At the front of the HealthLeaders Magazine, they have a FactFile every month with data from Truven Health. The one from March 2014 focused on price variation and transparency. I thought I'd share a few of the charts.
This first chart shows their projections about the impact of a price transparency tool on cost savings over three years. (BTW – If you're looking for information on price transparency tools, I would go to Jane Sarasohn-Kahn's blog HealthPopuli and look at her posts on transparency – Part I, Part II, Part III, Part IV, and Part V). Their projection was $6,786,000 in year 3 for an employer with 20,000 employees (or about 46,000 total covered lives if you assume a ratio of 2.3).
The other topic in the FactFile is about price variation and potential savings. They looked at three procedures and the variation in pricing for them. They then estimated the savings from those three procedures for an Chicago based employers.
As you can see, the variation is dramatic. What this will eventually lead to is called "reference-based pricing" where payers will agree to pay a fixed amount (or reference price) for a procedure and consumers will have to use transparency tools to figure out which providers will meet that price or pay out of pocket to go elsewhere. The hope is that this will drive down prices, make consumers aware of differences, and finally help people understand that price and quality are NOT correlated in healthcare.
Will Smart Sports Equipment Lead To Better Athletes?
For those that are part of the Quantified Self movement, this is just a natural extension. You can now measure your different sports.
Swingbyte – a sensor that clips to your golf club to monitor speed, acceleration, arc, and other stats.
94Fifty Smart Sensor Basketball – a sensor embedded in a basketball to track shot speed, arc, and backspin along with dribble speed and force.
FWD Powershot – a sensor that fits into the handle end of a hockey stick and measures speed, angle, and acceleration.
Zepp Baseball Sensor – a sensor stuck to the knob of a baseball bat that tracks the speed and plane of the swing and the angle of impact.
There's also the Babolat Play which is a smart tennis racket.
On the one hand, this stuff is fascinating and amazingly cool. On the other hand, who even knew that dribble force was something for me to be coached on. It will be interesting to see how athletes and coaches adopt these technologies and how they help improve sports over time. Will they increase the stress for the average athlete who was never going to be great and was just playing for fun? Will they improve everyone and help players and coaches really focus where they can make a difference?
This was just one of the really great data points I got from the Medication Adherence Clinical Reference page from the American College of Preventative Medicine. It's worth a read.
Non-adherence is thought to account for 30-50% of treatment failures.
Trust and communication are critical factors in adherence.
I was reading an article the other day about devices like FitBit and their use within corporate wellness programs. One of the questions it was asking was why use them when people abandon them after a while. I found this great chart from Endeavour Partners in their whitepaper which looks a lot like an adherence curve. They say that 1/3 of people abandon their devices within 6 months which makes it a hard investment for anyone.
It's the same question you might ask around mobile apps. While this chart shows that Americans install almost 33 apps, the questions is how long they use them.
So, what gives? Do we have unreasonable expectations? I would say yes.
We live in a ADD culture where people are constantly multi-tasking. People want things that evolve and constantly change. It's the same reason we don't want the same experience every single day. It's the reason that you've seen people from gaming coming into healthcare. They understand how to keep people engaged over time.
Whether you want to picture it as a customer journey or different phases, the reality is that messaging needs to evolve with the consumer. If you got the same letter every month, at some point, you don't even pay any attention to it. At some point, you wouldn't even open it.
When I worked in healthcare communications, it was the same challenge from a strategy perspective. How would we coordinate communications across channels? What would the first message say versus the fifth message? How do you avoid message or channel fatigue?
It's the same thing in the digital or device world. So, I ask the question…do we have unreasonable expectations about these tools by thinking that we can put them out there and sustain use of them? I think so. We need an evolving, constantly changing strategy about content, community, functionality, etc. to keep engagement sustained.
First CVS Caremark began offering mail order (90-day Rxs at lower cost) at retail stores (aka Maintenance Choice), and now with Specialty Connect, they are doing the same thing in specialty pharmacy.
Specialty Connect was a pilot program that won the PBMI Innovation Award this year. What it does is to allow consumers the choice of getting their specialty medications at either the CVS Caremark specialty pharmacy or picking them up at a local store. This is a change since: (1) many pharmacies don't typically stock specialty medications; (2) many PBMs require use of a specialty pharmacy (i.e., mail); and (3) specialty medications typically require some addition handling and counseling which may be difficult to do at a local store level.
Specialty Connect has demonstrated high levels of patient satisfaction as well as improved adherence for specialty pharmacy patients. In fact, pilot program results demonstrated a 13 percentage point increase (from 66 to 79 percent) in patients who were optimally adherent to their medication. Early program results also show that the program is improving upon the patient experience and reducing traditional barriers to getting started on medication, with 97 percent of patients successfully starting on therapy after only their first interaction at a CVS/pharmacy store. In addition, more than half of patients, many of whom were existing mail service pharmacy customers, chose to pick up their specialty medications at CVS/pharmacy.
