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Emily L. Wang '11
Harvard University, Department of Economics
Health care costs in Massachusetts are increasing much faster than the growth of the state economy. An investigative report by the Attorney General Office finds that prices paid by commercial health insurers to hospitals vary significantly amongst providers offering similar levels of service, and that such price variations are correlated only with market leverage. In this thesis, I examine several theories of why prices vary so much among MA hospitals. I identify five exogenous variables that explain 56 percent of the variation in prices. I discuss policy implications of these findings.
Health care is Massachusetts's largest industry and a major driver of the state's economy. Massachusetts is first in hospital access in the nation, providing insurance coverage for 97% of its residents, and ranks in the top ten in quality of care provided. Massachusetts's health insurers are also consistently rated in the top ten best insurers nationally. Yet Massachusetts hospital spending has always been higher than the national average, reaching 55% per person above the US average in 2008. Acute hospital costs per person in the state are the highest in the nation, at $3,015 per person in 2007. [1]
Proposed reasons for Massachusetts's high hospital costs are: a large and increasing share of total patient care given by costly teaching hospitals, high surgery rates, high number of MD's (the nation's highest physician-to-patient ratio), and the political influence of the large teaching hospitals. Such teaching hospitals are vital to the state's economy and spend large amounts of money on lobbying.
A new factor
On March 16, 2010, the Massachusetts Attorney General's Office released a Report for Annual Public Hearing, Examination of Health Care Cost Trends and Cost Drivers, that identified a new factor contributing to high hospital costs—price differentials. The investigation finds that prices paid by commercial health insurers to hospitals and physician groups vary significantly within the same geographic area and amongst providers offering similar levels of service. The AGO claims that price variations are not correlated with (1) quality of care, (2) the sickness of the population served or complexity of the services provided, (3) the extent to which a provider cares for a large portion of patients on Medicare or Medicaid, (4) whether a provider is an academic teaching and research hospital, or (5) differences in hospital costs of delivering similar services at similar facilities. Rather, Attorney General Martha Coakley argues that price variations are only correlated to market leverage as measured by the relative market position of the hospital compared to other hospitals within a geographic area. The AGO defines "leverage" as the ability of the provider to influence the insurer during contract negotiations, calculating leverage as the total revenue paid by an insurer to hospitals within one provider system. Coakley warns that higher-price hospitals are gaining market share at the expense of lower-priced hospitals. She asserts, "The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing."
The AGO report presents a rare opportunity to view subpoenaed data containing relative payments negotiated between providers and insurers that are normally kept hidden from the public eye. Understanding what drives price differentials among hospitals in Massachusetts is important to check the increase in future health care costs, and is made possible by these data. The legislative mandate for the AGO's investigation was spurred by the fact that health care costs in the state are increasing much faster than the growth in the economy, GDP, and wages. If unchecked, this increase would threaten the future viability of universal health care access and Massachusetts's role as a national leader in health care reform.
Explaining price differentials in the Massachusetts commercial insurance market will also be beneficial towards understanding price differentials among hospitals in other states across the US. In an interview, Thomas Glynn, Chief Operating Officer at Partners HealthCare in Boston from 1996 to 2010, states, "When you read the Attorney General's report, you get the impression that [price variations] are only in Massachusetts, where in fact they are in other states too." He notes that major price disparities among hospitals in the New Hampshire market rebuts the notion that the issue of rate differentials is somehow peculiar to Massachusetts. Just as hospitals within the dominant Partners system charge the highest prices for many services, hospitals within the dominant Dartmouth-Hitchcock system in New Hampshire also charge the highest prices for many services in the state. [2]
How prices are set
The AGO report brings some transparency to the public as to how prices for health care are set. Prices paid to providers are the result of many discrete negotiations. Each insurer negotiates a price for every service with each hospital. These negotiations result in disparate prices paid for the same or similar type of service between hospitals.
There has been extensive debate over whether prices in the health care market can be modeled by the intersection of supply and demand curves, and if so, how they are set. In this paper, I will address possible factors that can affect the price equilibrium by altering the intersection of these curves. These factors can either work by changing the elasticity of the curves, or by causing shifts in the curves.
For example, we can trace the higher price negotiated by a provider with an insurer to the higher demand by consumers for that same provider (Figure 1). Initially, the demand curve D for the provider intersects with the supply curve S1 at equilibrium price P0. Because of the heightened reputation of the hospital, consumers demand its services more, and so the demand curve becomes more inelastic, and is now represented by D1. Since there is more demand for its services, a provider may now want to increase costs to build more high-technology services or to train more staff. These increases in cost are represented by a shift back in the in the supply curve from S1 to S2, which in turn translates into a higher equilibrium price P2 in the marketplace.
Figure 1 can also be used to compare a hospital with a more elastic curve D to a hospital with a more inelastic curve D1. If costs increase and there is a upward shift in the supply curve, the hospital with the more inelastic demand curve will have a higher equilibrium price P2 than the hospital with the more elastic demand curve and equilibrium price P1.
Rebuttals to the AGO report
The AGO's finding that high and increasing hospital costs in Massachusetts are driven largely by hospitals' market dominance, not by high utilization or the quality or cost of providing care, is contested in a report commissioned by Partners HealthCare, and a second report commissioned by the American Hospital Association.
Partners' rebuttal finds (1) general conceptual and methodological issues in the report, (2) problems with its market share analyses, and (3) questions in its treatment of quality measures. It states that the AGO uses simplistic methodology to reach its conclusions, and that the major reason that hospital costs have escalated in Massachusetts is because hospital quality has improved, not because powerful providers have demanded higher prices. It cites as a major methodological issue the report's use of univariate analyses to examine relationships of price to quality, case mix, teaching status, Medicare/Medicaid census, and costs.
The AHA rebuttal focuses on the Attorney General's claim that negotiated commercial rates for hospital services at large provider organizations are substantially higher than those for other organizations, and that observed differences are due predominantly to market power/leverage. They note that "market power" should be defined to specifically mean the anticompetitive exercise of power to set prices that reduces consumer welfare, as the term is used by antitrust agencies and defined by the courts. They find that the AGO report uses market power claims without regard to market area or geographic analyses, including assessment of alternatives available. They stress that anticompetitive market power should not be confused with consumer preferences for certain providers, highly differentiated services, or specialized services. A hospital can become a highly desired provider simply by being perceived to provide excellent and state-of-the-art services, and strong consumer preferences for specific hospitals provide an incentive for them to improve services, enhance quality, or expand output of services in great demand, and to expect an appropriate return on the investments required to provide these services.
Theoretical framework
In this paper, I examine why prices for similar services vary so much among hospitals in Massachusetts. There are several plausible reasons, and it is important to test them in light of the ongoing debate about the causes of high hospital costs in this state. The Attorney General Office's report, while exposing a surprising disparity in prices paid by commercial insurers to different hospitals for the same services, does not present a rigorous economic framework to explain differential pricing among providers. The critiques of the AGO report by Partners and the AHA, while illuminating of major hospitals' justifications for their higher prices, are likely to be biased since they were commissioned by the hospitals themselves.
I will use more extensive multivariate modeling than the Partners and AHA reports (2010). Like Cutler and Sheiner (1999), I will take into account the effects of demographic and hospital characteristics in determining price. I note that use of total amount of revenue paid by an insurer to a provider system as a measurement of market leverage is endogenous to price, and thus cannot be used to explain price differentials. Instead, I will explore the effects of exogenous variables on price in my regression model. In particular, I will propose measurements of market competition that are based on total admissions. By using such predicted flows, in the form of an estimated demand model, rather than actual flows, I will attempt to avoid the endogeneity problem.
The following are several different theories that I propose to explain these price differentials, and that I will test in my models.
Market competition—two competing hypotheses:
A) Negative correlation between market competition and prices
For commercial insurers, the higher-spending markets are those that are the least competitive on the provider side. Small markets with only one or a few big hospital systems negotiate higher prices.
B) Positive correlation between market competition and prices
When a market has a lot of hospitals, an "arms race" mentality can drive up costs as they vie to buy the best new technology, attract doctors, and win patients, who because of insurance are indifferent to costs. The failure of an insurer to contract with a large provider organization would cause serious network disruption, not only because a large percentage of their members would be forced to seek care elsewhere, but because employers and others are less interested in purchasing products that do not include the dominant providers. This is because larger providers who have built up greater facilities, services, and "brand name" than other smaller hospitals, become "must-haves." As Berenson et al. note, "Must-have hospitals have market leverage over health plans, because plans cannot plausibly threaten to exclude them….[They] must be included in a plan's provider network to make the plan acceptable to customers." The demand curve thus becomes more inelastic.
Characteristic market power
Teaching or community hospital status will affect the prices negotiated by a hospital. Previous literature says that teaching hospitals are likely to negotiate higher prices than their community counterparts, as they must bear the cost of training programs, they have more staff to pay salaries to, more overhead costs, and they pay physicians money for teaching, not only for practice. This would cause the supply curve to shift upward, and thus for the supply and demand curve to intersect at a higher price.
Quality of care
One would expect to see a positive correlation between price and quality of care in a rational, value-based health market. Patients demand better quality of care so there is an outward shift in the demand curve. This may also have the effect of making the demand curve become more inelastic, as large movements in quantity would only cause small movements in price. Both situations have the effect of causing the supply and demand curves intersect at a higher price. Furthermore, better care indicates higher costs in the form of more physicians, more nurses, more specialists, and more testing.
Leverage theory/essential provider
A hospital with a larger array of unique services offered will be more likely to charge higher prices. This is because it will be one of only a few hospitals that patients can go to for a specific treatment. Market demand will become more inelastic.
Brand name
A positive correlation between prices and brand name would be expected. If consumers subjectively believe that a hospital is a "superior" hospital to go to, demand and thus prices will rise. Patient preference reduces the elasticity of demand and keeps prices up. Reputation could also lead to an outward shift in the demand curve, which would cause the equilibrium price to rise as will.
Income of area
If a hospital is located in an area that has well-insured patients, they may be able to charge more because they know that their patients will be able to afford the bill. Conversely, an area with higher income would have more patients demanding health care since they can afford it. Thus, higher income represents an outward shift in the demand curve, and hence a rise in prices. We would expect prices to be positively correlated with the income of the hospital's surrounding area.
