text:
Health Care Reform Memo: January 7, 2013
Deloitte Center for Health Solutions publication
The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.
Download the Infographic.
My take: Five themes of health care in 2013
From Paul Keckley, Executive Director, Deloitte Center for Health Solutions
2013 will be the most important year in the U.S. health care industry in modern history thus far. Our nation's fiscal challenges and our industry's bulk are on a collision course. The story line about health care in 2013 will center on five themes: Clarity, Costs, Compliance, Consolidation, and Consumers.
Last summer, the Supreme Court upheld the Affordable Care Act (ACA). In November, the election affirmed it is here to stay albeit certain to change. This year, we'll know whether states expand their Medicaid programs or not, and how they'll navigate their health insurance exchange (HIX) requirements either with or without federal help.
We'll learn the success of the first wave of medical homes and accountable care organizations (ACOs) created by providers and plans to assume risk and share in savings; and we'll get guidance about essential health benefits (EHBs) in each state, how the U.S. Internal Revenue Service (IRS) will enforce the individual mandate, how actuarial values and guaranteed issue will be regulated, and how the federal government will implement its federal HIX hub. By May 1, we'll know how health costs fared last year and whether the Independent Payment Advisory Board (IPAB) is prompted to jumpstart spending constraints by the Chief Actuary. And October 1, 2013, we'll see how the states open their HIX enrollments and how employers assess their strategy to pay or play.
And all this while the 113th Congress readies itself for the next election cycle while tackling the sequestration cuts on or before February 28, the continuing resolution to fund federal government operations by March 27, and the federal debt ceiling on or before March 31, 2013. Clarity anticipated; messiness assured!
|Election Type
|2014 Federal Elections
|113th Congress Composition
|112th Congress
|White House
|No election
|U.S. Senate
|U.S. House of Representatives
Admittedly, other legal challenges are likely. The individual responsibility requirement (aka "individual mandate") has been challenged in nearly 30 cases to-date and over 40 cases have been filed around the ACA's requirement that contraception be a covered benefit offered by employers, including Liberty University's challenge that Congress did not have the power to impose the individual responsibility or the employer shared responsibility provisions, and other issues raised surrounding the First Amendment Free Exercise Clause, the Religious Freedom Restoration Act, and the Fourteenth Amendment Equal Protection Clause. So while legal proceedings continue, for the most part, the ACA—with the rules and regulations, requirements, and funding mechanisms it creates—will be the basis for the industry's turn toward "the new normal."
Health costs will be the primary concern of stakeholders in the system this year:
Per the Congressional Budget Office (CBO), for 2011-2021, "national health spending is projected to grow at an average rate of 5.7 percent annually, which would be 0.9 percentage point faster than the expected annual increase in gross domestic product (GDP) during this period. As a result, the health share of GDP is projected to rise from 17.9 percent in 2010 to 19.6 percent by 2021. During this period, the ACA is projected to reduce the number of uninsured people by 30 million; to add approximately 0.1 percentage point to average health spending growth; and to add $478 billion in cumulative health spending." (Source: Keehan et al, "National Health Expenditure Projections: Modest Annual Growth Until Coverage Expands and Economic Growth Accelerates," Health Affairs, June 12, 2012)
The gap between health spending and the GDP is problematic: it is not sustainable long term, notwithstanding the benefits of employment growth and innovation it produces as an industry. Health costs will be the focus in 2013 because consumers, employers, and policymakers believe it necessary to reduce costs and possible to do so without compromising quality and safety. In response, in 2013…
…for small- and mid-sized employers, double-digit premium increases might encourage them to curtail insurance benefits altogether even after paying the penalty per the ACA. Note: between 2000 and 2010, 10 percent of employers—mostly smaller and mid-sized, dropped coverage. Deloitte's 2012 Survey of U.S. Employers concluded that another 9 percent might drop this decade due to cost.
…for larger employers, their calculated journey from defined benefits to defined contribution plans—so employees have more skin the game—is expected to accelerate as they keep an eye on the success of the HIXs as a long-term alternative channel for coverage.
Hospitals and facility operators will watch labor and supply chain costs closer than ever: tighter margins and shrinking revenues mean tough negotiations and lean operations. Effective efficiency gains of the past three years are table stakes: radical cost reduction is no longer optional.
Medical device and drug manufacturers are expected to continue to be caught in the cross fire: hospitals, doctors, and other providers requiring better deals, health plans that want steeper discounts, and increased government scrutiny to assure safety and outcomes accompanied by higher industry fees. Some might find shelter in promising global markets or non-regulated industry sectors, but most are expected to race to avoid being commodities via value-based pricing and deal-making. The drug companies will be watching to see how states manage their Medicaid expansion and what rebates they'll be required to pay. And increased regulatory scrutiny of Group Purchasing Organizations (GPOs) and Pharmacy Benefits Managers (PBMs) will require device, durables, therapeutics, and disposable manufacturers to maneuver strategically through a period of uncertainty.
The states will feel pressure from four sides: 1) state employee health benefits that are historically richer and more costly than private sector counterparts, 2) Medicaid and Children's Health Insurance Program (CHIP) enrollment expansion (7 million new enrollees since 2008) and utilization increases, 3) new costs for managing health exchanges and oversight of their health insurance markets, and 4) prison health—7 million adults in this country are incarcerated and long-term health is the system's fasting increasing cost. All this at a time when 30 states and DC face budgetary shortfalls averaging 9.5 percent (per the National Association of State Budget Officers [NASBO]).
And consumers: they bear almost 30 percent ($2,898 per capita) of total health cost already through co-pays, deductibles, premiums, and over-the-counter (OTC) health purchases. (Source: Deloitte Center for Health Solutions, "The hidden costs of U.S. health care: Consumer discretionary health care spending," 2012) They're reacting with their feet: 17 percent fewer visits from 2009 to 2011 (Source: Kaiser Family Foundation, "The Economy and Medical Care," November 2011) and voluntary use of cheaper options, like the 1,340 retail clinics and OTC substitutes for prescription drugs.
Seemingly, the answers to lowering costs across the continuum are straightforward. But reducing costs in a system where incentives reward doing more, and where each sector's expense is another's revenue, means likely skirmishes wherein each asserts their costs are appropriate and the others excessive.
|Estimates of waste in U.S. health care spending in 2011, by category
|Cost to Medicare & Medicaid (in billions)
|Total cost to U.S. health care (in billions)
|Failures of care delivery
|Failures of care coordination
|Administrative complexity
|Pricing failures
| $178
|Subtotal (excluding fraud & abuse)
|% of total health care spending
|Fraud & abuse
| $272
|Total (including fraud & abuse)
|% of total health care spending
Source: Health Affairs, "Reducing Waste in Health Care," December 13, 2012
In 2013, the entire industry will feel pressure to justify its costs and make adjustments that are uncomfortable.
Hardly a week goes by that the government doesn't report its success in weeding out fraud in the U.S. system. The federal government invested $102 million in the last four years to improve its capabilities in Medicaid fraud detection (per the Centers for Medicare & Medicaid Services [CMS]) and is two years into its Medicare initiative to replace "pay and chase" methods with powerful predictive models that identify the bad actors and intercept before payments are made. The government (the U.S. Department of Health and Human Services [HHS]) estimates savings of between $82 and $272 billion annually if fraud was effectively weeded out of the system.
Physician self-referral is likely to be in the spotlight: the ACA and Congressional oversight committees are likely to step up efforts to limit physician self-referral. While ownership of physician-owned hospitals was curtailed in the ACA, physician ownership of imaging and surgical facilities is a likely target.
Health plan compliance will be intense: administrative simplification vis-à-vis Section 1104 of the ACA set in motion key changes to the core operations of health plans (i.e., Eligibility and Claim Status specifications released in January of 2012, procedures for Electronic Funds Transfer (EFT), and Remittance Advice Transactions in August 2012, along with Health Plan Identifier and National Provider Identification). And states will embark on health exchanges and oversight of health plan compliance with EHBs, medical loss ratio (MLR) thresholds, and premium increases just for starters.
And compliance challenges for drug and device manufacturers will be no less intense in 2013 beyond their new excise taxes and rebates—new data capture and reporting requirements that start this month, required changes to Medicaid Average Manufacturer Price (AMP) definition and calculations, expansion of drug classes subject to the Medicaid rebates, pricing changes for 340B entities along with new integrity obligations around overcharges, the new Branded Prescription Drug Fee that's now applied to revenues from government contracts, and more. Device and drug manufacturers' compliance efforts will amp up exponentially at the same time their companies face intense pricing pressure from their customers and increased scientific evidence from regulators.
And perhaps the issue with incendiary potential: necessary care. Policymakers and regulators will investigate waste due to clinically unnecessary procedures and tests. Care that did not show a proven health benefit, and where a less costly alternative was not used, cost $158-$226 billion in 2011. (Source: Berwick, et al, "Eliminating Waste in U.S. Health Care," The Journal of the American Medical Association [JAMA], April 11, 2012) As incentives change from volume to value, as financial risk is shifted to doctors and hospitals for quality and cost, and as report cards provide scores for necessary care in each community, the issue of adherence to evidence-based care will be widely discussed. And in all likelihood, this issue will become the centerpiece for regulatory oversight and compliance in coming years.
The U.S. health care system is highly regulated already. There's no end in sight. Compliance is a big deal and will continue to be a moving target.
The health care industry is in a fierce race to deliver more value to its customers while lowering its operating costs. It is an industry unlike any other—labor intense, capital intense, highly regulated, complex, and non-transparent for the most part. To achieve that aim, its stakeholders are exploring new relationships that cross traditional boundaries and test infrastructure requirements, alignment of incentives and the willingness of leaders to compromise. The pace of consolidation is mind boggling…physicians and health plans, physicians and hospitals, hospitals and hospitals, hospitals and long-term care providers, biotech and pharmaceutical manufacturers, retail pharmacies and disease management companies, food manufacturers and alternative health providers, and so on. Consider…
Between January 1, 2007 and June 30, 2012, the numbers of hospital acquisitions or mergers has increased annually since a low of 50 in 2009 and is expected to be close to 100 in 2012 when the final numbers are released.
The numbers of deals involving medical groups increased 60 percent in the last year, with hospital and health plan acquisitions of larger groups and networks making headlines.
Drug manufacturers, facing patent expirations, stepped up acquisition efforts reporting $40 billion in deal value annually for the past three years. Many of these involve deals with biotech companies allowing the small molecule companies access to promising small molecules that portend the promise of personalized medicine.
And the medical device industry is on track to complete almost 185 deals in 2012—a frenetic pace maintained since 2009 in an industry most notably composed of more than 4,000 small manufacturers seeking market access.
What's driving the flurry of deals and consolidation: reality—for most to survive, it's a choice to go big or get out. Access to capital to be competitive, attract talent, invest in infrastructure, and grow requires scale. Most of the sectors in health care are smaller when contrast to other industries. There are 4,000 biotech companies but only 25 are a scale to operate as a public company. Likewise in other sectors where there are many smaller players and a few bigger: medical devices—approximately 6,000 companies; community hospitals—4,985 with 40 percent in multi-hospital or obligated ownership models; 400 health insurance plan operators with more than 80 percent of total enrollment in 46; and so on.
The health care industry in the U.S. will consolidate at a pace in 2013 that's unprecedented. Our studies suggest consolidation often disappoints, failing to deliver long-term sustainability or growth anticipated when the deals were crafted. So the story in 2013 will be consolidation to deliver measurable value—a standard that might be tougher to meet than most anticipate.
The U.S. health system has traditionally paid lip service to the notion of "consumers" because it deems every element of our system too complex for comprehension by the general public. Diagnosis and treatment is complex—choosing between treatment options based on signs, symptoms, risk factors, and co-morbidities requires medical training most believe. And the structural features of the system are complex: regulations at the state and federal levels, Medicare, Medicaid, CHIP, and other government programs. And the plethora of innovations—drugs, devices, alternative methods, and many more discourage a grasp of how things work and what they mean for most. It's the basic reason doctors, hospitals, drug companies, and device makers prefer to call them patients: it supports a confident sense of control over consumers and dispels notions that individuals might not require the care and feeding of their provider.