Hopefully, this and many of the other CVS Caremark successes will make people wonder why they ever wanted to break the company up into different business units. As I've said for years on the blog, in the press, and to many Wall Street analysts, the integration of the business units can offer huge value once the synergies are realized and the consumer experience is integrated.
It's great to offer a centralized call center to support specialty but will that be enough at the local store level? Will patients want some type of higher touch local presence? Can that be achieved through a telemedicine or kiosk type solution?
I remember about 5 years ago when most specialty people thought they had to treat patients with specialty diseases differently. I kept trying to argue that they are just like other consumers. You should think about the experience across channels and at the patient not just condition level. This seems to signal a movement towards this. They are using SMS (text messages) and other channels to communicate with them which was a foreign concept a few years ago.
The IMS Institute for Healthcare Informatics published a report in January called "Engaging Patients Through Social Media".
One of the things it highlighted is the incredible use of Wikipedia for healthcare information. People are typically going to Google and looking for a disease. Based on Wikipedia's page rankings, this often leads them there.
Now, what makes this more interesting is the article in the BBC News which says that 90% of wikipedia articles on health contain errors.
Of course, the trick in reading the article closely is that it says they found that "90% of the entries made statements that contradicted latest medical research". What's the difference? Well, we know that it takes years for evidence-based medicine to become adopted within healthcare. So, how long does it take the latest medical research to get updated on all the sites? What I would love to see is a comparison of Wikipedia to WebMD, Ebix, and Healthwise. That would be telling.
The 5/26/14 edition of Forbes has a great article on Novartis called "Will This Man Cure Cancer?". It's an interesting article and Novartis has really ramped up their focus on Oncology with their purchase of Glaxo's Cancer drugs. And, they recently got FDA approval for a lung cancer drug of theirs.
A focus on speed to stop having to turn patients away from a possible cure.
Cancer drugs already represent $11.2B of Novartis' $58B in sales.
Novartis has a 33% stake in Roche which has $31B in oncology sales.
Gleevec was it's big breakthrough oncology drug that Jimenez's predecessor believed in and has been so successful that it's a $4.6B drug where they've been able to quadruple the price.
It talks about transforming the campus working with architects like Frank Gehry and moving research to Cambridge, MA.
There is some discussion on a new therapy that they're working on based on some initial trials which uses CARTs (Chimeric Antigen Receptor T-Cells) to attach cancer. At the same time, Juno Therapeutics is on the same trail and raised $175M in their first round to research it.
I really liked one quote from Jimenez in the article that seems to imply a focus on the end goal not necessarily whether they win.
He goes on to talk about the issue of pricing especially around oncology drugs (but also applicable to specialty drugs in general). He calls it "a new brutal world" because costs will go up with the aging population and new medicines which will cause more backlash against price. He talks about looking at how to be innovative about pricing which could be interesting.
This is definitely worth a read. They have it nicely packaged up with a slide deck also once you register. Here's a few highlights.
Look at the gap between perceived value and satisfaction with clinical programs offered by specialty pharmacies.
Look at the huge jump in plans to educate physicians.
Look at the different adherence management strategies. I'm amazed at the low percentage using an outside vendor but the huge perceived effectiveness.
Look at some of the benefit strategies that companies are planning to use.
This is an interesting one that shows that companies are really going to focus on controlling specialty benefits in the exchange world in the future.
This shows the variation in terms of coverage (medical versus pharmacy) for different categories of drugs.
There's more in the deck and report, but these should be enough to tease you to read more.
— Debbie Stern, R.Ph., president of Rxperts, Inc., an Anaheim-based consulting firm, told AIS's Drug Benefit News for a story on the new EMD Serono Specialty Digest.
I like this quote from Debbie. It reminds me of my post from the other day "Care Is Coming To Your PBM" and is very much in line with the article I tweeted yesterday – Pharmacy Chains Continue To Blur The Line.
Did the provider follow evidence-based care? From NCCN? From a particular pathway?
Did they get all the genetic tests done?
Did they get too many tests?
Are they prescribed the right drug? Will that drug limit any future options for care?
Is the drug covered on formulary? If not, are there other ways to reduce the out-of-pocket costs to the member?
Is it a limited distribution drug?
Do they understand the side effects of the drug and/or treatment?
What does the patient want? What do they know?
Do they have a caregiver? How are they involved?
Are they getting the drug at the right site-of-care?
Are they working with a case manager? How is their care being coordinated?
Are there implications for ongoing care as a cancer survivor? How will they be coordinated?
If they need palliative care, what are their wishes? Does the family, patient, and provider all agree?