One would expect that prices would be positively correlated with the percentage of patient charges attributed to Medicare, Medicaid, other government payers, and/or free care due to cost-shifting. Disproportionate share hospitals may charge higher prices since Medicare and Medicaid pay less than private insurance, and the hospital needs to get reimbursed for more than simply what the government pays.
The data comes from a variety of sources. The Massachusetts Division of Health Care Finance and Policy, in collaboration with the Attorney General's Office, collected written testimony from Tufts Health Plan, Blue Cross Blue Shield, and Harvard Pilgrim Health Care. All three insurers provided data on relative differences in hospital prices in 2008. All three indices are created by taking a market basket of inpatient and outpatient services, and computing the total charge for these services at each hospital. These measures of relative payments are all adjusted by the Case Mix Index (CMI), or the severity of the cases. The sample size was 198. [3]
The National Bureau of Economic Research provided American Hospital Association (AHA) data on services offered by each hospital in 2008. The AHA 2008 Annual Survey of Hospitals lists hospital system affiliation. [4] The Massachusetts Division of Health Care Finance and Policy provided data on total admissions, teaching or community status, and the number of Medicare and Medicaid admissions at each hospital.
Quality of care data comes from the US Department of Health and Human Services Medicare Hospital Compare Website. Hospital "Outcome of Care Measures" show what happened after patients with certain conditions received hospital care. The death rates are the 30-day risk-adjusted death rates for heart attack, heart failure, and pneumonia; in other words, whether patients died within 30 days of hospitalization. The rates of readmission show how often patients are readmitted within 30 days of discharge from a previous hospital stay for heart attack, heart failure or pneumonia. Death rates and rates of readmission show whether a hospital is doing its best to prevent complications, teach patients about their condition at discharge, and ensure that patients make a smooth transition to their home or another setting such as a nursing home.
The Current Population Survey provided data on the median income of each zip code in Massachusetts in 2008.
I will test the effect of various hospital and market characteristics on price. Typically, major health plans and hospitals negotiate prices for inpatient health care services using a base case rate. The base case rate is controlled for the severity and complexity of each case. Additional prices are negotiated for a limited set of other inpatient services such as very high-cost or experimental procedures. For outpatient services, health plans have set standard fee schedules for all outpatient services (e.g. standard fees are set for radiology, laboratory work, observation, behavioral health, etc). The plans and hospitals negotiate a specific multiplier to each of these standard fees; for example, a provider with a 1.2 multiplier for radiology services would be paid 120% of the standard fee schedule rate for covered radiology services.
PRICE is a variable that measures the relative price paid to each hospital for a comprehensive market basket of both inpatient and outpatient services. In other words, relative price is the variation in the contractually negotiated amount that an insurer agrees to pay each provider in their network, as compared to the network-wide average. The health plans calculated this "payment relativity factor" controlling for differentiating factors such as volume, product mix, service mix (complexity), and case mix (acuity). It is thus possible to compare the pure "price" that insurers negotiate with different hospitals for all hospital inpatient and outpatient services.
I begin with a set of univariate models that model the effect of BRAND, SERVICES, and TEACHING on PRICE. These independent variables are reasonable to start with since it is likely that the "name brand" of the hospital would heavily influence demand, as would the number of specialty services provided at the hospital, since people would have nowhere else to go for such services. The teaching or community hospital status of a provider should also affect price since teaching hospitals attempt to differentiate themselves from community hospitals by attracting nationally renowned faculty specialists who can foster recognition for the hospital, leading to higher demand by consumers. Teaching hospitals are also costlier to operate, and consumers must bear the cost of the training programs.
The models are as follows:
(1) PRICEi= ß1BRANDi + ß2DUMMYTHP + ß3DUMMYBCBSi + εi
(2) PRICEi= ß1TEACHINGi + ß2DUMMYTHP + ß3DUMMYBCBSi + εi
(3) PRICEi= ß1SERVICESi + ß2DUMMYTHP + ß3DUMMYBCBSi + εi
BRAND is a variable that describes the subjective consumer "brand" perceptions of the hospital. This variable is constructed by taking the number of times a hospital is ranked in the top 50 hospitals in the US News and World Report for any of 16 specialties. These specialties include Cancer, Diabetes & Endocrinology, Ear, Nose & Throat, Gastroenterology, Geriatrics, Gynecology, Heart & Heart Surgery, Kidney Disorders, Neurology & Neurosurgery, Ophthalmology, Orthopedics, Psychiatry, Pulmonology, Rehabilitation, Rheumatology, and Urology.
SERVICES describes the specialty service lines offered by the hospital. I constructed SERVICES by counting the number of services a hospital offers from a selection of 14 different services. The services were chosen because they are advanced high-technology services that only large hospitals are likely to have. They include: Cardiac Catheterization Lab, Extracorporeal Shock-Wave Lithotripter, Full-Field Digital Mammography, Image-Guided Radiation Therapy Hospital, Intensity-Modulated Radiation Therapy, MRI, Open Heart/Cardiac Surgery, Proton Emission Therapy, Heart Transplant, Liver Transplant, Tissue Transplant, Kidney Transplant, Lung Transplant, and Other Transplant.
The above services represent a group of the most advanced, expensive, resource-intensive services offered. They require highly trained doctors, nurses and technicians and would not be economically feasible unless there was a large volume of patients using the services. Heart transplantation, for example, is only available in a few hospitals in Massachusetts. Such advanced and expensive services are used by hospitals to distinguish themselves from other hospitals in a competitive market.
The sum of services was represented by the z-statistic, SPECIALTIES. In addition, I looked at the number of neonatal intensive care beds (NEOINTENSIVE), neonatal intermediate care beds (NEOINTERMEDIATE), pediatric cardiac beds (PEDCARD), and cardiac intensive care beds (CARDINTENSIVE) that each hospital had. I converted these variables into z-statistics and then averaged across the z-statistics to compute SPECIALBEDS. I averaged the above two z-statistics, SPECIALTIES and SPECIALBEDS to arrive at SERVICES.
SERVICES thus captures the leverage of the hospital as measured by whether the hospital offers certain specialty service lines. I used two ways of measuring TEACHING that have comparable results: [5]
a) By setting the independent variable to be 1 if the hospital is a teaching hospital and 0 if the hospital is a community hospital. The following 15 hospitals are assigned a "1" as they are listed by the DHCFP as being teaching hospitals: [6] Baystate Medical Center, Beth Israel Deaconess, Boston Medical Center, Brigham and Women's, Cambridge, Caritas St Elizabeth's, Children's Hospital, Dana Farber Cancer Institute, Lahey Clinic Medical Center, MEEI, Mass General Hospital, Mount Auburn, St. Vincent's, Tufts Medical Center, and UMass Memorial Medical Center.
b) By assigning the variable to be the sum of the total number of interns and fellows in each hospital. [7]
THP and BCBS are the insurer dummy variables. For THP, I assigned a value of 1 for the Tufts Health Plan relative payments and a 0 for Blue Cross Blue Shield and Harvard Pilgrim Health Care relative payments. For BCBS, I assigned a value of 1 for Blue Cross Blue Shield relative payments and a 0 for Tufts Health Plan and Harvard Pilgrim Health Care relative payments.
In each of the initial univariate regressions (Table 1 of Supplemental Figures), the individual variables BRAND, TEACHING, and SERVICES are significant predictors of price. The p-value is less than 0.01 for BRAND, TEACHING (fellows and residents), and SERVICES, indicating statistical significance to the 1% level. The model with TEACHING (0/1 coding) has a p-value of <0.1, indicating statistical significance to the 10% level.
It is imperative, however, to check the independent variables for multicollinearity (Table 2 in the Supplemental Figures). The results draw attention to the fairly high correlations between the regressors BRAND, TEACHING, and SERVICES.
1) BRAND and SERVICES (r = .580)
2) TEACHING and SERVICES (r = 0.666)
3) BRAND and TEACHING (r = 0.480)
This suggests that the theories they measure are capturing the same effects in the regression models. To further confirm this, I paired the variables off to test what effect combinations of two of these three variables would have on price.
The next models tested are:
(5) PRICEi= ß1BRANDi + ß2SERVICESi + ß3DUMMYTHPi + ß4DUMMYBCBSi + εi
(6) PRICEi= ß1BRANDi + ß2TEACHINGi + ß3DUMMYTHPi + ß4DUMMYBCBSi + εi
(7) PRICEi= ß1SERVICESi + ß2TEACHINGi + ß3DUMMYTHPi + ß4DUMMYBCBSi + εi
I then construct another model in which all three variables were included:
(8) PRICEi = ß1BRANDi + ß2TEACHINGi + ß3SERVICESi + ß3DUMMYTHPi + ß4DUMMYBCBSi + εi
See Table 3 in the Supplemental Figures for tests of multicollinearity. In each of the regressions, one or both of the variables become insignificant. This strongly suggests that the three variables are highly correlated, and that it is thus necessary to drop two out of these three independent variables from the final regression. Because SERVICES remains consistently significant across all regressions, it is kept in the final model while BRAND and TEACHING are dropped.
The percentage of patients on Medicare and Medicaid are also likely to be factors of interest as they may determine price through cost-shifting. I tested the effect of these percentages on PRICE:
(12) PRICEi= ß1MEDICAREi + ß2MEDICAIDi + ß3DUMMYTHPi + ß4DUMMYBCBSi + εi
The Massachusetts Division of Healthcare Finance and Policy provided information on the number of Medicare and Medicaid Managed Care Admissions and Medicare and Medicaid Non-Managed Care Admissions at each hospital.
MEDICARE is equal to the share of total admissions that belong to total Medicare admissions. MEDICAID is equal to the share of total admissions that belong to total Medicaid admissions. See Table 4 in the Supplemental Figures for the effect of the percentage of Medicare and Medicaid patients on price. Since MEDICARE and MEDICAID are statistically significant predictors of price (p < 0.01 for MEDICARE and p < 0.05 for MEDICAID), I reasoned that these also should be put in the final regression model.