This notion is changing. And in 2013, the transition from a patient orientation to consumerism in health care will come full circle. The reason: consumers are demanding more value from the system due to its ever-increasing costs and poor service. Example: 52 percent gave the system a report card grade of "A" or "B" for meeting their health care needs and those of their families in 2012 vs. 14 percent who grade it "D" or "F." (Source: Deloitte Center for Health Solutions, "2012 Survey of U.S. Health Care Consumers," 2012) And 42 percent believe the ACA will bring about no change in quality vs. 38 percent believe quality will decrease (Source: Truven Health Analytics, Health Leaders, October 2012) and 62 percent say that at least half the money spent on health care is wasted, according to the "2012 Survey of U.S. Health Care Consumers."
The trifecta driving the change is simple: 1) technology: mobile applications will enable comparison of treatment options, costs, and the list of providers who adhere to best practices; 2) coverage: high-deductible plans and a growing individual insurance market is expected to drive price and quality sensitivity, and 3) transparency: regulators will require increased access to performance data from health plans, hospitals, drug manufacturers, long-term care providers, and physicians.
While it's still more comfortable to think of "patients," it is the consumer movement in health care that will be its most disruptive theme. The industry's incumbents might not be prepared; those from outside the industry see it as a huge opportunity.
Five themes in 2013—
Clarity…the ACA is the law; its implementation requires every stakeholder's attention.
Costs…radical cost reduction across the system is necessary to survival requiring new ways of managing people, processes, and technologies.
Compliance…the rules are complex, forthcoming, and massive. Proceed with caution.
Consolidation…go big or get out.
Consumers…how they define value, act as purchasers and voters, and behave as users will set the stage for the new normal. They're neither patient nor patients, they are consumers.
Happy New Year.
Paul Keckley, Ph.D., Executive Director, Deloitte Center for Health Solutions
Implementation update
ONC seeks public comment on HIT Patient Safety Plan
Late last month, the Office of the National Coordinator (ONC) for Health Information Technology (HIT) released its 39-page Patient Safety Action & Surveillance Plan for public comment outlining standard practices to enhance coordination between providers and industry stakeholders. Specifically, the plan outlines how to increase quantity and quality of data and knowledge about HIT safety, target resources, and corrective actions to improve HIT safety and patient safety, and promote a culture of safety related to HIT. Public comments will be accepted until February 4, 2013.
Background: ONC was created by Executive Order in 2004 and funded through the Health Information Technology for Economic Clinical Health (HITECH) Act. The objective was to establish a federal entity to serve as a resource to the entire health system to support the adoption of HIT and to reduce medical errors through enhancing medical technology. The HITECH Act also provided an avenue for providers to engage in meaningful use of HIT through the Electronic Health Record (EHR) Incentive Program. Since January 2011, 120,000 eligible health care professionals and 3,300 hospitals have qualified to participate in the program and received incentive payments. The deadline to meet the requirements for Stage 2 meaningful use is in 2014. For more information on Stage 2 meaningful use, read Deloitte's recent whitepaper: "Shaping the future: from Meaningful Use to meaningful user"
Related: CMS released a notice last week requesting information from hospitals, EHR vendors, and other interested parties regarding hospital readiness to electronically report certain patient-level data under the Hospital Inpatient Quality Reporting (IQR) program beginning calendar year 2014, a quality measurement and reporting program used to populate the HHS.gov hospital compare website, so that consumers can compare hospitals based quality factors. CMS is exploring whether hospitals would be able to use the same certified electronic health record technology (CEHRT) that is required for the EHR Incentive Program so that clinical quality measures and CEHRT data collection could be streamlined. CMS is seeking comment on whether stakeholders foresee challenges with this proposed process. Comments will be accepted until January 22, 2013.
My take: with or without pressures to constrain costs in health care, the adoption and use of EHRs across the continuum of care is widely seen as a necessary improvement in the health system—not as end in itself, but as a means of improving safety and quality, and reducing costs associated with error and redundant testing and unnecessary care. Stage 3 meaningful use, the implementation of ICD-10 and clinical integration via medical homes, accountable care, and bundled payments all presume the system has made a successful, albeit difficult and costly, transition to clinical and administrative decision support tools and systems, and incentives geared toward their required use. It's the engine driving the new normal.
CCIIO: guidance on state-partnership exchange model, new deadline for declaration of intent to transition from partnership to state-based model
Thursday, the Center for Consumer Information and Insurance Oversight (CCIIO) released guidance on the state-partnership exchange model for which applications are due February 15, 2013. States that wish to transition from a partnership exchange to a state-based exchange for plan year 2015 now have until November 18, 2013 to notify HHS. In its guidance, CCIIO also delineated the role of the federal government from the states' role based on whether a state opts to establish a "state plan management partnership exchange" or whether the state opts to play the role of consumer assistance and outreach coordinator. Per the ACA, a state can assume primary responsibility for carrying out activities through a state plan management partnership exchange or the state can play the role of consumer assistance and outreach coordinator. If state officials desire, they can take on both roles. CCIIOO is seeking comments from states on the logistics of the hybrid approach.
IRS provides guidance on employer shared responsibility
On December 28, 2012, the IRS released a 144-page proposed rule on the shared responsibility requirement: large employers (those with more than 50 full-time employees). Comments will be accepted until March 18, 2013, and a hearing will be held on April 23, 2013 to review the proposed rule. Highlights:
- Coverage must be provided to employees and their dependents. Dependents are defined as an employee's child who is under 26 years of age and does not include any individual other than children, such as an employee's spouse.
- If a large employer is comprised of a parent corporation and wholly owned subsidiary corporations, each of the corporations, regardless of the number of employees, is an applicable large employer member.
- The term "hours of service" has been adopted in place of the term "hours worked" when determining full-time employee status and includes hours when work is performed and hours for which an employee is paid or entitled to payment even when no work is performed.
Background: per Section 4980H, a "large employer" (employers with more than 50 full-time employees) is subject to a penalty of $2,000/full-time employee if "minimum essential benefits in an affordable insurance plan are not accessible to employees" (less than 60 percent actuarial value) or no coverage is provided beginning in 2014. This penalty applies if at least one full-time employee who is entitled to a premium tax credit or cost sharing reduction has applied for coverage via an exchange plan. The first 30 employees are exempted from the penalty, and the calculation for "full-time employee" has been clarified to allow a look-back period of three to twelve months to assess eligibility of seasonal employees who might not average 30 hours or more per week.
Update: court challenges—Hobby Lobby will not cover contraception services
After the Supreme Court's decision to deny Hobby Lobby's appeal to review the 10th Circuit District Court decision last week, the retailer announced it will not cover contraceptive services for employees. The 10th Circuit District Court denied Hobby Lobby's request for an injunction to prevent the company from having to comply with the ACA requirement that certain employers must provide contraceptive services as part of their health coverage.
Related: last month Korte & Luitjohan Contractors Inc. was denied a preliminary injunction regarding the contraception requirement in the ACA, but the appeal was reversed by the 7th Circuit Court of Appeals and an emergency injunction has been granted. And Liberty University's challenge to ACA is on the docket for the 4th Circuit this spring. Stay tuned.
Key agencies with ACA implementation responsibility in 2013
Agencies under HHS:
- CMS…watch for how it handles Medicaid expansion and continuation/expansion of demonstrations and pilot programs (i.e. Patient Centered Medical Homes, bundled payments, et al)
- CCIIO…watch for its handling of state HIXs and its rules about state EHBs and regulation of health insurance plans
- ONCHIT…watch for its monitoring of Stage 2 meaningful use and guidance on Stage 3
Others to watch:
- Patient-Centered Outcomes Research Institute (PCORI)…watch for directives about its research agenda and plans for comparative effectiveness roll-out
- Employee Benefits Security Administration (Department of Labor)…watch for guidance about self-insured employer coverage as exchanges come online
- IRS…watch for its rules and procedures for regulating the individual mandate and dispensing of subsidies for eligible individuals purchasing coverage through state HIXs; regulations and enforcement of employer taxes, if they do not provide coverage; regulation and enforcement of excise taxes on medical devices (effective January 1, 2013) and health insurance industries (effective January 1, 2014); guidance about how certain individuals may be exempted from minimum essential coverage; and others
- Office of Personnel Management (OPM)…watch for its role in setting up the federal "hub" allowing for contracting with at least two private multi-state insurance plans accessible in all state and federal exchanges
CMS: cancer, kidney specialists might run their own ACOs
December 20, Principal Deputy Administrator Jonathan Blum said CMS is considering allowing nephrologists and oncologists to form ACOs as demonstrations. Per Section 3022 of the ACA, specialists may participate in ACOs, but the Medicare Shared Savings Program must be led by primary care physicians. CMS has the power to test other types of ACOs as demonstrations, and the agency's innovation center already is testing an alternative for advanced provider systems, called the Pioneer ACO Model, but those ACOs also are rooted in primary care. (Source: HealthPolicyNewstand, "Inside CMS," January 6, 2013)
Legislative update
Congress passes American Taxpayer Relief Act to avoid fiscal cliff: sequestration, debt ceiling ahead
Last week Congress passed and the President signed into law the "American Taxpayer Relief Act of 2012" (ATRA) averting the "fiscal cliff." The deal postpones the start of sequestration for two months, but does not address the need to raise the debt ceiling or longer-term fiscal issues, thus requiring the new 113th Congress to resolve these by late February or early March 2013. ATRA highlights:
- Personal income taxes: income tax rates will not go up for individuals with taxable income of $400,000 or less and families with taxable income of $450,000 or less, but certain deduction limitations will apply to individuals with adjusted gross income (AGI) above $250,000 and families with AGI above $300,000.
- Unemployment benefits: the unemployment benefits for 2.1 million will be extended through December 31, 2013.
- Alternative minimum tax (AMT): the AMT patch is renewed for 2012 and the exemption will be permanently indexed for inflation in the future.
- The "doc fix"—a planned 27 percent reduction in Medicare pay rates to doctors was set aside for one year (at a cost of $25.2 billion, per the CBO) largely paid for by 10-year projected savings from cuts to hospitals and other providers (i.e., reductions in the Medicare Severity Diagnosis Related Groups, or MS-DRGs) ($10.5 billion); re-pricing of end stage renal disease (ESRD) payments ($4.9 billion), re-basing Medicaid Disproportionate Share Hospital (DSH) payments ($4.2 billion), and applying a competitive bidding program to diabetes test strips bought at retail pharmacies ($600 million).
- Long-term care: ATRA repealed the Community Living Assistance Services and Support (CLASS) Act (Sections 8001 and 8002 of the ACA) and the reclaimed unspent loans from $2.3 billion set aside for the Consumer Operated and Oriented Plan (CO-OP) program (Section 1322 of the ACA). To-date, 24 plans have received funding, and 26 had submitted proposals to HHS but will not receive funding. Note: ATRA replaced the CLASS Act with a new 15-member Commission on Long-Term Care tasked to create a national plan to Congress and the President to address long-term care services in the U.S. Within 30 days of the passage of the Act, three Commissioners will be appointed by President Obama, and the remaining 12 will be appointed by the House and Senate (50/50 Republican/Democrat appointees). Ideally, Congress will vote on the recommendations as early as fall 2013.
Title VI of ATRA includes 29 provisions relevant to health care covered in 46 pages of the 157 total in the new law. Pertinent health care industry related items from ATRA:
|ATRA Title VI
|Key policy changes
|Projected cost (2013-2022)
|Subtitle A—Medicare extensions (Sections 601-610)
|$25.2 billion
|$.1 billion
|$.5 billion
|$1 billion
|$.1 billion
|$.3 billion
|$.1 billion
|$.3 billion
|Subtitle B—Other Health Extensions
|$.8 billion
|$.6 billion
|$.3 billion
|Subtitle C—Other Health Provisions
|-$10.5 billion
|-$4.9 billion
|-$1.8 billion
|-$.4 billion
|-$.8 billion
|-$.6 billion
|-$.4 billion
|$.5 billion
|-$2.5 billion
|-$1.7 billion
|-$4.2 billion
|-$.2 billion
*Between -$50 and $50 million
Source: CBO, "Detail on Estimated Budgetary Effects of Title VI of H.R. 8, the American Taxpayer Relief Act of 2012," as passed by the Senate on January 1, 2013, January 2013
