Communist offensive designed to embarrass and defeat the United States not only in Vietnam but elsewhere in the world." With that threat in mind, says Schandler, JCS Chairman General Earle Wheeler and the chiefs of staff "saw Tet as an opportunity to force the president's hand and achieve their long-sought goal of a mobilization of the reserves." To that end they "elaborately solicited an 'emergency' request for reinforcements from a supposedly beleaguered field commander."9
Thus by design General Wheeler and the JCS set out to deceive not only the president and the secretary of defense, but also their military commander in the field, General William C. Westmoreland, Commander U.S. Military Assistance Command Vietnam (COMUSMACV). Westmoreland was led to believe that "the administration was ready to abandon the strategy of gradualism it had been pursuing and perhaps allow him the troops and authority he had long wanted in order to end the war in a reasonable timeframe." For his part, Westmoreland "envisaged a new approach to the war that would take timely advantage of the enemy's apparent weakness, for whereas our setback on the battlefield was temporary, the situation for him as it developed during February indicated that the enemy's setbacks were, for him, traumatic."10
But General Wheeler had his own agenda. In his report to Clark Clifford, the new Secretary of Defense, Wheeler "emphasized the gravity of the situation in South Vietnam and said nothing about a new strategy, about contingencies that would determine the level of forces required there, or about reconstituting the strategic reserve for possible use independent of Vietnam." Instead, "his report contained a very somber and pessimistic picture of the South Vietnamese government and army."11
Secretary Clifford was shaken by what he heard. As he later told Schandler, "Wheeler's report had really ominous overtones to it. It seemed to me he was saying that the whole situation was a precarious one, and that we had to have additional troops. I thought (and everyone did) that he was saying he needed 206,000 additional troops in Vietnam. Whatever the reasons, he made a case for 206,000 more men. He came back [from a February 1968 visit to Saigon] with a story that was frightening. We didn't know if we would get hit again, many South Vietnamese units had disappeared; the place might fall apart politically."12
Westmoreland had been set up. In stressing the negative aspects of the situation in Vietnam, General Wheeler "saw Tet and the reaction to it as an opportunity, perhaps the last opportunity, to convince the administration to call up the reserve forces and to reconstitute a military capability within the United States that would allow some military flexibility to meet other contingencies. Vietnam was the excuse but was not necessarily to be the major beneficiary of a call-up of reserve forces."13
But General Wheeler had been too clever by half. Instead of precipitating a reserve call-up as he had intended, his duplicity backfired and unwittingly gave what would prove to be the coup de grace to American involvement in Vietnam. When President Johnson was briefed on Wheeler's report, he told Defense Secretary Clifford to conduct a major re-evaluation of the war. "Give me the lesser of evils," he said.14
Unfortunately, what he got was evil itself. Before the re-evaluation even began, the troop request was leaked to the press by a disgruntled official. As Lieutenant Colonel (later Lieutenant General) Dave Palmer related inSummons of the Trumpet, his landmark 1978 analysis of the war, the news broke in headlines spread across three columns of the Sunday edition of the 10 March 1968 New York Times. "Looked upon erroneously but understandably by readers as a desperate move to avert defeat, news of the request for 206,000 men confirmed the suspicions of many that the result of the Tet Offensive had not been depicted accurately by the president or his spokesmen. If the Communists had suffered such a grievous setback, why would we need to increase our forces by 40 percent?"
"It was too much. The public rebelled. From that moment on the majority of Americans no longer supported the president in his conduct of the fighting." As Dave Palmer concluded, "the nation and its president had received a wrenching psychological defeat, had suffered a galling defeat of the very soul. That the defeat was largely self-inflicted made it no less real or crippling."15
The contrast between the duplicity and design of the senior civilian and military advisors to the president in Washington during the Tet Offensive, and the dedication to duty of those doing the fighting could not have been more stark. As far as the Army was concerned, three senior generals were key to the enemy's defeat-General William C. Westmoreland, Commander U.S. Military Assistance Command Vietnam, Lieutenant General Fred C. Weyand, the commander of II Field Force Vietnam, who fought the battle for Saigon during Tet 1968, and Lieutenant General Creighton Abrams, the Deputy COMUSMACV, who was sent north to command the effort to recapture Hue. Unlike General Wheeler, an Army bureaucrat who had never heard a shot fired in anger, all were front-line combat veterans of World War II and Westmoreland and Weyand were also combat veterans of Korea. All would subsequently serve as Army Chief of Staff after their assignment in Vietnam.
Of the three, by far the most controversial was General Westmoreland, who many blamed unfairly for our loss of the war. As recently as 1998 he was being castigated for his actions during the Tet Offensive. Earlier that year Bright Shining Lie, an HBO movie based on the life of John Paul Vann, severely distorted General Westmorelands' actions during the 1968 Tet Offensive and accused him of attempting to thwart General Weyand's efforts to defend against that attack.
But in his critique of that movie, Weyand himself called that characterization "shameful." The pre-Tet briefing by Westmoreland as depicted "is totally fictitious," says Weyand. "He certainly did not order me to move my units north immediately prior to Tet [and] was in total agreement in bringing my units back around Saigon. To my knowledge he never denied me anything I asked of him. The film version continues to malign a brave and courageous man who understood the war in all its complexities. . . . Considering his overall responsibilities, Westy looked at the war from a different perspective than I did with my attention focused almost entirely on the II Field Force area. [i.e., III and IV Corps and the Capital Military Region]. He had two wars to fight-the terroristic Viet Cong on the one hand and the North Vietnamese conventional forces on the other."16
It was Westmoreland's concentration on that "other war" that drew him the most flak. Critics are still arguing about the Tet Offensive's center of gravity. Were the border clashes that preceded Tet an attempt by the enemy to fake U.S. forces away from the population centers and increase their vulnerability to attack, as many critics still claim, or were the attacks on the cities themselves a diversion, with the real prizes being the two northern provinces of South Vietnam, Quang Tri and Thua Tien? Westmoreland addressed that question in an article in a February 1993 issue of Vietnam.
"I believed then, and I continue to believe," he wrote, "that the 'General Uprising' was in reality a feint, a secondary attack. Like any secondary attack, if it had succeeded, so much the better, and the enemy would have reinforced it for all that it was worth. But the General Uprising did not succeed. The main effort continued to be directed elsewhere, and that was to the two northern provinces of South Vietnam. Some have claimed that the enemy instigated a series of border fights, Khe Sanh in particular, to draw my forces away from the cities. I believe the opposite was true. The attack on the cities, and the earlier attacks at Loc Ninh in III Corps in October 1967 and Dak To in II Corps in November 1967 were designed strategically to divert our attention away from the vulnerable northern provinces of I Corps."
"I knew that if the enemy was willing to accept the catastrophic losses that would surely ensue, he might well get into the towns and cities, since no impenetrable breastworks surrounded them. I also knew it would be impossible for the enemy to hold them. If that was to be his main attack, it was doomed to certain defeat from the start."
" The most logical course for the enemy, it seemed to me, was to make a strong effort to overrun the two northern provinces while at the same time launching lesser attacks throughout the country to try to tie down American forces that might be moved to reinforce northern South Vietnam, the most vulnerable part of the country. Although the enemy could cause trouble in other areas, it was only in the north that I saw a possibility of other than temporary enemy success."
"As I anticipated, the enemy's main attack was centered on the two northern provinces of South Vietnam. There the two major battles of the Tet Offensive developed, at the old imperial capital at Hue in Thua Tien province and at the Marine base at Khe Sanh in Quang Tri province. . . . Unlike the fighting further south, the enemy reinforced its initial success by committing the NVA 5th and 324B Divisions into the ensuing battle. A further indication that the northern provinces were the focus of the enemy's main attack was the formation in Hue of a revolutionary government."
At the tactical and operational levels of war, Westmoreland had correctly gauged the enemy's intentions and had successfully frustrated them. But, as discussed earlier, at the strategic level in Washington, chaos reigned. "On March 31, 1968," Westmoreland noted, "just as the enemy's offensive petered out, President Johnson announced that he would not run for reelection, which was interpreted by many as a loss in national will. . . . Despite the valiant sacrifices of our soldiers, sailors, airmen and Marines, we had managed to snatch defeat from the jaws of victory."17
Fortunately for General Westmoreland, his MACV headquarters at Tan Son Nhut Air Base in the suburbs of Saigon remained secure throughout the entire attack, as did the headquarters of the Republic of Vietnam Armed Forces (RVNAF) Joint General Staff which was also located here. But it was a near thing. "On January 10, 1968," he wrote, "Lt. General Fred C. Weyand, the commander of [the corps-level] II Field Force, concluded that the enemy in III Corps zone was attempting to shift away from his border sanctuaries toward the population centers, including Saigon. Weyand thought I should cancel the preemptive border attacks in his area of responsibility that had been planned for the dry season. His information reinforced doubts that had been rising in my own mind, and I ordered the projected attacks cancelled so that American troops would be better able to react to enemy moves."18 That decision was one of the most critical of the Vietnam War.
The penetration of the walls of the U.S. Embassy in downtown Saigon by a VC sapper squad at the outset of the Tet Offensive was militarily insignificant, but it send shock waves across the United States. If the U.S. and South Vietnamese military headquarters at Tan Son Nhut had been overrun, it would have been catastrophic. The enemy planned to do just that, as they launched 35 battalions from their 5th, 7th, and 9th VC Divisions against the Saigon defenses, with the nerve center at Tan Son Nhut Air Base as their major prize.
If the original campaign plan had been carried out, Weyand would have had only 14 U.S. infantry, armor, and cavalry maneuver battalions within what Washington Post war correspondent Don Oberdorfer called the "Saigon circle," a 45 kilometer or 29 mile circle anchored on Saigon containing three-quarters of the people of III Corps tactical zone and nearly all of the important military and government headquarters. His other 39 maneuver battalions would have been deployed to the border regions. But thanks to his earlier suspicions, and with General Westmoreland's approval, General Weyand had 27 battalions within the Saigon circle ready to meet the attack.
At 0300 on 31 January 1968 the enemy attack began with the explosion of the ammunition dump next to Weyand's II Field Force headquarters at Long Binh north of Saigon. Between 0300 and 0500, Oberdorfer reported, Weyand "ordered nearly 5,000 mechanized and airborne troops into battle. . . . Mostly to defend United States installations at Long Binh, Bien Hoa Air Base and Tan Son Nhut Air Base."19 The most critical of those battles, perhaps the most critical of the Vietnam War, was the repulse of the enemy attack on Tan Son Nhut. The enemy main assault came from the west. Two VC battalions had infiltrated the city and staged at the Vinatexco cotton mill just outside the air base perimeter. Their initial attack was delayed by Air Force Security Police and two South Vietnamese airborne companies, but they were not strong enough to halt the advance.
At dawn, however, the enemy force was struck on the flank by the 25th Infantry Division's C Troop, 3d Squadron, 4th Cavalry, which on General Weyand's orders had moved overland from its base camp at Cu Chi, some 25 miles to the northwest. They had been guided into their attack position by flares dropped from his helicopter by their squadron commander, Lieutenant Colonel (later General) Glenn Otis.
"Armored vehicles fighting infantry in the open can do frightful damage," noted Professor Eric M. Bergerud in his history of the 25th Infantry Division in Vietnam, "and C Troop did. But they were in over their heads. Their opponents were armed to the teeth with antitank weapons and they greatly outnumbered the Americans. After fierce fighting, C Troop was nearly destroyed." With his A Troop pinned down by an NVA unit, Otis ordered his B Troop to reinforce C Troop. They attacked on line and broke the back of the enemy attack. "We can see in retrospect," Bergerud writes, "that the first day's actions, repeated by other U.S. and South Vietnamese units around Saigon, doomed the [enemy's] attack on the capital."20
"Except at Hue and Khe Sanh," said General Westmoreland, "most of the combat that could be considered part of the Tet Offensive was over by February 11, a fortnight after it began. All towns and cities south of the two northern provinces had been cleared. While sporadic fighting continued around Saigon, survival of the South Vietnamese capital was no longer in question."21 For that, Westmoreland had General Fred Weyand, "the savior of Saigon," to thank. A modest man, Weyand rejects that title. "The orders may have come from my headquarters," he said 25 years later, "but the 'saving of Saigon' was done by the men who laid their lives on the line and fought the battles."22
As was discussed earlier, General Westmoreland believed the Tet Offensive's main attack would come at Khe Sanh and Hue in the two northern provinces of I Corps, then under the control of the corp-level III Marine Amphibious Force (III MAF) commanded by Marine Lieutenant General Robert E. Cushman, Jr. Shortly after the Tet Offensive began, Westmoreland dispatched his deputy, General Creighton Abrams, to establish a forward MACV headquarters in I Corps and take overall command of the battle. Establishing his headquarters at Phu Bai near Hue, Abrams directed the redeployment of the some 45,000 Army reinforcements, including the 1st Cavalry Division (Airmobile) and elements of the 101st Airborne Division.
According to his biographer, "Abrams was direct in the steps he took to get on with the war. He brought in 8-inch artillery, the only weapon that could penetrate the thick walls of the old Citadel in the heart of Hue, the last position held by tenacious enemy forces. And he issued some very strong and very specific instructions to Cushman at III MAF. "I recognize the efforts being made by all concerned to reduce the siege of Hue," he said. "However I consider the measures taken so far to be inadequate and not in consonance with the urgency of the problem, or the resources you command."
"Then he spelled out what he wanted done: give the forces fighting within the city exclusive priority for fires of the 8-inch guns, priority of air support, and of necessary gunship and aerial rocket artillery support-even at the expense of other areas. . . . As any experienced field commander would immediately recognize, that kind of detailed instruction revealed a very high degree of dissatisfaction with the way Cushman had been running the operation."23
The subsequent battles at Hue and Khe Sanh were primarily Marine Corps affairs, and I will leave the discussion of those battles, as well as the defense of General Cushman and III MAF in the capable hands of the Marine Corps Historical Center's Dr. Jack Shulimson, whose U.S. Marines in Vietnam: The Defining Year 1968 has just been released. Suffice it to say here that by 25 February, the enemy had been cleared from Hue and the offensive in I Corps ended. MACV Forward was disbanded on 10 March and Abrams returned to Saigon, leaving the Army forces there under a new headquarters, "Provisional Corps Vietnam" (later XXIV Corps) subordinate to III MAF.
These three generals would have a major impact on the Army for almost the next decade. On 1 July 1968, General Abrams would replace General Westmoreland as COMUSMACV and Westmoreland would return to Washington to become Army Chief of Staff. In June 1972, General Weyand would replace General Abrams as COMUSMACV and Abrams in turn would return to Washington to replace Westmoreland as Army Chief of Staff. After the U.S. withdrawal from Vietnam in 1973 under the terms of the Paris "Peace" Accords, General Weyand would also return to Washington to become Army Vice Chief of Staff, replacing General Abrams as Army Chief of Staff after Abrams' tragic death in office in September 1974.
During their tours, they would be instrumental not only in pulling the Army up by its bootstraps as it withdrew from Vietnam, but also of ensuring no "stab-in-the-back" syndrome developed after the war. General Westmoreland in particular took the heat from the Army officer corps for "losing the war in Vietnam." While that was manifestly unfair, he did his nation a great service by deflecting that animosity from the politicians and the American people, thus avoiding the tragedy that plagued Weimar Germany after World War I and France after the withdrawal from Algeria.
Indeed, it can be argued in retrospect that General Westmoreland won his war. Sent out in 1964 to wage a counterinsurgency campaign against the Viet Cong guerrillas, he accomplished that mission, albeit through the enemy's own miscalculations. When the VC emerged from cover to spark a supposed "General Uprising," they suffered devastating losses from which they never recovered. When Westmoreland left Vietnam in July 1968, the Viet Cong were a spent force. For the remaining seven years, the war would be waged primarily by North Vietnamese regulars.
When the North Vietnamese entered Saigon on 30 April 1975, noted the late William Colby, the former head of the pacification program in Vietnam and former Director of the CIA, "an NBC camera crew caught one of the most significant pictures of the event. It filmed a huge North Vietnamese tank with its monstrous cannon as it broke open the gates of the Presidential Palace. The people's war was over, not by the work of a barefoot guerrilla but by the most conventional of military forces. . . . The ultimate irony was that the soldier's war, which the United States had insisted on fighting during the 1960s with massive military force was finally won by the enemy."24
1 By the Easter Offensive of 1972, NVA regulars accounted for about 90% of the day-to-day combat. See Douglas Pike, PAVN: People's Army of Vietnam (Novato, CA: Presidio Press, 1986), 49.
2 After supporting the war for some 31 months, American public opinion turned against the war in October 1967. While 44% still supported the U.S. involvement, 46% of those polled believed sending troops there had been a mistake. See John E. Mueller, War, Presidents and Public Opinion (New York: Wiley, 1973).
3 See Peter Braestrup, Big Story: How the American Press and Television Reported and Interpreted the Crisis of Tet 1968 in Vietnam and Washington (Novato, CA: Presidio Press, 1994), 471.
4 Carl von Clausewitz, On War, Michael Howard and Peter Paret, eds. (Princeton: Princeton University Press, 1976), 104-105.
5 M.A. Farber, "McNamara Discusses War at CBS Libel Trial," New York Times, December 7, 1984.
6 Vo Nguyen Giap, quoted in Stanley Karnow, Vietnam: A History (New York: Viking, 1983), 536.
7 See Bruce Palmer, The Twenty-Five Year War (New York: Touchstone Books, 1984), 45-46.
8 Ibid., 45.
9 Herbert Schandler, The Unmaking of the President: Lyndon Johnson and the Vietnam War (Princeton: Princeton University Press, 1977), 101.
10 Ibid., 106.
13 Ibid., 115-116.
15 Dave Palmer, Summons of the Trumpet: US-Vietnam in Perspective (Novato, CA: Presidio Press, 1978), 206.
16 FAX, General Fred Weyand, 2 June 1998.
17 General William C. Westmoreland, "Perspectives: What Did the North Vietnamese hope to gain with their 1968 Tet Offensive? Were they after the cities, or more?" Vietnam, Feb 1993, 62-70.
18 Ibid., 64.
19 Don Oberdorfer, Tet! (New York: DaCapo Press, 1984), 138-40.
20 For a detailed account of the Tan Son Nhut battle, see Eric M. Bergerud, Red Thunder, Tropic Lightning: The World of a Combat Division in Vietnam (Boulder, CO: Westview Press, 1993),
21 Westmoreland, op cite, 68.
22 Letter to the author, 22 Aug 1992. See also Harry Summers, "Personality: The Viet Cong counted on surprise for their seizure of Saigon, but General Fred C. Weyand saw them coming," Vietnam, Feb 1993, 8, 71-74.
23 Lewis Sorley, Thunderbolt: General Creighton Abrams and the Army of His Times (New York: Simon and Schuster, 1992), 213-18. See also Brigadier General Zeb B. Bradford, USA (Ret.), "With Creighton Abrams During Tet," Vietnam, Feb 1998, 42-49.
24 William Colby, Lost Victory (Chicago: Contemporary Books), 354-55.
Creating a Main Line of Resistance Tet and the Genisis of Operation Sea Lords
Dr. Leslie J. Cullen
As the year 1968 dawned over the Republic of Vietnam, the headquarters of United States Naval Forces, Vietnam (NAVFORFV) occupied a small complex of buildings in downtown Saigon. Centered on a rambling two-story nineteenth century French colonial villa, the compound housed Rear Admiral Kenneth L. Veth, Commander United States Naval Forces, Vietnam (COMNAVFORV), and his staff.
Though technically located in a combat zone, pre-1968 Saigon was infamous for its carnival-like atmosphere. Observers often wondered if there was truly a war on. American GIs on brief R&R tours wandered the numerous go-go clubs and saloons in search of readily available thrills, and jostled in the crowded streets with throngs of Vietnamese civilians on bicycles, in pedicabs, and in automobiles. The snarled traffic could be amusing when it was not dangerous. Viet Cong rocket attacks and bombings occasionally shattered the illusion of peace, as did the ubiquitous presence of heavily armed South Vietnamese soldiers. Distant rumbles of artillery often punctuated the street sounds, especially at night. Journalists, officers, and visiting VIPs could observe the war from the comfort and relative safety of the Caravelle Hotel bar veranda, sipping cocktails and looking across the Saigon River where tracers from the miniguns of AC-47 gunships arced out of the twilight into the swamps of the Rung Sat Special Zone.