Cancer is a great example of where everything comes together from a care coordination, testing, diagnosis, delivery, and pharmacy perspective. At the same time, we know that patients still see multiple doctors who don't coordinate their care. We know they get mis-diagnosed. We know that don't stay adherent with their medications. We know they don't always articulate their wishes. And, we know the amount of care spent in the last months of life is disproportionate (IMHO) to the minor life extension which they get (often in less than optimal conditions).
I always enjoy Bruce Temkin's reports and analysis. He just came out with his latest report on customer service.
It's not a healthcare focused report so you have to gleam a few things from his summaries although you can buy the report to see the details by company. Without doing that, I thought I'd point out a few things from his charts.
2. As it has in past years, healthcare continues to be at low end of the spectrum in terms of customer service. While you can divide up the market into pharmacies, physicians, hospitals, PBMs, and insurance companies (with many other players out there), one of the biggest groups which is covered in the survey is health insurance companies. They fall below airlines and way below other types of insurance companies – i.e., auto / home.
Seems like a great opportunity for someone to help those and the entire industry to think differently about customer service and consumer engagement.
Of course the question is whether this is just another one of many mobile companies making a play in healthcare or whether they'll actually survive for a few years and get traction.
But, Hubbub isn't just another one of the many wellness vendors out there. They're part of Cambia Health. You've probably still never heard of them, but Cambia is Regence which is a BCBS plan operating in Oregon, Idaho, Utah, and some counties in Washington. Additionally, they own and/or invest in lots of companies – e.g., HealthSparq, GNS Healthcare, OmedaRx, and Wellero (plus Hubbub).
So, this gives them some instant credibility. And, it's an interesting time in the market. The Population Health Alliance (which used to be the Care Continuum Alliance) recently put out a post looking for contributions around "Return on Value" or VOI (Value on Investment) which is the focus these days in Population Health Management.
This sounds a lot like what you see in the presentation and white paper by Hubbub.
Those are foundational for a lot of the work in healthcare, and I liked this graphic about motivation.
Whether the app works and captures my attention is still TBD. I did download it and register, but I didn't really get engaged upon registration. And, the website seemed better than the mobile app, but it still had a few issues in terms of how the large top image dominated most of my screen on my laptop.
At the end of the day, their key role like anyone in this space is to figure out how to engage the consumer (or patient or member or individual) as validated in a study they use.
In the spirit of the Internet of Things and the Smart Home, I was intrigued by a short article I read about Menssana Research which can identify 2,000 chemical compounds from our breadth…including signs of cancer and radiation exposure. Pretty cool!
I guess this explains how dogs can detect diseases in humans.
Of course, my mind jumped to the idea of how you could use existing devices (like Nest) which would be tied into our HVAC system and could monitor the overall air in an entire house and look for risks based on the air. (like my idea of the smart toilet) Maybe that's a little too scary like why an underwriter wants your cell phone data or too much like the Snapshot from Progressive. And, while on the one hand it's cool, I'm not always sure we're ready to know things too much in advance so the question would really be how early is the device identifying people and how accurate is it.
As I'm enjoying my time thinking about what's next, one of the things that I've thought a lot about key problem areas in our healthcare system. Obviously obesity is one of them. And, you have lots of companies trying to figure out what to do here.
Build an assessment tool (like Milliman or InterQual) which could be used for assessing patients and creating an evidence-based care plan.
Work with KitchenAid or others to create a branded line of smart devices which used the Internet of Things to do things like re-order healthy foods and suggest menus.
Work with Jiff's assessment tool or with Newtopia to study the ability to take data and create personalized diet plans.
Work with FitBit or other device company and a gamification company to create a kid's device linked to a game where the key player got fat tied to their activity level and where they opened up new levels tied to their behavior (e.g., eating healthy).
Create online communities for people to share stories and experiences (like PatientsLikeMe but moderated).
Move from physical locations to a virtual site using American Well technology blended with Withings scales.
Incorporate stress management and sleep management into the overall program.
Work with Healthways and the Blue Zones effort to create a family centric option tied into the schools and focused on getting everyone healthy across generations.
Create a mobile coach using embodied conversational agents (similar to avatars) to drive behavior change and create a location-based prompts (i.e., as I pull into McDonalds).
Work with manufacturers to create a "beyond the pill" approach to obesity drugs that incorporates coaching and behavior change with the pill being the final mile which should drive greater formulary coverage.
Create a detailed patient journey map based on ethnographic research for weight loss with different triggers and create a "Coach certification" that can be used with coaches to certify that they are following best practices.
Work with biometrics companies (e.g., LabCorp, Quest) or clinics (e.g., MinuteClinic) to create an early identification process for obesity and/or metabolic syndrome with a process for them to "prescribe" a specific program.
Research and design ethnic specific obesity related programs for sub-populations within the US. For example, partner with the large Hispanic groups to create a Spanish (language, experience, culturally relevant) programs.