We would also expect Quality of Care to have a significant impact on prices. The six quality of care measures reported by the Medicare Compare website are: the Hospital 30-Day Mortality Rates for Heart Attack (MORTHEART), Hospital 30-Day Readmission Rates for Heart Attack (READMHEART), Hospital 30-Day Mortality Rates for Heart Failure (MORTFAIL), Hospital 30-Day Readmission Rates for Heart Failure (READMFAIL), Hospital 30-Day Mortality Rates for Pneumonia (MORTPNEU), Hospital 30-Day Readmission Rates for Pneumonia (READMPNEU). Note that a higher QOC value indicates a worse score.
The diagram depicts the target hospital surrounded by its competitors.
- Let our target hospital (square) have 400 beds.
- Let a hospital with more than 500 beds be a pentagon.
- Let a hospital with between 300-500 beds be indicated by a right triangle.
- Let a hospital with less than 300 beds be indicated by a diamond.
- Let a hospital outside the 15-mile radius of influence be indicated by an X.
- All hospitals within the target's own system are removed.
The QOC variable is constructed by taking each individual quality of care variable and transforming it into a z-statistic, and then averaging across the z-statistics for the overall measure to be used in the regressions. QOCDUMMY is a dummy variable that identifies those hospitals that had no reported quality of care measures by the Medicare Compare website.
Finally, we would also like to see what the effect of market competition has on prices, as this was the entire premise of the Attorney General's Report. I formed several measures of market competition for the purposes of analysis.
BASIC Measure of Market Competition
The Target Hospital faces hospitals outside its own system as competitors. In the diagram above, all the shapes surrounding the target hospital are considered competitors. Competition is measured by taking the total number of weighted average beds the target hospital faces within a 15-mile radius. A 15-mile radius is commonly used in literature, as Horwitz (2007) notes. Gresenz (2004) found that 10.4 miles is the mean distance radius that captures 75 percent of discharges and 21.5 is the mean distance radius that captures 90 percent of discharges from acute care hospitals in non-rural settings, while 14.2 miles is the mean distance radius that captures 75 percent of discharges and 25.2 is the mean distance radius that captures 90 percent of discharges from acute care hospitals in rural settings. Thus, it is reasonable that a 15-mile radius could be used in both rural and non-rural settings as it captures the majority of discharges in the target hospital's area.
Hospital location is defined by the hospital's latitude and longitude. The distances between the hospitals are calculated with Google Earth. Weighted Average Beds is defined as the average number of beds available for immediate patient use, excluding beds not immediately available because of renovation, maintenance, or physical plant problems. The Weighted Average Bed measurement is calculated by taking the sum of the number of calendar days each bed is available, divided by 365 (366 leap year). [8]
LARGEST measure of market competition
The Target Hospital only competes with large hospitals with more than 500 weighted average beds that lie within a 15-mile radius. The target faces the pentagons; the other shapes have dropped out as competitors.
SAME SIZE measure of market competition
I divide the sample into three tiers. The first tier are those hospitals that have more than 500 weighted average beds, the second tier are those hospitals that have between 300 and 500 weighted average beds, and the third tier are those hospitals that have less than 300 weighted average beds. I then find the hospitals within 15-miles of the target hospital that are either within its tier or in the tier above it. Market competition is defined as the sum of weighted average beds that the target hospital faces according to these criteria. The idea behind this strategy is that hospitals will only be competitive with hospitals about its size or larger than it. The Target Hospital thus only faces hospitals in its tier and in the tier above within a 15-mile radius. In the diagram, the target faces the pentagons and right triangles, but not the diamonds.
These different measures of market competition yield comparable results. [9] I reason that the best measurement to keep in the final regression model is the BASIC measurement of market competition in which all hospitals are considered within the 15-mile radius, as a hospital will compete with all hospitals outside its system, not only with the largest ones.
I now arrive at the primary econometric model (Table 5):
PRICEi= ß1SERVICESi + ß2MEDICAREi + ß3MEDICAIDi + ß4 QOCi + ß5DUMMYQOCi + ß6BASICMKTCOMPi+ ß7DUMMYTHPi + ß8DUMMYBCBSi + εi
An expanded model with INCOME and TOTALADM can also be considered (Table 5):
PRICEi= ß1SERVICESi + ß2MEDICAREi + ß3MEDICAIDi + ß4 QOCi + ß5DUMMYQOCi + ß6BASICMKTCOMPi+ ß7INCOME + ß8TOTALADM + ß9DUMMYTHPi + ß10DUMMYBCBSi + εi
INCOME is the average income of the top 40 zip codes that travel to the hospital. This measurement for the income of the patients was chosen instead of taking the average incomes of the zip codes within a fixed radius of the hospital because the fixed radius measurement does not take into account the fact that some hospitals are referral hospitals. For example, most of MGH's patients do not come from the immediate surrounding area. [10]
TOTALADM is the total admissions at each hospital, which is also a proxy for the size of the hospital.
It should be noted that the coefficients of SERVICES, MEDICARE, MEDICAID, QUALITY OF CARE, and
MARKET COMPETITION in the two models are very similar. These are the coefficients of greatest interest, as they have statistically significant effects on relative price. Therefore, I disregard the effects of income and total admissions since they do not contribute appreciably to the primary economic model. Adding total admissions to the regression did not increase the correlation suggesting that hospital size was already accounted for by the services intensity. For the purposes of quantifying the results, we will consider the primary economic model as our final regression. The R2 value indicates that 56 percent of the variation in prices can be explained by the model, suggesting that it is a good fit for the data.
Table 6 lists the summary statistics. It is clear that there are some hospitals offering many specialty services, but that most hospitals do not. Furthermore, the mean and standard deviation for the "brand" variable show that only a few hospitals dominated the U.S. News and World Report, while the others did not make a single top 50 list at all. This is characteristic of a marketplace with a few, very dominant hospitals in the marketplace. It is also noteworthy that the range of the quality of care offered at the different hospitals is quite large, suggesting that Coakley's assertion that the same quality of care is being provided among all hospitals must be questioned.
Specification tests
The following are robustness checks are performed to support the result of the above primary econometric model.
In Table 7 of the Supplemental Figures, I use the BASIC measurement of market competition that treats all hospitals surrounding the target hospital within a 15-mile radius as competitors. The variable SERVICES is replaced in the primary econometric model with BRAND or either form of TEACHING. The models produce comparable results.
To further evaluate robustness, I replace the BASIC measure of market competition with the other two proposed measures of market competition (Tables 8 and 9). The regressions also showed similar results.
Since the predictors remain significant even after substitution with comparable independent variables, and the coefficients remain similar in magnitude, I conclude that the results are robust, and that my final regression model is appropriate for the data.
I propose that a five percent increase or decrease in prices would be considered a significant movement in prices. This shift is a good approximation for the range that private individuals are willing to pay for a service offered at several different hospitals, and is consistent with the merger guidelines notion of a significant price increase by the Department of Justice. From the angle of public policy, any price shift above this barline would be cause for scrutiny.
From Table 5, we can see a clearer picture of what exogenous factors Massachusetts policymakers can focus on as drivers of price variations among providers. A one standard deviation increase in the quantity of services leads to a 7.8 percent increase in prices. A one standard deviation rise in quality of care leads to a 12.9 percent rise in prices. These two variables are in terms of z-statistics. For the other variables that are not in terms of z-statistics, I multiplied their coefficients by their standard deviations to get the percent price shift from the mean = 1. A one standard deviation rise in Medicare leads to a 12 percent decrease in prices. A one standard deviation rise in Medicaid leads to an 8 percent decrease in prices. A one standard deviation rise in market competition leads to a 5 percent fall in prices.
We see from the results that all of the coefficients represent a major deviation in price from the mean. The predictors cause large shifts in price that are similar in magnitude. This suggests that all the hospital and market characteristics listed above are important drivers of price differentials, and furthermore affect price to approximately the same magnitude.
My results call into question the Attorney General's report, which states that price differentials are solely determined by market leverage, and by no other theories. Clearly, the other theories are just as important, if not more so. Moreover, market competition causes a smaller shift in prices in my model in comparison with the effects of the other theories.
My models and regression results show that MEDICARE and MEDICAID are among the most significant predictors of price (to the 1% level, with p < 0.01). This is not what the AGO found. My results yield a negative coefficient on Medicare and Medicaid, suggesting that hospitals that want to negotiate higher prices need to decrease their reliance on Medicare and Medicaid patients. A possible explanation for this result is that private prices are affected negatively since hospitals with a greater share of Medicare and Medicaid patients will have a lower average price, because the government is free to set whatever prices it wants, and the hospitals have little bargaining power over the federal and state governments. Specifically, if a hospital has a lot of Medicare and Medicaid patients its average price will be less. This is because Medicare and Medicaid patients do not pay the provider as much as the private patients for a given service. For example, when an insurance company comes to negotiate with the hospital over prices, it will ask how much the hospital was paid to take care of the average pneumonia patient the previous year. A hospital with many Medicare and Medicaid patients will have a lower average price for its pneumonia patients than a hospital with many privately insured patients, and thus be at a disadvantage in negotiating a price for the next year.
Services are, as I show, highly correlated with size, teaching status, and brand, and are a marker of large academic teaching hospitals, which have the clout to negotiate higher rates with commercial insurers. Hospital executives cite this as a likely reason for price differentials in their testimony at the March 2010 DHCFP hearing. Berenson et al. (2010) state, "Another source of 'must-have' status comes from providing unique, specialized services, which the hospital then uses to demand and win higher rates for all services."
Glynn says, "There is a confusion about prices. They are not based on the good or service provided but rather based upon an existing insurance model instituted in the 1950s." In the 1950s, insurers had to decide how to ration specialty beds among the Massachusetts hospitals. For example, to prepare for the event of a plane crash at Logan Airport, a set number of burn units had to be built in the state. Blue Cross Blue Shield thus decided how many beds for burn patients would be allocated to each hospital. Since Massachusetts General Hospital was an established teaching hospital at the time, and had the most highly trained personnel and facilities, it was reasonable for MGH to receive the most number of burn units. However, rather than charging each individual burn victim the full price of the burn treatment service, MGH covered costs by raising prices for other services, such as the price for a cholecystectomy. Thus, the cost of a more basic procedure (such as removal of a gallbladder) offered at MGH "is never based on its true costs, but rather based on the insurance model, as this is how the system was designed," says Glynn. More specifically, the cost of the service can be approximated by the sum of its true cost and a portion of the cost of expensive specialty services offered at MGH.