On the night of January 31, 1968, when the Viet Cong launched the opening salvo of the 1968 Tet Offensive, American facilities in and around the South Vietnamese capital numbered among the primary targets. The sudden ferocity of the attacks caught Americans stationed in Saigon-including the NAVFORV staff-off guard. Admiral Veth remembers, "The first thing we knew about it was when we were all waked up (sic) in the middle of the night, and all hell broke loose in the way of gunfire and explosions." Veth and his staff gathered what weapons they could find in the compound-two machine guns, several side arms, and a box of fragmentation grenades-and clambered atop the roof of the villa. For the rest of the night and into the early morning that small group of naval officers watched tracers, rockets, and flares etch the Saigon skyline and listened to their radio as disjointed reports of Viet Cong attacks came from around the city.1
The totality of the enemy effort became clear in the week that followed, and the initial panic within South Vietnam itself gave way to domestic turmoil and political repercussions in the United States. For the American military, the 1968 Tet Offensive produced mixed results. The enemy seriously overestimated the impact the offensive would have on the South Vietnamese government and people, and this miscalculation resulted in severe casualties and an undeniable battlefield victory for the United States and South Vietnam. Of more importance, however, Tet has entered the annals of American military history as one its greatest intelligence disasters.2
After official assertions concerning Saigon's safety and the supposedly successful interdiction of Viet Cong supply and communications networks in the areas south and east of the city, Tet came as a nasty surprise. The counterinsurgency efforts, it seems, had not accomplished their planners' goals. Despite that salient fact, many in the United States Military Assistance Command (MACV) returned to confident predictions of looming success. Captain Earl Rectanus, who in 1968 served as NAVFORV staff intelligence officer, noted that the MACV and NAVFORV staffs were playing a public relations game instead of determining how the Viet Cong had amassed such a capability: ". . . we were going through all of this PR, is really what it was, and everybody was working to try to get evidence, back-up, to tell Washington that it really wasn't the disaster the media had been playing it up to be."3
In a combined atmosphere of military victory and official denial of Tet's implications, the United States Navy in Vietnam continued its standing strategy of using its in-country assets to patrol the coastal zones and major rivers. Those assets included Task Force 115, commonly known as the Market Time patrol force, which operated a dozen radar picket destroyer escorts (DERs), thirty-one cutters (WPBs), five high-endurance cutters (WHECs), eighty-four aluminum-hulled Swift boats (PCFs), and a large number of coastal junks and smaller craft. This small armada-working in conjunction with patrol aircraft-carried out an ongoing coastal surveillance effort along South Vietnam's 1,400-mile coastline. Market Time, in its three-year existence, had virtually choked off all seaborne infiltration by steel-hulled trawlers into the Republic of Vietnam.
Task Force 116, also known as Operation Game Warden, used scores of river patrol boats (PBRs) divided into five River Patrol Groups to deny the Viet Cong access to the main rivers and canals in the teeming Mekong Delta in III and IV Corps. In September 1968, TF 116 PBRs boarded and inspected more than 11,000 sampans and other small craft in the Delta.4 Despite this enormous and ongoing effort, Tet demonstrated that waterborne infiltration into southern South Vietnam-via canals and interior rivers-continued.
The final task force-the Mobile Riverine Force (MRF)-used a variety of river patrol and assault craft to support sweep and clear operations in the Delta by the 2nd Brigade of the United States Army's 9th Infantry Division. The combined action of these task forces limited North Vietnamese and Viet Cong access to South Vietnam's waterways, all of which were then and still are vital lines of transportation and communication.5
The Navy's ongoing operations, despite their positive results, did not stop the enemy from infiltrating sufficient personnel and materiel to mount the 1968 Tet Offensive. MACV intelligence officers noted however, that even if the patrolling hindered the insurgency, the Navy's efforts were unable to interdict it entirely. The enemy adapted to American patrolling methods and altered schedules of movement and location accordingly. Chased from the Mekong and Bassac Rivers, infiltrators reverted to the lesser rivers and canals that laced the entire southern third of South Vietnam. Many of these waterways ran close to the Cambodian frontier, across which men and logistics moved with relative ease.
Interestingly, the Navy had known for four years that the enemy possessed such a capability. In early 1964, before American forces became actively engaged in South Vietnam, Captain Phil Bucklew, at the behest of then-CINCPAC, Admiral Harry D. Felt, took part in an exploratory mission to determine what could be done to counter waterborne infiltration. Bucklew and his staff traveled the Delta extensively, interviewing dozens of Vietnamese military personnel and their American advisors. At the Cambodian border, Bucklew personally witnessed the Viet Cong openly moving supplies by sampan inside "neutral" Cambodia. In his report to CINCPAC, Bucklew described the totality of the infiltration effort, criticized the South Vietnamese response as inefficient and woefully inadequate, and suggested that halting the Viet Cong would require a coastal blockade augmented by extensive patrolling of the internal rivers. The report went on to recommend that the Navy establish "a viable means of controlling the rivers by implementing barricades, curfews, checkpoints, and patrols" (emphasis added).6
Granted, Market Time, Game Warden, and the Mobile Riverine Force had done this in part, but the effort did not fully realize Bucklew's intentions. The navy had yet-as of early 1968-to heed his observation that blockading and patrolling alone would not suffice. An active effort at interdiction in the lesser rivers and along the Cambodian frontier-not just along the Mekong and Bassac-was crucial to defeating the insurgency.
The Navy disregarded Bucklew's ultimate conclusion because it lacked the intelligence gathering capacity to determine that seaborne infiltration of South Vietnam-as countered by Market Time-paled in importance to materiel the North Vietnamese and Viet Cong infiltrated from Cambodia along internal waterways. Once the Navy launched Market Time, it stubbornly refused to consider the implications of Bucklew's study. The irony is compounded when one considers that the very effectiveness of Market Time caused the North Vietnamese and Viet Cong to do precisely what Bucklew predicted they would do-use the waterways along the Cambodian frontier to move logistics in a region where countermeasures were virtually nonexistent. Hence, the enemy was able to conclude successfully the build-up necessary to launch the attacks of early 1968. "It took," concluded historian Clarence Wunderlin, "the traumatic jolt delivered during the Tet Offensive to awaken naval planners to their strategic flaws."7 The Navy suffered from a gap of conception described by Marc Bloch as the tendency of finding it "useful to ask oneself questions, but very dangerous to answer them."8
In the end, it took more than the jolt of Tet to cause the Navy to alter its modus operandi in the Mekong Delta; it took a change of command. Despite the realization of what the enemy had accomplished by doing an end run around the Navy's patrolling systems, Veth clung stubbornly to the fixed pre-Tet strategy. He said, ". . . there was some agitation to go up a lot of the canals with our riverine boats and, let's say, harass the countryside, but for the most part we avoided that, again, because the chance of being ambushed by the enemy was so great and there wasn't much to be accomplished. . . . There just wasn't much to be gained by going up a lot of the little canals and streams that ran into the major rivers."9 Veth's passive strategy and his unimaginative attitude regarding the possibilities of a wider application of in-country naval power irritated General William C. Westmoreland's successor as COMUSMACV, the hard-charging, irascible General Creighton Abrams.10
Vice Admiral Elmo R. Zumwalt Jr., Veth's own successor, was also a hard-charger. His superiors recognized the 1942 Annapolis graduate and World War II veteran's leadership attributes very early in his career. At age forty-seven Zumwalt became the youngest three-star admiral in the Navy's history, and immediately thereafter-in mid-September 1968-he arrived in Saigon to follow Veth as COMNAVFORV.
Zumwalt began his tenure in Vietnam with an extensive seven-day tour of his new command; from the major installations to the smallest advisory post on the rivers; from the Mekong Delta to the DMZ; the admiral's observations helped him to develop a thumbnail sketch that he did not like. Zumwalt-who was certainly aware of the Bucklew Report and its implications-concluded that the Navy's effort in Vietnam, despite the fine performance of individual units and personnel, suffered from underutilization of its in-country assets and from a lack of guidance and strategic vision at the top. Captain Howard J. Kerr-then an aide to Zumwalt-took the tour with the admiral and recalled of it: ". . . we came away from those days with a clear understanding that the staff in Saigon was cut off from the forces in the field. Their relationship was one of telephone calls and messages. . . . It was just a sleepy, large, moribund staff which had fallen into a pattern of reading message traffic."11 Zumwalt decided that the aggressive leadership of the task force commanders and the initiative and effort of the 38,000 officers and men under his command could be put to greater use. The admiral and his staff began searching for a new strategy; a strategy that would take into account the Tet-hardened conclusions of the Bucklew Report; a strategy that would change the focus of the navy's previous efforts from mere patrolling to a more forward and active drive to interdict the enemy's lines of supply and communication and destroy his base camps in the Delta. The genesis of what became Operation Sea Lords arose from this decision.
Sea Lords-which stood for Southeast Asia Lake Ocean River Delta Strategy and embodied the totality of Zumwalt's and NAVFORV's vision-encompassed all three preexisting task forces that heretofore had been operating independently of one another and brought them together in a strategy unified in its conception and execution. Since the Tet Offensive demonstrated that the previous strategy did not effectively hinder enemy infiltration, Zumwalt and his staff decided to combine and refocus the Navy's in-country assets. Market Time continued as before, but the PCFs now moved up the major rivers, freeing the Game Warden PBRs to move further inland and establish a system of named barriers. These barriers extended from Saigon north and west to the Parrot's Beak region of the Cambodian border, and along a series of canals extending from the Mekong and Bassac Rivers west and south to the Cambodian border and the Gulf of Thailand.12 The barriers consisted of mobile bases aboard Tank Landing Ships (LSTs) and more fixed facilities called Advanced Tactical Support Bases (ATSBs), which the Navy located at intervals along the interior waterways. Each LST or ATSB served as a support facility for PBRs and the heavier craft of the Mobile Riverine Force as they patrolled deeper than ever before into the interior of III and IV Corps.13
Sea Lords contained a second component complementing the forward and aggressive barrier strategy: denial of sanctuary to the enemy in remote regions previously defaulted to him. As we have seen, under Admiral Veth the Navy generally avoided the distant and inaccessible reaches of III and IV Corps, specifically the infamous Rung Sat Special Zone southeast of Saigon and the Ca Mau Peninsula at the southern extremity of the Republic of Vietnam. The NAVFORV staff developed a unique plan for each.
In the Rung Sat, stepped up river patrolling, ground sweeps, and harassment and interdiction fire kept the Viet Cong off balance in what had formerly been a sanctuary. The Navy instituted a cooperative plan with other Free World Forces-including the Australians, South Koreans, South Vietnamese, and Thais-for operating in the area and conducting coordinated operations. The frequency of Viet Cong attacks on commercial shipping using the Long Tau ship channel to the port of Saigon fell dramatically. The result, wrote NAVFORV staff historian Richard Schreadly, became "a model for what could be made of a seemingly hopeless situation, given leadership, singleness of purpose, and a spark of imagination."14
In the Ca Mau Peninsula-regarded by American advisors as one of the most eerie and inhospitable places in South Vietnam-the Navy launched a unique and innovative operation-Sea Float. A floating base anchored in the Cua Lon River, Sea Float served as a platform from which the Navy carried out interdiction patrols, SEAL team operations, and civic action efforts. As a result of this audacious placement of an American presence in a region long defaulted to the Viet Cong, Vietnamese civilians made refugees during the 1968 Tet Offensive returned to their homes in the Nam Can District adjacent to the base, and American observers witnessed a sharp rise in regional economic activity. "Sea Float's effect," Zumwalt concluded, "was that it greatly accelerated pacification."15
Because Sea Lords-with its post-Tet emphases on interdiction, denial of sanctuary, and pacification-unified the American naval effort, it is unquestionably one of the better strategies to emerge from the American military experience in Vietnam. Given the political limitations Washington placed on the theater of operations, it was as near total-geographically-as Zumwalt and his staff could make it with the available resources. Statistically, Navy records indicate the level to which Sea Lords operations interfered with Viet Cong logistics. A July 1969 NAVFORV study indicated that the barrier operations to date generated 900 firefights resulting in more than 1,600 enemy killed. Naval forces captured more than 160 tons of weapons, and in Zumwalt's opinion this statistic was worth far more than the omnipresent "body count."16 If interdiction was the key, the admiral reasoned, then numbers and types of weapons seized outweighed dead Vietnamese, however high their numbers. "We were not there specifically to see how many Viet Cong we could kill," recalled Lieutenant Commander Robert Powers. "We were there . . . to stop their bringing supplies in that were disrupting the countryside, and . . . to deny their influence."17 Powers' statement-and NAVFORV's approach-reflect one of the central aspects of the American experience in Vietnam. In a limited war of shifting goals, what constitutes success?
Success and failure can be subjective concepts. Many observers regard much if not all of what the United States did in Vietnam as unsuccessful because of the ultimate negative outcome of the entire conflict. To do so in the case of Operation Sea Lords would be inaccurate. Taking into consideration changing American policy in the aftermath of the 1968 Tet Offensive, General Abrams-and Admiral Zumwalt under him-could consider little more than how to stabilize a fluid situation long enough to allow the struggling South Vietnamese to improve their political and military structures and consolidate a defensible position. In that light, Sea Lords-despite its inability to eradicate waterborne infiltration through the Mekong Delta, made an enormous difference. It interrupted Viet Cong and North Vietnamese logistics networks. It cost the enemy in personnel, materiel, and in Zumwalt's estimation, the key factor of time. Sea Lords, in its imaginative and forward application of naval power, repeatedly disrupted enemy timetables and forced the communists to alter or delay their plans. Compared to the period prior to Tet 1968, the results of Sea Lords and its subordinate operations speak for themselves.
1 John T. Mason Interview with Rear Admiral Kenneth L. Veth, USN (Ret.) August 10, 1977 (Annapolis: United States Naval Institute Oral History Series), pp. 405-06.
2 Glenn Helm, "Surprised at Tet," Pull Together; Newsletter of the Naval Historical Foundation and the Naval Historical Center, Spring/Summer 1997, pp. 1-5.
3 Paul Stillwell Interview with Vice Admiral Earl F. Rectanus, USN (Ret.), November 19, 1982 (Annapolis: United States Naval Institute Oral History Series), p. 17.
4 Richard L. Schreadly, "Sea Lords", United States Naval Institute Proceedings, 96:8 (August 1970), p. 23.
5 The secondary literature on United States Navy operations in South Vietnam is broad, but for specific operations see Victor Croizat's The Brown Water Navy: The River and Coastal War in Indochina and Vietnam(Poole, UK: Blandford Press, 1984); Thomas J. Cutler's Brown Water, Black Berets: Coastal and Riverine Warfare in Vietnam (Annapolis: United States Naval Institute Press, 1988); Edward J. Marolda, By Sea, Air, and Land: An Illustrated History of the U.S. Navy and the War in Southeast Asia (Washington: Naval Historical Center, 1994), and R.L. Schreadly's From the Rivers to the Sea: The United States Navy in Vietnam (Annapolis: United States Naval Institute Press, 1992). For a study of the Coast Guard's contributions to Operation Market Time, see Alex Larzelere's The Coast Guard at War; Vietnam, 1965-1975 (Annapolis: United States Naval Institute Press, 1996) and Dennis L. Noble's "Cutters and Sampans," United States Naval Institute Proceedings, June 1984, pp. 47-53.
6 Quoted in Thomas Cutler, Brown Water, Black Berets, pp. 72-76.
7 Clarence E. Wunderlin, Jr., "The Paradox of Power: Infiltration, Coastal Surveillance, and the United States Navy in Vietnam, 1965-68," The Journal of Military History, 53, July 1989, pp. 275-289.
8 Marc Bloch, The Historian's Craft (New York: Vintage, 1953), p. 17.
9 John T. Mason Interview with Rear Admiral Kenneth L. Veth, USN (Ret.), August 10, 1977, p. 388.
10 In fairness to Veth, his unassertive approach to the war indicates more than the simple disdain in which General Abrams held him. There was a larger attitude within the Navy that the in-country war in South Vietnam paled in significance to the "real" war-the air war against North Vietnam flown from the aircraft carriers of the Seventh Fleet. For that reason, South Vietnam gained a reputation at best as a detour from a successful career track, or at worst, a "dumping ground" for inferior officers. The Navy's tendency to give less than ideal follow-on assignments to officers coming out of NavForV had the dual effect of reinforcing this negative perception and removing any incentive for highly motivated officers to volunteer for a tour in Vietnam. In the wider Navy, preoccupied as it was with the Soviet threat-and with Operation Rolling Thunder-the brown water war in Vietnam placed a distant third on anyone's list of priorities.
11 Paul Stillwell Interview with Captain Howard J. Kerr, USN, September 22, 1982 (Annapolis: United States Naval Institute Oral History Series), pp. 26-27.
12 The barriers included Operation Giant Slingshot, Operation Search Turn, Operation Tran Hung Dao, Operation Barrier Reef, and Operation Double Shift.
13 For contemporary descriptions of barrier operations and their support facilities, see Robert C. Powers, "Beans and Bullets for SEALORDS," United States Naval Institute Proceedings 96: 12 (December 1970), pp. 95-97; and R. L. Schreadly, "Nothing to Report: A Day on the Vam Co Tay," United States Naval Institute Proceedings 96: 12 (December 1970), pp. 23-27.
14 R. L. Schreadly, "The River War in Vietnam, 1950-1970," United States Naval Institute Proceedings 97, Naval Review Issue, May 1971, p. 205. For the official USN view of the Rung Sat, see "Rung Sat Special Zone Intelligence Study," ComNavForV Miscellaneous (8), Box 597, Operational Archives Branch, Naval Historical Center, Washington DC.
15 Author Interview with Admiral Elmo R. Zumwalt. Jr., USN (Ret.), April 18, 1997, Lubbock, Texas.
16 Commander, U.S. Naval Forces Vietnam/Chief Naval Advisory Group Newsletter #9, 1 July 1969, ComNavForV/ChNavAdvGrp Newsletter File, Box #585, Operational Archives Branch, Naval Historical Center, Washington DC.
17 Etta Belle Kitchen Interview with Captain Robert F. Powers, USN, October 30, 1982 (Annapolis: United States Naval Institute Oral History Series), p. 80.
The Impact of Tet on the U.S. Air Force
Bernard C. Nalty
The Tet Offensive altered the course of the air war in several ways, direct and indirect, immediate and gradual, in some instances accelerating or magnifying changes already under way when the enemy attacked in January and February 1968. Tet directly and immediately persuaded the administration of President Lyndon B. Johnson that an open-ended war of attrition could not force the North Vietnamese to abandon their attempt to conquer the South. The Johnson administration reacted by imposing a ceiling on the American commitment to the defense of South Vietnam, cutting back and then ending the air war against North Vietnam in the hope of luring the Hanoi regime into negotiating a peace settlement that would somehow enable South Vietnam to survive as an independent state.
The United States had been trying for years to manipulate North Vietnam into following a certain course of action, but since 1965 emphasis had rested on using air power to help bludgeon Hanoi into behaving as the United States desired. The Johnson administration had embraced an aerial strategy of stick and carrot-fierce attacks on important but heavily defended North Vietnamese target systems like transportation or oil storage, followed by pauses during which the enemy could reconsider his conduct and change it.
Because Hanoi had not responded as expected, and the bombing of the North was becoming increasingly expensive in lives and aircraft, different targets had to be found.
President Johnson's decision to end the bombing of the North in the hope of encouraging negotiations shifted the air war to South Vietnam, Cambodia, and Laos. Battlefield targets and lengthy supply lines replaced North Vietnam's military infrastructure as the target of the air war, while President Johnson took the first tentative steps toward returning responsibility for the war to the South Vietnamese, thus reversing the course of events since 1965.1
During the lull in fighter combat that followed the imposition of restrictions on the air war in the North-and the suspension later in 1968 of strikes there-the Air Force missed an opportunity to review replacement policy, replacement training, and combat tactics. Determined to spread the experience of Vietnam broadly throughout the service and thus avoid involuntary second tours, the Air Force persisted in replacing individuals rather than rotating units until the spring of 1972, when the Easter invasion required the deployment of entire fighter wings, complete with support elements and additional crews.