Partner with the ADA and NKF to jointly address metabolic syndrome together.
Work with the AMA and medical schools to teach MDs how to treat and talk with obese patients (something they don't do well today).
Work with a grocery store or food company to create an augmented reality process for smart phones or Google Glass that would highlight healthy foods on the shelf and help people shop better.
Work with Medicaid to create a process by which people earned cell phone minutes or lower copays based on activity and participation.
Just some ideas that I thought I'd share.
As the parent of kids, I'm obviously concerned about what they do as they grow up. On the one hand you want them to learn to make decisions. On the other hand, you don't want to endanger them. That requires helping them to understand right from wrong. That requires helping them to make smart decisions and understand the long-term implications of them.
This is where I struggle with the modern attitude towards the legalization of marijuana. While it may not be a "gateway drug" according to science, it is certainly highly correlated with future drug use, and it has a negative impact on health. Additionally, it's addictive for about 10% of people and more addictive when you're younger.
As someone who has watched people throw away their life on drugs and the son of someone who worked in drug and gang rehabilitation centers, I personally see it as a slippery path. I agree that alcohol may be the gateway "drug" when not used appropriately and can be very dangerous for kids and for many adults who can't control themselves. You can find lots of research on alcohol related deaths due to increased disease burden or simply drunk driving.
So, like many health related topics, the information out there is very confusing for our kids. On the one hand, we point out what your brain looks like on drugs (if you remember the PSA from the 80s and 90s).
On the other hand, we talk about medical marijuana, and we have states where it's now legal to buy marijuana like Colorado. But, the idea of walking down the street and seeing cannabis stores is crazy to me.
At the end of the day, I think we want to keep our kids safe and help them avoid anything addictive – tobacco, drugs, and alcohol. (And, yes…you could take this further to look at caffeine or sugars or other things that impact their health.) At a minimum, we want to help them understand the facts and make sure they know the risks and determine if they fit the addictive profile or not. They already have a hard time navigating childhood and adolescence…let's be careful not to make it too easy for them to fall off track. Unfortunately, decisions like this have broader implications on our next generation even if they don't actually use marijuana.
Of course years ago, we used opium, cocaine, and herion as medicine also…but we outgrew that phase of "modern healthcare" so maybe this too will pass.
This statement alone should scare anyone as you think about all the new consumers coming into the healthcare system. That will only stress the system more leading me to believe we'll see bigger drops in satisfaction in the years to come.
In general, I found the industries to be very tightly clustered. I'm going to reach out to them to see how to interpret that.
The American Customer Satisfaction Index (ACSI) is a national economic indicator of customer evaluations of the quality of products and services available to household consumers in the United States. The ACSI uses data from interviews with roughly 70,000 customers annually as inputs to an econometric model for analyzing customer satisfaction with more than 230 companies in 43 industries and 10 economic sectors, as well as over 100 services, programs, and websites of federal government agencies.
ACSI results are released throughout the year, with all measures reported on a scale of 0 to 100. ACSI data have proven to be strongly related to a number of essential indicators of micro and macroeconomic performance. For example, firms with higher levels of customer satisfaction tend to have higher earnings and stock returns relative to competitors. Stock portfolios based on companies that show strong performance in ACSI deliver excess returns in up markets as well as down markets. And, at the macro level, customer satisfaction has been shown to be predictive of both consumer spending and GDP growth.
I've been thinking a lot about the excitement of being an entrepreneur or an innovator and how that compares with being a consultant. While I could find a few articles out there comparing these two career paths, I thought I would share my observations.
Self-motivator – In both cases, you have to able to drive yourself. You're responsible for your career and your success. You're always under pressure to perform, and you're typically part of a small, core team. It's important that you can motivate yourself to push past the finish line. I think of both like running a marathon.
Quick learner – Your role in both types of organizations is constantly changing. You're adapting with the business and the market. This requires the ability to understand and see trends. It requires the ability to connect with clients and monitor the market. It requires the ability to learn new things and to have a desire to learn new things.
Able to pivot quickly – Change is a constant in almost any role in business today, but the pace of change in the start-up world is amazing. You need to understand this pace of change and how to be a change agent in both these roles. How do you help people with the organizational change that's required to make your project a success.
PPTS – No…this isn't being an expert at PowerPoint although that may be an important skills. PPTS stands for People, Process, Technology, and Strategy. You need to understand all four of these areas of the business. You don't have to code to be a great consultant or entrepreneur, but you need to understand technology and its impact on business.
Think and do – While there are a few opportunities to just develop strategy and move on or to simply operate an outsourced project, I think you need to understand how to take ideas from concept through implementation. This means that you understand how to work with the CEO and how to work with the call center agent.