My take: it's ironic that hospitals were hit by cuts to accommodate the physician pay fix. At a time when hospitals and physicians are being pushed to become clinically integrated and take risk in contracts with Medicare, employers, and health plans, and as acute margins are shrinking, hospital operators are necessarily thinking "go big or get out." Physicians and hospitals are increasingly co-dependent per the law's requirements for clinical integration, and regulators are systematically reducing acute margins by setting Medicare fee schedules for ambulatory services at rates the same for hospital-based and physician office services. The trend toward physician-hospital consolidation is accelerating: regulators and payers (employers, health plans) are hopeful that clinical integration results in lower costs and improved outcomes from improved coordination of care and concerned that these efforts not result in higher costs or increased leverage over payers.
Medicare in the spotlight in 113th Congress
Congressional leaders on both sides and the White House agree that entitlement reforms—Medicare, Medicaid, and Social Security—are necessarily part of a long-term deficit reduction and economic growth plan. They are not in agreement on how changes should be made or when.
Per the U.S. Bureau of Economic Analysis, entitlement programs cost $24 billion in 1960 vs. $2.2 trillion in 2010—100 times higher in 2010 (+727 percent inflation adjusted) or $7,200 for every person in U.S. The big three: $518.4 billion for Medicare covering 49.4 million, $405 billion for Medicaid covering 62.7 million, and $690 billion for Social Security. In the current $941 billion fiscal year (FY) 2013 budget of the HHS, outlays for Medicare (56 percent) and Medicaid (30 percent) dwarf other categories.
My take: Medicare is arguably the most problematic since its funding is 100 percent federal. Every day, 8,000 people become eligible for Medicare as Baby Boomers age into the program, swelling its enrollment to 81 million by 2030. The costs of the benefits these receive from the program is expected to exceed what enrollees paid in through withholding taxes by 3 to 1. The math is perplexing: medical inflation costs plus increased enrollment plus sicker enrollees who live longer plus a program that's wildly popular with seniors equals the policymakers dilemma.
Several proposals for Medicare reform will be revisited in the 113th Congress. No doubt, means testing, increasing the age of eligibility, restrictions on first-dollar coverage via MediGap policies, premium support, Medicare Advantage (MA) expansion, and other changes will be on the table. The bottom line is this: Medicare in its current form is not sustainable. The reality that major changes are necessary is politically risky. It leads to rhetoric about death panels, government takeover of health care. and more. It's nonetheless a necessary national discussion we will have this year.
Major Medicare reform proposals likely to be reconsidered in 2013:
|Medicare cost containment proposal
|Policy recommendations
|Estimated cost savings
Enhanced competition: on the basis of quality and price between traditional fee-for-service Medicare and MA plans, use buying power to reduce prescription drug costs
Federal contribution: based on the cost of the second-least expensive plan or traditional Medicare (whichever is less expensive), growth of per-beneficiary federal support capped at GDP+1%
Employer tax exclusion: slowly phase out the tax exclusion for employer-provided benefits
Benefit structure: uniform cost-sharing, out-of-pocket maximum to protect seniors against catastrophic costs
Premium changes: end first-dollar supplemental coverage, increase Part B premiums from 25% to 35% over five years
Produces total savings of $10.3 billion from 2013-2042 in the Medicare program
Reduces debt as percent of gross domestic product (GDP) from 155% in the baseline projection for 2042 to 58%
|The Senior Protection Plan2
Enhanced competition: use competitive bidding for all health care products (e.g., nondurable medical products, durable medical equipment nationwide, clinical laboratory services)
Price and quality transparency: require private insurers to make prices transparent, price transparency for medical devices, publicly release claims data
Reform health care delivery: accelerate the use of alternatives to the fee-for-service model for payment, better coordination of care for dual eligibles
Sustainable growth rate (SGR): repeal the SGR in its entirety
Produces total savings of $385 billion over 10 years
Generates up to $100 billion over ten years as a result of tax policies related to health care
|House GOP3
No changes: for those currently in the Medicare program or near retirement
For younger adults: creates a Medicare Exchange where seniors are given a choice of different private plans that compete alongside the traditional fee-for-service option
Risk-adjusted plans: insuring those with greater health needs are protected against high premiums, adverse selection
Means-testing: those with greater income would pay an increased share of their premiums
Enhanced competition: premium support and competitive bidding to ensure guaranteed affordability for seniors
Repeals: the IPAB
Cuts spending by $5 trillion relative to the fiscal year (FY) 2013 budget plan from the President
Increases by 0.5% to 19% total revenues as percent of GDP by 2040 as compared to Congressional Budget Office (CBO) Alternative Fiscal Scenario
Decreases by 15.25% to 18.75% total spending as percent of GDP by 2040 as compared to CBO Alternative Fiscal Scenario
|The Heritage Foundation4
Eligibility age: raised gradually from 65 to 68 and then be indexed to life expectancy
Premiums: gradually increase the premiums for Parts B and D and index to income, within five years transition to a defined-contribution or premium support model adjusted by income
Enhanced competition: expand competition in the program to encourage greater innovation, restrain spending, and slow costs
Reduces debt as a percent of GDP from 79% in 2013 to 28% in 2037
Reduces spending as a percent of GDP from estimated 2037 level of 35.7% to 18.3%; revenue remains the same at estimated 2037 level of 18.5%
SGR: reforms the SGR and requires the fix to be offset, recommends that the Centers for Medicare & Medicaid (CMS) develop an improved payment formula
Medicare fraud: increases statutory authority and funding to CMS to reduce Medicare fraud
Reforms cost-sharing rules: establishes a single combined annual deductible of $550 for Parts and B, instates a 20% uniform coinsurance on health spending above the deductible
Prescription drug rebates: extends the Medicaid drug rebate to dual eligibles participating in Medicare Part D
Reduces deficit by $4 trillion through 2020
Reduces debt as a percent of GDP to 60% by 2023, 40% by 2035
|Mandate on manufacturers to pay minimum rebate6
A proposal to require manufacturers to pay a minimum rebate on drugs covered by Medicare Part D for beneficiaries who receive the Low-Income Subsidy contains the following components:
|CBO scored the current proposal as achieving savings of $137 billion over ten years (2013-2022) or approximately $15 billion in its first full year of implementation
1 Bipartisan Policy Center, "Domenici-Rivlin Debt Reduction Task Force Plan 2.0," December 2012
2 The Center for American Progress, "The Senior Protection Plan," November 2012
3 House Budget Committee, "Fiscal Year 2013 Budget Resolution," March 2012
4 The Heritage Foundation, "Saving the American Dream: The Fiscal Cliff and Beyond," December 2012
5 Report of the National Commission on Fiscal Responsibility and Reform, December 2010
6 Health Affairs, "The Medicare Part D Drug Rebate Proposal: Rebutting An Unpersuasive Critique," December 28, 2012
Congress responds to Newtown, final rule on MHPAEA requested
In the aftermath of the Sandy Hook Elementary School deaths of 26 children and adults, 32 members of Congress sent a letter to HHS Secretary Kathleen Sebelius, U.S. Department of Labor (DOL) Secretary Hilda Solis, and U.S. Department of Treasury (DOT) Secretary Timothy Geithner last week urging the agencies to issue a final rule on the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA requires medical and mental health benefits to be provided at parity―requiring an insurance plan cover physical and mental health benefits both benefits at the same level. The authors of the letter state: "a recent GAO report found that insurance plans have actually increased the number of exclusions for mental health and addiction treatment since the passage of MHPAEA."
Note: mental health and substance abuse services are one of the ten EHBs required to be covered by health plans offered in the individual and small-group markets, both inside and outside the HIXs, per the ACA. These benefits must be offered at parity.
Study: Medicare, Medicaid should incorporate physician payment incentives used by private plans
The Middle Class Tax Relief and Job Creation Act of 2012 required that GAO examine private-sector initiatives that base or adjust physician payment rates on quality and efficiency, and the initiatives' applicability to the Medicare program. Based on its analysis of nine plans, the 43-page report concluded…
- Private plans generally measure performance and make incentive payments at the physician-group level rather than at the individual-physician level. Physician organizations favor this approach.
- Private plans use nationally endorsed performance metrics and noted the need for a standardized set of metrics across all payers. Physician organizations concur that a standardized set of metrics would be less administratively complex.
- Most private plans provide financial incentives tied to meeting absolute benchmarks—fixed performance targets—or a combination of absolute benchmarks and performance improvement. Physician organizations prefer incentives tied to absolute benchmarks over those based on how physicians perform relative to their peers. Physician organizations also favored incentives that reward improvement because baseline levels of performance vary.
- While private plan incentive payments vary in size and in method, private entities typically provide such payments within seven months of the end of the performance measurement period. Physician organizations stated that financial incentives should be distributed soon.
Source: "Medicare Physician Payment Private-Sector Initiatives Can Help Inform CMS Quality and Efficiency Incentive Efforts," CMS, December 26, 2012
State update
CMS releases guidance on conversion to MAGI calculations for Medicaid expansion eligibility
Last week, CMS released guidance to states regarding the modified adjusted gross income (MAGI) thresholds for the Medicaid program and CHIP detailing how states that opt to expand Medicaid eligibility to 133 percent of the federal poverty level (FPL) should convert their current net income eligibility thresholds to MAGI thresholds per Section 2002 of the ACA. States that expand Medicaid to 133 percent FPL must use the MAGI threshold to determine eligibility for the newly-eligible population. Currently, state Medicaid programs use several other factors to determine eligibility, such as gender, disability, and health status; the MAGI will only take income into account.
Abortion legislation
According to the Guttmacher Institute, 19 states passed a total of 43 provisions in 2012 that restrict access to abortion services vs. 92 abortion restrictions enacted in 2011. More than half of the new restrictions were passed in six states: Arizona (7), Kansas (3), Louisiana (3), Oklahoma (3), South Dakota (3), and Wisconsin (3). Most state legislative activity is related to limits on later-term abortions, coverage in HIXs established under the ACA, and medication abortions.
Study: states spend 2 percent of tobacco settlement funds on smoking cessation
In 2012, states will collect $25.7 billion in revenue from the 1998 tobacco settlement and tobacco taxes and spend $459.5 million on smoking cessation programs targeting kids and adults. (Source: Campaign for Tobacco-Free Kids) Note: 46.6 million of America's 196.4 million adults smoke, accounting for $97 billion in direct and indirect costs and 423,000 deaths annually.
State round-up: health insurance exchanges
Thursday, Arkansas received conditional approval from HHS to move forward with a state-partnership exchange. Note: Delaware was the first state to receive conditional approval for a state-partnership in mid-December.
Also last week, HHS announced that it has approved the following state-based exchange proposals: Utah, California, Hawaii, Idaho, Nevada, New Mexico, and Vermont. To date, 17 states (CA, CO, CT, HI, ID, KY, MA, MD, MN, NM, NY, NV, OR, RI, UT, VT, WA) and the District of Columbia have received conditional approval of their blueprints for state-based exchanges.
Per the table below, 18 states and the District of Columbia will operate a state-based exchange. According to the Kaiser Family Foundation, seven states are planning for a state-partnership exchange and the remaining states will default to a federally-facilitated exchange.
|State-based exchange
|State-partnership exchange
|Federally-facilitated exchange
Note: updated as of January 4, 2012
Sources: Kaiser Family Foundation, National Association of State Health Policy: State Reform, and Politico Pro.
HIX announcements:
- Connecticut's HIX has begun soliciting health insurance issuers and stand-alone dental plans to provide qualified health plans (QHPs) through its HIX. Insurance providers must respond to the solicitation by March 29, 2013 and open enrollment will begin on October 1, 2013 for a January 1, 2014 effective date.
- Mila Kofman has been named the executive director of the District of Columbia's health insurance exchange. Formerly Maine's Superintendent of Insurance, Ms. Kofman was elected unanimously by the exchange's board of directors. She began her duties last Wednesday.
- HHS has not yet made a decision on Mississippi's application for a state-based exchange, citing the unresolved dispute between the state's Insurance Commissioner Mike Chaney (R), and Governor Phil Bryant (R). Chaney submitted the state's exchange proposal in mid-November without the support of the Governor. In a December 28 letter, Governor Bryant asked HHS Secretary Kathleen Sebelius to block the state's application, arguing that Chaney does not have the authority to act on the state's behalf.
- State HIX timeline:
Date Upcoming timeline for states that have elected a state-partnership exchange model and who are interested in a plan management role Early 2013
- Begin to identify the entity performing the plan management functions and governance structure
- Begin to submit evidence of legal authority to perform plan management functions
- Begin to:
- develop procedures for day-to-day oversight and monitoring of QHP;
- develop a plan for supporting QHP issuers and providing technical assistance;
- develop approach for QHP issuer recertification, decertification, and appeal of decertification recommendations.
February 15, 2013