The training of fighter-pilot replacements continued to emphasize numbers and deadlines, with air-to-air combat receiving whatever time and resources were available upon completion of the standard curriculum. As a result, individual replacement pilots seldom trained in combat tactics and formations until joining a tactical fighter outfit in Southeast Asia.
With one exception, scrapping the policy of assigning pilots to the rear seats of F-4 Phantoms, the Air Force made no major changes in fighter operations in the aftermath of the Tet offensive. The so-called Guy In Back evolved from an apprentice waiting for an opening in the front seat into a Weapon Systems Officer, a non-pilot who located targets and spotted threats for the aircraft commander. Besides increasing the pool of front-seaters, the new policy enabled the back seater to concentrate on sharpening his vital skills rather than learning to command an F-4.2
The Tet Offensive put an end to Air Force civic action at the time this assistance program was most needed. Until Tet, airmen, many of them off-duty volunteers, had helped South Vietnamese civilians living in villages near the American air bases. The Americans provided inoculations, instruction in the essentials of public health, and contributions of cash and labor to sustain schools and clinics and build or repair housing. Since the airmen who carried out civic action were recently fired on from some of the villages they had been helping, enthusiasm for the program rapidly evaporated. No wonder that commanders proved reluctant to send their men among people who had either participated in the Tet Offensive or failed to warn of the enemy's presence.3
Besides putting an end to civic action, Tet made the Air Force shift its tactical transports from routine flights to emergency operations. Until highways again became safe for convoys, aircraft had to haul supplies and reinforcements that otherwise would have traveled in trucks; one such airlift mission required a flight of only 14 miles. Because the fighting that closed roads also isolated some crews from their transports, the reaction to Tet started slowly but rapidly gained momentum after 16 additional C-130s arrived from Japan.4
The Tet fighting also disillusioned an influential segment of the American press, notably Walter Cronkite, a respected television newsman, who visited South Vietnam as the Tet Offensive ended. He reported that the urban destruction caused by the counterattacking American and South Vietnamese forces made a mockery of the publicized objective of building a South Vietnamese nation. As if to dramatize the contradiction between building and destroying, an anonymous Army officer, justifying the bombing of enemy-occupied Ben Tre, declared that "it was necessary to destroy the village in order to save it."
The press reaction to Tet, along with the scaling back of war aims from imposing a settlement to negotiating one, intensified the existing opposition to the conflict. Demonstrations against the war had already taken place, including a so-called siege of the Pentagon in October 1967, persuading the administration to begin during November to use its commander in South Vietnam, General William C. Westmoreland, to drum up support for the war. Unfortunately, the Tet fighting gave lie to the general's highly publicized reports of steady progress, and contributed to the mood of disillusionment. Humorist Art Buchwald suggested, for example, that Westmoreland's kind of optimism could have turned the Battle of the Little Big Horn into a victory for Colonel George Armstrong Custer.5
Those who hoped to end the fighting increased their efforts, as did those who argued that the United States should settle for nothing less than victory. A new President, Richard M. Nixon, now sought to appease both extremes by minimizing American casualties as he continued the war. In 1969, he announced the policy of Vietnamization and withdrawal, arming and training the South Vietnamese to fight the war, which the United States had taken over in 1965. American ground troops, many of them draftees, would begin coming home.
At first, President Nixon and his advisers intended to time the troop withdrawals to reflect progress in negotiating a settlement and strengthening the South Vietnamese armed forces, but it proved impossible. The President's National Security Adviser, Henry A. Kissinger, warned at the outset that troop withdrawals might become like salted peanuts, each sharpening the public's appetite for another. As the program of withdrawals took on a life of its own, American air power, wielded by professionals and nominal volunteers, and South Vietnamese ground forces increasingly provided the shield for Vietnamization and withdrawal.6
President Nixon insisted on minimizing American losses as the withdrawals continued, substituting air power for the ground forces, including many draftees, that thus far had suffered a lion's share of American casualties. In February 1968, for example, during the grim fighting to defeat the Tet offensive, Air Force units suffered 260 casualties, with 39 men killed in action. The total American losses, however, averaged some 450 killed and almost 1,600 wounded each week during that same month.7
The administration feared a North Vietnamese offensive launched as the American withdrawal neared completion. Air power played the pivotal role in guarding against such an attack, hitting the enemy in South Vietnam, occasionally in North Vietnam, and in Laos and Cambodia. But the aerial shield at times had to be reinforced by ground action. In 1970, for example, after a year of secretly bombing North Vietnamese bases in Cambodia, American troops, supported by aircraft, joined in a three-month incursion into that country. In 1971, South Vietnamese troops, supported by American aircraft, failed to choke off traffic on the Ho Chi Minh Trail, the major enemy supply route through southern Laos.8
The Tet Offensive-or more precisely the feint toward Khe Sanh-temporarily diverted resources from an attempt, undergoing test in late 1967 and early 1968, to establish an electronic barrier across the Ho Chi Minh Trail. Sensors detected traffic and fed data to a computer at Nakhon Phanom, Thailand, which helped direct air strikes against the supply complex. When shifted to the vicinity of Khe Sanh, the sensors covered the limited number of approaches to the base and generated an impressive list of targets for air strikes and artillery. Success here encouraged the campaign against the trail, an effort that ultimately cost some $2 billion and produced claims of tens of thousands of trucks destroyed. However, jungle cover, strong antiaircraft defenses, and a skillful and determined enemy prevailed over electronics; the system failed, for example, to detect the tanks that traveled the Ho Chi Minh Trail to spearhead the enemy's Easter Offensive of 1972.9
The Tet Offensive of 1968 did not suddenly cause drug use, racial animosity, and lack of discipline, the problems that within two years inflicted painful wounds on the Air Force. At the time of the Tet fighting, drug abuse seemed to mean smoking marijuana, and the air arm believed that racial friction was a problem only for the services that relied on draftees rather than volunteers.10
This complacent attitude did not reflect reality, however. Many a volunteer had chosen the Air Force to escape the danger, discomfort, and stricter discipline of the Army or Marine Corps and was merely serving his time. The pressure of the draft had thus forced into uniform many reluctant airmen, and they shared the attitudes of their contemporaries in civilian life and in the other services -racial animosity, an acceptance of drug use, and indifference, if not contempt, toward authority.11
The declining public support for the war, accelerated by the Tet fighting, affected the morale of officers and airmen in Southeast Asia. Debate took place in Congress and demonstrations against the war, and less frequently for it, flared in American streets. In the absence of unified and articulate public support, airmen came to believe that only suckers went to Vietnam, and commanders used to being obeyed discovered that they had to reason with enlisted men and even junior officers. As an earlier generation of Air Force-trained pilots began retiring from the airlines, replacements stood ready to leave the service and its recurring tours of dangerous duty.12
After the failed Tet Offensive, North Vietnam blunted the ground thrusts into Cambodia and Laos and prepared for a future offensive, while maintaining pressure on the Americans with hit-and-run raids against airfields and fire support bases. Long periods of tedium, punctuated by occasional moments of terror when rockets or mortar shells began exploding, caused young airmen to seek escape. They found it all too easily in heroin refined from the opium of the golden triangle, where the territories of Burma, Thailand, and Laos converged. Drug abusers formed an alienated minority within the Air Force; since being discharged, even dishonorably, seemed an escape rather than punishment, these individuals were impervious to ordinary discipline.
To reach them, the Air Force combined the promise of rehabilitation, which proved especially attractive among those who hoped to rid themselves of drug addiction before returning to the United States, with the threat of detection and punishment. The Air Force routinely offered amnesty, detoxification, and rehabilitation to anyone who turned himself in before being apprehended; those who were caught could expect punishment and a resulting delay in their return to civilian life. A program of education warned of the danger of drugs, and a combination of random and regularly scheduled testing-the latter focusing on persons whose tour of duty in Southeast Asia was ending-increased the likelihood of being caught. Despite these efforts, drugs remained a problem as long as Air Force units served in Southeast Asia.13
While the drug problem pitted users of hard drugs against users of alcohol-dopers against foam-heads-and both against a system they perceived as unjust, racial strife set whites and blacks against each other despite policies of equal treatment and opportunity in force for two decades. Only in battle, where a person's life depended on teamwork, did the races cooperate spontaneously. Elsewhere a sense of unity rarely prevailed, reflecting divisions in civil society over race and Vietnam, which increasingly seemed a white man's and rich man's war but a black man's and poor man's fight.
A resurgent racism, based at least in part on essentially economic grounds infected both whites and blacks. At their most extreme, white racists charged that blacks were taking over white jobs and neighborhoods, and black racists saw every white as an oppressor determined to keep them poor and powerless. This mutual hatred did not vanish when a person donned an Air Force uniform; indeed, it often became the lens through which members of both races viewed their assignments and the training and treatment they received.
When existing policy and ordinary discipline failed to relieve racial tension, the Air Force sought to improve communication and understanding between the races, at first through interracial discussion groups and advisory committees. In 1971, a study directed by Colonel Lucius Theus of the Air Force, a black officer serving in the Office of Secretary of Defense, produced a program, adopted for all the services, that trained instructors and developed a curriculum to teach racial amity. The education effort had begun by the time the Vietnam War ended in the cease-fire of January 1973.14
A tangle of threads linked the disaffected airmen of 1970, and the Air Force in which they served, to the Tet Offensive. Disillusionment arising from the Tet fighting fueled opposition to the war that ultimately helped isolate airmen from the society they defended and from each other. The Tet Offensive also elevated negotiation to the status of a war aim. The change in objective, plus public disenchantment with lengthy lists of casualties, led to a policy of Vietnamization and withdrawal. This policy, in turn, brought about an emphasis on air power to hold the enemy in check, along with an understandable reluctance to be the last American killed in Vietnam. The end of Air Force civic action and the temporary reliance on air transport to do the work of truck convoys resulted directly from the Tet Offensive but had minor impact on the course of the war. The critical flaw in the American reaction to Tet may well have been the inability, due largely to the nation's disillusionment with the war, to link the troop withdrawals firmly to progress toward both a negotiated settlement and the successful Vietnamization of Saigon's armed forces.
Whatever the failings of American policy, President Nixon succeeded in giving the American people what they wanted and liquidating the war. As he did so, the Air Force encountered two problems-drug use and racial conflict-that defied ordinary methods of discipline. The service managed to fashion and carry out new programs that neutralized both until the war ended, but only when peace returned could the Air Force make real headway against them.
1 U.S. Department of Defense, The Department of Defense History of United States Decisionmaking on Vietnam, Senator Gravel Edition (Boston, 1971), vol. IV, pp 555-556, 575-602; David M. Barrett, Uncertain Warriors: Lyndon Johnson and His Vietnam Advisers (Lawrence, Kansas, 1993), pp 124-126, 144-159; Mark Clodfelter, The Limits of Air Power: The American Bombing of North Vietnam (New York, 1989), pp 134-146.
2 Marshall L. Michel, III, Clashes: Air Combat over North Vietnam, 1965-1972 (Annapolis, Maryland: Naval Institute Press, 1997), pp 166-172, 183-185, 290.
3 Lee Bonetti, USAF Civic Action in Republic of Vietnam (HQ PACAF [Pacific Air Forces], Project CHECO [Contemporary Historical Evaluation of Current Operations], April 1, 1968), pp 24, 36; Maj A. W. Thompson,USAF Civic Action in Republic of Vietnam (Hq PACAF, Project CHECO, March 17, 1969), pp 4-5,22-24; comments, Capt Paul Boulanger, base civic action officer, Tan Son Nhut Air Base, Effects of Tet on Civic Action, n d [March 1968].
4 Maj A. W. Thompson and C. William Thorndale, Air Response to the Tet Offensive, 30 Jan-29 Feb 1968 (Hq PACAF, Project CHECO, August 12, 1968), pp 42-45, 47-49, 51; history, 834th Air Division, July 1967-June 1968, pp 33-34.
5 Peter Braestrup, Big Story: How the American Press and Television Reported and Interpreted the Crisis of Tet in 1968 in Vietnam and Washington (Boulder, Colorado, 1977), vol I, pp 253-256, vol II, appendix 26; Don Oberdorfer, Tet! (Garden City, New York, 1971), pp 184-185, 246-251; James T. Patterson, Grand Expectations: The United States, 1945-1974, vol X of The Oxford History of the United States (New York and Oxford, 1996), pp 635-636, 680-681.
6 Henry Kissinger, The White House Years (Boston, 1974), pp 271-272.
7 Thompson and Thorndale, Air Response to the Tet Offensive, p 71; Directorate of Management Analysis, Hq USAF, USAF Mgt Summary, SEA, February 23, 1968, p 1, and March 1, 1968, p 1.
8 Phillip B. Davidson, Vietnam at War: The History, 1945-1975 (Novato, California, 1988), pp 559-564, 573-596; Department of Defense Report, Selected and Ground Operations in Cambodia and Laos, September 10, 1973.
9 Eduard Mark, Aerial Interdiction: Air Power and the Land Battle in Three American Wars (Washington, 1994), pp 341-344; Hearings before the Electronic Battlefield Subcommittee of the Preparedness Investigating Subcommittee of the Senate Committee on the Armed Services, 91st Congress, 2d Session, Investigation into the Electronic Battlefield Program, pp 84-90; Report of the Electronic Battlefield Subcommittee of the Preparedness Investigating Subcommittee of the Senate Committee on the Armed Services, 92d Congress, 1st Session, pp 12-13.
10 TIG [The Inspector General] Brief. vol xx, no 6 (March 29, 1968), p 17, (September 27, 1968), p 20; hist, Office of the Surgeon General, USAF, January-June 1968, p 149, July-December 1970, p. 33.
11 William L. Hauser, America's Army in Crisis: A Study in Civil-Military Relations (Baltimore, 1973), pp 98-102; Jack D. Foner, Blacks and the Military in American History: A New Perspective (New York, 1974), p 216; Air Force End of Tour Report, Col Arden C, Curfman, Comdr, 483d Combat Service Group, Cam Ranh Bay Air Base, October 1970-October 1971, n d, pp 7-11.
12 Air Force End of Tour Report, Col Robert M. Slane, Vice Comdr and Comdr, 553d Reconnaissance Wing and Comdr, 6251st Combat Service Group, 1970-1971, November 15, 1871, pp 7-8.
13 Msg, Chief of Staff of the Air Force to All Major Commands, 081623Z March 1971, subj: Privileged Communication for Drug Abusers, unnumbered supporting document to hist, Pacific Air Forces, July 1970-June 1971, vol II; Maj Richard B. Garver, Drug Abuse in Southeast Asia (Hq PACAF, Project CHECO, January 1, 1975), pp 7-14.
14 Maj Alan Osur, "Black and White Relations in the Military," Air University Review, vol xxxii (November-December 1981), pp 76-77; Air Force historical interviews, Lt Col Robert G. Zimmerman with Col John E. Blake, Comdr, Travis Air Force Base, California, 1970-1971, July 24, 1974, pp 66-87; and Shelby Wickham with Lt Col Thomas J. Sizemore, Chief, Social Actions Office, Wright-Patterson Air Force Base, Ohio, 1974-1977, March 3, 1977, pp 16-19; David J. Garrow, Bearing the Cross: Martin Luther King, Jr., and the Southern Christian Leadership Congress (New York, 1986), pp 429-430, 469-470.
Speakers Biographies
Colonel Harry G. Summers Jr., U.S. Army (Ret.) is a highly respected authority on the Vietnam War. He speaks from first hand experience. Colonel Summers is a veteran of infantry combat in Korea and Vietnam, for which he earned the Combat Infantryman Badge, a Silver Star, Legion of Merit, Bronze Star, and two Purple Hearts. He holds bachelors and masters degrees in military arts and sciences and has taught strategy and tactics at the Army War College and the Army Command and General Staff College. Colonel Summers is the military correspondent for U.S. News and World Report, and a television commentator. His first book, On Strategy: A Critical Analysis of the Vietnam War, was a seminal work that stimulated study of the conflict. He has since published almanacs on the Korean and Vietnam wars, and an analysis of the Persian Gulf War. He has remained close to our Vietnam veterans as the Editor of Vietnam Magazine.
Leslie J. Cullen is a new scholar who has already distinguished himself. In 1992 he earned a B.A., summa cum laude, in 1994 an M.S., and in 1998 a Ph.D., all in History and from Texas Tech University, Lubbock, Texas. He received a U.S. Military Academy/Reserve Officers Training Corps Military History Fellowship in 1996 and won awards as an Outstanding Graduate Student and an Outstanding Teaching Assistant from Texas Tech, where he is now on the faculty. Dr. Cullen's doctoral dissertation is on Admiral Elmo R. Zumwalt Jr, the Chief of Naval Operations from 1970-1974, and Commander Naval Forces, Vietnam during the pivotal years from 1968 to1970.
Bernard C. Nalty is a veteran of our Colloquium on Contemporary History program. He presented a paper at our 1991 conference on "Command and Control of Air Operations in Vietnam." Mr. Nalty has had a long and productive career as a government historian, having served 40 years, from 1954 to 1994, in the historical offices of the U.S. Marine Corps, Joint Chiefs of Staff, and U.S. Air Force. He has published numerous articles and books, including in the latter category Strength for the Fight: A History of Black Americans in the Military and a volume on Marine combat operations in World War II. He was general editor of a two-volume history of the Air Force and has also authored Air Power and the Fight for Khe Sanh.
Note: The views or opinions expressed or implied are those of the speakers alone and not those of the Department of the Navy or any other agency of the U.S. Government.
Published: Mon Feb 06 09:59:22 EST 2017
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2 Mid Terraced Bungalow For Sale
The Broadway, Oakington
Today - 22 nd January
Tomorrow - 23 rd January
Tuesday - 4 th February
LOCATION Oakington is a small village just 7 miles north-west of Cambridge which can easily be accessed via the A14, which is just over a mile from the village, or the guided bus way which also connects to St Ives. The village has a junior and infant's school which feeds into the highly regarded Impington Village College, a public house, village shop, garden centre with tea rooms, a number of small businesses and holds village events on the recreation ground.
ENTRANCE HALL Doors to rooms, loft access (partly boarded).
LIVING ROOM 16' 1" x 10' 5" (4.9m x 3.18m) Double glazed window to front, gas fire.
KITCHEN/BREAKFAST ROOM 12' 1" x 7' 5" (3.68m x 2.26m) Double glazed window to rear and door to garden, range of fully fitted wall and base units with drawers under, rolled edge worktop surface over and tiled splash back, sink unit and mixer tap, plumbing for washing machine, space for cooker, fridge and freezer, breakfast bar, wall mounted gas boiler.
BEDROOM ONE 14' 10 narrowing to 12' 9"" x 8' 7" (4.52m x 2.62m) Double glazed window to front, range of fully fitted wardrobes with overhead storage and bed side tables, dressing table and drawer set.
BEDROOM TWO 8' 10" x 8' 0" (2.69m x 2.44m) Double glazed window to rear.
WALK IN CUPBOARD 4' 9" x 4' 1" (1.45m x 1.24m)
BATHROOM Obscured double glazed window to rear, WC, hand basin, bath with shower fitting over, airing cupboard housing hot water tank.
GARDEN AND PARKING To the front of the property are two allocated parking spaces and gated access leads to the rear garden. The rear garden is mainly laid to lawn, enclosed by fencing, has various flowers and shrubs set to the boarders and beds, a brick built outbuilding with power connection, timber shed, paved patio area and outside tap.
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by Kate Stewart
Author: Kate Stewart
Published: May 1st 2019 by Little A
The inspiring true story of an indomitable librarian’s journey from Nazi Germany to Seattle to Vietnam—all for the love of books.
Growing up under Fascist censorship in Nazi Germany, Ruth Rappaport absorbed a forbidden community of ideas in banned books. After fleeing her home in Leipzig at fifteen and losing both parents to the Holocaust, Ruth drifted between vocations, relationships, and countries, searching for belonging and purpose. When she found her calling in librarianship, Ruth became not only a witness to history but an agent for change as well.
Culled from decades of diaries, letters, and photographs, this epic true story reveals a driven woman who survived persecution, political unrest, and personal trauma through a love of books. It traces her activism from the Zionist movement to the Red Scare to bibliotherapy in Vietnam and finally to the Library of Congress, where Ruth made an indelible mark and found a home. Connecting it all, one constant thread: Ruth’s passion for the printed word, and the haven it provides—a haven that, as this singularly compelling biography proves, Ruth would spend her life making accessible to others.