It's interesting that QOC correlates with price. This is the opposite of what Coakley argues in the AGO report. However, she used different measures of QOC, which shows that QOC is a contentious variable to assess. Insurance companies tend to use check lists to monitor quality of care (e.g. if the hospitals are following published best practices guidelines, such as giving aspirin to heart attack patients, and immunizing elderly patients against the flu), whereas Medicare Compare looks at actual results in patients (mortality rates, readmission rates).
I find that the more competition a hospital faces, the lower its prices are. This is reasonable since a hospital that dominates a geographic area would likely be able to set prices. However, this negative correlation is probably largely due to the medium size hospitals. I do not think it applies to the large teaching hospitals in Boston, since they are mostly fully occupied because of trimming of excess beds in the last twenty years, so they do not need to compete with each other for patients.
My models explain 56% of the variation in prices. The testimony from the hospital and commercial insurance executives at the March 2010 DHCFP Hearing would suggest that much of the remaining variation in prices is due to bargaining that goes on in contract negotiations each year. Jack Dutzer, President and CEO of Fallon Clinic, stated in oral testimony to the Attorney General's Office, "We believe both that [Fallon Clinic is] fundamentally more efficient than most of the healthcare systems around us and that we have much, much more to do in order to become even more efficient. The opaque nature of the relationship between payers and providers, however, keeps us from knowing just how efficient we are and to what degree we may be part of the problem." Such behind the scenes negotiations are not measured econometrically.
Policy proposals
The Attorney General Report claims that leverage theory is the only theory that causes the demand curve to be inelastic. One must be cautious, however, in deciding which policies to pursue from the results of the AGO investigation. Antitrust laws against collusion will have less effect if market competition is not the only factor affecting price, as I have shown in my thesis. Heavy regulation of market leverage will not work if there are many other variables affecting the elasticity of the demand curve. Policies aimed to curb market dominance (like in the case of MGH) to make the demand curve more elastic, and thus lower price, may be a waste of resources if reputation, teaching status, and high quality of care will keep the demand curve very inelastic regardless.
I discuss some policies that could be pursued. Insurers in Massachusetts have traditionally offered wide-open networks, meaning members can use the hospital or provider of their choice. But as health care costs have continued to increase at 7.5% a year, "tiered" and "limited" networks have been promoted as an immediate way to control costs. Massachusetts insurers report brisk business in plans that offer lower premiums in exchange for limits on use of popular but expensive hospitals or practices. However, executives at Partners, one of the high cost providers targeted, warned that when people became seriously ill and found that they would have to pay more to go to their first choice hospital, they would be angry at their insurers. They also warned that their hospitals might not be able to continue to use their profit margins to subsidize unprofitable services such as rehabilitation and mental health.
Another initiative that the Commonwealth is promoting is the Patient-Centered Medical Home. This is focused on better treatment and follow-up of chronic medical conditions, such as congestive heart failure and diabetes, and emphasizes patient-centered care delivered by teams of primary care providers, including physicians and nurses, to coordinate health needs, visits to specialists, hospital admissions, and reminders for checkups and tests. But it should be noted that there is as yet no hard data that demonstrate that hospital costs for treatment of a group of PCMHI patients would be lowered compared to a comparable group of patients given their usual care. [11]
The Commonwealth could also examine the type and number of services provided in each hospital. In this thesis, I showed in my final model that a selected group of expensive, high technology services correlated with hospital price disparities. If hospitals could avoid unnecessary duplication of these and similar expensive services, they might be able to bring down overall costs.
My model shows that the percent of patients on Medicare and Medicaid correlates negatively with price. Hospitals claim that Medicare and Medicaid are underpaying the actual costs of taking care of their patients. This gives a strong incentive for the financially strong hospitals to develop services aimed at younger, employed, commercially insured patients, since their insurers will pay at a higher rate. [12] As a consequence, the financially strong hospitals receive higher payment levels, and become even stronger financially than those hospitals that have a large percentage of Medicare/Medicaid patients. The simple solution to this driver of price disparities would be for the federal and state governments to increase reimbursement for Medicare and Medicaid patients to the relatively generous levels of twenty years ago, but this solution is impossible with current federal and state budget deficits.
The AGO should continue to annually publicize rankings of provider prices for similar services. The bad publicity gives higher-cost providers an incentive to lower their prices. Children's Hospital, which is at the top of costly providers, announced at the end of last year after the AGO report that they were lowering their prices for selected surgical services by 20% and prices for radiology services by 17%. They are also sending their specialists to several community hospitals to deliver care in more convenient and lower cost settings.
The AGO should investigate and prohibit insurer/provider contract provisions that perpetuate market disparities, such as payment parity provisions, which lock in payment levels and reduce providers' incentive to offer lower prices to insurers, product participation provisions, which limit the ability of insurers to offer new products, supplemental payments, which are separately negotiated and contribute to the lack of transparency in payment rates, and growth caps, which prevent smaller providers from expanding to compete with the larger providers. [13]
I have found that market leverage is not the only determining factor of price differentials among hospitals in Massachusetts. It appears that differences in prices are in fact value based. In other words, higher prices are explained by something that consumers or society value, such as better quality, increased complexity of services provided, reputation of the hospital, and training new doctors. But controlling market leverage should not be completely disregarded from a policy standpoint. Dutzer of Fallon Community Health Plan adds in his oral testimony at the DHCFP hearing, "Continuing an imbalance of reimbursement for intangible values of reputation and/or market dominance will hurt our efforts to bring affordability and stability into the nation-leading efforts of our state to provide quality and access to all residents of the Commonwealth."
Finally, I acknowledge that all empirical studies have some variability that is not explained by the model. No model can capture all the idiosyncratic factors that affect each hospital's costs and rate negotiation process. I should also note that an econometric model does not prove causality, only that dependent and independent variables are correlated. In addition, the factors affecting hospital costs are constantly changing as the payer environment changes.
I thank David Cutler of the Harvard Department of Economics for his guidance, insight and encouragement in this research. I also thank Stan Veuger of the Department of Economics, Thomas Glynn of the Harvard Kennedy School, and Jean Roth of the National Bureau of Economic Research.
Attorney General Office's (AGO) Report for Annual Public Hearing on March 16, 2010, Examination of Health Care Cost Trends and Cost Drivers.
Berenson, R.A., P. B. Ginsburg, P.B., Kemper, N. Unchecked provider clout in California foreshadows challenges to Health Reform. Health Affairs 29: 4699-4705 (2010)
Boston Globe Spotlight Team. A healthcare system badly out of balance: the Partners effect. Boston Globe, November 16, 2008.
Commonwealth of Massachusetts DHCFP website: Health Care Cost Trends March 16, 2010 Hearing. Written Testimony from Witnesses. www.mass.gov/dhcfp/costtrends/written testimony
Cutler, D. and Sheiner, L. The Geography of Medicare, American Economic Review, 89:228-233 (1999)
DHCFP Factsheet February 2010, www.mass.gov/dhcfp/costtrends
DHCFP website: Patient-Centered Medical Home Initiative, www.mass.gov/dhcfp/pcmhi
Dranove, D.and White, W. D. Recent theory and evidence on competition in hospital markets. J. Economics and Management Strategy 3:169-209 (1994).
Dreyer, P. Analysis of the Attorney General's Report Titled "Examination of Health Care Cost Trends and Cost Drivers"
Graduate Medical Education Directory 2010-2011, American Medical Association, 2010
Gresenz, C.R., Rogowski, J., Escarce, J. J. Updated variable-radius measures of hospital competition. Health Services Research 39:417-430 (2004)
Guerin-Calvert, M. E., and Israilevich, G. A Critique of Recent Publications on Provider Market Power. October 4, 2010
Horwitz, J., Nichols, A. What do nonprofits maximize? Nonprofit hospital service provision and market ownership mix. National Bureau of Economic Research, Working paper No. 13246 (2007)
Kowalczyk, L. Partners HealthCare rebuts AG findings on cost. Boston Globe, June 17, 2010.
Sager, A., and Soloway, D. Written Expert Testimony at the DHCFP March 16, 2010 Hearing. www.mass.gov/dhcfp/costtrends/written testimony
- [1] DHCFP Factsheet 2010. ↩
- [2] From a 2010 Partners Healthcare presentation given in response to the AGO Report. ↩
- [3] See appendix for complete list of 66 hospitals included in this study. N = 198 since there are three insurers. ↩
- [4] For example, Mass General and Brigham and Women's Hospital are both members of Partners HealthCare. ↩
- [5] See section on specification tests. ↩
- [6] The DHCFP defines teaching hospitals using the Medicare Payment Advisory Commission's definition of major teaching hospital as having "At least 25 full-time equivalent medical school residents per one hundred inpatient beds." ↩
- [7] From the Graduate Medical Education Directory, 2010-2011. ↩
- [8] See: http://my.mass.gov/?pageID=eohhs2subtopic&L=6&L0=Home&L1=Researcher&L2=Physical+Health+and+Treatment&L3=Health+Care+Delivery+System&L4=DHCFP+Data+Resources&L5=Hospital+Summary+Utilization+Data&sid=Eeohhs2 ↩
- [9] See specification tests section. ↩
- [10] See DHCFP data. ↩
- [11] Reference: DHCFP website on Patient-Centered Medical Home Initiative. ↩
- [12] Alan Sager and D. Soloway, Written Expert Testimony at the DHCFP March 2010 Hearing. ↩
- [13] Testimonies of BCBS, HPHP, THP at the March 2010 DHCFP Hearing. ↩


text:
Jihad on Earth and ill-will toward Kuffars
The Christmas message of 'Peace on Earth and goodwill to all' is diametrically opposed to everything that Islam stands for, which is 'Jihad on earth until unbelievers are exterminated or converted, then more jihad to exterminate the wrong kind of Muslims' .