- Last date to submit a declaration letter indicating that the state plans to pursue a state partnership exchange and the blueprint application.
April 2013
- Suggested start to the QHP certification submission process.
May-June 2013
- Participate in consultations with HHS to ensure successful operation of the QHP certification process.
July 31, 2013
- Complete the QHP certification process and send final recommendations and QHP data to HHS.
August 2013
- Plan-preview period to address any QHP issuer data errors
(Source: "Affordable Insurance Exchanges Guidance: Guidance on the State Partnership Exchange," CCIIO, January 3, 2012)
State round-up: Medicaid expansion
As of January 4, 2013, 15 states and the District of Columbia will expand and 23 states are undecided/undeclared.
|Not participating or highly likely not to participate
|Undecided or undeclared
Note: states do not have a deadline to make a decision on Medicaid expansion and may opt in or out of participation at any time. This chart was compiled using publically available information (as of January 4) and is subject to change.
Other recent announcements:
- Texas health care providers submitted proposals to the state outlining how they plan to modify the provision of care for their poor and uninsured. Lawmakers are seeking federal approval to begin grant incentives to health care providers who implement experimental programs that improve care while reducing costs. The waiver could provide Texas' health care providers with $29 billion over the next five years.
- Last Thursday, Colorado Governor John Hickenlooper (D) announced that his state will exercise its option to expand Medicaid coverage. The expansion is expected to provide eligibility to more than 160,000 additional individuals and will be accompanied by cost-control measures estimated to save $280 million over the next decade.
- State Senator Michael Lamoureux (R) of Arkansas seeks compromise on an agreement to expand Medicaid. Governor Mike Beebe (D) supports the expansion but acknowledged passing the proposal would require a three-fourths majority in both the state's GOP-controlled legislative bodies.
Industry news
Value-based purchasing: year one results for hospitals
Last Thursday, Medicare announced bonuses and penalties for nearly 3,000 hospitals as it ties almost $1 billion in payments to the quality of care provided to patients that take effect this week. The program compared hospitals on how they followed evidence-based standards of care and how patients rated their experiences. In many regions, the hospitals with the highest ratings were not the best known or most widely seen as "best hospitals." Notably, hospitals in Maine, Nebraska, South Dakota, Utah, and South Carolina fared best, while hospitals in the District of Columbia, Connecticut, New York, Wyoming, and Delaware worst per the CMS data.
In addition, 1,557 hospitals will be rewarded with up to a 1 percent increase in their Medicare rate and 1,427 will see a 1 percent decrease in their rate in 2013—the first year the Hospital Value-based Purchasing (HVBP) initiative impacts payments to hospitals.
Background: the HVBP program is one of several Medicare pilots seeking to shift responsibility for outcomes to providers. In October 2012, Medicare reduced payments to 2,217 hospitals because due to avoidable readmissions. In 2015, the ACA requires the government to begin a quality payment program for physician groups of 100 professionals or more to be expanded to all doctors by 2017.
The HVBP program is based on a hospital's scoring: 70 percent based on how frequently hospitals followed 12 basic clinical standards of care, such as controlling heart surgery patients' blood sugar levels and giving them beta blockers to lower their blood pressure; and 30 percent for hospital satisfaction survey ratings of former patients (i.e., the communication and responsiveness of doctors and nurses and the cleanliness and quietness of their environment).
Meaningful use update: majority of hospitals, one-third of medical practices registered
According to the CMS' November report on the Medicare and Medicaid EHR incentive payment programs, $9.3 billion was spent in 2011: $6.1 billion to 3,393 of 4,193 eligible hospitals, and $3.1 billion going to 162,051 of 335,879 eligible physicians and eligible professionals, mostly working in ambulatory care; and $189 million to 11,117 eligible professionals in a few MA programs.
Note: December 31 was the deadline for physicians and other eligible professionals to report and attest to meaningful use in calendar year 2012. Providers must meet federal requirements for meaningful use by completing their 90- or 365-day reporting period and attest to meaningful use by February 28, 2013.
HHS: first HIPAA breach involving fewer than 500 records
Hospice of North Idaho will pay HHS a settlement in the amount of $50,000 because of a security breach involving the fewest number of individuals (less than 500) impacted by a security breach to-date. The Hospice reported to the HHS Office for Civil Rights (OCR) in 2010 that an unencrypted laptop computer with electronic health information of 441 patients had been stolen. OCR began its investigation seeking violations of the Health Insurance Portability and Accountability Act (HIPAA) and found that the Hospice lacked the policies and procedures required by HIPAA to address mobile device security. OCR Director Leon Rodriguez is using this case as an example to show that HHS will hold those in the health care industry accountable for their actions, no matter their size.
Background: although the hospice was not required to report the breach within 60 days of its discovery since it involved a small number of records, the HITECH Breach Notification Rule requires that breaches of protected health information (PHI) of less than 500 individuals be reported to the Secretary of HHS on an annual basis. OCR and the HHS ONC have launched an educational initiative, "Mobile Devices: Know the RISKS. Take the STEPS. PROTECT and SECURE Health Information," to offer health care providers and organizations tips on how to protect patient health information used on mobile devices.
Study: MA use rates lower than FFS
Medicare Advantage (MA) plans use rates for emergency and ambulatory surgery were 20-30 percent lower than Medicare fee-for-service (FFS). Note: enrollment in MA plans increased from 4.6 million in 2003 to 12.8 million in 2012 and accounts for 27 percent of total Medicare enrollment. (Source: Landan et al, "Analysis of Medicare Advantage HMOs Compared with Traditional Medicare Shows Lower Use of Many Services during 2003-2009," Health Affairs, December 2012)
Note: data suggest MA plans have attracted younger/healthier enrollees thus accounting for some of the difference. In the Landan study, cohort samples were compared by self-reported health status and then adjusted to, in part, reduce bias. However, the authors acknowledged that they did not have access to diagnosis-specific data which would have allowed for more precise measurement of differences based on medical risk/health status.
Study: hospice operator survey
Of 775 hospice operators surveyed, 78 percent indicated they had protocols for disallowing individuals with potentially high cost medical needs (i.e., chemotherapy) from enrolling due to financial risk imposed by Medicare. Note: there are 3,500 hospice programs in the U.S.—a 53 percent increase since 2000. Medicare spent $13 billion for hospice care for 1.1 million beneficiaries in 2010. (Sources: Carlson et al, "Hospice Enrollment Policies Contribute to Underuse of Hospice Care in the U.S.," Health Affairs, December 2012; Carlson et al, "Geographic Access to Hospice Care in the U.S.," Journal of Palliative Medicine, 2010: 13)
Study: pill coloring linked to medication non-adherence
Researchers found that inconsistency in the shapes and colors of bioequivalent drugs can change how patients use their medication. Focusing on individuals prescribed antiepileptic drugs, the study found that patients whose pills changed color were 53 percent more likely to discontinue using their medication as directed. (Source: Kesselheim, et. al, JAMA, "Variations in Pill Appearance of Antiepileptic Drugs and the Risk of Nonadherence," December 31, 2012)
Study: access to psychiatric patient records in hospitals
A study of 18 hospitals found that 44 percent of hospitals maintain electronic psychiatric records, 28 percent make psychiatric records accessible to non-psychiatric physicians, and 22 percent do both. In addition, the 7-, 14-, and 30-day readmission rates were found to be lower in hospitals that both stored their records electronically and made them accessible to non-psychiatric physicians, 4 percent vs. 6.6 percent, 5.8 percent vs. 9.1 percent, 8.9 percent vs. 13 percent, respectively. (Source: Kozubal, et. al, International Journal of Medical Informatics, "Separate may not be equal: A preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers," December 20, 2012)
Note: mental health conditions (i.e., substance abuse, mood and stress disorders, etc.) are considered risk factors and therefore relevant to diagnosing and treating other medical problems. However, in some communities, mental health providers are reluctant to share records and/or patients are fearful their records might violate their confidentiality.
"Some of the biggest ideas for cutting health care spending got pushed to the side when President Barack Obama and Congress turned their attention to cutting a smaller fiscal cliff deal. But now, Republicans say they'll insist on real spending cuts in the debt limit—sequestration fight. And if Obama continues to resist big entitlement changes, the health care industry could be in for another round of cuts."
—"A health care guide to the debt limit fight," Politico, January 4, 2013
"(Post election), the politics of health reform will move from the front burner of presidential politics to a series of smaller and more distinct arenas. In most of these, supporters of the law will have the upper hand—and most issues will be fought out on the less visible terrain of administrative decision-making in Washington and the dispersed, discrete, and varied decisions of states."
— Lawrence Jacobs, Joel Ario, "Post Election, The Affordable Care Act leaves the Intensive Care Unit for Good," Health Affairs, December 2012, p 2603
"Although there are unresolved methodologic issues related to the measurement and interpretation of patient experiences—regarding survey content, risk adjustment, and the mode and timing of survey administration—we believe that both theory and the available evidence suggest that such measures are robust, distinctive indicators of health care quality. Therefore, debate should center not on whether patients can provide meaningful quality measures but on how to improve patient experiences by focusing on activities (such as care coordination and patient engagement) found to be associated with both satisfaction and outcomes, evaluate the effects of new care-delivery models on patients' experiences and outcomes, develop robust measurement approaches that provide timely and actionable information to facilitate organizational change, and improve data-collection methods and procedures to provide fair and accurate assessments of individual providers."
— Manary et al, "The Patient Experience and Health Outcomes," New England Journal of Medicine [NEJM], December 26, 2012
"A continued focus on operating efficiency, stable reimbursement levels, modest managed care rate increases, and a higher than expected 2013 Medicare market basket increase all contribute to a stable landscape. However, Fitch believes there is increased uncertainty beyond 2013 as opportunities for further cost cutting wane and a wave of expected reimbursement reductions are realized under the full implementation of the Patient Protection and Affordable Care Act (PPACA) beginning in 2014."
—Jim Lebuhn, Senior Director, "Fitch Ratings 2013," December 24, 2012
Fact file
- Drug approvals by FDA in 2012: 39 new drugs in 2012 vs. 30 in 2011 and 21 in 2010; ten had fast track status, eight approved in December—highest since 1996 when 53 approved. (Source: U.S. Food and Drug Administration [FDA])
- ACA costs: ACA will reduce deficit $109 billion from 2013-2022. (Source: CBO)
- CO-OPs: to-date, 23 state-run, member-governed CO-OPs have been approved and HHS has loaned $2 billion toward start-up costs. (Source: HHS) Note: ACA provides for up to $3.4 billion for start-up costs.
- Community health center funding: $13 billion into clinics via the American Recovery and Reinvestment Act of 2009 (ARRA) and ACA to expand access to 36 million by 2019 from 17.1 million served in 2008. (Source: HHS)
- Online consumers: through December 21, e-commerce sales reached $38.7 billion—up 16 percent from the same period in 2011. "One final observation worth making is that the number of visitors an e-commerce site has does not appear to be related to its customer service rating. Companies appear to hold their own fates based on their retail practices and not their visitor count." (Sources: ComScore, Research company ForeSee "E-Retail Satisfaction Index (U.S. Holiday Edition)," assessment of 100 online shopping sites by 24,000 consumers)
- Managed Medicaid: represents $60 billion in new premiums through 2014 and $230 billion through 2020. (Source: Forbes, July 11, 2012)
- December jobs report: the U.S. economy added 155,000 jobs in December leaving unemployment at 7.8 percent; health care industry added 45,000 jobs led by ambulatory services (+23,000), hospitals (+12,000), and nursing and residential care facilities (+10,000). For 2012, health care employment increased 338,000. (Source: U.S. Bureau of Labor Statistics)
- EHR cut and paste: a study of 2,068 electronic patient progress reports in the intensive care unit of a Cleveland hospital found that 82 percent of residents' notes and 74 percent of attending physicians' notes were at least 20 percent made up of material "cut and paste" from patients' prior records. (Source: Thornton, et. al, Critical Care Medicine, "Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes," December 2012)
- CT scans radiation risk and consumer awareness: in a survey of 235 patients receiving CT scans, 34 percent were unaware that the scan would expose their body to radiation. Among those aware, 85 percent underestimated the amount of radiation and only 5 percent believed it would increase their lifetime risk of cancer. (Source: Busey, et. al, Archives of Internal Medicine, "Patient Knowledge and Understanding of Radiation From Diagnostic Imaging," December 2012)
National health reform: What now?
At Deloitte, we continue to explore and debate the key questions facing
Subscribe to the health care reform memo
Health care reform memo — The weekly health care reform memo is available for subscription. Please visit www.deloitte.com/us /healthmemos/subscribe.
- Step 1, confirm your sector(s) of interest.
- Step 2, select the health care reform memo as one of your subscriptions.