This wasn’t just a career for Ruth Rappaport. It was her purpose.
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Viewing Room Main Site
CollectionArtists + DesignersExhibitionsFairsViewing RoomPressGallerySearch
Jasmin Anoschkin
Golden Kissing HotDog
ImagesThumbnailsBack
JASMIN ANOSCHKIN (Finnish, b.1980)
Golden Kissing HotDog, 2018
Ceramic and 24k gold
14" H x 17.25" W x 9.5" D
Jasmin Anoschkin is a Finnish artist working with ceramics, wooden sculptures, drawings and painting. She is a member of the Arabia Art Department Society and has exhibited widely for the past ten years. The unique world of Anoschkin’s sculptures includes expressive statement pieces, like Donkey, highlighting a magical world of animals that have spirits. As if animated, the animals call to the viewer, inviting one into a land of make believe.
Anoschkin’s aesthetic features an amalgamation of sources, combining the aesthetic language of contemporary folk art with pop culture and the toy industry. With an affinity for white and neon colors, she selects the colors and glazes for her works as she sculpts, often using leftovers from other artists or standard Arabia finishes. Many of her pieces have a story implied within them, often created by combining elements of her own life and her friends’ experiences.
Jasmin Anoschkin’s breakthrough exhibition and artwork was Bambi, shown at the Mänttä Art Festival in 2009 and also in 2010 at the 100th Anniversary of the Association of Finnish Sculptors in Wäinö Aaltonen Museum of Art. It was subsequently acquired by the Finnish State Art Collection. In 2012, she was chosen to be the year’s young artist in the Satakunta region of Finland. During the years of 2009-2010, she was a visiting artist at the Arabia Art Department Society before becoming a full member in 2014. In the autumn of 2017, her work will be published as a series of postage stamps. Her work is permanently on display in the lobby of the Helsinki City Museum.
Artists + Designers
New York | 35 East 10th Street | New York NY 10003 | 212 343 0471 | info@hostlerburrows.com
LOS ANGELES | 6819 MELROSE AVENUE | LOS ANGELES CA 90038 | 323 591 0182 | LA@HOSTLERBURROWS.COM
©2019 Hostler Burrows Site Index
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Panasonic DMC-LZ5 Test Shots
Camera Reviews / Panasonic Cameras i Full Review
DMC-LZ5 Overview
Samples Test Shots Thumbnails
Digital Cameras - Panasonic Lumix DMC-LZ5 Test Images
Not sure which camera to buy? Let your eyes be the ultimate judge! Visit our Comparometer(tm) to compare images from the Panasonic Lumix DMC-LZ5 with those from other cameras you may be considering. The proof is in the pictures, so let your own eyes decide which you like best!
"Sunlit" Portrait:
(This is my new "Outdoor" Portrait test - read more about it here.)
The lighting in this shot is deliberately awful, about what you'd expect from noontime sunshine here in the Atlanta, GA area. (In fact, the color balance has been chosen to pretty well match the hazy sunshine here in mid-August.)
The reason for the harsh lighting is to provide a real "torture test" of how cameras handle conditions of extreme contrast; and in particular, how well they do holding onto highlight detail.
Overall color: Matching summer sunlight here in the South, the lighting in this scene is a bit more yellow-tinged than that in many parts of the country, or in the fall or winter. - So there may be an overall warm cast to the color. That said though, there's a fair range of color represented in the bouquet, presenting a tough challenge for the cameras. For some reason, the blue flowers seem particularly hard to handle, with many cameras rendering them as purple. (In real life, they're a light shade of navy blue, with just a bit of purple in them.)
Skin tones: The overall slight warm cast will tend to leave Marti's skin tones a bit on the warm side as well. Nonetheless, look to see if her skin seems overly pink or if they have a too-bright tinge of yellow: Some cameras oversaturate skin tones (make their color too intense), leading to an almost sunburned look. A little oversaturation can make for a more "healthy-looking" complexion, but it doesn't take much variation for skin tones to look unnatural.
Highlight detail: When Marti's skin tones are at a more or less normal level of brightness, how much detail can you see in her shirt? Does it blow out entirely to white, or can you still see the creases and folds in the fabric?
Overall contrast: Most consumer digital cameras produce bright, contrasty images, because that's what most consumers like. Unfortunately, under bright sunlit conditions, many such cameras produce images with little or no highlight detail, and dark, plugged-up looking shadows.
Shadow detail: The area under the flower bouquet is in quite deep shadow. Does the camera in question retain good detail here, with low image noise? To see, you may need to download the image and play with it in Photoshop(tm) or another imaging program. Brighten the image, and see how far detail extends into the shadows. Photo printers are generally much better at showing shadow detail than are CRTs, so you'll want a camera that preserves good detail here. The ability to boost brightness without encountering too much image noise is important if you ever have to "rescue" an underexposed image on the computer.
Detail in areas of subtle contrast: Most digital cameras employ some sort of noise-suppression to remove electronic noise from their images. Noise suppression is a good thing, but only if it's not overdone. Too much noise suppression will "flatten out" subtle detail in areas of reduced contrast. You can often see this in hair, where the individual strands become blurred, and the image takes on an almost watercolor effect. Look at the detail in Marti's hair, and compare how it looks with different cameras in the Comparometer.
To view the entire exposure series from zero to +1.7 EV, see files LZ5OUTAP0.HTM through LZ5OUTAP5.HTM on the thumbnail index page.
Closer Portrait:
The original intent of this shot was to illustrate why you really want a zoom lens if you intend to take close-up shots of people. Fixed focal length lenses tend toward the wide angle end of the spectrum, meaning that you have to get very close to your subjects to fill the frame with them. This results in very unnatural, chipmunk-like face shot, with exaggerated noses and rounded cheeks.
These days, most digital cameras come equipped with zoom lenses, so you won't have to worry about the "Chipmunk look" in your portrait shots. (Just zoom the lens out to its telephoto position when you're taking close-in shots like this.)
To view the entire exposure series from zero to +1.3 EV, see files LZ5OUTFACAP0.HTM through LZ5OUTFACAP4.HTM on the thumbnail index page.
Indoor Portrait, Flash:
Normal Flash
Slow-Sync Flash
This shot duplicates indoor shooting conditions in most US homes, with fairly bright incandescent room lighting. The challenge here is for the camera's flash to blend naturally with the room lighting, and produce good, neutral color overall. - Some cameras will be overly affected by the room lighting, even with their flash enabled, and the result will be a strong orange cast. Another common failing is for the highlights from the flash to take on an unnatural bluish cast.
Finally, exposure is important here, and frequently a tough challenge for the cameras. Marti's white shirt is central in the scene, reflecting a lot of the light from the flash right back at the camera. As a result, most cameras underexpose this shot, and require some positive exposure compensation to produce a good result. - And that's an important consideration in itself: Does the camera even permit adjustment of its flash exposures? Many do not. These photos are a tough exposure challenge, if they come out OK, the camera in question can probably be coaxed into delivering a good flash exposure of any subject within its range.
Note too, that the normal flash shot (as opposed to the slow sync one, if the camera offers that feature) will be sharply rendered, any subject or camera movement frozen by the quick pop of the flash. That makes this shot a good one to look for the effect of over-aggressive noise suppression in Marti's hair.
To view the exposure series from zero to +1.7 EV in the normal flash mode, see files LZ5INFP0.HTM through LZ5INFP5.HTM on the thumbnail index page.
To view the same series in the Slow-Sync flash mode, see files LZ5INFSP0.HTM through LZ5INFSP5.HTM on the thumbnail index page.
Indoor Portrait, No Flash:
Incandescent White Balance
Manual White Balance
The incandescent lighting used in most US homes actually has a very strong yellow color to it. Our eyes have an amazing ability to ignore color casts like this, something digital cameras struggle to emulate.
The incandescent lighting used for this shot is thus not only very common here in the US, but also very difficult for most digital cameras to deal with. While we probably want a little yellow color to remain in the image (to convey some of the mood of the original scene), too much will look unnatural and distort colors.
Most cameras' auto white balance systems have a great deal of difficulty with this shot, but many incandescent white balance settings struggle as well. (It seems that many cameras' incandescent settings are actually calibrated to the tungsten lighting used in professional studio systems, which isn't nearly as warm-toned as typical household lighting.)
If you intend to do much shooting indoors after dark, pay careful attention to this test, as cameras vary widely in this regard.
To view the entire exposure series from zero to +1.3 EV, see files LZ5INMP0.HTM through LZ5INMP4.HTM on the thumbnail index page.
ISO Series:
"ISO equivalent" refers to a camera's light sensitivity. ISO 200 represents twice the sensitivity of ISO 100, meaning that you can use a shutter speed that's twice as fast. Higher ISO settings are often required to get any picture at all when shooting after dark, but even in full daylight, using a higher ISO can help you freeze fast action. The problem is, increasing a digital camera's ISO also increases image noise. In practical terms, this means that higher-ISO images often can't be used to produce prints as large as lower-ISO ones. The tricky thing here is that high-ISO images often look much different when printed at various sizes than they do when viewed on-screen. In particular, for any level of image noise, you'll often find that while noise is quite evident at larger print sizes, as you reduce the size of the prints, there will come a point where it suddenly ceases to be an issue. We routinely print high-ISO photos from the cameras we test on our studio printer (currently a Canon i9900) at a range of sizes, and report our findings. If you're interested in investigating the effect of image noise for yourself, don't judge cameras' performance by how their images look on your CRT, viewed pixel-for-pixel. Rather, download the test shots linked in the table below and output them on your own printer, so you can see how prints of various sizes will actually look.
One additional note about this particular test series though: Because they're shot under household incandescent lighting, the camera has to boost its blue-channel signal quite a bit to get back to a neutral color balance. Since the blue channel is generally the one with the most noise, this makes this shot a real acid test of noise performance. Noise levels in high-ISO shots taken under daylight conditions usually won't show as much noise. (See the "Far Field" test for examples of high ISO shots captured in daylight.)
ISO Series
ISO 80 ISO 100 ISO 200 ISO 400
House Poster:
Daylight White Balance
Like several of our tests, these images are actually photos of a high-resolution poster, shot under studio lighting. As of this writing, the poster in question was produced from a high-resolution scan of a 4x5-inch transparency, scanned to a resolution of about 150 megapixels. Even at that, it's starting to show its age, as the combination of camera lens, film emulsion and scanner resolution mean that many of the current 5+ megapixel cameras come close to capturing all the detail that's present. (We have a new poster under production, produced from 45 separate digital images, "stitched" into a single 400+ megapixel image, that should comfortably outpace the resolution of portable digital cameras for years to come.)
Why did we choose to shoot a picture of a picture? The idea was to show a typical subject (a house and surrounding foliage) in a way that would be absolutely consistent from camera to camera. Any outdoor subject is going to vary considerably from day to day, as the lighting changes with the weather, atmospheric conditions, and season. Shooting a poster lets us compare images from cameras shot weeks, months, or even years apart, with the sure knowledge that nothing has changed from one shot to another.
Things to look for here are fine detail, as seen in the foliage and tree limbs against the sky, sharpness in the corners, and the preservation of subtle detail in the shaded brick patterns. - Many cameras with overactive noise suppression severely blur the brick patterns that are in shadow.
Far-Field Test
While the House poster in the shot above provides absolute repeatability from test to test, it doesn't offer the range of brightness (dynamic range) that the original scene had, nor does it contain the nearly infinite range of fine detail found in nature. For these reasons, we still shoot the original house, even though the vagaries of nature mean that no two shots will ever be directly comparable. (In fact, over the eight or so years since we first shot this subject, the trees in front of the house have now grown so large that they obscure much of the subject. - We're unfortunately going to have to switch to a different subject in the near future.)
Things to look for here are how well the camera handles the range of light levels from very bright to quite dark, and how well it renders the very fine detail visible in various parts of the image.
Note though, that because this is shot outdoors, the character of the light is unavoidably going to change quite a bit, depending on the atmospheric humidity and the time of year. - You thus shouldn't rely on it for absolute comparisons between cameras, since it's unlikely that conditions will be identical from one test to the next.
For this subject, we shoot examples of pretty much anything the camera is capable of, with a resolution series to show how well the camera "downsamples" its images to make lower-resolution copies, an ISO series, color effects, contrast and saturation adjustments if they're available, etc.
Resolution Series:
(Medium Focal Length) "Fine"
JPEG "Normal"
2,816 x 2,112 LZ5FAR2816F LZ5FAR2816N
2,048 x 1,536 LZ5FAR2048 -
1,280 x 960 LZ5FAR1280 -
640 x 480 LZ5FAR0640 -
Color Effects Series:
Color Effects Series
Warm Color
Lens Zoom Range
Simply reading "4x zoom range" doesn't do a lot to help you visualize what that means. It also says nothing regarding just how wide the wide-angle end of that range is. To give you an idea of exactly what each camera's zoom lens does, we shoot this series of images, showing results at maximum wide angle, maximum telephoto, and telephoto with "digital zoom" enabled. (Note of course though, that so-called "digital zoom" just crops out and enlarges the central pixels of the image, achieving increased size at the cost of reduced resolution.)
6x Telephoto
Digital Telephoto
Musicians Poster
This is another poster, shot in the studio under controlled lighting. It's intended to give an idea of how well various cameras render a range of skin tones, but it often winds up as more of a referendum on the camera's white balance system. The background of the image has a lot of blue in it, which frequently tricks white balance systems into overcompensating toward warmer hues. The poster is also rather low resolution, having been made from a 20 megabyte digital file. As such, it can't be relied upon to reveal much about detail rendition of modern, high-megapixel cameras.
Macro Shot
Standard Macro Shot
Macro with Flash
Many are interested in close-up or "macro" photography. This test shows the best results we could obtain using each camera's macro mode. What to look for:
Minimum Macro Area: What's the smallest area that the camera can photograph? - We calculate this and report on it in the Test Results section of each review.
Softness in corners?: The images from most digital cameras get fairly soft when shooting in macro mode. Some are better than others though, you can use the texture of the paper fibers or the details in the dollar bill to compare corner sharpness between models.
Flash performance in macro mode?: Macro mode flash performance varies widely between cameras. Some can't throttle down the flash enough, others throttle down enough, but have very uneven lighting, while others have lenses that project into the path of the flash, casting strong shadows. The Macro with Flash shot here will show you what to expect.
"Davebox" Test Target
This subject is a good all-around laboratory test target, useful for the more analytically-minded in making objective comparisons between cameras. Things to look for:
White balance: How well do the various white balance modes render the neutrally-colored subject?
Color Accuracy: The "MacBeth" color chart is a widely available standard color target. The color values can be used to make very precise measurements of color accuracy. (We use this target internally at IR in conjunction with the Imatest image-analysis program to get a sense of how cameras handle color in various parts of the spectrum.)
Shadow detail and noise: The charcoal briquettes in the black box at the bottom of the box are an excellent test of shadow detail.
Highlight detail: The white-on-white of the gauze at lower right is a good test for highlight detail.
Specular reflections: The shiny pot lid at top right reflects the studio lights right back into the lens. Cameras these days handle light overloads like this pretty well, but this test subject still reveals problems with "charge bleeding" in some cameras.
The results in the tests below mirror those seen above in other test shots. The test series are repeated here, for the benefit of our more quantitatively-oriented readers.
Low-Light Tests
Low light photography is an area where there are really enormous differences between digital camera models. This test starts at a light level about equivalent to typical city street lighting at night (one foot-candle), and then progresses down from there, each successive test being at half the light level of the preceding one. You may also see the effect of poor low-light autofocus in some of these shots, although we use a different test setup to check autofocus performance more directly. (The results of which are reported on in the main Test Results section.) Things to look for here include:
Exposure limit: What's the darkest level a camera can handle at each ISO setting? If the leftmost images are reasonably bright, the camera should do fine with typical city night scenes. If you're shooting in the more dimly-lit suburbs, you'll need a camera capable of producing good images one, two, or three steps to the right of that.
Autofocus Limit: How dark can you shoot and still get well-focused pictures?
White Balance: Does the camera's white balance suffer at low light levels? (Many do.)
Noise Levels: Look at the photos, print them on your own photo printer. How large a print can you make at acceptable quality levels, at various ISO settings and light levels?
Detail loss to anti-noise processing?: Do details in the white gauze and even in the lettering on the test targets suffer at lower light levels?
(Note: If you'd like to use a light meter to check light levels for subjects you might be interested in shooting, a light level of one foot-candle corresponds to a normal exposure of two seconds at f/2.8 and ISO 100.)
1 fc
11 lux 1/2 fc
5.5 lux 1/4 fc
1.3 lux 1/16 fc
0.67 lux
Flash Range Test
Digital camera makers have gotten better with their flash-range ratings. In the early days, many cameras had rather "optimistic" flash range specs, to put it politely. These days, the manufacturers seem to be toeing the line. (No doubt at least in part because of tests like this.) Consistent with our philosophy of testing worst-case conditions, this test also involves some use of each camera's zoom lens. Flash range is greater at wide angle focal lengths than at telephoto ones. If you're shooting at the wide angle end of the lens' range, you might get better flash range than what's shown here. - But you'll never get a nasty surprise if you let the test shots below be your guide to flash capability.
8 ft 9 ft 10 ft 11 ft 12 ft 13 ft 14 ft
ISO-12233 (WG-18) Resolution Test
This is the standard ISO-12233 resolution target. It can be used with automated image-analysis tools like Imatest, but for our reviews, we generally just report the number of lines of resolution that we can see cleanly resolved in it.
The chart numbers correspond to hundreds of lines of resolution per picture height. - The reference to picture height is to provide a consistent measure of resolution, regardless of image aspect ratio. (Height to width ratio.)
In evaluating lines of resolution, it's important to set as a threshold the point at which artifacts (jaggies or blurring of the lines) start to overcome the target details themselves. We tend to be a bit more conservative than some reviewers in the number of lines we'll say a camera has: The point here isn't to try to figure out the point at which you can just barely convince yourself that you're still seeing the target lines, but rather to call a halt when the camera is no longer cleanly resolving the target detail. We also report the point at which the target lines entirely merge into oblivion, as the "extinction point." This last point doesn't relate to image resolution in any sense, but does correlate somewhat with perceived edge sharpness.
Things to look for on this target include:
Resolution: How many lines are resolved, both horizontally (across the vertically-oriented resolution wedge) and vertically (across the horizontally-oriented resolution wedge.)
Where do artifacts start?: This is a more subtle measure. Somewhere well before the lines start to merge with each other, you'll see subtle patterns of thickening and narrowing, artifacts caused by the camera's sensor and image processing system. In an ideal world, these artifacts would be invisible. With most cameras, they are nearly so, but some models produce rather pronounced "jaggies."
Extinction point: As described above, the point at which the target lines fade away more or less completely. Generally correlates with perceived sharpness.
Barrel/Pincushion distortion: Barrel distortion refers to a tendency for straight lines near the edges of the frame to bow outward in the middle. Pincushion distortion is just the opposite, lines near the edge bow inward in the middle. The amount of distortion is expressed as a percentage, dividing the amount of the bow by the length of the line over which you're measuring it. Most lenses show significant amounts of barrel distortion at wide angle, on average about 0.8%. That doesn't sound like a lot, but it's very visible if you have straight lines near the edges of the frame. Pincushion distortion is usually seen at telephoto focal lengths, and varies widely between cameras, from none at all to as much as 0.6%.
Chromatic Aberration: Chromatic aberration appears as a slight colored fringe around the edges of objects, usually just in the corners of the frame. If the coloration is intense, it can be very distracting in your images, particularly where dark objects are silhouetted against the sky. Obviously, the less of this the better.
Corner Sharpness: Most cameras lose sharpness in the corners of the frame, at least somewhat, and particularly at larger apertures. Look at the resolution target elements in the corners to see how much the image softens there, and how far into the frame the softness persists.