So it's no wonder that Islamists hate Christmas. Sometimes they attempt physical attacks in order to turn a time of celebration into a time of disaster, but more generally they work by infiltration and subversion to gradually remove Christmas from the public sphere (scroll down to 'Downgrading Christmas' for discussion of this aspect of cultural jihad).
Examples of Christmas bombing attacks are...
Muslims' failed Strasbourg Christmas Market attack 2000
Ten Islamic militants narrowly failed plot to blow up a Christmas market in Strasbourg in December 2000. The German court said the group had planned to blow up pressure cookers packed with explosives, a technique they allegedly learned in Afghan camps.
The target was the popular Strasbourg Christmas market set up around the city's cathedral, which was shown in a video with a voiceover by one of the four saying that the passers-by were the "enemies of God" and would burn in hell. Last month, Mr Tessier said the bombing "was avoided by a hair". http://news.bbc.co.uk/1/hi/4102023.stm
Muslim attempts to blow airliner over Detroit on Christmas Day
On Christmas Day 2009, Umar Farouk Abdulmutallab, a former UCL student, tried to detonate plastic explosives hidden in his underwear and kill the 278 passengers and crew on Northwest Airlines' flight from Amsterdam to Detroit. http://www.jihadwatch.org/2010/10/after-christmas-jihad-bomb-attempt-uk-academics-ignore-deny-minimize-problem-of-jihadist-activity-am.html
German intel showed al-Qaeda operatives en route to country, Christmas markets a possible target
Such an attack would cause economic damage, with the additional symbolic impact of attacking an event related to a non-Muslim religious celebration. http://www.jihadwatch.org/2010/11/german-intel-showed-al-qaeda-operatives-en-route-to-country-christmas-markets-a-possible-target.html
Christmas tree bomber wanted to kill children.
Beslan showed us that Islamists delight in killing kafir children, and Christmas provides an ideal opportunity to do it. 'Mohamed Osman Mohamud, 19, attempted to detonate what he believed was an explosives-laden van at an annual Christmas tree lighting ceremony in Portland, Oregon. However, undercover FBI agents had been monitoring his plans and had ensured that the "bomb" was a dud. FBI operatives apparently cautioned Mohamud several times about the seriousness of this plan, noting that there would be many children at the event. But Mohamud responded that he was looking for a "huge mass that will ... be attacked in their own element with their families celebrating the holidays," the court documents said. http://www.telegraph.co.uk/news/worldnews/africaandindianocean/somalia/8164440/Somali-teenager-tried-to-set-off-car-bomb-in-US.html
Muslim tried to cause mass carnage among Swedish Christmas shoppers.
The wife of a suicide bomber has been arrested on suspicion of helping her husband bring terror to the streets of Sweden in the run-up to Christmas last year.
Read more: http://www.dailymail.co.uk/news/article-2037568/Widow-suicide-bomber-arrested-terror-squad-suspicion-helping-husband-plan-attack-Christmas-shoppers.html
It Just Isn't Christmas without a Muslim Bombing
...If gift wrapping and church going are Christmas traditions, carrying out massacres during other people's holiday celebrations is a Muslim tradition. In Israel, holidays are a time for extra special caution. The Passover massacre in which dozens of senior citizens attending a holiday meal were murdered, the Yom Kippur War in which Muslim armies invaded Israel on the holiest day of its year or the Purim bombing outside a Tel Aviv mall using a nail bomb, are just some of the obvious examples of Muslim religious tolerance at work.
It's not limited to Jews or Christians either. In 2008, a number of bombs went off in Delhi just before Diwali. And back in 1991, Muslims planned to massacre thousands of Hindus during Diwali. Had they succeeded, the death toll might have been bigger than 9/11. Nearly two decades ago, North America was put on alert that importing Muslim immigrants, also meant bringing along their genocidal tendencies. Like renting rooms to tenants whose dogs have a little rabies problem, importing Islam, also means bringing in the same people who have been murdering Christians, Jews, Hindus and countless others around the world, ever since Mohamed's namesake first preached that he had a unique revelation and an exclusive license to kill, rob, rape and subjugate in the name of Allah.
While the news stories will insist that Mohamed Osman Mohamud (twice the Mohammed for twice the mayhem) was "lured" into a life of terror, he was just doing what Muslims since the time of Mohammed have naturally done. "O you who believe! fight those of the unbelievers who are near to you", the Koran proclaims to the devout Muslim. For Mohamedx2, the "unbelievers" were grouping together at a Christmas tree-lighting ceremony in downtown Portland. And his goal was simple enough, "I want whoever is attending that event to leave, to leave dead or injured."
While we may go on denying it, for Muslims this is a religious war. And what better target for terror, than an infidel's religious event?
The clergy at interfaith conferences may yammer on about how we're all the children of god, but Muslims know better. They are the slaves of Allah and we are heretics and idol worshipers. It's their duty to fight us, until we submit and accept Muslim rule. The more we resist, the more they're obligated to kill us until we give in and there's a mosque on every corner and the Koran replaces the Constitution. It's a religious duty for a Muslim to make the Way of Allah triumphant all across the globe. To Muslims, this is a sacred duty and a way of life, that is not a detail, but the heart of the Koran....
Read the rest at http://sultanknish.blogspot.com/2010/11/it-just-isnt-christmas-without-muslim.html
Anti-terror squad arrest 12 men 'planning UK terror attack'
Christmas plot at advanced stage, say police. Twelve men were arrested early this morning in a major national counter-terrorism operation, police said today.
The men - five from Cardiff, four from Stoke-on-Trent and three from London - were detained on suspicion of the commission, preparation or instigation of an act of terrorism in the UK.
Read more: http://www.dailymail.co.uk/news/article-1340117/Police-arrest-12-people-plotting-terror-attack.html
WASHINGTON -- An Islamic extremist has threatened in an audiotaped message to set off bombs in countries celebrating Christmas.
"Your [Christmas] fireworks will act as an alarm for the time of our devices to blow up -- devices that we, not Santa Claus, are going to offer to you as gifts, to turn your night into day and your blood into rivers," said a member of the Shumukh al-Islam forum.
Hours later, a bomb blast wounded six people today during Christmas Mass at a church in the Philippines.
And in northern Nigeria last night, Islamist sect members launched a failed attack on a church during Christmas Eve services.
Downgrading Christmas
Apart from these violent attacks, Muslim infiltrators and subversives throughout the West are trying to downgrade and secularise Christmas, removing all its Christian associations to turn it into a politically correct 'Winterval'.
The motivations for this relentless campaign against Christmas are three-fold:
(1) Supremacism: to remove a Christian festival from its officially recognised place in the calendar.
(2) Protection of Muslim children from Christian influence.
(3) The Scrooge syndrome: resentment of kuffars having a good time.
How often have we seen Muslims carrying banners saying 'Islam will dominate'? This is one of their favorite slogans.
Muslims believe that Islam should be dominant and supreme over all other religions. So it enrages them to see a Christian festival having pride of place in the lands they are conquering. However, if they can't abolish Christmas they can secularise it, and strip it of its Christian associations, starting by taking the 'Christ' out of Christmas to give 'Winterval'.
Winterval is the officially recognised term in British local authorities in Muslim dominated areas, eg Birmingham:
UK: shopping center Santa banned — in case he offends non-Christians
"BOSSES have banned Santa from a shopping centre - in case he offends non-Christians.
The Scrooges struck at Birmingham's famous Bullring. A spokeswoman said: "We wish to be sensitive to people of other religions over the festive period. There are a lot of people in the region who are not Christians and do not celebrate Christmas." http://www.jihadwatch.org/2004/11/uk-shopping-center-santa-banned-in-case-he-offends-non-christians.html
The Wintervalisation of Christmas is very similar to their implacable drive to dominate public space in the lands of the kuffar: http://crombouke.blogspot.com/2010/01/muslim-domination-of-public-space.html
2. Protection of Muslim children from Christian influence.
Christmas is a magical time for children, and Islam has nothing to compare with it. There are no seasonal festivals in Islam because the Islamic year is innaccurate (a few days short of the full 365 - Allah was useless at mathematics), consequently their festivals such as Eid gradually wander through the calendar from month to month and season to season.
Also, the baby Jesus is a far more attractive personality for children than the filthy old pedophile Mohammed, and the Christmas story - with its animals, star and wise men - is much more appropriate to those of tender years than the Muslim stories of Mohammed's antics with six year old Aisha.
"During the Christmas season, Christians all over the country illuminate their houses with lights, put up Christmas trees, and exchange gifts. TV is full of jingle bells and all the stores are decorated for Christmas. All this is very tempting to small children; children love putting up lights and decorating for holidays... http://www.islamonline.net/servlet/Satellite?pagename=IslamOnline-English-Ask_Scholar/FatwaE/FatwaE&cid=1119503543368
So it's no wonder that Muslim clerics rage against the 'Westoxication' of the younger generation by Christmas. Muslims are in any case forbidden celebrate any kuffar festival.
"O Muslims!
Celebrating the holidays and the occasions of the Kuffar is certainly Haram. You are not permitted to do it. Nor are your rulers allowed to make these (Kufr) holidays as official holidays, since it is an imitation of the Kuffar.
Imitating the Kuffar in any of their religious affairs or in any gesture that distinguishes them as groups is forbidden. Al-Bukhari narrated in his Sahih (book) that Abu Saeed Al-Khudri reported that Allah's Messenger said: "You will indeed follow the ways of those before you, hand span by hand span, and an arms length after another. Even if they enter into a lizards hole, you will follow them. We asked, is it the Jews and the Christians? He replied, Who else!"
This hadith condemns imitating them. It is a proof for the prohibitions of imitating the Jews and the Christians in their occasions, symbols, or any matter related to their belief.
Celebrating the holidays of the kuffar is an act of imitation which is forbidden in Islam. Allah's Messenger warned us against it. At-Tirmidhi narrated that Ibn Abbas reported that the Prophet said: "He is not one of us who imitates other than us. Do not imitate the Jews or the Christians." http://www.khilafah.com/index.php/concepts/islamic-culture/4557-celebrating-the-holidays-of-the-kuffar-is-haram
Muslim lawyer brands Christmas 'evil'
Muslim preacher Anjem Choudary has branded Christmas "evil" in a sermon posted on the internet. The lawyer, who recently praised the Mumbai terror attacks, urged all Muslims to reject traditional Christmas celebrations, claiming that they are forbidden by Allah.