text:
Shimano Bike Mini Tool $22
This 11-function minitool from the Japanese cycle engineering leader is an all-in-one pocket toolbox. It's equipped with 2-8mm hex keys, normal and Philips screwdrivers plus a Torx key. All are nickle-plated in one ultralight (96 grams) folding array.
Tokyo Otaku Mode
Sushi Socks $6
Just try and stifle a smile over the sight of socks neatly rolled up like sushi. Made in Tomoyama, Japan, multicolor Sushi Socks (patterns are knitted, not printed) come in "flavors" like octopus, red caviar, tuna, shrimp, egg, and more.
Various Projects
Various Key Tag: I Like Sottsass $15
For the Memphis-obsessed, there's no designer better than Ettore Sottsass. Sport your favorite design movement on your keys with Various Projects' straightforward "I Like Sottsass" key tag.
Draw Your Own Book $15
Operating under the premise that simplicity fosters imagination—keeping rules to a minimum—Supereditions presents Draw Your Own Book. These blank-page, pocket-size volumes call on anyone with a mind's eye to fill in the backstory behind titles like The Magic Sausage, The Angry Fairy, The Kingdom Up My Nose and more.
Jacobsen Salt Co
Artisan Sea Salt Slide Tin $3
Harvested from the cold waters off the coast of Oregon, Jacobsen Salt Co's beautifully flakey crystals strike the perfect balance between earthy minerality and full on salty ocean flavor. Loved by chefs like Thomas Keller (Per Se) and April Bloomfield (The Spotted Pig), Jacobsen's salt has the refinement of centuries-old fleur de sel with the zing of new American enthusiasm.
Cool Weather Edible Seedbombs $13
This two-pack of cool weather edible seed bombs includes Pot Marigold, "Seven Top" Turnip and Tatsoi. Greenaid hand rolls their seed bombs using socially responsible labor practices and works in partnership with Chrysalis, a non-profit that creates employment opportunities for formerly homeless men and women in Los Angeles.
RMS Beauty
Raw Coconut Cream $18+
Coconut oil has emerged as something of a magic elixir of late, and RMS Raw Coconut Cream lives up to the hype. Imagine a natural, organic version of your grandmother's cold cream that, on top of working as an all-in-one makeup remover, cleanser and moisturizer, nourishes hair and lashes and soothes sunburns like only the wonder oil can do.
Chiaverini Cherries Jam $10
With packaging as sweet as its contents, Chiaverini's canned jam makes for a pleasant little foodstuff gift. Available at the equally adorable and sophisticated London shop, The Hambledon, the brand's Florentine origins date back to 1928.
Cotton Bureau
Skulls and Bolts T-Shirt $24
James Victore protégé Chris Thompson likes to draw skulls on just about everything—and the upshot is a perfected take on the classic design motif. His Skulls and Bolts t-shirt is as badass as it if playful, and comes in sizes fit for men or women.
Hooray for Boobies! Socks $25
Subtle but effective, Soxfords' "Hooray for Boobies!" mid-calf socks add a dash of daring style while helping raise money for breast cancer research. For each pair of the dark grey Peruvian Pima cotton socks sold, $5 will be donated to support Breast Cancer Awareness efforts.
Seth Casteel
Underwater Puppies $15
Award-winning pet photographer and animal rights activist Seth Casteel compiled his captivating photographs of puppies under water into a book featuring 72 highly entertaining portraits.
Emily Spivack
Worn Stories $16
Brooklyn-based writer Emily Spivack has been publishing essays about people and their clothing since 2010 on her blog, Worn Stories. The highly personal accounts vary in tenor, but all maintain a thoughtful, honest sensibility. She's now taken the stories into the physical realm with her book of the same name, which includes narratives from the likes of Paola Antonelli, Rosanne Cash, Marina Abramovic, Rachel Comey, Pat Mahoney and more.
Smile Squared
Donate Smiles $5
Family-run Smile Squared donates a bamboo toothbrush to a child in need for each toothbrush purchased, but you can also eschew the brush and still join their altruistic effort with a simple $5 donation. Studies show clean teeth are not only cosmetically uplifting, but regular brushing also prevents heart disease.
Murray's Original Pomade $3
The pomade of choice for music legend DJ Harvey when he's going for a "Jewish gangster" hairstyle, Murray's Original Pomade was developed in 1926 by Chicago barber C.D. Murray, who wanted to make a high-quality but inexpensive wax-like grooming aid.
Glass Food Storage $15+
These BPA-, BPS- and phthalate-free glass containers come in a variety of sizes and with its own colorful silicone sleeve that uses button tabs to secure on the lid. They're safe to use in the oven, microwave, freezer and dishwasher, making lunches and leftovers easier and more attractive than ever before.
Hands Baggu $9
Baggu's ingenious design makes for the most functional and stylish eco-bag out there. Joining their line of of reusable shopping bags this season is a new "hands" print, which with peace signs and shaka signs, spreads the good vibes while on the move.