Resolution Series, medium focal length
2,816 x 2,112 LZ5VRES2816F LZ5VRES2816N
2,048 x 1,536 LZ5VRES2048 -
1,280 x 960 LZ5VRES1280 -
640 x 480 LZ5VRES0640 -
Resolution Test, Zoom Series
2,816 x 2,112
(Fine,
Wide Angle) LZ5VRESW
Telephoto) LZ5VREST
Viewfinder Accuracy/Flash Uniformity
Viewfinder accuracy is an important parameter, especially for shots where framing is critical. The optical viewfinders on most digital cameras match the (poor) accuracy of those on film cameras, typically showing only about 85% of the actual final frame area. It's likely that this is a deliberate design choice by the camera engineers, to help avoid users accidentally cutting off the heads of their subjects. We disagree with this approach, or at least feel that it should be mitigated a bit, perhaps by increasing the accuracy to 90 to 95%.
Unlike the optical viewfinders, the LCD viewfinders on most digital cameras tend to be quite accurate. There are exceptions though, and it's unfortunately not uncommon to find an LCD monitor that only shows 90% or less of the final frame.
Things to look for on this test chart are:
Optical and LCD viewfinder accuracy: When we shoot this target in the studio, we line things up so the bold black outline on the target is just visible at the edges of the viewfinder frame. The resulting photo then very directly shows how accurate the viewfinder is.
Flash Uniformity: The flash units on many digital cameras don't illuminate the scene very evenly, especially at wide angle focal lengths. We shoot the viewfinder target with the flash enabled, so the photos here also show how uniform the flash is.
Wide Angle, LCD
Telephoto, LCD
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Border Attorney Fellow - Texas ProBar, American Bar Association (ABA)
The South Texas Pro Bono Asylum Representation Project (ProBAR) empowers detained immigrants through high-quality legal education and representation. Located in Harlingen, Texas, ProBAR serves adults and unaccompanied children in immigration detention in the Rio Grande Valley.
The ABA recruits employees seeking opportunities for challenging and substantive work defending liberty and pursuing justice in the U.S. and around the world. The ABA offers competitive employment benefits which include medical, dental, vision, life and disability insurance, flexible spending accounts, a 401(k), commuter benefits, and more. Accountable for providing direct representation for ProBAR clients in immigration cases, including representation in Immigration Court and the United States Citizenship and Immigration Service (USCIS), while helping to support the broader immigration efforts of ProBAR’s legal team. Under the supervision of Supervising Attorney, the HIAS Border Fellow will provide direct legal representation to individuals seeking asylum, withholding of removal, and Convention Against Torture protection, with a focus on representing individuals in the Migrant Protection Protocols (MPP) Program.
Provided legal representation in removal defense cases, including MPP cases
Under the supervision of ProBAR Legal Director, support ProBAR’s legal team, including the DOJ accredited representatives, pro bono attorneys, and other staff as assigned, through regular engagement, case assistance and mentorship
Oversee and provide legal orientation, counseling and education regarding asylum and other potential relief available to the population served by ProBAR
Stay up to date on rapidly changing asylum laws and policies; comply with data and program reporting requirements
Support efforts of HIAS to engage the Jewish community around the issues of immigration detention and asylum, including identifying opportunities for pro bono attorney and non-attorney engagement and submitting one contribution to the HIAS blog or other communication (such as a video, presentation, briefing call, etc.) per trimester (every four months)
Performs other related duties as required
Possession of a Juris Doctorate degree from an ABA-accredited law school and be in good standing of any state and/or the District of Columbia
A minimum of 1-3 years of experience with immigration law, including removal defense work before the immigration court
Fluent in English and Spanish in written and spoken forms
Intermediate proficiency in Microsoft Office products and Google tools
Excellent interpersonal skills, including good communication skills, listening skills and attitude
Strong case management, legal research, and legal writing skills required.
Demonstrated ability and willingness to zealously pursue new and untested legal theories
Ability to work both independently and in a group setting
Ability to work flexible hours, including some evenings and weekends
Valid driver’s license, access to an automobile, insurance, and willingness to drive to off-site locations
This position requires the ability to travel to and enter care provider facilities funded by the Office of Refugee Resettlement, Administration for Children and Families, United States Department of Health and Human Services which provide housing and services to unaccompanied children. This position will require the provision of legal services to unaccompanied children in such care provider facilities. In accordance with the federal regulation, background check will be required for this position
Passion for social justice for immigrants required and a willingness to engage with the Jewish community
Experience with removal defense or the intersection of immigration and family law or criminal defense
Dedication to serving immigrant communities with a sincere commitment to working on behalf of low income immigrants
Experience working with detained immigrants or other incarcerated populations
Experience working with marginalized populations and survivors of trauma
To apply for this position, or for more information, click here.
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Home » About Us » History
Kenneth C. Rowe starts Industrial Marine Products Limited.
IMP opens IMP Fishing Gear Limited (U.K.) in Grimsby, U.K.
IMP buys Fairey Canada Limited consisting of two hangars at the Halifax International Airport and creates the Aerospace Division.
Holiday Inn was built and is now known as the Atlantica Hotel Halifax.
IMP buys Hammonds Plains factory from N.S. Government Agency, I.E.L.
IMP buys Down East Aviation and enters the general aviation FBO (fixed base operator) business.
IMP is appointed by Shell as Airport Dealer for Gander, NL, pumping 100 million litres/year of jet fuel.
IMP Fishing Gear Limited (U.S.) opens in New Bedford, Massachusetts, and builds a new retail store and warehouse.
IMP buys John Leckie Inc. and Atlantic Net Rope & Twine Limited to double in size IMP's marine fishing gear business.
First contract with Aeroflot to fuel aircraft in Gander. This opened the door for later expansion into Russia.
IMP's first trip to Russia to explore new business opportunities.
IMP buys Blanchette Frères Limited of Quebec City to expand the aviation FBO network across five airports in Quebec.
IMP buys CAN-med Surgical Supplies Limited in Halifax.
IMP buys Innotech Aviation in Montreal and Toronto.
Joint Venture, Aeroimp, was created by IMP and Aeroflot to build what is to become the Aerostar Hotel in Moscow. This was the second J.V. company to be established between Canada and what was then called the USSR.
IMP opens an office in Cyprus.
IMP buys Execaire Inc. in Montreal, Canada's largest executive jet management and charter company.
Moscow Aerostar Hotel opens as the city's first 5-star western hotel.
IMP buys Amherst Aerospace from the Province of Nova Scotia and establishes IMP Aerospace Components Limited, now known as IMP Aerostructures.
IMP opens IMP Fuels (home heating fuel distribution).
IMP builds new facility for IMP Aerospace Components Limited in Amherst.
IMP buys Forsea Ltd. in Moncton (a fishing equipment supplier).
IMP buys Air Atlantic establishing IMP as a regional scheduled airline.
IMP constructs a new 80,000 sq.ft. hangar facility at Innotech Montreal.
IMP buys Pacific Avionics & Instruments Limited in Vancouver.
IMP opens MediChair in Halifax becoming the city's first mobility equipment healthcare store.
IMP buys Air 500 Limited, a Toronto-based executive aircraft management company.
IMP successfully competes for the U.S. Navy H3 (Sea King) helicopter maintenance support contract - the first time an entire airframe contract granted outside of the U.S.
Pier 21 Foundation, National Historic Site, named one of its grand event spaces, the Kenneth C. Rowe Heritage Hall.
IMP successfully competes for the Canadian Search and Rescue Helicopter In-Service Support contract and has been the contractor of choice ever since, maintaining the Cormorants Canada-wide.
IMP launches CanJet Airlines, Canada's first low-cost airline flying 1.2 million passengers per year with up to 14 Boeing 737 aircraft.
IMP Solutions is created becoming Atlantic Canada's largest I.T. company by 2017.
IMP buys Oak Island Resort, now known as Oak Island Resort & Conference Centre.
IMP constructs a new 60,000 sq.ft. CanJet hangar at the Halifax International Airport.
IMP starts up the Bathurst Call Centre operation.
IMP constructs Hangar 8 at the Halifax International Airport.
IMP is first recognized as one of Canada's Best Managed Companies, maintaining this recognition up to and including 2017.
IMP buys Medtec Marketing of Burnaby, BC (health imaging equipment reseller).
Dalhousie University's School of Business Administration Building named the Kenneth C. Rowe Management Building.
IMP buys Harding Medical in Halifax, Moncton, Sydney, and Charlottetown.
IMP builds largest hangar at the Halifax International Airport - Hangar 9, which is over 90,000 sq.ft. in size.
Moscow Aerostar Hotel is sold.
IMP Aerospace is awarded a $ 600 million contract extension for the Cormorant Search and Rescue helicopter in-service support.
Innotech constructs a new aircraft paint hangar in Montreal.
IMP develops 2 condominium projects, one in Halifax, the other at the Oak Island Resort.
Innotech enters into a long-term business aircraft completions contract with Bombardier.
IMP Aerospace signs a contract with Royal Norwegian Air Force to re-wing P-3 aircraft.
IMP Aerospace Components awarded a long-term contract with Boeing to manufacture Chinook helicopter sub-assemblies.
CanJet enters into a long-term partnership with Transat Tours to provide Boeing 737-800 aircraft for charter.
IMP rebrands its 4-star hotel in Halifax as Atlantica Hotel Halifax.
IMP becomes a member of the Platinum Club of Canada's Best Managed Companies Program and has maintained this recognition every year since.
IMP Solutions expands its business process management practice to Ottawa.
Kenneth C. Rowe inducted into the Canadian Business Hall of Fame.
IMP rebrands Oak Island Resort as Atlantica Oak Island Resort & Conference Centre.
IMP Aerospace awarded a multi-million dollar combined production program to re-life the Canadian Aurora fleet with upgraded systems and wings.
IMP receives the following top employer awards for 2011: Canada's Top 100, Nova Scotia's Top 15, Atlantic Canada's Top 25, and Financial Post's 10 Best Companies to Work For.
IMP Marine Division is sold.
Dalhousie University names its business school, the Rowe School of Business.
IMP Aerospace rebrands to IMP Aerospace & Defence with IMP Electronic Systems and IMP Aerostructures.
IMP buys Cascade Aerospace in Abbotsford, BC, maintaining Canada's fleet of C-130 Hercules aircraft.
IMP acquires Image Air Charter Limited, a Toronto-based executive aircraft charter company.
Cascade Aerospace wins a multi-million dollar contract to upgrade C-130 aircraft for the Mexican Air Force.
CanJet Airlines ceases operations.
IMP acquires Blue Ocean Contact Centers Inc.
IMP Aerospace awarded a multi-million dollar contract to re-wing Chilean Navy P-3 aircraft.
IMP Aerospace tasked with a multi-million dollar avionics update (Block 4) for Canada's fleet of Aurora aircraft.
Atlantica Hotel Halifax is sold.
IMP Group celebrates 50 years of profitable growth.
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80-year-old man boosted across finish line
Gary Bennett won his age bracket at Saturday's Race the Rainbow 10K in Anderson.
80-year-old man boosted across finish line Gary Bennett won his age bracket at Saturday's Race the Rainbow 10K in Anderson. Check out this story on independentmail.com: https://www.independentmail.com/story/news/local/south-carolina/2017/03/21/80-year-old-man-boosted-across-finish-line/99461876/
Mike Ellis, mike.ellis@independentmail.com Published 4:52 p.m. ET March 21, 2017 | Updated 5:10 p.m. ET March 21, 2017
Cheryl Hunsberger and Gary Bennett pose for a picture after finishing a 10K race Saturday in Anderson.(Photo: Contributed)
Bennett, 80, was the only person in his bracket, so that helped thin out his competition.
He was doing his signature run-walk style, Bennett said and he got a little push at the end by another racer, Cheryl Hunsberger.
The two had met before the run and were close to each other for most of the track.
"I wanted to keep her ... in view," Bennett said.
As long as someone was within his sight, he was in good shape and he could tell himself he could pass her, he said.
Toward the end, Hunsberger pulled away. When she was done, she didn't see Bennett behind her.
Hunsberger began running about two years ago with First Flight, an Anderson group that teaches people how to go from not running at all to finishing long races. She was taught to make sure everyone finishes.
That's exactly the attitude runners should have, said Alison Manley Youngblood.
So Hunsberger returned to the course to find him and root for him.
"He was determined to finish," Hunsberger said. "He said he feels like he was 40."
With help from teachers, Westside football players, autistic child settles in
Bennett is no stranger to races.
He co-founded a running club in Palm Beach, Florida, in 1975 and has been in more marathons than he can count, at least 35.
"A 10K," he said, "that really pushes me at this point in time."
After a few years of taking it easier, he's getting back into running and plans to tackle a 5K this weekend at Furman University.
Bennett said that while he would have crossed the line no matter what, having someone come and encourage him made a huge difference.
"She's just a very thoughtful person," he said. "Runners are really good at the camaraderie and finishing together."
Follow Mike Ellis on Twitter @MikeEllis_AIM
Read or Share this story: https://www.independentmail.com/story/news/local/south-carolina/2017/03/21/80-year-old-man-boosted-across-finish-line/99461876/
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The Last Book About Donald Trump
Home > General > State/City > Florida
Synopsis In the cold dead of night, the Hatcher brothers break into Slade’s house, kill his wife of six years, Emily, and leave him for dead. But Slade is still breathing when his friend Josh Evans and his wife Lynn, Emily’s twin sister, find him draped over his wife’s body. After six months of recuperation, Slade and Evans set out on the trail of revenge. In the town of Oakhill, Texas, Evans is killed, but not before Slade shoots and kills the outlaw in a gunfight. Taking his body back to his...
Synopsis Victor Alvarez follows few rules, the real-deal. A bounty hunter par-excellence, and with the backdrop of 1980s, Tucson, Arizona, he tracks and hunts some of the most ruthless and dangerous criminals free on bail - with may narrowing escapes and jaw-dropping shootouts and thrilling car chases ever penned. It's what Alvarez's fans have come for - and he doesn't disappoint. The retired army cop and detective, returns in 6 thrilling stories of high adventure and suspense, with some...
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Jay-Z & Timbaland Sued For Copy Infringement By 81-Year Old R&B Singer
Jay-Z, Roc-A-Fella Records, Sony Music, and Timbaland were all accused of wrong-doing in the legal papers filed by Ernie Hines' attorney.
GZA Compares Gun Violence In Hip Hop To Wildfire: "Put Them Out Or They Spread"
GZA: "hip-hop started (initially) to stop violence."
Mac Miller Compares Current Status Of Rap Game To Golden Age
Mac Miller reflects on the new generation of rappers, drawing a comparison to the golden age of hip-hop.
676 Views 58 Comments
Dizzy Wright in Las Vegas - Golden Age Tour (Behind The Scenes - Episode 6)
By Jason Ray
Watch Dizzy Wright in Las Vegas - Golden Age Tour (Behind The Scenes - Episode 6)
Dizzy Wright - Golden Age Tour (Behind The Scenes - Episode 5)
Watch Dizzy Wright - Golden Age Tour (Behind The Scenes - Episode 5)
4,341 Views 1 Comment
Crowd Surfing Done Right! Dizzy Wright's Official "The Golden Age" Tour BTS (Episode 3)
Watch Dizzy Wright's Official "The Golden Age" Tour BTS (Episode 3)
Dizzy Wright's Official "The Golden Age" Tour BTS (Episode 2)
Dizzy Wright "The Golden Age Tour (Promo Video)" Video
With HotNewHipHop as the presenting sponsor, Dizzy shouts out HNHH and talks about his upcoming "The Golden Age" Tour. Look out for upcoming behind-the-scenes footage of Dizzy and Funk Volume when he hits the road on September 7th.
Check out the tour dates and make sure to come out and see Dizzy live! Get your tickets at http://www.myfunkvolume.com/tour.
Dizzy Wright Recalls When His Mom Wrote His Rhymes & Time Spent Homeless
Dizzy Wright speaks on his upbringing, Bone Thugs, and his mother's role in his career.
Watch Stussy Revisit "Yo MTV Raps" In New Documentary
Stussy stresses the importance of the iconic television show, "Yo MTV Raps!" in a new two-part documentary.
Aaron Hernandez Murder Victim's Lawyer Speaks After Docuseries Debuts
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PLN editor appears on Anderson Cooper 360 re private prison escapees
CNN, Jan. 1, 2010. http://ac360.blogs.cnn.com/2010/08/10/video-man...
PLN editor appears on Anderson Cooper 360 re private prison escapees - CNN 2010
On August 9, 2010, PLN editor Paul Wright appeared on Anderson Cooper's show on CNN (AC360), to discuss private prisons in the context of a recent escape from an MTC-operated facility in Arizona.
A transcript of the show, which is available at the following link; Paul's comments are indicated by "[PW]":
http://www.livedash.com/transcript/anderson_cooper_360/49/CNN/Monday_August_9_2010/272975/
00:08:42 They're on the run, they won't go lightly, that's what a marshall says about this pair, John McCluskey and Cassalynn Mae Welsh.
00:08:56 She threw tools over the fence helping him and tracy province escape.
00:09:03 Province has been captured today near Yellowstone National Park.
00:09:10 McCluskey AND Welch are believed to be driving a gray Nissan Sentra.
00:09:17 Accomplice charges have been announced against McCluskey's mother and ex-wife.
00:09:27 The search area extends all the way to Canada.
00:09:29 Up close tonight, the spotlight is on the privately run prison they broke out of.
00:09:39 Former FBI assistant director Tom Fuentes.
00:09:41 Let me start with you, tom, what does a manhunt like this look like on the ground?
00:09:46 Where do you think it is at this point?
00:09:50 One of the first steps is to look at family members to see if the fugitives attempt to link up with a family member to obtain money and assistance, and that's exactly what you have here with McCluskey going to his mother and getting some undisclosed amount of funds from her, the difficulty that creates, investigators also try to determine are they using credit cards, where is the locations where those cards were used, say to obtain gasoline or bus tickets or train tickets or some other funding.
00:10:21 And so if they have cash in hand that eliminates that electronic trail until they run out of it.
00:10:29 It also will create the problem of when they run out of funding, acts of violence to continue having vehicles, having the ability to move around.
00:10:37 These folks broke out of a privately run prison.
00:10:42 Are privately run prisons less well controlled?
00:10:45 Are they easier to break out of?
00:10:48 [PW]: Yes, actually the 20-plus year history of the private prison history has been significantly unsafer than federal run prisons.
00:10:54 Why?
00:10:56 [PW]: Because the whole model is premised on cutting costs.
00:11:00 [PW]: The biggest expense is the staffing.
00:11:07 [PW]: One of the ways private prison companies cut the costs, they understaff their prisons, pay their employees less, give them little in the way of benefits, which leads to high staff turnover.
00:11:18 [PW]: They have less employees that are less well trained and less of them.
00:11:23 [PW]: And this case is just another in a long history of escapes, murders and other incidents that endanger public safety, that's been the calling card of the industry.
00:11:37 These two compare themselves to Bonnie and Clyde.
00:11:40 Why is that significant?
00:11:42 The reason that would matter, if they truly believe that, Bonnie and Clyde wanted to be notorious, they wanted to kill people and be known for being violent, for being dangerous and being famous.
00:11:56 As opposed to, an escape where they're trying to escape by stealth and sneak away, sneak out of state, sneak out of the country if they can undetected, the Bonnie and Clyde if that's true, not just something that McCluskey hyped himself with, it would be significant.
00:12:11 Yeah, I'm not sure how he would know that information unless it's something that came from the other two.
00:12:17 Certainly they would have tried to get as much information.
00:12:22 Do we know if the two who were apprehended are talk something.
00:12:24 We don't know.
00:12:25 We know they will be looking for his cooperation to see who McCluskey may be in contact with.
00:12:34 Should criminals with violent records be held in private prisons?
00:12:39 [PW]: I think the better solution is eliminate the private prison industry.
00:12:44 [PW]: This is not the first time we've had an experiment with private prisons, private prisons have been around for a long time.
00:12:50 [PW]: They were abolished in the 1920s basically over public outrage, corruption.
00:12:57 [PW]: Incidents like this that endanger public safety.
00:13:03 [PW]: They made a comeback in the 1980s, and we're seeing that time after time after time public safety is endangered.
00:13:06 [PW]: What we have here is a case of [private] profit, public safety is at risk.
00:13:10 [PW]: Families like the Haas', who were murdered when these people escaped from prison.
00:13:17 [PW]: That's the type of thing that endangers public safety.
00:13:19 [PW]: Prisoners are also at risk.
00:13:21 [PW]: These [private] prisons have much higher rates of assaults, murders and escapes that endanger everyone.