"Decorating the house, purchasing Christmas trees or having Christmas turkey meals are completely prohibited by Allah. Many still practise this corrupt celebration as a remembrance of the birth of Jesus.
"How can a Muslim possibly approve or participate in such a practice that bases itself on the notion Allah has an offspring? (Like his three daughters?)
The very concept of Christmas contradicts and conflicts with the foundation of Islam.
"Every Muslim has a responsibility to protect his family from the misguidance of Christmas, because its observance will lead to hellfire." http://www.telegraph.co.uk/news/uknews/3699565/Muslim-lawyer-Anjem-Choudary-brands-Christmas-evil.html
Nativity plays are politically incorrect
Many schools in Britain are now banning the traditional nativity play as part of the process of creeping Islamisation: http://www.dailymail.co.uk/news/article-1091594/Primary-school-cancels-nativity-play-interferes-Muslim-festival-Eid.html
Santa Claus banned due to complaints from Muslims:
Santa Claus, as portrayed by Dennis Jackson, won't be visiting students at the Head Start classes in St. Peter this year.
Jackson has made appearances the past four years at the classes for students who need help preparing for school, but this year officials said, "No, no, no."
The reason: The classes have many immigrant children who don't celebrate Christmas, says the Mankato Free Press.
Santa's a little frosted, the paper says.
It kind of burnt me up," he said.
The official explanation from Chris Marben, who coordinates regional Head Start programs through Mankato-based Minnesota Valley Action Council: "We have Somali families in the program. We're respecting the wishes of families in the program."
She didn't say how many objections were made, but said more than one would be enough to cancel Santa.
"The simple truth is that southern Minnesota has become a much more culturally diverse society than it was a few decades ago," she told the paper. "Part of our challenge in Head Start is providing an environment where young children from many different cultures can all feel comfortable."...
Muslim teacher in carol concert tirade is made Ofsted inspector
A hardline Muslim teacher who caused a furore by denouncing pupils for celebrating Christmas has been made a Government schools inspector.
Israr Khan's Ofsted appointment was described by a former colleague as 'absolutely astonishing'.
Mr Khan, now headmaster of an Islamic school, launched into his tirade during a concert rehearsal at Washwood Heath Secondary School in Birmingham in 1996 after the choir including around 40 Muslim youngsters, had sung a number of popular Christmas songs, including carols.
He leapt from his seat, yelling: "Who is your God? Why are you saying Jesus and Jesus Christ? God is not your God - it is Allah."
As children in the audience began booing and clapping, a number of choir members - both white and Asian - walked out, some in tears.
Mr Khan, a maths teacher, was asked to work from home pending an investigation but there was no disciplinary action.
It has been claimed that Washwood Heath school was then a 'hotbed of Islamic fundamentalism'. Rashid Rauf - the airline terror bomb suspect whose extradition is currently being sought from Pakistan - was a pupil there at that time.
Mr Khan left Washwood Heath a year later to found the independent Islamic Hamd House Preparatory School in Small Heath, Birmingham, where he is headmaster.
Earlier this year, he was appointed as a governor of Anderton Park Primary School, in Sparkbrook, Birmingham.
A former Washwood Heath colleague laughed openly when told of Mr Khan's role as an Ofsted inspector where he has the responsibility for passing or failing schools.
He said: "Given the man's history, it's absolutely astonishing. It's just the cheek of the man that he's been able to reach that position. He always was an extremely clever man.
"He gave me many insights into the Islamic cause and their hatred of the US and the Western World. He had a big support base among some of the Muslim parents.
"But there were some very influential, radical elements at Washwood Heath at that time and Israr Khan was very close to all that."
Earlier this year, Anderton Park, where 99.5 per cent of the pupils are Asian, received a dismal Ofsted report which branded its teaching and its achievements as inadequate.
One Muslim father, who asked to be known only as Mohammed, said: "As a governor, Mr Khan will be able to exert a great deal of influence over the school and its policies.
"By his previous actions, he seems to represent what I would call a hardcore attitude to Islam."
Mr Khan declined to comment about his appointment, waving questions away at his large home in Moseley, Birmingham.
An Ofsted spokesman said: "Israr Khan was appointed as an additional inspector via a highly competitive recruitment and selection process. He has undergone all the relevant security checks."
3. Resentments against kuffars enjoying themselves.
The Ayatollah Khomeini made Scrooge look the Party Animal of the Year: "Allah did not create man so that he could have fun. The aim of creation was for mankind to be put to the test through hardship and prayer. An Islamic regime must be serious in every field. There are no jokes in Islam. There is no humor in Islam. There is no fun in Islam. There can be no fun and joy in whatever is serious." -- Ayatollah Khomeini http://www.jihadwatch.org/2006/12/islam-pun-ad-canned.html
Fanatics from a banned Islamic hate group have launched a nationwide poster campaign denouncing Christmas as evil.
Organisers plan to put up thousands of placards around the UK claiming the season of goodwill is responsible for rape, teenage pregnancies, abortion, promiscuity, crime and paedophilia.
They hope the campaign will help 'destroy Christmas' in this country and lead to Britons converting to Islam instead.
The placards, which have already appeared in parts of London, feature an apparently festive scene with an image of the Star of Bethlehem over a Christmas tree.
But under a banner announcing 'the evils of Christmas' it features a message mocking the song the 12 Days of Christmas.
It reads: 'On the first day of Christmas my true love gave to me an STD (sexually transmitted disease).
'On the second day debt, on the third rape, the fourth teenage pregnancies and then there was abortion.'
According to the posters, Christmas is also to responsible for paganism, domestic violence, homelessness, vandalism, alcohol and drugs.
Another offence of Christmas, it proclaims, is 'claiming God has a son'.
The bottom of the poster declares: 'In Islam we are protected from all of these evils. We have marriage, family, honour, dignity, security, rights for man, woman and child.'
The campaign's organiser is 27-year-old Abu Rumaysah, who once called for Sharia Law in Britain at a press conference held by hate preacher leader Anjem Choudary, the leader of militant group Islam4UK.
Former Home Secretary Alan Johnson banned Islam4UK group earlier this year, making it a criminal offence to be a member, after it threatened to protest at Wootton Bassett, the town where Britain honours its war dead.
Mr Rumaysah told the Mail that he was unconcerned about offending Christians.
He said: 'Christmas is a lie and as Muslims it is our duty to attack it.
'But our main attack is on the fruits of Christmas, things like alcohol abuse and promiscuity that increase during Christmas and all the other evils these lead to such as abortion, domestic violence and crime.
'We hope that out campaign will make people realise that Islam is the only way to avoid this and convert.'
Mr Rumaysah, who said his campaign was not linked to any group, boasted that the posters would be put up in cities around the country, including London, Birmingham and Cardiff.
Read more: http://www.dailymail.co.uk/news/article-1340794/Muslim-group-launches-poster-hate-campaign-festive-period.html
How miserable Muslims use Christmas Lights to teach their children to hate kuffars
"After you have fully explained to them the differences, and informed them in regard to the extreme Kufr that the decorations and lights are representing in pagan religions and in Christianity, ask them what they think of the lights and decorations now. Most likely, their response will be dramatically changed!
The distinction between a hasty incomplete answer and one with a full explanation is that you are not leaving room for lingering curiosity and also are not undermining their intelligence or opinion. By respecting their intelligence and opinion you are opening their minds to listen.
With an honest, straightforward explanation, you will, Insha Allaah, be able to take all the sparkle out of the lights, and instead, turn on the light of knowledge in their mind."
Interfaith harmony through carols
So perhaps we should modify our Christmas celebrations to appease miserable Muslims. Here's a list of Christmas carols which could be rewritten to be more acceptable to the Religion of Peace:
Bang Bang Verily You Die
Bombing in a Winter Wasteland
Death to the World
Do They Know It's Jihad?
Frosty the Boobytrap
Hijacked Three Ships
I'm Dreaming of a Shi'ite Christmas
I Stoned Mommy for Kissing Santa Claus
Jingle Belts
Little Bomber Boy
No-go Town of Bethlehem
Oh Come all ye Fanatical
Oh TannenBOOM
Repulsive Jews Below
Slay Ride
While Shepherds Screwed Their Flocks
Wreck the Halls
...and of course, that all time favorite, Violent Night...

subset: commoncrawl


text:
The stock market can be an exciting yet scary place for investors who are just starting out. Individual investors who decide to manage their own portfolios may need to hit the books and be ready to take a comprehensive approach. There is no lack of information about investing in the stock market, but figuring out where to start can be difficult. Setting up goals and defining the investment plan can help start the investor down the right path. As many seasoned investors know, there can be times when nothing seems to be going right. Keeping a clear head and focusing on the relevant information can help the investor stay steady when the going gets tough.
Shares of Shell Midstream Partners, L.P. (NYSE:SHLX) ended last session at 21.13. Following today's trade, we note that the stock has moved 0.04876963% since the opening bell. The company has a current market cap of 4706762000. The stock's high price over the last month is presently 21.8576.
Following the Chaikin Money Flow indicator, we note that the current 20 day value is 0.03765056 for Shell Midstream Partners, L.P. (NYSE:SHLX). Traders will watch to see if the indicator can help confirm an ongoing trend. In the midst of a bullish trend, the CMF value staying above zero may point to continuous buying pressure and the possibility of a sustained rise in price. In the midst of a bearish trend, the CMF value staying below zero may show continuous selling pressure and the possibility of continued price decline.
Scanning the equity market, we note that the stock's current Oscillator Rating is showing "Buy". Traders will take note of many different factors when examining a stock's health. Flipping over to the Moving Average Rating, we see that the current sentiment is pointing to a "Buy".
Watching volatility readings, we can see the current value for the stock is 1.42925202. Volatility for the week stands at 3.09716928, and the monthly reading is 2.49336666. Volatility involves the amount of risk in relation to the amount of change in a stock's value.