subset: commoncrawl


text:
To perform a search, enter a keyword, phrase or item number in the search field and click "search."
We offer two ways to locate information:
The country best known for Port,
Madeira and corks is often overlooked when consumers think of red and white still
wines - but take note! The table wines of the region have improved dramatically in the past few decades. The
winemaking areas trickle down the country's narrow shape, bordered by the Atlantic on the west and Spain on the east.
Notable...Read More About Portugal
Port Wine
Port is a fortified wine that is made by adding brandy during fermentation. The addition of spirits kills the yeasts,
which in turn halts the fermentation process. This results in a wine both sweet and high in alcohol. Named for its
home city Oporto, true Port must come from the designated area. The grapes used are a blend,, but the favored grape
thought to...Read More About Port
Ship on us for a month!
After your free trial, StewardShip is just $49/year.
*Some exclusions apply


text:
Nell (Hangul: 넬) is a south korean modern rock band. Formed in 1999, the band consists of Kim Jong Wan (김종완) on vocals, guitar and keyboard, Lee Jae Kyong (이재경) on lead guitar, Lee Jung Hoon (이정훈) on bass guitar and Jung Jae Won (정재원) on drum.
our SoundCloud page
our Twitter page
Nell's Official Internet PresenceKim Jong Wan's Twitter
This blog was created with the sole purpose of providing Nell fans with information and updates on all things Nell. Everything posted here was gathered/compiled/translated etc. by the all-around dedicated nellband team. Sharing is caring, but please give us credit when taking or reposting.
None of the media content here belongs to us unless otherwise stated.Nellband team
Admins: Kureyo, Jjoongie, Pencil's Admirer;
Translator: Eduipe;


text:
Main Content
The rebellion has begun! And this time it's not about corporate greed, social inequality, civil rights, nor political differences—this time it's all about style. At this very moment, somewhere in the shadows, there is a secret society of geriatric fashion designers scheming to take over the world with their tasteless clothing and their über-lame style. You see it all around you, in schools, parks and shopping malls—people wearing ugly, bland gear without being aware that they look totally ridiculous. Well it's too bad the fashion globalist elite didn't count on the likes of a rebel like you, man. You just won't let anyone tell you what to wear. So while other dudes are brainwashed into wearing pink tees, you can rock your nonconformist swag in this Rebellion jersey tank top from Metal Mulisha. With a Metal Mulisha skull printed at the left chest with tonal brand lettering printed below, the company's establishment date printed at the back yoke and contrast-colored embroidery, this lightweight tank will let you stand out amongst the others and hopefully encourage some of them to open their eyes and ditch the latest fads.
- 100% Polyester fabric
- Imported
- Metal Mulisha embroidery
- Metal Mulisha screen print
- Mock jersey tank top
- Rib-knit V-neck collar & arm holes
Mulisha Customers also liked:
Special event items are produced by manufacturers only after the outcome of a game or event. These are advanced sale items and will ship immediately after they are received in our warehouse.
Manufacturer direct items are shipped directly from the manufacturer. These items are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite number, and/or designs. Some options may be limited by league rules.


text:
PandaBoard Accessories & Peripherals
From OMAPpedia
Revision as of 05:31, 3 April 2011 by Manfred.bartz (Talk | contribs)
This page contains a list of community verified accessories & peripherals for PandaBoard. The official list of verified accessories is at PandaBoard.org.
Please feel free to edit this page and add other accessories you have gotten to work.
Power supply
The PandaBoard needs a 5Vdc power supply:
- The official PandBoard.org accessories page recommends the Digi-Key T951-P5P-ND (5V/4A)
- Caution (from the System Reference Manual): Only use a 5Vdc regulated power supply to power the PandaBoard. Connecting a supply with an output higher than +5Vdc could cause possible board damage.
- Is 4A really necessary? This depends on the configuration you use, mainly how you supply the attached USB devices. If you intend to fully load the USB ports, yes you need a 4A power supply. But with all USB devices on a powered hub the PandaBoard uses e.g. 560mA @ 5V. So a 1.5A supply should be OK as long as you don't load up on directly connected USB devices.
- The plug packs which come with USB hubs are usually rated 5V 2A. They are fine subject to limitations as above.
- Model: AT-7
- iMO-AT7-Configure and Setup
- Bus 001 Device 009: ID 0eef:0001 D-WAV Scientific Co., Ltd eGalax TouchScreen
- Purchased: thinkgeek.com
JTAG Emulators
- Blackhawk USB-560M Emulator (was able to connect with CCSv4 on PandaBoard and was able to read registers/memory)
- XDS100v2
- Samsung P2570HD (DVI input on Display and HDMI output on Panda)
- Optoma PK201 (Tested on Panda and works like a champ!)
SD cards
- Kingston 8GB SDHC Class 6 - very good/fast card! (Tested on Panda)
- Patriot 8GB SDHC Class 4 - Warning: very slow card! (Tested on Panda)


text:
US: Retailers' August 2012 sales roundup
The following is a general roundup of US apparel and shoe retailers' August 2012 sales results.
Get full access to all content, just $1 for 30 days
A Message From The Editor
just-style gives you the widest apparel and textile market coverage.
Paid just-style members have unlimited access to all our exclusive content - including 14 years of archives.
I am so confident you will love complete access to our content that today I can offer you 30 days access for $1.
It's our best ever membership offer – just for you.
Leonie Barrie, editor of just-style
Leonie's offer to you
Risk-free, money-back guarantee
Most Popular
- Tesco's H1 profit plunge: What the analysts say
- Marks & Spencer to extend mobile phone monitoring
- Asos FY profit drop: What the analysts say
- China tightens on corporate social responsibility
- Mango continues on global growth trajectory
- Cambodia clothing factory collapse injures eight
- H&M and The North Face commit to responsible down
- Collapsed Cambodia factory had structural issues
- Transparency boosts Cambodia factory improvements
- More reform needed in Bangladesh apparel sector
Market research
- Ethiopia – the emerging textile and clothing industry
- Apparel Market in China to 2018 - Market Size, Trends, and Forecasts
- Global market review of denim and jeanswear – forecasts to 2020
- Prospects for the Textile and Clothing Industry in Vietnam
- Wool in the 21st Century: new prospects for a familiar fibre


text:
Worries over the safety of hydraulic fracturing or "fracking," as a method to drill for oil and natural gas continue to grow across the United States.
Just a few months ago, anti-climate zealots in the U.S. House of Representatives attacked the Environmental Protection Agency's programs to cut pollution in our air.
The Western Governors' Association is hoping to take some common sense steps to prepare for the disruptions that come with climate change.
From National Parks and National Monuments to wilderness areas, our open spaces provide a great opportunity to celebrate America's Independence Day.
The Wilderness Society and a coalition of more than 100 local and national groups sent a letter to members of the House of Representatives on June 14 asking them to oppose a bill that would end protections for vast tracks of pristine wild lands.
TWS President Bill Meadows commented in the National Journal's ongoing "Energy and Environment" forum, calling for an end to unnecessary subsidies for the oil and gas industry, and better support for the burgeoning wind and solar industries in the U.S.
Earlier this month I was fortunate enough to help organize and participate in one of the first trail stewardship projects in one of Idaho's newest Wilderness areas, Big Jacks Creek Wilderness. It was an experience that was physically challenging and richly rewarding. The Wilder
President Obama's conservation initiative, America's Great Outdoors took another step forward on June 13.
The Grand Canyon is one of the world's most iconic places. A stunning slash in the earth where we can go to experience the power of nature and hear ― the sound of helicopter blades and airplane engines?
If you agree that the grand landscapes of the Old West are worth sharing with future generations, then you would have joined in the applause recently at the National Museum of the American Indian.
Tweets about "@wilderness"
Tell congress it's time to stop sitting on more than two dozen wilderness bills.


text:
Main Content
Commemorate Kevin Harvick's win in the first 2013 NASCAR Budweiser Duel Race with this die-cast car! Featuring a high-quality paint job and incredibly realistic details, this die-cast car is a 1:24 scale replica of Harvick's car.
- 1:24 Scale die-cast car
- High-quality graphics
- Limited edition collectible
- Officially licensed NASCAR product
Harvick Fanatics also liked:
Special event items are produced by manufacturers only after the outcome of a game or event. These are advanced sale items and will ship immediately after they are received in our warehouse.
Manufacturer direct items are shipped directly from the manufacturer. These items are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite number, and/or designs. Some options may be limited by league rules.