00:13:27 [PW]: This business model is one where profit and fiduciary duty of the company is to their shareholders, not to the taxpayers that pay their salaries, unlike the FBI or public prisons where they do have a duty to the public.
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Bryony Stone
The Graduates 2017
Maxwell Granger’s refreshingly disparate and tongue-in-cheek portraiture
North Yorkshire-born graduate Maxwell Granger ended up at London College of Communication after a short-lived trip to rival art school Camberwell. “I went round Camberwell initially with my best mate, and we hated it so much that we quite literally pegged it down the road all the way to Peckham Rye,” Maxwell grins. “We both decided – while running – that LCC was for us.”
“I chose the course because it seemed pretty broad and not like most of the other illustration courses out there,” Maxwell tells us of his experience studying Illustration and Visual Media at LCC. “I knew that I wouldn’t be able to handle a conventional illustration course as I’d get bored. It worked out pretty okay.” Where other tutors might have steered him sharply in the direction of a pencil, Chris and Angela, the tutors of the school’s left-of-centre course encouraged Maxwell to pick up a camera and focus his lens through shiny veneer of the art school bubble. His style, a curious collision of self-conscious with brazen, quickly earned him attention from _Mushpit _, Coeval, Vice, ShowStudio, Trip, MPAF, 1 Granary, Splash And Grab, High Snobiety — and a recent commission from It’s Nice That which sent the photographer squirrelling underground deep into the TfL lost property archives.
“I’d describe my style as pretty disparate, inconsistent, not very stylish,” Maxwell says with characteristic irreverence. “I approach everything with a very conflicting and contradictory approach. A lot of me pretends that things are really cool and funny when they’re not but I think I’m quite convincing, and usually bring people round to great and normal ideas such as: brands should make collections designed exactly in the style of really cheap market fakes because they’re heavily branded and clearly what the people want.”
Beneath tongue-in-cheek bravado, Maxwell is quickly learning that the creative world moves fast, furiously, and doesn’t look back. “My favourite project was probably my final major as it was a load of photos of middle-aged women from my hometown, which now as I’m writing this, seems like a pretty played out thing to do that you’d see on any online photography blog. However at the time of doing it, it felt a lot more all-encompassing, whole and really quite interesting.”
The recent graduate has also discovered that when it comes to work, you get out what you put in — as long as you remember to sign up that is. “If you’re looking to be taught how to do something, you have to sign up for it, otherwise you can’t spend three years moaning about not being able to use the acid etching room,” he says. “You can however, spend three years bragging about how you pretended to be inducted into the acid etching room and waste your valuable university time making some pretty ‘experimental’ ‘lo-fi’ and generally low-quality printing work.”
Despite Maxwell’s somewhat controversial belief that “without a fine art course, LCC is just more of a school dedicated to housing everyone in the world who likes 35mm flash photography, queuing up outside shops for clothes and complaining about people who queue up outside shops for clothes”, he admits that the past three years have seen a significant development in both his creative ability and assurance. “I feel more confident about the stupid ideas I have now, and since gaining a minute degree of commercial validation, I’ve been able to make my ideas slightly more convincing in order to rope people into doing stuff they wouldn’t probably ordinarily do.”
Supported by A/D/O
Founded by MINI, A/D/O is a creative space in Greenpoint, Brooklyn dedicated to exploring new boundaries in design. At its heart is the Design Academy, which offers a range of programming to professional designers, intended to provoke and invigorate their creative practice.
www.maxwellconradgranger.com
Bryony joined It's Nice That as Deputy Editor in August 2016, following roles at Mother, Secret Cinema, LAW, Rollacoaster and Wonderland. She later became Acting Editor at It's Nice That, before leaving in late 2018.
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Home nankid Reshape the future today at THE FUTURE CITY: An Interactive Digital Park
Reshape the future today at THE FUTURE CITY: An Interactive Digital Park
By Rayrose Samson At September 07, 2017 0
An extraordinary learning experience awaits young and the young-at-heart at the Future City. Put your seatbelts on as we take off to the future and explore how we can help reshape your child’s future today through one-of-a-kind interactive installations that will put your eyes and minds in awe.
Open for just one weekend, The Future Park together with NESTLÉ NANKID OPTIPRO FOUR,—a milk designed specifically for your child’s growth and development that helps secure your child’s healthy future through the power of Optimized Protein, launches FUTURE CITY: An Interactive Digital Park.
From September 9-10, this pioneering digital park opens its doors to guests as a way to educate and empower children and their parents about how their decisions today, can affect their future.
Future City uses technologies from all over the globe. The park contains 6 unique and engaging stations that will give guests the chance to participate in one-of-a-kind experiences that will surely nurture the minds of the kids and kids at heart.
The Future City visually illustrates how science has become the blueprint for brighter, safer future for our children. Guests can begin their exploration and discovery at the Future Dome where they will be given a glimpse of the technological advances that will soon define future cities—from towering smart skyscrapers, solar powered walls, interactive cityscapes, and autonomous vehicles.
Visitors of Future City will be given access to several stations that will surely broaden the mind. A Sketch Village where the patterns you color come to life, a Checkpoint where you can assess your future health, and interactive walls and floors featuring digital games.
After the guests go through these stations, seeing what the future can be and how it can be affected with the choices and lifestyle we make, from there, they will be ushered into a room that highlights an interactive wall demonstrating the evolution of science for nutrition and development, and how scientific advances have helped secure a child’s healthy future.
A big point of apprehension about the future, especially for parents, is their child’s health. Family history plays a big part in determining what diseases and conditions will be inherited by their kids and educating yourself about what can be done to prevent these from being passed on is the key to ensuring your child’s better future health. To that end, the Family Health Screener can help parents assess these possibilities, which will also be unveiled at the pop-up interactive digital park.
All in all, the Future City is a fitting fusion of interactive material and abstract concepts demonstrated in a visual and engaging way for kids and the kids at heart to appreciate and enjoy.
The interactive nature of The Future City is central to the entire exhibit’s message, not just in terms of technology and infrastructure, but for bigger and far more essential choices for your child’s health and development. Exploring the science behind the different elements that drive our lives—the environment we move in, the things we eat, the activities we do—it helps us understand just how relevant all these our to securing a brighter, safer, healthier future for generations to come.
Never settle for anything less especially when it comes to your child. Give your child optimum nutrition and reshape their future today.
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NSF SDCI Bedrock Award
NSF SDCI Bedrock Award more
Community Cloud Study
User Story Examples
Internet2 NET+ Frequently Asked Questions
Background on the NSF SDCI Bedrock Award
Collaboration management platforms (CMPs) and services complete the basic vision of federated identity by adding components to do effective and scalable access controls and permission management. Together attributes are able to be created, managed and transported to relying parties that can then directly make decisions about users accessing resources.
CMPs are intended to provide consistent, scalable identity and access control information to both collaboration applications (including wikis, event and ad hoc calendaring, mailing list processors, etc.) and domain applications (including grids, shell-based services, science gateways and portals, etc.)
Such platforms are built by repackaging enterprise middleware, such as Shibboleth, Grouper, LDAP, etc. for use in virtual organizations. At this point, CMPs are typically built by assembling a coherent service from a variety of separate middleware and application servers, but a VM and a resulting cloud-based service are expected once the field is better understood.
While many of the core ideas for CMPs came from the US, other countries, most notably the Netherlands, Switzerland and Norway have advanced the practice considerably. Several countries are planning a national level collaboration service. (See, for example, SURFconext in the Netherlands at http://www.surfnet.nl/en/Thema/coin/Pages/Default.aspx).
The Internet2 middleware activity received a significant NSF OCI grant, beginning September 1, 2010 and ending August 31, 2015, called "Building from Bedrock: Infrastructure Improvements for Collaboration and Science." The intent of "Bedrock" was to enhance and package enterprise tools for CO (collaborative organization) use and work intensively with several major collaborations for deployment.
Bedrock focused on the identity management needs as well as the domestication and integration of applications for large and small VOs. Working with a variety of VOs, the work paved the way towards stronger collaborations and better science within the VO.
Harvesting the science content from LIGO data is a collaborative effort between instrumentalists, data analysts, modelers, and theorists. Efficient collaboration begins with scalable and robust identity management infrastructure that can easily be leveraged and integrated with the wide spectrum of tools LIGO scientists use to collaborate and analyze the LIGO data. Middleware from Internet2, including Shibboleth and Grouper, is enabling more LIGO science through easier collaboration and access to resources.
-- Scott Koranda, Senior Scientist at the University of Wisconsin-Milwaukee and lead architect of the LIGO Identity Management effort
Work ranged from international to local campus in scope, as the project team collaborated with federations around the world such as the Netherlands' SURFnet and Japan's Gakunin and specific universities with VO-like challenges such as the University of Chicago. No matter the size or scope of the organization, problems of provisioning and deprovisioning identity and and access management benefit from the Bedrock project.
Common use case:
Research groups from several notable institutions around the globe form a collaboration. As part of their normal cyberinfrastructure, each institution manages the identity of their own students and researchers, including authentication and attribute information and the local provisioning and deprovisioning of standard user accounts. But the collaboration is not housed under any one institution; it forms a separate "virtual" organization. The virtual organization wants to integrate information about the researchers from the member institutions with information and permissions specific to the collaboration. Administrators of the virtual organization are responsible for permissions to access research resources, managing group information which incorporates both research considerations and up-to-date institutional information. A single set of identity management services will in turn automatically populate/provision/control access to mailing lists, wiki space, groups, calendaring, videoconferencing and net meetings, and more as well as to domain science applications. The integration of education and research is significantly improved: A researcher can grant permissions to research resources by class; the students can use their usual local accounts to access remote resources; a student's permissions can begin as soon as they add the class; a student's research permissions can be automatically deactivated if they disenroll from the class. Improved ease of use and enhanced security both result.
When a researcher or student leaves one of the associated institutions, and that institution deprovisions their account, that information will automatically feed back to the VO which will in turn automatically deprovision their access to the VO space.
Participating VOs in the initial stages of Bedrock development included:
LIGO (The Laser Interferometer Gravitational-Wave Observatory) - the largest NSF funded physics project.
iPlant - the overarching cyberinfrastructure for the NSF Plant Biology Division within the Directorate for Biological Sciences.
The Internet Society (ISOC)
The Earth Science Women's Network (ESWN)
Project Bamboo - a multi-institutional, interdisciplinary, and inter-organizational effort that brought together researchers in arts and humanities, computer scientists, information scientists, librarians, and campus information technologists.
One of the additional possibilities of Bedrock is to set up a small service instance for Internet2 and/or InCommon. Beyond providing a collaboration service for those that might want it (several smaller NSF VOs have asked), it would provide critical feedback to the development processes within the grant.
See https://spaces.internet2.edu/display/COmanage/Home, particularly the mockups, to better understand the approach.
NSF SDCI (Software Developent for CyberInfrastructure :
NSF Award Announcement
Internet2 Press Release (pdf)
CO Requirements Assessment
SSH Requirements Assessment
COmanage Project
Grouper Working Group
Shibboleth®
NOTE WELL: All Internet2 Activities are governed by the Internet2 Intellectual Property Framework.
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Education Featured Articles Home Other Resources Publications School Support Services Tools and Guides
Making the Grade? Questions to Ask About School Services Privatization
Author: In the Public Interest
Click here for full report
Our children rely on the everyday heroes who provide them with nutritious meals, clean up their classrooms, and make sure that they get to school and back home again safely. The bus driver, the cafeteria worker, or the custodian in a school is often one of the most important school relationships a
student has. These essential school staff members serve as mentors, cheerleaders, and protectors of the children they see every day.
School districts that contract out these jobs give up control over the vital services school staff provides. An examination of private contractors’ track record shows that these companies often provide inferior service in the quest to maximize profits. Schools have experienced a number of problems after outsourcing school services including dirty classrooms, unreliable bus routes, improperly administered medicines, less
nutritious meals, and unkempt grounds.
Promised cost savings also often fail to materialize. According to a review of outsourcing experience across the county by Mildred Warner, Professor of City and Regional Planning at Cornell University, “Expectations of costs savings are not well supported by a careful reading of economic theory, and empirically the evidence for cost savings is weak.” In fact, some districts that privatized school services later “insourced” or brought these services back in-house, and have experienced significant cost savings by doing so. The San Diego Unified School District ended its bus services contract in 2010 and has saved $1 million per year by providing these transportation services itself.
This guide provides examples of important questions that decision makers should consider when faced with a proposed privatization effort. Advocates, including school service personnel, teachers, parents, and members of the community can use these questions to ensure that decision makers keep students’ and the broader district’s best interest at the heart of these conversations. They should be able to answer each of these questions before making the decision to privatize school services. These questions can be helpful to use during meetings with school administrators, in testimony at school board hearings, and even in meetings with allies to draw attention to problems with a proposed privatization initiative. While this is not a complete or exhaustive guide, it provides a framework for examining and evaluating school services privatization.
Virtual Public Education in California: A Study of Student Performance, Management Practices and Oversight Mechanisms at California Virtual Academies, a K12 Inc. Managed School System
Backgrounder: The Cost of Private Prisons
Backgrounder: Insourcing
Ask the Right Questions Before Privatizing
Backgrounder: Prison Privatization
Backgrounder: The High Costs of Privatization
#MoW50: Communities of Color, The Middle Class and Outsourcing
Looting the Urban Commonwealth: Privatization and the Politics of Austerity
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Argentarius Stationery
Bit8 Advertising
Bethard Business Cards
BetHard.com is a gaming company that offers casino, odds and live casino online, through both computer and mobile usage. We were approached by BetHard to redesign their business cards. The brief was simple. They wanted to showcase themselves, as the corporate company they are; yet still showing the fun, energetic and powerful side, which is part and parcel of the business market they are in – the Gaming Industry. BetHard’s logo is that of a clenched fist, made up of two colours yellow and green, and already symbolizes both the powerful and playful side of the company. We took all these elements to create a business card made of three layers of paper: two black and a middle yellow paper layer, same as the yellow used in the logo. The logo was printed on the second yellow layer, by using only the green colour, and is revealed by a cut out from the top black layer. This not only makes it more alluring to look at but also involves the sense of touch when one picks up the card and feels the step in the layers created by the cut out form. It also represents the playful side of the company.
By ticking this box, you acknowledge that you are sending us items of personal data, and you confirm that you have read and agree with our Privacy Policy, which sets out in detail the identity and contacts details of the Controller and the Processor, the personal data we collect, the purposes and legal basis for collecting such data, the recipients of such data, the data retention periods and your rights in relation to data protection.
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+356 21384 308
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One Direction’s Niall Horan says his ideal girl is someone he can ‘have a laugh with’
The One Direction singer – who is reportedly dating drama student Amy Green and has been linked to Demi Lovato in the past – revealed his ideal girl would have to be funny.
He told chat show host Ellen DeGeneres: “I like someone that’s cute, someone I can have a laugh with, and I also like people that are American.”
However, things are reportedly getting serious with British student Amy after he visited the set of Britain’s 'The X Factor' and introduced her as his girlfriend.
A source said: "Niall was introducing Amy to people as his girlfriend and they were very happy from the look of things. He was kissing and cuddling her when people weren't watching and seemed really into her.
"She was very posh and I have to say they seemed like a real couple. It's definitely early days but Amy was on his arm as his girlfriend and not just a girl friend."
Sources close to Niall say the pair have only recently started dating but he is very happy with Amy.
A friend explained: "They're dating - it's early days but they're very cute together."
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Five Star Deluxe Ireland Honeymoon 6 Night Tour
Discover Dublin, Waterford, Kerry and Clare on this 5-Star Deluxe Ireland Honeymoon. On this tour you will stay in some of the best hotels in Ireland.
Discover Dublin, Waterford, Kerry and Clare on this 6 night honeymoon tour of Ireland. On this tour you will stay in some of the best hotels in Ireland including the Merrion Hotel in Dublin, the Cliff House Hotel in Waterford, The Park Hotel in Kenmare and Dromoland Castle. As you explore each location your Irish Tourism Itinerary will guide the way for you.
6 Nights Accommodation with Full Irish Breakfast
Personal Irish Tourism Touring Guide
Discount vouchers for many of Ireland’s best visitor attractions
Cobh Heritage Centre
Titanic Walk
Trinity College & Book of Kells
Bantry House & Gardens
Waterford Crystal Centre
Muckross House, Gardens & Traditional Farms
The Merrion Hotel, Dublin for 1 Night
The Cliff House Hotel, Waterford for 1 Night
Park Hotel, Kenmare for 2 Nights
Dromoland Castle, Clare for 1 Night
Superior & First Class Hotels
Luxury Accommodation & Service in our 4-Star
Country Manor Houses
Deluxe Accommodation in our 4 & 5 Star Irish Castles
Our Recommended & Handpicked B&B's, all rooms with private bath facilities
Any Combination of the above
Day 1 - Dublin City
Dublin City is a fantastic stop on any honeymoon tour of Ireland due to the wealth of cultural activities available at its doorstep and the host of exciting touring options available. Your Irish Tourism Itinerary will detail the places we recommend you visit including Christchurch Cathedral, Trinity College and The Guinness Storehouse to name but a few. This evening you may wish to spend some time in temple bar where some of Dublin’s best pubs, bars and restaurants line the cobblestone street that ends at Christ Church Cathedral. This area is often referred to as the city’s ‘arts zone’ and here you are sure to find a good selection of Irish Music as well as stylish shops and galleries. Your accommodation in Dublin will be the super luxury Shelbourne Hotel. The Shelbourne has been welcoming honeymoon couples to Dublin since 1824 and continues to this day to offer the highest standards of accommodation and service. The hotel has a prime city centre location giving you a great opportunity to discover much of Dublin on foot.
Day 2 - Dublin to the Cliff House Hotel
You have a number of options for your journey to the Cliff House Hotel from Dublin, the most direct route will take you via historic Kilkenny where you can visit Kilkenny Castle or Saint Canice Cathedral. The longer route will take you via the coast of Wicklow and Wexford or you could even choose a third option passing by Glendalough where you will find lovely lakeside romantic walks. The Cliff House Hotel is the perfect location for a romantic getaway; the hotel features an intimate spa as well as a Michelin-starred restaurant with a breath-taking seafront position. From the hotel there are lovely romantic Cliff Walks, you will also find a splendid beach in the area, some good pubs and the historic Ardmore Cathedral.
Day 3 - The Cliff House Hotel to the Park Hotel Kenmare
Stops we recommend on your journey today include Cobh, Cork City and Blarney Castle. The port town of Cobh serves as a poignant reminder of Ireland’s far reaching history of emigration. Millions of people left from Cobh during the great famine years and beyond and this Cobh was also the final departure port of the ill-fated Titanic in 1912. Two great museums pay tribute to these events and both are well worth a visit. Further west Cork City can be explored, the city has fantastic shops, bars, restaurants and cafes, Shandon Church is well worth a visit, as is the English Market. Before you leave Cork you may decide to visit Blarney Castle, famous here and abroad, legends tell us that if you climb to the top and kiss the Blarney stone you will be forever endowed with the gift of the gab! Your accommodation for the next two nights is the outstanding Park Hotel in Kenmare where luxury adorns each unique bedroom through rich fabrics, original antiques and interesting art. The hotel also has a deluxe spa, 25 metre swimming pool, an onsite cinema and daily lifestyle classes.
Day 4 - The Ring of Kerry
Kenmare where the Park Hotel is located is ideally situated to explore the famous Ring of Kerry. On your journey you will pass majestic mountains and magnificently beautiful coastal scenery, dotted with towns and villages that have kept a lot of their distinctive Irish character. Start in Kenmare where the beautiful Kenmare Bay which stretches 50 kilometres from Kenmare out to the Atlantic Ocean is located. Further west you will come across Caherdaniel, the ancestral home of Daniel O'Connell, known in Irish history as 'The Liberator' and further still Waterville, a favourite holiday spot of Charlie Chaplin who visited often with his family. Continuing around the ring, the next town you come to is Ballinskelligs which has another beautiful sandy beach and on from there visit Valentia Island, where you will find a striking mix of period buildings & houses most notably The Royal Hotel and the former Transatlantic Cable Buildings on the waterfront. The Ring of Kerry may well be the highlight of your honeymoon in Ireland!