Motivational – Most entrepreneurs and consultants are somewhat evangelistic and they're always involved in the selling process (in any role). They are selling and building ahead of the curve which means they have to compel people to act. They are also working with multiple vendors and cross-functional teams that don't report to them. Success is dependent on their people skills and the ability to motivate these different groups.
I've found that I love business development (working with clients and vendors). I enjoy bringing ideas from concept through pilots and then determining how to scale them. I love doing research and presenting. I enjoy working cross functionally. I enjoy leading teams and pushing the envelope to get people to think different. Ultimately, I enjoy solving problems. I like being the person who's brought in with a business challenge and can then figure out the solution – do the research, evaluate the options, create a plan, implement the plan, and create a process of continuous improvement.
I think the industry is going through another inflection point which is what Mark Merritt from PCMA pointed out a few years ago is the core skill – adaptability. If you think about the trends, I think there are several key things that make this an interesting time to be in the industry. And, everyone is fighting commoditization by trying to differentiate themselves.
The focus on specialty will make integration between care management and traditional PBM services critical.
The complexity of care is driving a huge focus on evidence based medicine (e.g., Best Doctors or Eviti) which will eventually lead to companion diagnostics and personalized medicine.
Pharma is trying to figure out their role in this new world and will start looking at creative ways to blend product and services (e.g., Merck's investments in Vree Health).
The market is full of change with new technologies and new start-ups that will lead to more unique mash-ups, and I still think you could see Google Health come back in some form.
Medication adherence continues to be such a huge opportunity that no one's cracked with over 100 vendors that I identified, and no one has figured out how to fully integrate medical and pharmacy benefits to address specialty medications.
And, the fundamentals are good for the industry.
The PBMs are big and need to grow so they'll have to do some creative things.
People continue to get older and take more medications.
A company with an entrepreneurial (or intrapreneurial culture).
A role working directly with clients (no Ivory Tower role).
A mission driven organization which wants to change the world and improve outcomes.
A passionate leader and team that I can learn from.
The creation of the "softer, gentler" PBM is one of my predictions driven by the rise in specialty pharmacy. While generic fill rates and mail order penetration still matter to earnings, the focus across the industry is on specialty.
What can we expect in terms of pipeline?
How can we treat the patient not just fill the drug?
This will bring back a focus on how pharma and the PBMs work together which has had a bumpy past. Initially the two were very close. Then, with the rise of generics and more trend programs like prior authorization and step therapy, the PBMs and pharma butted heads frequently.
Envision just hired the former head of Accredo as their CEO.
All of the trend reports focus on specialty – Express Scripts, CVS Caremark, CatamaranRx, and Prime Therapeutics.
And, I think this screenshot from the Barclays Global Healthcare Conference Presentation given by Express Scripts shows that they are focused on this care and delivery intersection by continuing to show the success from the Therapeutic Resource Centers.
So, what do you think? Will the PBMs become more care management focused? Will they integrate with the other care providers? Will this be the beginning of their focus on working with ACOs and PCMHs? Will this change their approach? Will we see PBMs differentiating around key, chronic diseases like the specialty pharmacies have done? Will this create an opportunity for integrated PBMs (i.e., Humana, Cigna, Aetna) to differentiate?
The CVS Caremark publication Insights 2014: Advancing The Science Of Pharmacy Care came out the other day. They took a different approach than the detailed trend report which Express Scripts put out. Their document is more of a white paper about "7 Sure Things".
Prescription trend is on the rise.
Generics have peaked…and you're going to feel the difference.
Specialty drives trend. But do you know how much?
Price is King…Not much of a surprise there.
Money matters to members. Cost share does influence behavior.
Adherence is the answer. No one said it was going to be easy.
If you're managing a pharmacy program and you're surprised by any of these, I would suggest you look for another job.
While utilization was up 2.1%, the primary driver was price which increased 8.2%. These factors were mitigated by a 6.0% change in mix.
I like the chart below which shows trend with and without generics coming to market.
Of course, specialty continues to be the real story in all the PBM reports.
They share the AWP trend broken out below and give some crazy examples of AWP price inflation (e.g., 573% for clomipramine) with some explanation for why this happens.
Here were their top 10 specialty drug categories. The top 5 are the same as the CatamaranRx list, but the bottom 5 are in a different order.
On a scary note, they predict that Rx trends may jump back into the double digits for the next 4 years.
At the end, they give 5 sure strategies that clients should do.
Overall, this was certainly the easiest "trend report" to read. It tells a clear story which is probably great for the average client and would drive more discussion with your account manager.
Is Your PBM Really Different?
But, as I've seen, value isn't just about cost. That maybe one leg of the stool, but you need to improve outcomes and the consumer experience (i.e., The Triple Aim). With that in mind, I created a checklist of what I want to know to see if a PBM is really different.