text:
Why is Bargnani on the floor?
Lowry can't handle pressure?
Derozan isn't getting plays ran for him with Gay off?
Why is Gay off? (Fouls are stupid at this point, team is struggling)
We have no rebounding presence!
Bring in John Lucas...
Fields really sparked the D right here presence is felt! huge block there on that Lowry layup.
my boy A Randolph on the floor now. lets see what he does ahahahah
A key that opens many locks is a master key, but a lock that gets open by many keys is just a shitty lock
That's it! I can't take it anymore! Can we please trade for Blair right now? I'm sick and tired of our shitty rebounding! Old Bargs is back! Worst rebounding big man in the history of the NBA!
There are currently 1 users browsing this thread. (0 members and 1 guests)


text:
Beck & Hersey is a product of the times. The brand has been around for a few years now and is becoming increasingly popular. You can see when you look at Beck & Hersey clothing that they have been styled by what influences are around us. We stock a good range of the latest Beck & Hersey sweatshirts with the unmistakable printed designs that reminds us of the world we live in. The classic look of Beck & Hersey trainers finish the look off well and all at affordable prices.
Beck and Hersey – Much More than Just Footwear
Beck and Hersey footwear is funky and stylish, but the brand stretches far beyond shoe design.
Join the Style Revolution with Beck & Hersey
You can join the style revolution with radically different Beck & Hersey clothing that makes a statement about you, your fashion sense and your ideologies with its bold prints and edgy slogans.
Break the Rules with Beck & Hersey
You can break the rules with Beck & Hersey clothing that refuses to conform with its bold colours, outrageous prints and daringly different designs that offer a bad boy charm and bags of statement style.
High Definition Clothing from Beck & Hersey
Buy clothes that stand out from the crowd with Beck & Hersey clothing that comes with high definition designs as standard; for an impactful alternative to everyday streetwear.


text:
Great served toasted with lashings of butter and icing sugar.
Preheat oven to 180C (350F).
Lightly whisk eggs, milk and vanilla together.
Sift flour, baking powder and cinnamon into a bowl, add sugar and coconut, and stir to combine.
Make a well in the centre and gradually stir in the egg mixture until just combined.
Add melted butter and stir until the mixture is just smooth, being careful not to over-mix.
Pour into a greased and floured 21 x 10 cm (81/2 x 4 in) loaf tin and bake in the preheated oven for 1 hour, or until bread is cooked when tested with a skewer.
Leave in tin to cool for 5 minutes, and remove to cool further on a wire rack.
Serve in thick slices, toasted, buttered and dusted with icing sugar. Makes 8-10 thick slices.
» Metric Converter
Pinot Noir, Chardonnay and Pinot Gris are the best wines to pair with Coconut Bread.
Please note, LifeStyle cannot respond to all comments posted in our comments feed. If you have a comment or query you would like LifeStyle to respond to, please use our feedback form.
» Related
Recipe by Bill Granger from bill's food
Dear Sir/Ma, We have direct providers of Fresh Cut BG, SBLC and MTN which are specifically for lease. Our bank instrument can be engaged in PPP Trading, Discounting, Signature Project(s) such as Aviation, Agriculture, Petroleum, Telecommunication, Construction of Dams, Bridges, Real Estate and all kind of projects. We do not have any broker chain in our offer neither do we get involved in chauffer driven offers. We deliver with time and precision as set forth in our agreement. Our terms and Conditions are reasonable, below is our instrument description. DESCRIPTION OF INSTRUMENTS: 1. Instrument: Bank Guarantee (BG/SBLC) 2. Total Face Value: Min of 1M Euro/USD (One Million Euro/USD) to Max of 5B Euro/USD (Five Billion Euro/USD). 3. Issuing Bank: HSBC, London or Deutsche Bank Frankfurt or any Top 25 WEB 4. Age: One Year, One Day 5. Leasing Price: 5.0% of Face Value plus (0.5+X)% commission fees to brokers. 6. Delivery: Bank to Bank SWIFT. 7. Payment: MT-103. 8. Hard Copy: Bonded Courier within 7 banking days. All relevant business information will be provided upon request. If Interested kindly contact me via Email:~ email@example.com Skype ID: bgjan.farnholt Jan Jacob Farnholt
» 14h ago
Darwin ---the capital city of the Northern Territory Darwin has a pace that might - almost - be described as brisk, at least by Northern Territory standards. The city's populace now reflects its proximity to Asia: the mix of some 50 cultures including Aborigines, Vietnamese, Filipinos, Malays, New Guineans, Pacific Islanders, Japanese, Indonesians and European Australians, provides a strong cosmopolitan flavour. The Northern Territory's capital, Darwin was founded in 1869, after more than 40 years of failed settlements in the north – abandoned one after another because of malaria outbreaks, cyclones, Aboriginal attacks and supply failure due to the sheer distance from the other white settlements. It was named after Charles Darwin, one of whose shipmates on the Beagle discovered the bay in 1839. The best way to appreciate Darwin's multiethnic mix is to visit this market, held every Thursday and Sunday evening from April to October, with stalls selling foods from around the world and handmade craft including crocodile products, indigenous art and jewellery. If you have come to Darwin city, you will understand the local culture and history of Darwin, taste some delicious food and enjoy the amazing scenery here ,also take some photo is a pretty good experience . do you think so. If you can ,take the photo to the profession canvas prints shop to made a canvas painting, it is can as a gift to your friends or hangs in your home to add more beauty to your home. custom canvas online photo on canvas-Canvas Prints http://www.customcanvasonline.com.au/split-image-canvas-prints-stretched-ready-to-hang/
» 1d ago
We offer fresh cut bank instrument for lease/sale, such as BG, SBLC, MTN, Bank Bonds, Bank Draft, T strips and others. Leased Instruments can be obtained at minimal expense to the borrower compared to other banking options. This offer is opened to both those and corporate bodies. Description of Instrument: 1.Instrument: Bank Guarantee (BG)/SBLC 2.Total Face Value: MINIMUM 1MILLION EURO/USD - MAXIMUM 100BILLION EURO/USD 3.Issuing Bank: HSBC London or AA rated Bank in Western Europe or USA. 4.Term: One Year, One Month 5.Leasing Price: 5% of Face Value plus 0.5% Lessor agent [Closed] & X% Lessee agent (open) 6.Style of speaking: SWIFT TO SWIFT 7.Payment: WIRE TRANSFER 8.Hard Copy: Bonded Courier surrounded by 7 We are RWA ready to close leasing with any interested client in few banking days, if interested do not hesitate to contact us via banking days Our BG/SBLC Financing can help you get your project funded, loan financing by providing you with yearly renewable leased bank instruments. We work directly with issuing bank lease providers, this Instrument can be monetized on your behalf for 100% funding: For further details contact us with the below information. Contact : Khan.kamal Email: firstname.lastname@example.com Skype ID: kamal.lease Intermediaries/Consultants/Brokers are welcome to bring their clients are 100% protected. In complete confidence, we will work together for the benefits of all parties involved.
» 2d ago


text:
Please help me with my little problem....
I've just installed my webserver with PHP
and it works (i think) fine.
There is however one problem. Sometime
when i want to install a script i got the
error that de variable is not defined and i
get a list of variables that are not defined.
I think the problem has got to do with the
fact that i cannot call the PHP like this:
the php script then says that the variable
setup is not defined...


text:
To perform a search, enter a keyword, phrase or item number in the search field and click "search."
We offer two ways to locate information:
A sweet, dried black cherry nose, with hints of currant, leading into the same flavors in the mouth. The wine is soft, rich, with enough tannin for aging.
This small, family operation specializes in Pinot noir, offering traditional barrel aged wines, as well as ECO wine, a sulfite-free Pinot noir made from organically grown grapes. Other varietals include both dry and late harvest Gewürztraminer and Riesling; Gamay noir, and Oregon Blush.
Named for the river that runs through the valley from Portland to Eugene, Willamette Valley is home to some of the best Pinot Noir vineyards in the Northwest. While along the same north/south line as Seattle, the Willamette Valley is protected from Pacific rains by the Coast Range on the western border and the Cascade Ranges to the east. Though sunshine is...Read More About Willamette Valley
Pinot Noir(PEE-noh nwahr)
Pinot Noir is a finicky grape. It only grows in
the right climate, with the right soils and the right care. Perhaps because
it is so difficult is why it is so loved. Pinot Noir hails from Burgundy, a region known for crafting the most collectible and sought-after wines from this varietal.
Not only does Pinot reign in Burgundy, it is also...Read More About Pinot Noir
Ship on us for a month!
After your free trial, StewardShip is just $49/year.
*Some exclusions apply


text:
Uploading this file I agree to the terms of service.
Do not upload any copyrighted files that you don't own the rights to or don't have permission from the owner to distribute even if you have no intent of actually distributing them.
Max File Size: 5120 Kb (5 Mb) | All file types allowed
InWorG.com is a files and images sharing service that allows you to easily upload, link and share your images and files on MySpace, eBay, blogs, message boards and web sites.
You don't need to open an account to use InWorG.com!There is no time limit on the storage of uploaded files!Download files to your mobile phone for free!Send files as email attachments! ...and much more
Beautiful, natural, nude girls. The most imitated nude art site in the World! Met-Art galleries • Veronika C.
All models appearing in this site were at least 18 years of age. All photos and scenes are copyright of their respective owners.
©2007-2014 InWorG.com, all Rights Reserved.
1023 users online | Friends | Tag | Sitemap | Short URL


text:
The ALS Association Jim "Catfish" Hunter Chapter
ALS Ice Bucket Challenge Takes U.S. by Storm
Thanks for the support! Read More »
Monday November 10, 2014
Purchase your tickets today! Learn More »
Big ALS Raffle
Only $10 per Ticket! Learn More »
Walk to Defeat ALS® Season Starts
It's time to put on your walking shoes! Get Started »


text:
Brandon Lloyd Signed Framed TD Photo
Each Brandon Lloyd Signed Framed TD Photo is hand signed by the Patriots wide receiver and is handsomely matted and framed. This unique photo shows #85 smiling as he makes a touchdown reception against the Buffalo Bills on September 30, 2012. A limited number of these framed 11"x17" photos are being made available, gets yours while supplies last!
ProShop Memorabilia is exclusive autographed and game worn items directly from your team.
$199.95 $24.95 Only 1 left in stock - order soon.