Day 5 - Dromoland Castle
Set off early today to give you enough time to truly enjoy the luxury surrounding Dromoland Castle. The castle is steeped in history, its roots going back as far as 1014 when the son of Brian Boru held a fortress here. The current structure was built in 1800 and was opened to guests in the early 1960’s. Dromoland Castle is undoubtedly one of Ireland’s most luxurious castles due to the high standard imposed on every feature; from the well-designed bedrooms to the impeccably landscaped grounds. The hotel has a superb spa and leisure centre that is perfect for the discerning honeymoon couple and plenty of other activities for you both to enjoy, from the onsite falconry, archery, horse-riding and fishing to their world renowned golf course. Dromland Castle is a great location to discover all that Clare has to offer including the Burren where you will find romance in every corner! Scramble over karst limestone formations where the bleak landscape and unusual plants give the area an other-worldly ambience. In the Southern area of the Burren the limestone rock gives way to the black shale and sandstone that form the magnificent Cliffs of Moher. The cliffs are one of Ireland’s most visited attractions and they offer outstanding ocean views. Well-worn visitor walkways lead in both directions, offering various viewing points.
Day 6 - Return to Dublin
If you missed Blarney Castle before, you will have another opportunity to visit on your return to Dublin. You will also pass through the town of Cahir where another famous castle can be found! Cahir Castle is one of Ireland’s most complete castles, retaining its impressive keep, tower and much of its original defensive structure. The castle also features an excellent audio-visual show which informs visitors about its eventful history. As you travel North towards Dublin the Rock of Cashel also known as Cashel of the Kings will be the next stop on your journey. Cashel was the traditional seat of the kings of Munster for several hundred years prior to the Norman invasion. The striking complex has a character of its own with a 12th century round tower, High Cross and Romanesque Chapel, 13th century Gothic cathedral, 15th century Castle and the restored Hall of the Vicars Choral. On your return to Dublin check into the Shelbourne hotel for the final night of you luxury honeymoon in Ireland.
The Cobh Heritage Centre provides information on life in Ireland through the 18th and 19th centuries, the mass emigration, the Great Famine, and on how criminals were transported...
Below, you will find a price for this self drive tour including your car rental. While we offer very competitive rates for our car rental inclusive packages, this allows you to shop around for your own car rental price should you wish to.
Pricing for other accommodation and transport options is also available upon request. Please also note that all of our driving tours itineraries and sightseeing guides are available to those wishing to avail of one of our experienced driver guides.
Please note we charge in Euros. Prices in other currencies are for indication only and subject to fluctuation.
Personal Irish Tourism Touring Guide & Discount vouchers to hundreds of Ireland’s attraction included
Your Accommodation & Car Rental Package rate includes an Economy class car eg., Opel Corsa or Fiat Punto.
7 Night Irish Castles and Manors Platinum Tour
10 Night Irish Castles and Manors Platinum Tour
Irish Castles and Manors Silver 7 Night Tour
10 Night Irish Castles and Manors Silver Tour
10 Night Irish Castles and Manors Gold
7 Night Irish Castles and Manors Gold Tour
8 Night Irish Castles and Manors Silver Tour
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ISPUT - IMPROVE SYDNEY PUBLIC TRANSPORT
New Railways
Regional & Rural
Sydney Metropolitan Map
Sydney CBD Lines
Concise Overview
Other Transport Issues
Newcastle Light Rail
Sydney Light Rail
Sutherland Light Rail
Barangaroo South
Inner East Light Rail
Inner West Light Rail
Kings Cross Taxis
Newcastle Light Rail EIS
North West Sydney
Public Transport Inquiry
Rozelle Metro
Sustainable Sydney 2030
Sydney CBD Metro
Railway Statistics
Tramway Statistics
Elections Contested
2015 Sydney State Election
2008 Ryde By-Election
2004 Ryde Local Gov’t
South Coast Line
Click to enlarge this map
This website contains plans for 16 new or extensions of existing Railway lines for Regional and Rural New South Wales. Construction should occur over the next thirty years with three lines under construction at the same time.
The first railway line that operated in New South Wales ran from Sydney to Parramatta on 26 September 1855. Services reached Albury on 3 February 1881.Other lines extended to Broken Hill on 15 July 1919 and Murwillumbah on 24 December 1894. The first electric train to operate in New South Wales ran from Sydney to Oatley on 1 March 1926.
Who was responsible for this development? Mr. John Whitton arrived in Sydney in December 1856. He was appointed Engineer-in-Chief of the New South Wales Railways and at the time there was only three kilometres of completed railway. Upon retirement in 1890 there was 3,538 Km of completed railway. He is acknowledged as the ‘Father of the NSW Railways’.
John Whitton had to resolve a number of issues in order to construct the railways. The Governor Sir William Denison supported horse drawn tramways and Whitton argued that only a railway could work the volume of freight envisaged. Whitton was a strong supporter of a uniform rail gauge, coal fired locomotives and bridges and rails made of iron. Governments were loathe in spending more than the minimum required and over time whitton won the day to expand the railways and needless to say he went onto win the arguments.
As with the Bradfield line which is named after Dr. J.J. Bradfield the Whitton Line is named after John Whitton and will include the restoration of Whitton as a commissioned railway station. Whitton Station was formerly on the Hay branch line and opened as Hulong in 1881 and renamed Whitton. The station was decommissioned some years ago. Whitton Station would contain two full length platforms.
Australia and New South Wales has a history of drought, bushfires and floods. New regional and rural railway lines can and should have irrigation pipelines placed alongside the lines. In the 1920s Dr. J.J.Bradfield proposed a series of inland pipelines to irrigate Queensland. The Queensland Government ignored his plans and consequently he came to New South Wales.
Severe flooding occurred in 1955 in Maitland and Nyngan, New South Wales in 1990 as did Bourke and the North Coast of New South Wales in 2009, Charleville, Queensland in 1990 and Ingham, Queensland in 2009. Bushfires occurred in New South Wales in 1939, 1977, 1994 and 2006. Victoria faced these disasters in 1939, 1983, 1985, 2006 and in 2009. South Australia was ravaged by bushfire in 1983 as was Tasmania 1967, Queensland in 1967, 2005 and Canberra 2003. There is a school of thought that back burning should not occur in National Parks. Perhaps New South Wales has too many National Parks.
New Railway lines can be built alongside highways such as the Pacific and Princes that are totally inadequate and long overdue for upgrading. New railway lines provide for life-saving fire breaks wherever they are laid. The planned railway lines that are contained in this website are designed to operate in a straight line and on a high viaduct where required. All railway lines in New South Wales will be electrified and completely dual track with full length platforms.
All the planned regional and rural lines are interconnecting and will traverse New South Wales from west to east and north to south and all points in between. Dubbo Parkes, Orange, Yass Junction and Canberra would be upgraded to include additional full length platforms and a station roof to protect passengers from the elements similar to Calais or St. Pancras Railway Stations.
If Dr. J.J Bradfield and John Whitton could see the benefits of railway over horse drawn tramways and metro rail why can’t we ‘see the wood for the trees’ in a modern twenty-first century?
South Coast Line Railway Stations
Ulladulla Surface Station Island Platform
Batemans Bay Interchange Station Island Platform
Moruya Surface Station Island Platform
Narooma Surface Station with additional Platform
Cobargo Surface Station with additional Platform
Bega Surface Station Island Platform
Merimbula Surface Station Island Platform
Eden Surface Station Island Platform
Bombala Surface Station with additional Platform
Nimmitabel Surface Station with additional Platform
Cooma Surface Station with additional Platform
Bredbo Surface Station with additional Platform
Queanbeyan Existing Surface Station with additional Platform
Canberra Interchange Station with additional Platform
Barton Surface Station Island Platform
Tumut Surface Station Island Platform
Rosewood Surface Station Island Platform
Albury Interchange Station with additional Platform
Railway Station Entrances
Railway Station entrances are to be functionary and not grandiose so as to maintain a uniform appearance and ensure that Taxpayers Dollars are used judiciously thus allowing for additional Railway Lines to be built.
All Regional Railway Lines will be electrified to:
Improve Services,
Lower Operating Costs,
Requires Greater Generating Capacity that Improves Local Electricity Supplies
Railway Funding
Funding for the South Coast Line involves the following sources:
Railways Lottery
Restaurant/Lounge Carriages
Railway Bonds
Existing unused Railway Corridors and Station Platforms will be brought into use to reduce costs of construction.
The South Coast Line involves the use of Heavy Rail Technology to allow for maximum connectivity with the existing Heavy Rail Network.
After all these are YOUR RAILWAYS: OUR FUTURE
Nimmitabel Station
Queanbeyan Station
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Dogs kill 17 pigs in President’s College farm attack
President’s College suffered another setback when 17 of the pigs were slaughtered, presumably by a pack of dogs.
Farmhands made the shocking discovery on Wednesday when they reported for duty at the school farms.
The slaughter of the pigs will put a dent in the school’s coffers, according to the administration, since the animals were being reared to provide pork to meet the demand for this year’s Christmas season.
According to a source at the college, when farmhands turned up for work they discovered that some of the pigs were partly eaten. Two badly wounded ones were alive.
Initially, it was suspected that a large cat had done the damage but the culprits were soon revealed when a pack of dogs returned to the pens later in the day to finish off their prey.
“Most of the bites were consistent with those inflicted by dogs,” the source said.
This newspaper understands that several dogs frequent the President’s College compound and would usually converged behind the school canteen where a reliable food supply is assured.
However with the closing of school for the August holidays, the supply has diminished significantly.
“Sometimes one of the pigs would get away from the pen the dogs would attack it viciously,” the source explained.
The college is now reviewing its security arrangement since the guard on duty did not report any strange noises which is almost certain when pigs are being attacked.
Authorities are also in the process of securing the pens to prevent any recurrence of the attack.
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Liz Webster Nominated for Award
Community Wellbeing’s Liz Webster was nominated alongside Jo Payne and Gerald Collins for the Twitter Extraordinaire Award 2018 by the Tesco National Charity Partnership for her significant work across social media in regards to the Make, Move and Munch clubs programme across Sandwell.
Her tweets highlighted her dedication to healthy lifestyles and self-care, and getting those messages out into the community. This ties hand in hand with the award as it recognises individuals who have used Twitter in an original way to engage their followers in what they are doing for the National Charity Partnership.
Liz was slightly disappointed not to win but was to glad to have been nominated.
She said: “It was unfortunate not to win the award however it was great to receive acknowledgement for the engaging content I have been putting out across social media as well as being invited to the awards evening at the Park Plaza Embankment in London.”
PR, Marketing and Communications Officer, Anil Patel manages the social media platforms at The Kaleidoscope Plus Group and believes Liz was very deserving of her nomination.
He said: “Liz is a real advocate and pioneer of social media and takes full advantage of the platform.
“She consistently creates engaging content for both the Make, Move and Munch clubs and The Kaleidoscope Plus Group and it is no surprise that she was shortlisted for such a prestigious award.”
THE KALEIDOSCOPE PLUS GROUP JOIN FORCES WITH SOS TO COMBAT THE STIGMA OF SUICIDE
The Kaleidoscope Plus Group Has Surpassed 100 Followers on LinkedIn
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Home Religion Belgium’s Euthanasia Law Draws Catholic Protest
Belgium’s Euthanasia Law Draws Catholic Protest
Ian Kano
Euthanasia is becoming a big issue in Europe, and Belgium is one country that allows patients to end their own lives with the aid of a medical team. While there is a lot of regulation and oversight, the issue is extremely problematic and is against all religious laws. The big problem in Belgium started when Cathobel Belgium’s church news service posted on January 9th an article that raised questions about the Federal Euthanasia Control and Evaluation Commission, stating that it violated its own statutes by failing to investigate suspected legal abuses.
What amazed Auxiliary Bishop Jean Kockerols of Mechelen-Brussels is that “It’s shocking that, 15 years since its creation, this commission has not referred a single file to prosecutors or condemned a single doctor, “and added that “It is acting as judge and jury, and not fulfilling its role. It isn’t broadening the application of the law, but violating it.”
Supported by Bishop Kockerols, who said to Cathobel on January 11th that the commission was “not working as it should” and that the Church knows that this is a standard lax in the procedure. He added that the Church would support “any steps to ensure it (the commission) functions as it’s supposed to.” He added that “We’re against euthanasia in every form, and the church’s official position is well known.”
The Belgian federal euthanasia commission is headed by Dr. Wim Distelmans, a medical euthanasia practitioner. The commission states that all patients must be verified before approval. However, the number of assisted deaths reported by the commission is growing at an alarming 27% per annum.
The Belgian parliament legalized euthanasia on 28 May 2002, and in December 2013, the Belgian Senate voted in favor of extending its euthanasia law to terminally ill children.
In some reports, abuse of the commission’s regulations shows a number of cases including a dementia patient that was killed without consent were not reported, or the case of a 38-year-old autist that was killed without the regulated documentation.
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Bishop Kockerols stated that “Even if there’s little chance for now of legal changes, the church can work on a moral and pastoral level with medical staff and support critical voices.” He added that he was pleased that certain leading Belgians were debating the complexities of euthanasia practice and hoped that they would eventually decide to halt this regulated murder. He concluded that “We’ve been discussing the tougher application of church rules to those who endorse euthanasia. But we also have to be prudent, considering each situation with its nuances.”
Not all is simple in Belgium, even the Catholic organizations there add to the confusion. On August 8th, Pope Francis told the charitable organization Brothers for Charity, a Belgian Catholic Charity that provides psychiatric aid to patients and supports euthanasia for psychiatric patients, that they must stop this practice and sign a letter stating that they “fully support the vision of the magisterium of the Catholic Church, which has always confirmed that human life must be respected and protected in absolute terms, from the moment of conception till its natural end.”
If they do not desist, Pope Francis said that “then also we will start the correct procedure foreseen in canon law.”
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An avid reader and writer, Ian is an engineer with an MSc in Management Science and over 30 years experience in various sectors of industry, service and tech.
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Abbas claims Jerusalem Embassy is ‘slap of the century.’
Finding Support From Your Faith When You Lose a Spouse
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Making Room Sale
MY LOYALIST
EXPLORE STYES
WHY JN?
JN LOYALIST
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District of Montana
Financial Litigation Unit
LECC
Project Safe Childhood
Project Safe Neighborhoods
U.S. Attorneys » District of Montana » News
Billings man sentenced for distributing meth
BILLINGS—U.S. Attorney Kurt Alme announced today that Billings resident Robert John Bigback was sentenced on Tuesday to five years in prison and five years of supervised release for distributing methamphetamine.
Bigback, 23, pleaded guilty on July 16, 2018 to two counts of distribution of meth.
U.S. District Judge Susan P. Watters presided at sentencing.
After receiving information about meth for sale in April 2017, the FBI drug task force used a confidential informant to buy meth from a co-defendant at a hardware store in the Billings Heights. After the co-defendant counted the money, Bigback gave the informant the meth. Another meth sale was arranged a few days later and occurred at Rimrock Mall, where Bigback conducted the sale in the bathroom of a department store. The two sales involved about 20 grams of pure meth, which is the equivalent of about 160 individual doses and has a street value of about $2,000.
Assistant U.S. Attorney Lori Suek prosecuted the case, which was investigated by the FBI Task Force.
This case is part of Project Safe Neighborhoods (PSN), a program bringing together federal, state, local and tribal law enforcement agencies and the communities they serve to reduce violent crime and make neighborhoods safer for everyone. The Department of Justice reinvigorated PSN in 2017 as part of its renewed focus on targeting violent criminals.
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Georges St-Pierre to face Michael Bisping for UFC middleweight title
GSP to face Bisping for middleweight title
Mar. 1, 2017 10:00 a.m.
TORONTO — Former welterweight champion Georges St-Pierre is starting his comeback with a bang — against UFC middleweight title-holder Michael Bisping.
The two will meet for the 185-pound crown in the second half of 2017, according to the UFC.
“It’s on,” Bisping said in a social media post featuring the fight poster.
The 35-year-old St-Pierre has not fought since November 2013 when he won a narrow decision over Johny (Bigg Rigg) Hendricks for his 12th straight win. The Montreal mixed martial arts star then took a hiatus, saying he needed time away from the sport.
England’s Bisping won the middleweight championship from Luke Rockhold at UFC 199 in January 2016, subsequently defending the title against Dan Henderson.
The 38-year-old Bisping (31-7-0) had been campaigning for a big-money fight against St-Pierre (25-2-0).
St-Pierre’s previous UFC fights were all at 170 pounds.
The two fighters are slated to appear at a news conference Friday in Las Vegas prior to the UFC 209 weigh-ins.
For the UFC, St-Pierre versus Bisping is a welcome marquee fight at a time when lightweight champion (The Notorious) Conor McGregror is awaiting the birth of his child, former light-heavyweight title-holder Jon (Bones) Jones is trying to sort out his life outside the cage and former women’s flag-bearer (Rowdy) Ronda Rousey is contemplating her fighting future after beatdowns at the hands of Holly Holm and Amanda Nunes.
St-Pierre was a pay-per-view heavyweight for the UFC at the time of his departure from the sport. He kept training during his time away and had to undergo knee surgery after a practice injury.
The Canadian was known for his elite cardio and ample toolbox, equally able to strike or wrestle.
His popularity is shown by the fact that, despite his time away from the sport, he has 1.54 million Twitter followers. Current welterweight champion Tyron (The Chosen One) Woodley has 132,000.
Bisping is a sharp-tongued Brit who won Season 3 of “The Ultimate Fighter” reality TV show. A former light-heavyweight who dropped down to middleweight, his career has been on the upswing in recent years.
A well-conditioned fighter who can pepper opponents with punches, Bisping has won his last five bouts including a victory over middleweight icon Anderson Silva.
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High School Rowing Championships
Repair the Roof Campaign
Program Reference
The following age categories are per Rowing Canada Aviron (RCA) Rules of racing.
1. Under 17 (Junior B) – A rower or coxswain shall be classified as an Under 17 competitor until the 31st of December of the year in which he or she reaches the age of 16. After that date, the rower shall be classified as a Junior rower.
2. Under 19 (Junior) – A rower or coxswain who is no longer an Under 17 competitor shall be classified as a Junior competitor until the 31st of December of the year in which he or she reaches the age of 18. After that date the rower shall be classified as an Under 23 rower.
3. Under 23 – A rower or coxswain who is no longer a Junior shall be classified as Under 23 until the 31st of December of the year in which he or she reaches the age of 22. After that date, the rower shall be classified as Senior.
4. Senior – A rower or coxswain who is 23 years or older during the calendar year in which he or she is competing.
5. Master – A rower may compete as a Master from the beginning of the year during which he or she attains the age of 21.
Master’s Age Classifications:
AA age: 21-26 years
A age: 27-35 years
B age: 36-42 years
C age: 43-49 years
D age: 50-54
E age: 55-59
F age: 60-64
G age: 65-69
H age: 70-74
I age: 75-79
J age: 80 and over
or as outlined in the CRA Rules of Racing section 2
2.10 Lightweight competitors
Lightweight shall be classified as follows:
v Men: No individual rower shall weigh more than 72.5 kg.
Exception: Events for 64 kg. Lightweight men are also recognized where the maximum allowable weight for individual rowers is 64 kg.
v Women: No individual rower shall weigh more than 59 kg.
Exception: Events for 52 kg. Lightweight women are also recognized where the maximum allowable weight for individual rowers is 52 kg.
PART 3 EQUIPMENT
3.1 Classes of Boats
The following classes of boats are recognized by RCA:
Single Scull (1x)
Single Scull (1x) (fixed seat with pontoons - adaptive)
Double Sculls (2x)
Double Sculls (2x) (fixed seat - adaptive)
Pair (2-)
Coxed Pair (2+)
Quadruple Sculls (4x)
Four (4-)
Coxed Four (4+)
Coxed Quad (4x+)
Six (6+) (Fixed seat)
Eight (8+)
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Sussex News
Jailed in July: The most evil criminals put behind bars in Kent last month
The courts across the county witnessed some awful cases
Andy RobinsonSenior Reporter
The faces of the most evil criminals jailed in July (Image: Kent Police)
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All crime comes at a detriment to its victim but some offences can have a more devastating impact than others.
July saw a series of awful cases before Kent's courts.