Engagement – What channels do you use to engage the consumer? How do you integrate those channels? What percentage of members engage with you when you outreach to them? What is your A-B testing strategy? What consumer insights can you share with me? How do you measure engagement (e.g., PAM score)? What is your segmentation approach? Do you have someone in charge of the consumer experience? Can you show me your customer journey maps?
Digital – What is your digital strategy? What percentage of your members have downloaded your app? How often do they use it? Why do they use it? How long do they keep it on their phone? What value do they get from it? How are you using other channels? Are you using social media with a purpose or just trying everything (see new whitepaper on digital transformation)? Where do you members congregate online? How does this vary by age, gender, condition, number of Rxs, etc.? Does your involvement make a difference in engagement, outcomes, adherence?
Innovation – What's your biggest innovation? Are you making money off it? How does it help you sell? How does it help your customers to differentiate themselves? Do you have a budget? Resources? Is it just an ivory tower exercise? How do you sustain it? How are you using crowdsourcing? Are you working with any VC firms or incubators to develop new ideas? What percentage of ideas come from your clients? From your employees? What's your innovation funnel look like? How many ideas die after a pilot? Are you able to scale pilots that are successful?
Big Data – What types of data do you get – medical, lab, EMR, patient reported, device? Do you buy data? How do you integrate this data? Do you have predictive models? How are they used? Do you have published studies on the results? What insights have you gained from the data? How have you integrated the data into your solutions? How do you move things from data to insights to action?
Integration – What type of integration do you have – with POS systems and retailers, with physicians and practice management systems, with providers and EMRs, with mobile solutions, with remote monitoring companies? How do you create a simplified consumer experience across the care continuum? Are you working with wellness and disease management companies? Are you coordinating care for complex patients? Do you provide support for cancer survivors? How do you work with pallative care companies? How do you support the family or the caregivers?
Partnerships – Who are your partners? How does 1+1=3? What's unique about the relationship? How do customers benefit by your relationship? How do consumers benefit? How do providers and pharmacies benefit?
Physician Strategy – How do you work with physicians? What data do you give them about their patients? What insights do you give them? Do they just see you as a block or have you found a positive way to collaborate? What do you do to influence physician's prescribing habits? How are you working with physicians to address adherence? How are you using your data and predictive models to integrate them into providers evidence-based medicine algorithms?
Outcomes – What programs do you offer to clients and consumers that are focused on an outcome that may reduce Rx utilization? How do you work with dieticians or social workers? What percentage of your members have a PDC of greater than 80%? How do you track lab values and clinical values versus just an Rx count? What are you doing to reduce readmissions? How are you impacting all of the STARS measures (not just the pharmacy ones)?
Pharma – How are you working with pharma? Are you helping them to extend "beyond the pill"? How early do you get involved in their pipeline? For complex conditions, are you helping them to demonstrate outcomes? Are you looking at how to collaborate with key medications – e.g., oncology? Have you looked at how to blend care with prior auth with Rx for conditions like obesity?
Payment – What's your approach to transparency? Is it just pass-through pricing? Do you do risk based pricing? How? How do you contract with pharma? Have you worked directly with any ACOs? Have you taken risk?
This isn't new…I've been talking about this for years. Here's my whitepaper on this from 3 years ago.
And, here's a presentation that I've given on this topic at several conferences.
One of the early comments in the document caught my eye. While simple, it is still so true in healthcare.
Their trend numbers were lower than Express Scripts and CVS Caremark.
They did a good job of tackling the impact of healthcare reform on the PBM marketplace and why this creates more opportunities.
They point out that no true biosimilar has been approved in the US (which I didn't realize). They also point out that international experience is that biosimilars will save 10-15% not the 40% projected by the CBO.
They have nice clean charts around price inflation (deflation) for brand and generic drugs.
The average cost of a specialty drug rose to $2,860 in their book-of-business.
The top 10 specialty drug classes represent 86% of specialty drug spend.
The report talks about medication adherence using PDC (proportion of days covered). They show some good adherence rates in key classes (which always brings up questions about methodology).
o Over what time period?
o Is this all members prescribed an Rx?
o Is this all members with one Rx?
o What is the percentage of members with over 80% PDC (versus the average PDC)?
Here's their forecast for the next few years in terms of trend.
They are projecting a generic fill rate of as high as 90% by the end of 2016!
o Member risk scoring and personalized interventions.
o Tailored clinical programs, including step therapy, quantity limits and prior authorization.
o Aggressive management of controlled drugs to reduce misuse and abuse.
o Formulary management tailored to address client-specific, high-cost medication classes.
o Exclusive specialty through BriovaRx, a high-touch, patient-centric model.
o Plan designs with copay differentials that promote cost-effective choices.
o Multi-channel communications that engage members in their healthcare.