text:
Got a 'job' to do? Want to grow some privacy? Let vines help.
Screen an area. Decorate a deck. Create a cascade of color. It's all easy with our selection of magnificent vines. From the honeysuckles to the passion flower, there's a wide selection for all garden situations.
We also have an extensive selection of Clematis Vines.
There are no products matching the selection.
We're sorry, but the following items are currently unavailable
The following items are either out of season or we've sold out of our inventory. Please feel free to browse our selection and Sign Up for our Newsletter to be notified when these products are available for next season! We often have similar items available, so please utilize our search or filters (on the left) to explore other options. Or, call us at 877-309-7333 for help.


text:
Please select a language you
want to receive our newsletter in:
The Benelux is crazy for cycling, both for sport and daily transportation. Bike paths in Holland and Belgium crisscross beautiful countryside, in windmill dotted flatlands, along canal embankments through medieval town centers. Luxembourg is laced with cycle paths but be ready, part of this country is called Little Switzerland and can not be described as flat!
Cyclists will definitely take pleasure in the Grand-Duchy of Luxembourg on the 575 km of its national network of cycle routes. These paths are well marked and have good surfaces; where local routes are employed, roads with little traffic are chosen. Cycling through Luxembourg is the best way not to miss any of the charm or diversity of this gem of a European country.
Cross the Ardennes into Belgium and you'll find lots of like-minded souls on a fair weather weekend.
There is nothing quite like biking through its contrasting landscape of flatlands in Dutch-speaking Flanders and rolling hills in French-speaking Wallonia, both a cyclist's dream. Miles of bicycle paths fun alonside romantic canals winding between quaint towns, charming castles, outdoor cafés and incredible restaurants.
Holland was made for cycling – or is it the other way around? Relatively flat with a mild climate, unending cycle paths, short distances between towns, and motorists who are very bike-aware make pedalling around the Netherlands an absolute pleasure.
All 12 provinces have something unique to offer so you'll never be faced with a monotonous landscape. Consider the rural provinces of Friesland and Groningen in northern Holland, where you can jump across to the Frisian islands or roll up to inspect an ancient hunebed, or burial mound. Glide through the green heart of the urbanized Randstad, the densely populated triangular area between Amsterdam, Rotterdam, and The Hague. In Overijssel, Drenthe, and North Brabant the cycle paths traverse woods and heath.
A journey around the IJsselmeer (the former Zuiderzee) includes traditional fishing villages and cheese towns, and in the spring there are the bulb fields. For those craving more exertion there are hilly routes through the dunes of Texel and the provinces of North and South Holland, through the Veluwe forest in Gelderland, and in the rolling hills of southern Limburg. And you thought it was all going to be the same?
The Balkan Peninsula forms the southeast part of Europe, a region where different cultures.
Dramatic scenery, winter sports, the northern lights and the midnight sun, saunas, and reindeer.
Central Europe is eager to welcome you to discover its treasures!


text:
Chris Butler's first Giro d'Italia ended Saturday when the BMC Racing Team rider was diagnosed with a hairline fracture of his right pelvic bone.
Crashed Monday
Butler crashed on Monday's third stage, but did not learn the full extent of the injury until X-rays were taken after he finished Saturday's 217-kilometer race. BMC Racing Team Chief Medical Officer Dr. Max Testa said Butler did not want to stop. "But it would be worse if he crashes again, and, because of the pain, he was riding completely twisted," Testa said. "We'll keep him off the bike for a few days, the put him on a rehabilitation program and hopefully he'll be back in a few weeks."


text:
Shop the HBO Gift Guide and get gifts for him. We have unique gifts and fun stocking stuffers. Find Game of Thrones t-shirts, Eastbound & Down gear, and Boardwalk Empire glasses, and more great gift ideas. Whether youre shopping for men, dads or boys, youll find something to suit every guys taste.
- exclusive
- Veep Lanyard
- 0.0(No reviews)
- $9.99
- exclusive
- Wool Newsboy Cap
- 0.0(No reviews)
- $32.95
Can't find what you're looking for? Suggest a product ›


text:
To view this video download
Flash Player
There are roots-rockers and then there's Webb Wilder. The self-proclaimed "Last Of The Full Grown Men" is large enough for the big screen, hip enough to star in cult classic B movies, and tough enough to maintain a devoted worldwide fan base through a relentless never ending tour schedule. More Like Me, his first collection of new material since 2005, is classic Webb Wilder, an ... Read more in Amazon's Webb Wilder Store
Show availability and shipping details
There's a problem loading this menu right now.
Learn more about Amazon Prime.
Your Shopping Cart is empty.
Give it purpose—fill it with books, DVDs, clothes, electronics, and more.
If you already have an account, sign in.
There's a problem previewing your cart right now.
Check your Internet connection and go to your cart, or try again.


text:
"The emotion that can break your heart is sometimes the very one that heals it…" Nicholas Sparks
Thank you everyone for your well wishes and kind comments… My heart goes out to all who have lost so much; lives, homes, memories… I am deeply touched and saddened by the devastation that Mother Nature has wrought… but we shall all recover. Today, I ventured outside after being cut off for two days, and what I saw on the news and on the internet made me weep. We don't have power, cell or internet access (pales in comparison to many). We have toppled trees and branches everywhere and the possibility that power won't return for a while; so I stopped by my local Barnes & Noble to write this quick post. When feasible, I will stop by and thank all of you who left messages and comments. A big thank you to all who have helped the many; govt, 1st responders, news outlets, red cross, kind folk… Blessings to all.
"The wound is the place where the Light enters you." Rumi
When the sky darkened around me and the winds screamed angrily, I realized how petty the things that usually bother me had become. When we are under the peril of a thunderstorm that is wrecking havoc all around us… how can we not call on that which is mightier than us? Stay safe and blessings to all. I love you!
"The human heart has a way of making itself large again even after it's been broken into a million pieces." Robert James Waller
I will follow up tomorrow as they are telling us to wrap it up… Stay safe all and prayers and blessings to all who are hurting… Thank you again to all who have shown compassion and caring…
*Please bear with me as I catch up on your blogs and commenting… I'm back on track with reading and responding to your blogs; albeit at a slow pace. Thank you all for your patience! :-)
Positive Motivation Tip: Stand still when fear grips you and turn within… there are divine guardians reaching out to you.
PHOTO CREDITS/ATTRIBUTIONS: All Photos via Wikipedia, DenverPost.com, Flickr or mine…Sandy's storm, East River at 11am today via D. Shankman, via Wikipedia, Family watching the waves via CNN.com, via Flickr, or via my personal collection
Until Next Time…
Ask. Believe. Receive. ©
Elizabeth Obih-Frank
Mirth and Motivation
Positive Kismet
Related articles
- Reflections: Post Hurricane Sandy… (eof737.wordpress.com)
- Inspirational Haiku: Stand Still – Hurricane Sandy… (eof737.wordpress.com)
- photos: Lindenhurst, NY after Hurricane Sandy (brooklynvegan.com)
- Join Us In Helping Those Affected By Hurricane Sandy (wycd.cbslocal.com)
- Send Us Your Hurricane Sandy Storm Photos (washingtonian.com)


text:
I'm thinking about booking a campground and was curious where everyone was staying.
I was looking at Dolly Copp and there aren't many good reservable sites left. Are most of the sites un-reservable?
I'm thinking about booking a campground and was curious where everyone was staying.
I was looking at Dolly Copp and there aren't many good reservable sites left. Are most of the sites un-reservable?
Next up: Vermont City Marathon: May, 2011
I've got a site at Moose Brook. Really liked it last year. Dex and Baxter shared the site with us. DoNotGoGentle and his whole crew were a couple spots over.
Summit Club Member
Seek the Peak 11
Seek the Peak 10: Lions Head/Tuckermans Ravine
Seek the Peak 09: Boot Spur (redux)
Seek the Peak 08: Huntington Ravine
Seek the Peak 07: Tuckermans Ravine/Lions Head
My 48: Washington (07/07, 07/08, 07/09, 09/09, 07/10), Lafayette (08/08, 08/09), Lincoln (08/08, 08/09), Pierce (07/10), Carrigain (09/10), Cannon (10/10), Jackson (11/10), Field (11/10), Tom (01/11)
We're staying at Shapleigh Bunkhouse at Highland Center since we are starting a 4 day hut hike the day after STP. Campground didn't make sense for us with only 2 nights. Everything in the area fills up really fast around this date. We made our reservations in March and the AMC lodging (both huts and lodges) were already getting full. Campgrounds and hotels aren't a much better story unfortunately...
Keep close to Nature's heart...
and break clear away, once in awhile,
and climb a mountain or spend a week in the woods.
Wash your spirit clean. - John Muir
Hiking photos: http://picasaweb.google.com/mtruman42
Hiking Blog: http://theramblingsblog.blogspot.com/
Seek the 2011 Peak page: Mark Truman's Pledge Page
Just got a place at Moose Brook for Friday and Saturday night. Should be fun.
Next up: Vermont City Marathon: May, 2011
I am staying at the Ammonoosuc camp ground Friday the 25th till Friday the 1st.. Can't wait.
Last edited by CHRIS; 06-04-2008 at 03:16 PM.
I'm staying on the summit of Mt Washington!
Is there really any BAD weather???
Don't rub it in!Originally Posted by WSR88D
Brad (a 6288 club member)
http://bradstreet.zenfolio.com Personal Photo sales site
http://public.fotki.com/bradbradstreet Personal photo web site
http://public.fotki.com/MWO/saved/2012/ MWO image & video archive site 2006-2012
Tim, Debi and I (along with various and sundry family members yet TBD) will be at Moose Brook!
We're looking forward to seeking everyone out and saying hello. Maybe we'll wear our STP shirts from last year so that we're obvious. Last year, we were identifying each other by the flip-flops.
I haven't worn my STP shirt very much because it is long sleeve but I will be wearing it up there for sure.Originally Posted by Tim&Val
Is there really any BAD weather???
We've secured the shelter at Moose Brook for STP weekend. It is an open sided shelter with a picnic table and huge fireplace. I say the apre dinner party/party will be here, if anyone is still awake after climbing and eating turkey.
Mount Washington:http://ghostflowers.com/nhscenics/mountwashington.html


text:
More cpp/lock options/cpp events
Every time LabTool starts, it waits for the host computer to send it the firmware to execute.
We can use an invariant to help us reason about a piece of code that many programmers find hard to get right by any other means.
Honoring women in STEM
Possibly the worst sin of calling malloc is that it might take a very long time to complete.
We can think of an invariant as being a claim or belief about the state of program that we expect to be true each time control reaches a particular point in the program.
This month,
Dr. Dobb's Tech Digest explores DevOps. We highlight the emerging trend of using lightweight containers to standardize dev environments and deployment stacks
, and much more!
Download the latest issue today. >>