The 20 day Keltner Channels upper envelope is 21.52551568. The 20 day Keltner Channels lower envelope is 20.75777655. The Keltner Channels indicator was introduced by Chester Keltner in his book How to Make Money in Commodities. Keltner's ideas have since been expanded upon and are widely used by technical traders.
Donchian Channels may be useful for technical traders. The primary function of the indicator is to measure volatility. The bands will widen when volatility is high, and they will become narrow with low volatility. The 20 day upper band level is 21.8576. For the same period, the lower band level is 20.62.
Trading on volume of 95511, Shell Midstream Partners, L.P. (NYSE:SHLX) has seen a change from the open of 0.025 since the stock opened at 21.105. Monitoring today's activity, the stock has hit a high point of 21.23 and slipped to a low of 21.035.
Checking in on the Awesome Oscillator, we see that the reading is 0.11596029. Traders may follow this oscillator to measure market momentum. Created by Bill Williams, the Awesome Oscillator calculates the difference of the 5 period and 34 period SMA.
One of the most important factors that investors look at when examining stocks is the consistency of earnings results. When the quarterly earnings report is released, investors watch closely to see if the company is performing up to expectations. A company that fails to meet projections may see large price swings following the report. Of course one bad quarter may not signal trouble, but a company that continually disappoints during earnings season may need to be further examined to help figure out what is going on. Experienced investors will closely watch stock price movements before and after earnings events in order to gain a truer understanding of how the market is reacting to the reports.


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What are the essentials details of your wedding? Do you know what our role is in your special day? We wear many hats actually. We not only provide your guests with great food but will also manage everything from start to finish on the day of your wedding. Our crew of wonderful and experienced serving staff that will take care of you and your guests, manage the set-up and clean-up of your event, and work to keep your timeline on track. So we'll need to know the details of how you want your day to be managed.
Fill out the form below and send it to us or bring it with you to your consultation appointment. It not only will help us understand your plans but also will prompt you to think about the details as well.


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B-Side EP Release Party
Posted on August 11, 2015
When: 08/19/2015| 6-10pm
Where: Revolution Hall Rooftop, 1300 SE Stark, Portland
Hopworks Urban Brewery and New Belgium Brewing are releasing our second collaboration ale on Wed. Aug. 19 at Revolution Hall. The beer, Organic B-Side EP, is a kettle soured peach ale brewed in honor of our shared certifications as B Corporations.
Join us to try the limited B-Side EP for the first time while enjoying sweeping views of downtown Portland from the rooftop of Revolution Hall. The beer has a light tartness and hints of stone fruit while remaining bright and crisp. We'll also serve our first collaboration, B-Side Peach IPA, and a number of our other beers.
The party is open to the public. Light catering is provided by Elephants Catering and in honor of the B Corp themed party, B Corporations across Portland will showcase products. Finally, members of HUB and New Belgium's team will be on hand to chat about beer, B Corps, bikes, or anything else that starts with B.


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Cute Pun Illustrations Of Everyday Objects By Heng Swee Lim
Community member
These cheerful and punny illustrations by Lim Heng Swee (a.k.a. ilovedoodle) will brighten your Monday. In his art, everyday objects become cheerful little characters that make playful puns and observations about everyday life and staying positive.
This prolific artist has spent the last 5 years creating a new cute illustration almost every day, and people have taken notice – he has thousands of followers, a successful Etsy shop, and big brands like Nike, Gap and Threadless have all used his designs! Read on for his answers to Bored Panda's questions about his work.
More info: ilovedoodle.com | Etsy | Behance | Tumblr | Facebook (h/t: dt, demilked)
"Ideas won't just pop out easily! As a freelance illustrator, I have to be very disciplines and do a lot of homework," Heng Swee Lim told Bored Panda.
"My normal practice is going through a lot of data (pictures, article, news, songs, movies, etc.) which most likely would spark your creativity, taking notes on every possible object, quote and situation"
"I love to challenge myself and not limit myself to only 1 style. I think different ideas/stories need different styles of illustration to deliver the message"
"I love all of my works but, if have to choose, I will slightly lean to the simple style. A lot of time, when an artwork develops from a simple sketch to a complicated colourful illustration, I don't always feel right with it and at the end always found that the simple first doodles/sketches are the best"
Thank you, Heng Swee Lim, for talking to Bored Panda about your work!
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19 November 2005 11:00
http://validator.w3.org/feed/docs/apiby KoshigoeBushou & 1 other
W3Cのウェブサービス版Feed Validator
1 (1 marks)
Founded in late 2003 and heartquartered in France, we are non-profit and independant.
We believe in the open web, think internet services should be sustainable, build for the long term.
While we are re-launching the service, we only accept new members through invitation.
last mark : 19/11/2005 11:12


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Matt Hawkins and Linda Sejic build up "Wildfire" #1 by taking nothing more than a controversial topic from today's headlines and extrapolate it down one possible (if extreme) outcome, and in doing so also build up a fascinating and frightening story. Genetically modified organisms are seen by some as a path to saving the world and by others as a means that will destroy, so Hawkins succinctly summarizes this debate with a couple of real-life quotes on the first page, and then turns his fictional characters loose to further explore it.
On one side is scientist Beth Silva, who is researching and developing GMOs with funding by a large corporation known as Biogenesis. On the other is activist Gerald Lerner, who actively campaigns against GMOs. This is simply and beautifully set up in the form of a television interview by reporter Michelle Crawford where the two sides are identified and their beliefs defined, making things immediately clear to readers. The only scene prefacing the main story is a brief but ominous and apocalyptic double page spread whose meaning can be pieced together upon reading the rest of the issue.
This fictional debate not only shows each side's position and situation, but also serves as a catalyst that actually furthers the story, rather than being inserted as just an expository sequence. The GMO controversy is the main topical issue that's examined, but Hawkins also brings in other current topics like government oversight and media manipulation, and the name Biogenesis, while in its impersonal context means the development of new living organisms, evokes the recent Major League Baseball scandal involving Biogenesis of America. It's a fascinating discussion because of its close-to-home nature, and because both opposing opinions are well-developed and analyzed in the course of the discussion.
Hawkins appears to side with the anti-GMO camp, as Silva gathers her team and prepares a media demonstration of their research that hides its failures that remain unknown to the public. That's not to say he puts the protestors in a totally sympathetic light, though; their actions in fact may very likely have caused the exact cataclysmic situation that they've been trying to prevent. There are no big explosions, no fight scenes, no military strikes, and no big sci-fi hocus pocus; it's instead about ideology, and the everyday world of backroom meetings and skewed public disclosures that make the story's understated turning point no less tense or suspenseful.
Sejic keeps the story firmly grounded in reality, as well; save for the opening spread, there's really nothing that in the story that needs to be drawn larger than life, so she doesn't try. Instead, she competently conveys Hawkins' story, with little distraction or pizzazz. The foregrounds are delineated clearly, while the backgrounds are often blurred, which adds a sense of depth to the art that makes the everyday environment of this story seem all the more lifelike.
The story slows a bit when Hawkins steps away to focus on the assistant of Silva's daughter and his younger teenage sister, which has no seeming relevance to the rest of the story, at least what's presented this issue. Overall, though, "Wildfire" #1 makes an engaging statement on current events, and doesn't really have to reach all that far to explore a seemingly possible and legitimately disturbing consequence.


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Planning Ahead With #WalmartBaby
This post is sponsored by Walmart, in collaboration with The Motherhood. Although I received compensation for sharing this information, all thoughts are my own.
We're six months into our third pregnancy and we can't wait to welcome our baby to her new home. It hasn't been the easiest journey this time around, but well worth it.
One of the many perks is that we're closer to the hospital than we were with our second delivery — so convenient, right?
Although our hospital bag has been packed since October, we're always thinking of new ways to better prepare ourselves for the big day.
Planning Ahead With #WalmartBaby
Since moving into our home, we've become avid Walmart shoppers. From everyday items to home decor, we've been making numerous trips to Walmart while converting our house into a home. It's down the street, so who wouldn't take advantage? 🙂
The baby section at our local Walmart is next to the fridge aisle, where we grab snacks for our boys. During our last visit to Walmart, we picked up Parent's Choice Size 1 Diapers and Parent's Choice Fragrance Free Baby Wipes to have on hand for when we arrive home from the hospital.
I was impressed with how inexpensive the Parent's Choice diapers are, and can't wait to try them with our little one. As for the wipes, we've been using them with our two-year-old as he prepares to potty train. He's always loved the feeling of being clean, and we even have them in our diaper bag in case of any emergencies. Parent's Choice Fragrance Free Baby Wipes are made with 100% plant-based material, are hypoallergenic and pH balanced. They're also ultra soft, gentle on skin and dermatologist tested.
With more than 275 products available, Parent's Choice has all the essentials for moms.
From bedding to diapers, wipes and more, Parent's Choice has been in American homes for nearly 20 years.
The brand offers affordable items parents will need for their child's first years of life, and are convenient because they:
– Work well;
– Help you save money; and
– Can be picked up at your local Walmart or shipped to your door for free.
For those of you who are expecting or know someone who is expecting, I highly recommend doing the following:
1. Start packing your hospital bag as soon as possible.
Pregnancy brain is real and the last thing you want to be is unprepared for the day you go into labor. I know some moms prefer to pack the day of, but it would be in your best interest to pack early. You don't want to have your family and friends running back and forth because you forgot something.
2. Carry change. Lots of it.
Hospital food has improved throughout the years, but it's rare that your delivery will include a meal beforehand. Most hospitals don't like to feed their patients until after labor. Your family and friends might want a treat while they wait, and the cafeteria might be closed. Vending machines are always running, so be sure to carry change with you.
3. Discuss your birth plans often with your family, friends, and doctor.
You just never know who might be in the room when you deliver, and thankfully my husband has been able to stand by my side throughout the birth of our sons. It's important that everyone is on the same page with how you'd like everything to go. I had to remind our last doctor three times that I wasn't going to have a C-Section and that I had a successful VBAC with our second child (and that's one of the reasons I wanted to switch doctors at 26 weeks).
Do you have any labor tips to share? Comment below.