I was excited to see them dedicate a whole section talking about engagement.
o The need for the right message.
o The need for targeting algorithms.
o The need to vary channel based on preference.
They share some details on their hospital discharge program which sounds right from a PBM perspective – focused on medication reconciliation and adherence. My key question would be understanding if they address the other risks of re-admission while they have the patient on the phone (i.e., treating the patient not the Rx and not the disease).
I haven't heard as much about MTM lately so it was nice to see them talk about it and see some results which seem really good.
This seems to be a much improved document than the one I reviewed years ago from SXC.
My only challenge with the format was that it prints the two pages on one page in the PDF (but that could be user error).
The methodologies used by each PBM can and may vary. Therefore, these are not necessarily perfect comparisons.
The client mix by PBM does matter (see chart below from the CVS Caremark report this year which shows the differences by client type).
Here are the summaries from the 3 Drug Trend Reports showing the trend in PMPM costs based on traditional categories, specialty medications, and an overall trend.
I always enjoy reviewing the PBM Drug Trend Reports. Even though these past two years I've been focused more on the care management side of healthcare, I continue to see these two paths colliding in interesting ways in the near future.
Overall trend was 5.4% which they did a nice job of breaking out according to different lines of business.
They also showed the breakout of trend comparing specialty drug trend versus traditional oral solid medications.
Specialty trend was up 14.1% based on a 2.5% increase in utilization and an 11.6% increase in unit cost.
A key point is that specialty now makes up 27.7% of the total drug spend for a payer (and that doesn't even count the ~50% of specialty drugs billed under the medical benefit).
While they make a key point with data that member cost share is going down and actual out-of-pocket costs are only going up marginally, I think it ignores the reality that consumers are feeling the pain of out-of-pocket spending more especially with all the High Deductible plans out there.
On top of being able to drill down on Medicare and Medicaid, you can also look at a Worker's Compensation specific version of the drug trends. This is interesting since that business is different than the traditional PBM market and is an area that Express Scripts has gone aggressively after in recent years.
One thing I couldn't find in the document (which is hard to read in the current format) is the average number of Rxs PMPM or PMPY which is just a good stat that I personally track.
You can see companies building innovation teams and innovation labs within healthcare. You see lots of new entrants trying to figure out how contribute in this space (e.g., Qualcomm Life). But, some of these just become ivory towers where they pontificate and put out cool ideas. Others disappear because they can never be commercialized. Others fall into the "fast fail" bucket of companies, and only a portion of those actually innovate well.
With that in mind, I was reading two reports which I thought I'd share with some initial reactions.
The Boston Consulting Group report "Fulfilling the Promise of mHealth Through Business Model Innovation".
There were some things missing that I personally would have called out.
What about learnings from prior models like electronic prescribing?
What about things like EMR integration and the difficulties there?
What about the issue of privacy and security?
What about the fact that people abandon devices and apps very quickly?
What about learnings from gamification or incentive management?
What about the whole issue of FDA approval of apps and devices?
What about what the large companies are doing – Aetna, Cigna, CVS, Walgreens, WalMart? I think understanding their view of this market is so critical.
Triple Tree report "Connected Health".
The report shares an interesting stat that 45% of the companies that applied for their rewards were led by MDs in 2009 while it's only 21% now. To me that shows the movement of IT and business executives into the healthcare space.
Triple Tree does talk about remote monitoring and CMS which I think is important. While the Veteran's Administration was mentioned in the BCG report, I think that the government efforts here and influence was generally overlooked.
Overall, two interesting reports. Worth a read although I would choose the Triple Tree report over the BCG one if I had time to only read one.
Short answer = they appear to understand the customer experience.
Obviously some companies like CVS and Walgreens are both retailers and pharmacies. They are clearly in the healthcare business and with CVS stopping selling cigarettes, they are clearly trying to show their commitment to healthcare.
Other retailers like Walmart are clearly in the pharmacy business. They've also done lots of different programs around healthcare, and there are always rumors of more. And, they are also in the grocery business.
Target is an example of a retailer that has gotten into the pharmacy and clinic business and now in the grocery business.
Kroger is a very traditional grocery store company who has had pharmacies (like about 50% of grocery stores) and has made several steps to get into the healthcare space.
I tee this up because whenever I see the Temkin Experience Ratings I'm always amazed that the grocery chain with the worst experience rating is similar in value to the best healthplan experience.
I think by now we all understand that the healthcare experience actually matters…and will matter even more in an exchange world where they have more freedom to find a plan that works for them.
We've seen some companies focus on this (e.g., Cigna with their Chief Experience Officer who is now the Chief Experience Officer at Prime Therapeutics). You can see PWC's report on this and also compare different industries to healthcare. You can go and visit this deck on 13 great healthcare experiences. At the end of the day, the healthcare experience is one leg of the Triple Aim and is a key opportunity for differentiation.