One man was jailed for repeatedly stabbing his brother while another left his victim with a bleed on the brain after a brutal attack.
A criminal who violently sexually assaulted a woman in an alleyway pleaded guilty, as did a child sex offender.
Awful footage shows moment teenage boy is stabbed but his mum wants you to watch
An arsonist was also sentenced to life behind bars after targeting a hospital.
Here are the faces of the five men whose crimes shocked the county last month and the stories behind their horrid offences.
Keiran Tutt
Keiran Tutt (Image: Kent Police)
A man was jailed for stabbing his victim multiple times in Ramsgate.
Keiran Tutt, 22, admitted a charge of causing grievous bodily harm with intent at Canterbury Crown Court on July 26.
The court heard how shortly before midnight on December 16 last year, the 22-year-old walked to an alleyway near his home in Park Road with a man that he knew.
An argument resulted in Tutt repeatedly stabbing his victim.
The man was rushed to hospital for treatment while Tutt was located by officers a short while later and arrested.
He was given an eight year sentence due to the risk he poses to the public.
Investigating officer Detective Constable Neil Moore said: "The level of violence shown by Tutt in this incident is disturbing and this is reflected in the sentence imposed by the court.
"The injuries his inflected on his victim were severe and it is fortunate that they were not fatal.
"We take knife crime seriously, it ruins lives and can devastate communities.
"We want people to feel safe and will not hesitate in taking action against those who carry and use weapons."
Edmas Milto
Attacker stalked woman before violent sexual assault in Chatham alleyway
A violent attacker who stalked a woman before violently sexually assaulting her in a Chatham alleyway has been jailed.
The offender who attempted to rape the woman as she was walking alone has been sentenced to 10 years and eight months in prison.
Edmas Milto stalked the woman for almost a mile before carrying out the serious sexual assault as she walked through an alleyway in July 2018.
The 24-year-old, of Canterbury Street in Gillingham, pleaded guilty to attempted rape and assault and was sentenced at the same court on Friday (July 26).
The court heard that shortly after 2.50am on July 24 last year Milto grabbed the woman as she walked in an alleyway in Haig Avenue.
A violent and prolonged assault then took place, during which he attempted to rape her.
The incident was captured on CCTV and after the attack officers were able to track Milto’s movements through Medway to the general area of his home address.
Following extensive patrols in that area, Milto was detained when an officer saw him and recognised him from the CCTV images.
Detective Inspector Kaye Braybrook, the senior investigating officer for this case, said: "Milto subjected the victim to an extremely violent and degrading attack and his actions clearly show him to be a serious danger to women.
"The investigation team were able to build a strong case against him with the support of the victim who has shown such bravery in how she is dealing with this life changing attack.
"He will now spend a substantial amount of time in custody, where he is unable to cause further harm to the public."
Gregory Davis
Gregory Davis (Image: Kent Police)
This 36-year-old man was sentenced to 15 years behind bars for a horrific attack on a man and police officers.
Gregory Davis, of Thornden Wood Road in Herne Bay, had beaten his victim unconscious which prompted officers to search for him.
On July 24 last year, Davis went to the home of an ex-girlfriend and banged on the door until a man answered.
He then punched the man in the face, dragged him down a set of concrete steps and kicked and stamped on his head and body before throwing a bottle of ammonia at him.
His seriously injured victim was rushed to hospital unconscious and with a bleed on the brain.
Davis was found shortly after carrying an axe by two Kent Police Specials.
The 36-year-old threw the axe in a garden and tried to escape but was stopped and arrested.
While en route to the police station, he threatened to kick an officer in the back of the head to cause a collision and spat at the officers who arrested him.
He was sentenced at Canterbury Crown Court
At Canterbury Crown Court, Davis admitted charges of possessing an offensive weapon and the two assaults on police.
He denied causing grievous bodily harm with intent but a jury found him guilty and he was sentenced on July 18.
He will have to serve at least 10 years in prison before he will be considered for parole and must also serve an additional three years on licence.
Investigating officer PC Justine Cullen said: "Davis chose to go to someone’s home that day to try and pick a fight. And when his victim refused to reciprocate, he attacked him anyway.
"This was a sickening assault, carried out under the delusional belief by Davis that it will somehow make him look like a better man.
"Not content with attacking the man and leaving him for dead, Davis then turned his aggression towards police officers, frontline professionals who work hard to keep people safe.
"I am pleased the court has recognised the severity of Davis’ action and jailed him.
"I thank the victim for his support of the case and I wish him all the best for the future."
Luke Stimson
Luke Stimson (Image: Kent Police)
A child sex offender was sentenced to almost a decade in prison after repeatedly abusing a child.
Luke Stimson, of Coopers Lane in Fordcombe near Tunbridge Wells, was arrested after allegations were reported to Kent Police in December 2017.
The 40-year-old's phone was seized and was found to contain a number of illegal images which had been shared through a messaging app.
At Maidstone Crown Court, Stimson pleaded guilty to two counts of sexual assault and one of sexual assault by penetration.
He also admitted counts of taking indecent images of a child and sharing indecent images of a child.
On July 18, he was sentenced to nine years and ten months behind bars.
He was also made subject of sexual harm prevention order for ten years and added to the sex offenders’ registers indefinitely.
During police interview, Stimson blamed a dependency on alcohol for his actions - which took place between 2014 and 2017 - and referred to the abuse as "silly mistakes".
(Image: Daily Mirror)
Judge Philip Statman praised the courage shown by the victim in coming forward and also commended Detective Sergeant Lisa Featherstone, of the West Kent Vulnerable Investigation Team, who he said had left "no stone unturned".
DS Featherstone said: ‘Stimson repeatedly abused a vulnerable child for his own gratification, but has continually sought to diminish the gravity of his offences by dismissing them as mishaps and misunderstandings.
"In reality, the damage these type of offences cause is incalculable, leaving victims having to live with these memories for the rest of their lives.
"Successful convictions such as this are just one of the reasons we continue to urge anyone who has been a victim of sexual abuse to contact the police.
"It is never too late to report any sexual offence and we will always treat any information with the upmost confidence and sensitivity."
Luke French
A serial arsonist who risked a hospital's mortuary, two MRI scanners worth £1million and oxygen containers going up in flames has been jailed for life.
A judge told Luke French he was 'a very dangerous young man' who would remain a public risk for an indefinite period.
French started two fires in the grounds of Medway Maritime Hospital, in Gillingham , just 15 minutes apart just after 10pm on September 5 last year.
The 29-year-old, who has a history of fire-setting dating back to when he was 14, set plastic packaging and an industrial rubbish bin alight in separate incidents.
It was only the quick actions of hospital staff who spotted the blazes and extinguished the flames that averted serious consequences, Maidstone Crown Court heard.
Prosecutor Gabby Henty said the bin fire occurred adjacent to two large MRI scanners each worth £500,000, while the plastic was set alight next to bin cages and in close proximity to an overflow mobile mortuary.
"But perhaps most seriously, also where the mobile oxygen containers were and which connect to the main oxygen supply to the hospital," she added.
French was captured on CCTV starting the fires and then lurking with an accomplice in the hospital entrance, either to watch the flames or to avoid detection.
Earlier that evening, the pair also set two bins alight in nearby Chatham which had to be extinguished by the fire brigade.
French, of Peregrine Drive, Sittingbourne, pleaded guilty to two offences of arson and one of arson being reckless as to whether life would be endangered.
He had only been released from prison five months earlier, and after five parole board hearings, for another arson offence.
Judge Williams ordered he must serve a minimum of five years behind bars but told French the parole board may never consider it safe to release him.
The court heard French, who suffers from ADHD, anxiety and depression, had had 'an interest in fire' since mid-childhood.
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SoutheasternKent's busiest railway station has more passengers a day than Ashford International and TonbridgeDartford has seen a huge increase in numbers over the past year
SupermarketsMum invents simple Aldi hack to take the stress out of packing shoppingThe woman has sworn by this tip for years when shopping at Aldi and has now shared it with other customers to make the checkout process a doddle and stress-free
ThanetThanet: 10 things that made me smile on a walk through RamsgateFrom helpful signs to the stunning harbour and places to eat, there's plenty to make you happy when wandering around town
FolkestoneWe fact checked 11 things people always say about FolkestoneSome common statements are simply out-dated, while others still have a valid point
SupermarketsWe tried own brand crisps from Sainsbury's, Tesco, Aldi, Morrisons and AsdaThe perfect crisp is hard to find, which is why we put the efforts of five leading supermarkets to the test
FolkestoneWe fact checked 11 things people always say about Folkestone
Some common statements are simply out-dated, while others still have a valid point
MedwayHeartbroken family's worry after missing Medway girl left home and didn't go to school
The Hundred of Hoo Academy pupil's disappearance has been described as 'very out of character'
Dartford CrossingPolice anger over lorry driver's dangerous reaction to M25 crash near Dartford CrossingIn the wake of the crash traffic had slowed on the opposite carriageway, with tailbacks stretching back to Lakeside in Essex
FolkestoneDebenhams pens emotional farewell to loyal customers as it shuts forever
"We would like to thank all our customers for your support over the years."
WeatherMan shares amazing de-icing hack which clears your car instantly
Temperatures have plunged below zero in Kent, so it's likely your car will need a little help before you get going
SevenoaksMy grandsons left me a letter on my doorstep, I found them dead minutes later
Billy and Joe Smith were tragically found hanged n woodland
Dartford CrossingM25 and Dartford Crossing traffic stretching back to A2 and M20 after lorry and car crash
All traffic has been held on the crossing heading southbound towards the Queen Elizabeth II bridge
GravesendLive: Emergency services rush to Gravesend incidentMultiple police cars and ambulances spotted Milton road
WeatherHealth warning as heavy snow, freezing fog and temperatures of -7C to sweep Kent
A 1,000-radius cold plume will result in potential blizzards, toxic air pollution and 10 days of fog and grey skies, according to forecasters
Traffic & TravelLive M25 Dartford Crossing traffic updates as crash closes carriagewayThere is stationary traffic due to accident on the M25 anticlockwise from junction 3 for the M20 to junction 2 for the A2
Ashford'Persistent' burglar who snatched handbag caught while using victims' bank cardsJack Edmed was arrested after he bought alcohol, cigarettes and fast food
ThanetPictures show huge crowds as Suggs from Madness and Fat Boy Slim takeover Margate seafront
From the van they not only gave out the slightly unseasonal treat of ice creams, but also 100 free tickets to Dreamland's new festival Hi-Tide
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Governance and City
Governor’s Biographies
Old Witleians
Old Witleians’ E-newsletter
Old Witleian Community
1930s & 40s class notes
1950s class notes
Former staff class notes
Old Witleian Contact Details
Inspection and policies
ISI Inspectorate area
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Book an open morning
Venice Tour
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Grafton House
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Careers & Higher Education
Pre-Sixth Form
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Kestrel Magazine
King Edward's Witley - Senior School - Academic
Breadth and balance are key to giving every pupil the opportunity to succeed
King Edward’s ethos is to ensure every pupil has the chance to discover their strengths and to shine, whatever their interests and passions. We deliver a broad and balanced curriculum, where choice is central and the individual learner is given priority. Our emphasis is on coaching, helping pupils to take increasing ownership of their own academic progress as they move through the School. This then builds good habits for Sixth Form studies. All pupils enjoy cross-curricular activities and trips that add interest and value to this broad and enriched curriculum.
At King Edward’s, pupils develop creativity and collaboration in Music, Art and Drama, participate in many sports and discover new interests through our Clubs and Societies from archery, strategy gaming to bee-keeping.
All our academic staff are subject specialists committed to inspiring and stimulating pupils in all lessons. Each pupil has an academic tutor with weekly meetings and frequent feedback to pupils and parents. Parents use the parent portal Firefly to access regular progress grades and written reports. There is an annual parent and staff conference for each year group. Teachers and House staff are always available to arrange additional meetings with parents as required.
1st and 2nd Form Curriculum
In 1st and 2nd Form we are committed to giving our girls and boys every opportunity to experience a wide range of subjects so they can explore their interests and talents.
Studies are structured around the National Curriculum but extend well beyond. The core disciplines of Maths, English and Science make up a significant proportion of our teaching, to ensure pupils have the foundation required whatever route they take in their GCSEs, the Sixth Form and beyond.
Alongside the core subjects, pupils have the chance to experience three humanities – History, Geography, Religious Education – two to three modern languages French, German and/or Spanish, and Latin. Some pupils opt to take Classical Civilisation instead of Latin, ensuring that all our pupils have a sound grounding in myths, ideas, and the history that underpin and continue to shape western culture.
An array of creative pursuits completes their timetable options including Art, Design Technology, Food and Textiles, Music, Computing, Drama, and Sport.
3rd Form and GCSE Curriculum
A continued breadth of academic and co-curricular in 3rd Form ensures all pupils are well placed to choose a varied, balanced programme of studies when making decisions about their GCSE courses.
The core disciplines – Maths, English (Language and Literature), double Science, and one Modern Foreign Language are taught in ability sets.
An additional three GCSE subjects are chosen from the following options: Art, Classical Civilisation, Computing, Drama, a second Modern Foreign Language, Geography, History, Latin, Music, Physical Education, Religious Studies or Technology (Design Technology or Food Technology). We also invite our keenest scientists to apply for the Triple Science, studying Biology, Chemistry and Physics as separate GCSE courses.
The GCSE option blocks are constructed to meet the choices of individuals, but checks are made to ensure that pupils follow a balanced programme and keep career and further study options open. GCSE subject selection is done in consultation with teachers, House staff, parents and the pupil.
All 1st to 5th Form pupils follow a non-examined course in Personal, Social, Health and Economic (PSHE) which complies with statutory guidance on the delivery of sex, health, financial and citizenship education.
Pre-Sixth
King Edward’s offers a Pre-Sixth one-year GCSE programme. The Pre-Sixth year is a terrific way to prepare for the challenges and rewards of a full Sixth Form programme at King Edward’s. It provides pupils aged 15-16 a taste of boarding life, improves their level of spoken and written English and includes the opportunity for cultural trips around the UK, including Oxford, Cambridge and London. Living in our mixed day and boarding Houses, our Pre-Sixth pupils are fully integrated with their peers and build deep friendships. We offer pupils a rich mix of core subjects and three pathways: academic, scientific and creative. Please refer to the Sixth Form Booklet for subject details.
The Sixth Form curriculum at King Edward’s offers a choice of A-level and the International Baccalaureate (IB) Diploma Programme to equip our pupils with the right qualification that suits their strengths and opens up the global marketplace for universities and jobs.
Whichever course of study is selected, every opportunity is taken to promote a genuine appreciation of academic disciplines as well as fostering life-long learning. The virtues of both routes are widely recognised by British universities including Cambridge, Oxford, Imperial and the other prestigious institutions in the Russell Group. The IB Diploma Programme benefits from a global recognition, while the A-levels suit the pupil with a passionate fascination for their subject.
We ensure, through a mix of aptitude tests and interviews with both senior teachers and our specialist Head of Careers and Higher Education, that every pupil, whether opting for IB or A-level, has a course that will allow them to flourish and fulfil their potential.
Universities traditionally make offers to pupils based on three A-levels hence most of our pupils will follow the three-subject pathway with the option to take Further Maths as a fourth A-level. Pupils taking three A-levels are offered the opportunity to complete the IB Theory of Knowledge course and the Extended Essay helping to boost UCAS points. An alternative course in a language or other IB subject can also be chosen alongside A-levels.
Universities welcome the IB’s Creativity, Activity, Service (CAS) hours as evidence that pupils have broader interests, hence at King Edward’s all A-level pupils must accumulate CAS hours.
International Baccalaureate Diploma Programme (IB)
The IB offers both the rigorous and challenging Diploma Programme, where pupils must take three Higher Level subjects and three Standard Level subjects spread across a range of disciplines, as well as completing the IB Core: an extended essay, the Theory of knowledge course and a commitment to completing Creativity, Action, and Service (CAS) hours.
Recognised all over the world, the IB is a direct track into British and international universities and offers excellent preparation for tertiary education.
The International Baccalaureate Organisation aims to develop enquiring, knowledgeable and caring young people who help to create a better and more peaceful world through intercultural understanding and respect. The IB encourages pupils across the world to become active, compassionate and lifelong learners, through challenge and rigorous assessment.
For an overview of our IB programme, please see the graphic below. To find about more about the individual IB subjects offered please explore our Sixth Form booklet.
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Mental Health First Aiders
As part of King Edward’s Wellbeing and Development Programme, Miss Laura Sessions (PSHE Co-Ordinator) organised a two day training course for fifteen members of staff from both Barrow Hills School and King Edward’s Witley to complete their Youth Mental Health First Aid qualification. This was an internationally recognised two day course delivered by trainer Jane...
King Edward's Witley@KESWitley·
Our @KESWitley 3rd Form pupils had great fun this afternoon in their after school Asian Cookery Class activity. They learned how to make egg fried rice. Wonderful smells and colours, delicious. #KESWCommunity #AsianCuisine
3rd form @keswitley pupils having great fun making
King Edward's Witley
Monday 20th January, today, is widely known as ‘Blue Monday’. Reported as ‘the most depressing day of the year’, due to combined factors such as the weather, debt and weight gain since the festive period.
Mental health charity Mind is derisive of the notion of Blue Monday, claiming the concept has no foundation in scientific research. A statement on their website says: "Here at Mind, we think it’s dangerously misleading. Those of us who live with depression know that those feelings aren’t dictated by the date. Implying that they are perpetuates the myth that depression is just 'feeling a bit down', something that doesn’t need to be taken seriously."
However MIND are campaigning for people to carry out one act of ‘self care’ on this date.
A friendly message to try and take time today to look after yourself....even if it's only for 15 minutes. ... See MoreSee Less
King Edward's Witley and Barrow Hills School are partner schools under the Bridewell Foundation.
King Edward’s Witley (aged 11-18)
GU8 5SG
Email: admissions@kesw.org
Barrow Hills School (aged 2-13)
GU8 5NY
Email: info@barrowhills.org
King Edward’s is within easy reach of major air, rail and road links. FIND US
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(-) Clinical leadership
(-) Carers
(-) Performance
How is the health and social care system performing? September 2013: Quarterly monitoring report
The NHS will struggle to meet its target of delivering £20 billion in productivity improvements by 2015 according to our latest quarterly monitoring report.
By John Appleby et al - 18 September 2013
Exploring the system-wide costs of falls in older people in Torbay
Using Torbay’s unique patient-level linked data set, we explore the NHS and social care costs of the care pathway for older people in the 12 months before and after being admitted to hospital as a result of a fall.
By Yang Tian et al - 22 August 2013
How is the health and social care system performing? June 2013: Quarterly monitoring report
Our latest quarterly monitoring report confirms that the government's target has been missed as A&E waiting times hit a nine-year high.
By John Appleby et al - 4 June 2013
The Care Bill: Second reading in the House of Lords: Briefing
The King's Fund welcome the Care Bill as a significant stepping stone to wider reform of care and support and the new duties on local authorities to promote wellbeing.
Are 'family and friends tests' useful: agree, disagree, neither, don’t know?
Family and friends tests are an established method of obtaining feedback on performance for many private sector businesses. But how well is this sort of customer feedback suited to public services like the NHS?
By John Appleby - 14 May 2013
Medical leadership is vital for quality patient care
Doctors should be encouraged to enter into leadership roles. It is essential for raising the standard of patient care, writes Chris Ham.
By Professor Sir Chris Ham - 30 April 2013
British Social Attitudes survey 2012: public satisfaction with the NHS and its services
The topline results and satisfaction trends relating to the NHS and health care issues from the British Social Attitudes survey 2012.
By John Appleby - 18 April 2013
The Nuffield Trust health and social care ratings review: Consultation response
Our response to the independent review by the Nuffield Trust commissioned by the Secretary of State for Health to consider whether aggregate ratings of provider performance should be used in health and social care.
How is the health and social care system performing? February 2013: Quarterly monitoring report
This quarter's monitoring report finds that, while most NHS organisations are on track to meet financial targets, it is clear that pressures are growing towards the end of the second year of the so-called Nicholson Challenge.
By John Appleby et al - 14 February 2013
The NHS in England in 2013
Funding and service pressures are likely to have an impact on the quality of care in 2013, says Chris Ham.
By Professor Sir Chris Ham - 2 January 2013
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