Fatima Torres
Former B2B editor and marketing manager turned Family & Lifestyle blogger. Fatima is passionate about life and being social. When she isn't running around with her husband, three kids, and two pups, Fatima helps other bloggers and local businesses with their online marketing strategy. If you have any questions or would like to connect, feel free to reach out via email: firstname.lastname@example.com
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36 Comments
Bohemian Babushka
Congrats de Nuevo on baby #3. And it's a girl! Perfecto. Also Perfecto (and maybe tempting) is having a Wal-Mart so close. They really do have good variety and their house brand is as good as the more expensive brands. Best of luck with 3. May your Trio be a blessing like BB's were. BB2U
Fatima Torres
Thank you! It feels like it'll be a challenge, but I'll keep your lollipop trick handy (still remember that one!) when it does get a bit crazy. And yes, I didn't know Walmart had so much to offer.
so many great products available at Wal-Mart. Happy to see the smallest member and those that are yet to come are thought of as much as the rest. Thanks for sharing
Fatima Torres
Thank you! We're excited to welcome our newest member of the family. Planning ahead really does help.
These are all really spectacular tips! It is so important to ensure that we plan ahead for that big day.
Packing the bag is always important. Mine was packed way too early in hopes of the baby coming early.
Jessica Taylor
Whenever I was pregnant, Walmart was the only place I registered! They seriously have everything!
Fatima Torres
They really do have pretty much everything you need.
Everyday Made Fresh
Those are great tips. My youngest is 12, and the only tip I can think of is plans change…and it's ok!
Fatima Torres
Thank you, that's a great tip. I've learned that throughout the years no matter how much you plan, things happen. But planning ahead is better than not.
As I don't have a child and non is planned I cannot relate, however, this reminded me a lot of when I'm packing for a big trip like Interrail. Very smart!
Joan Cajic
Congratulations on six months and I can imagine the excitement. These are really great tips and I'm with you with the pregnancy brain, one can definitely end up forgetting some useful stuff.
Fatima Torres
Thank you, and yes, you just never know what can happen at the last minute. Always better to prepare in advance.
These are some great tips. I did have a bag packed before I had my kids just in case. My birth plan was easy. I was all, "Get me the epidural, stat."
Fatima Torres
Ha! Always smart to keep it simple.
Ana De-Jesus
Ah congrats on the pregnancy and it is great that you are closer to the hospital this time. I love how you have already packed your hospital bag and it is great that Walmart is helping you plan ahead. I wish I was as organized as you!
Corinne and Kirsty
I feel like I am so not ready for kids. I am the least organize person. Even reading this, I would not prepare. Even knowing, I'd be so chilled until the last minute ahah!
Fatima Torres
We were the least ready when we had our first. You'd be surprised how much life can change when you see a positive pregnancy test.
Sarah Bailey
I've not heard of Walmart Baby before but it sounds like a great way for parents to be to start making plans for the things they will need for their little ones.
I like that you ended your post with asking for any tips. A mommy of no matter how many kids is always open for tips! I did use that brand of diapers and other various store brand products. They were still of quality products.
I don't have any kids but this was a great post to have in mind for the future! It's very informative and definitely something i need for the future 🙂
-Kimberly Samantha
Marie Goldstein
Good luck with baby #3! Sounds like you are a pro!
Silvia Martinez (@mamalatina)
I had a doula and it was one of the best decisions ever. She was there the whole time and helped my husband and I navigate through the hospital and procedures. Congrats on your pregnancy!
Parent's Choice Size 1 Diapers and Parent's Choice Fragrance Free Baby Wipes seems like a nice choice for babies. I think I'll recommend this to my mommy friends.
Except for when my babies were brand new, I always used Parent's Choice diapers and wipes. They were affordable and worked great. It's been ten years since I had a baby. Glad to know that the same brand is still doing well!
Cindy Gordon
Wal Mart has some honestly great choices for babies. I love seeing what they have to offer.
These are all really awesome tips! It is so important to plan ahead for that big day.
I always shopped at Walmart when my girls were in diapers. I still shop there for many things for my whole family. It's one of our favorite places to shop.
Blair Villanueva
I dont have a baby yet, however the idea of having baby bag ready as possible is totally cool. At least we still have time to add many stuffs. When is your due date?
Ayesha Heart
Great tips to keep in mind, thank you so much. It'll be very useful for me soon 😀
Congrats on the baby girl on the way! Informative post as I dont have kids yet!
Fatima Torres
Yes, we did the same with our firstborn. We packed the same month we found out we were expecting, haha.
You make a great Mommy. I like the way you are always prepared, way ahead of time. I need to share these tips with my sis in law 🙂 Cheers!!
COngrats on your baby #3. I am so looking forward to having my own babies.
Planning ahead is so important and useful, babies are so expensive, so anything you can stock up and buy in advance helps.
Wildish Jess
I'm definitely the mom who packs last minute for the hospital bag. I packed way early with my first then a week or two before with my second.


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Movida has been a buzzing center point of Sydney's foodie attention of late. Having only recently opened it's doors, a typical booking would most likely promise failure on multiple attempts but like any good thing worth having, it takes a little time. 20 minutes on the phone in fact. Just waiting.
It's a comforting and casual area with wooden edges dominating the space and in the center of it all is the kitchen, open for the world to see behind windows.
The tapas there oddly aren't for sharing. Just as well. There are a few joys there that you might not want to share.
Their bread was just house baked that afternoon and a dollar (donated to the Sydney Children's Hospital Foundation) will see you possibly having multiple servings much the waitresses slight chagrin.
|Anchoa 4.5 each
|Bocata De Buey 8.5 each
|Ostra 4 each
|Cigarillo De Queso 5.5 each
The goat's curd cigar arrives highly recommended by our waitress, it's creamy light goat's curd center boosted by the rich tomato sauce that doesn't overwhelm the quince exterior.
|Calabacin 9 each
|Carrillera 24
|Cecina 19.5
|Patatas Bravas 14
|Conejo Agridulce 26.5
Our waitress for the night was affectionate, bubbly and warm and she just turned this into a magical evening although the general constant reminders to order the from 'A La Parilla' section as soon as possible can create some unnecessary tension. I wouldn't say it's cheap but it surely is better than the 50 or so one way ticket to Melbourne for the same food.
I can end with the whole Frank Camorra has taken over the Melbourne Spanish culinary scene and has always been the envy of Sydney-siders sort of line that usually typifies any conversation in the past involving the words 'Movida' or I can just say it's great food. I prefer to delve into the latter. It is evidently brilliant food. This isn't Spanish food as I've come to know it. It's taken on its head, flipped around, exposing and refining the ingredients into exciting forms. I can't help but be a fan.
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Now when you communicate with a renter, you can do so by replying to their message via email. You no longer have to log into the site to see their message and respond. You can handle it all through the ease of your email account.
Many of you have requested it and we understand the need for it – you want to be able to respond while on the road, using your phone and your primary means of communication, email. Well, now you can!
You will still have to log in to the site to search for renters and make your initial contact. Also, if you want to send them new listings after emailing back and forth, you'll have to log back into the site to do that.
However, once you've contacted them or if they've contacted you via one of your listings, you can respond and communicate by simply replying to the email that gets sent to you with their message.
In terms of pricing, nothing changes. If a renter contacts you anonymously and you decide to respond to them, you are charged a credit to communicate with them but nothing after that. Also, you'll still be charged a single credit to search and reach out to a renter.
Good luck!
The Naked Apartments Team


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I know it's been a little while since I've written anything here on the "blog" part of my website. Frankly, however, I was starting to get tired of having the Andrew Breitbart thing there at the top of the page, so I thought I'd bump it down some by posting about another dead asshole, the "painter" (in the same sense that Skrillex is a "musician") Thomas Kinkade, who died this weekend of "natural causes."
Again, I know it's often considered bad taste to say not-nice things about the recently departed, but seeing as how Mr. Kinkade's multi-million dollar empire was built upon a foundation of bad taste, in this case it seems rather fitting.
Reading Kinkade's Wikipedia page the other day, I came upon this quote that made my skin crawl:
There's been million-seller books and million-seller CDs. But there hasn't been, until now, million-seller art. We have found a way to bring to millions of people, an art that they can understand.
I'll admit I have a tendency to wax sanctimonious when it comes to this subject, but artistic integrity is something I happen to feel strongly about, so sue me. It should always, always be about the art first. I don't begrudge anyone for being financially successful as an artist; if people like what you create so much that they're willing to pay for it, more power to you. But when making money is your primary motivation, and you're more than willing to compromise whatever principles you may or may not have had to begin with in order to maximize your profit potential, then we have a problem. The above quote is wrong on so many levels I don't even know where to begin. First and foremost, Kinkade cavalierly admits that he's only in it to make dump truck loads of cash. Second, he acts as if he's somehow doing the world a favor by spreading his kitschy bullshit into every kitchen and bathroom in middle America. And last, but certainly not least, he backhandedly insults his audience (although I'm not saying he's necessarily wrong on this point) by suggesting that they're so backwards and provincial they need their art to be significantly dumbed down so they can comprehend it.
Obviously, I'm not saying Thomas Kinkade deserved to die just because his pictures suck. But let's be honest, did the world really need another pastel painting of a fucking lighthouse?


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Sunday, 27 March 2011
British Summer Time
The clocks have gone forward and it's finally British Summer Time. Bring on the birdsong, warm air, new flowers, smell of cut grass, picnics in the park, dinner in the garden and most of all the SUNSHINE and all the happieness and freckles it brings!
Sunday, 20 March 2011
Happy Spring Equinox
It was the Spring Equinox today, where the night and day are the exact same length, and from now on the days are only going to get longer and warmer. Bring on Summertime!
Papercut Commission in progress . . .
Friday, 4 March 2011
Flower Pressing
Now that plants and leaves and flowers are starting to grow and bloom, it's time to start Flower Pressing!
I have a brilliantly large flower press from FredAldous.co.uk. They do plain one's which you could decorate yourself as a present for someone, (Mother's Day maybe).
I realise I am a ridiculously slow 'blogger', but I have been working on a few projects, so watch this space...
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