You'll hear this buzzword – "beyond the pill" – come up every once in a while in a discussion with a pharmaceutical manufacturer. As the drug pipeline has dried up and generics have become the norm for oral solid medications, the question is how do these behemoth companies "pivot" to leverage their massive global footprints, their feet on the street, their deep disease specific insights, and their medications.
I'm a big believer in this strategy. Imagine what they could do in terms of services to wrap around obesity drugs. Imagine how they could support patients with diabetes or with cancer. While the short-term view is that these actions might help differentiate them from a formulary or specialty pharmacy perspective, I would argue that they might actually come out with new business models like Merck is doing with Vree Health.
What is the patient journey?
Where is the patient (especially from a digital perspective)?
What are the patient's expectations for you (pharma) or another entity?
How do the other constituents in the care team interact with you? With the patient?
How do you create a culture of empowerment, consumer focus, and transparency to really understand the needs of different constituents, react to them internally, and embrace issues dynamically?
In this consumer experience space, I often look to Bruce Temkin's work and research. He does a great job at a cross-industry perspective. In healthcare, I've been very motivated by the work of Ingrid Lindbergh who was at Cigna and then moved to Prime Therapeutics. She's my role model for what I want to do in a large healthcare company.
Two things got me thinking about this topic. First, I was struck this weekend that there was research showing that people who struggle to buy food for their families are non-adherent. I really hope that anyone in this field wasn't surprised by that fact. Of course, the struggle is that everyone working in the field is often constrained by their view of the world which often doesn't include much experience with poverty.
Second, I was sent a new research piece by Accenture called "Great Expectations: Why Pharma Companies Can't Ignore Patient Services". It made me think about Dennis Urbaniak's move from Sanofi where he was leading a lot of innovation to a Managing Director at Accenture. Perhaps, he will bring some of this type of innovative thinking to more pharma companies.


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Get off the beaten track with East Ayrshire tourism
Jobs galore – Grand Hall recruitment fair a roaring success
"A great event, well organised and lots of different opportunities on offer" - the comment of one of nearly 700 people who flocked to East Ayrshire Council's Recruitment Fair where over 50 employers, advice and training agencies were on hand to give advice and offer jobs and apprenticeships to job seekers of all ages.
New units bring opportunities to Cumnock Town Centre
Cumnock's multi-million pound regeneration has moved into a new phase with with launch of the brand new 935 sqm Farmfoods store and retail units right in the centre of town.
Growth deal confirmed as Ayrshire celebrates major investment boost
Galston regeneration enters exciting new phase as new street design agreed
Galston's built landscape is set for another boost to its regeneration plans with a newly announced £3.5m project which will open up the landscape, provide a brand new commercial unit and create more accessible facilities within the former Burgh Chambers which will be restored to its former glory.
New Ayrshire partnership seeks non exec directors
Future economic growth in Ayrshire is set for a big boost with the formation of a new Ayrshire Regional Economic Partnership which brings together local authorities and their partner organisations, education and business to stimulate the local economy and build inclusive growth.
Recruitment Fair set for 7 March
Kilmarnock's Grand Hall is set to be filled with businesses showcasing vacancies on 7 March as East Ayrshire Council's Employability team hold another in their highly successful series of recruitment events aimed at matching up people with prospective employers and training courses.
Ayrshire given major jobs and investment boost after green light given for Growth Deal
Ayrshire is set for a major jobs boost after it was confirmed that over £240million is set to be ploughed into the local economy.
Ayrshire Growth Deal negotiations reach final stages
Ochiltree and Catrine get placemaking approval
Plans for the future of land use in Ochiltree and Catrine took a step forward this week as East Ayrshire Council's Cabinet approved the latest stage in the Placemaking processes for the two communities.
These boots are made for walking... with the Coalfields Community Landscape Partnership
East Ayrshire Community Coalfields Landscape Partnership is celebrating their launch with two events and a series of walks designed to bring the communities together to share memories, ideas and enjoy their surrounding environment.
"Call for Projects" set to improve coalfield landscapes
The landscape around East Ayrshire's former mining communities is set to be transformed with the help of an initial Heritage Lottery Fund (HLF) grant of nearly £200k.

redpajama_set_name: RedPajamaCommonCrawl


The BAS is holding its annual meeting in London on Friday 20th September 2019 (The Lumen URC, 88 Tavistock Place, London WC1H 9RS).
This year the theme is Epigenetics in Male Reproduction.
Please note the change of date and venue for the annual BAS meeting, alongside extension to the abstract submission date.
The British Andrology Society is once again hosting an exciting meeting for PhD students and PostDocs. The one day event on Epigenetic's in Male reproduction is running on 20th September 2019 at Lumen URC, 88 Tavistock Place, London WC1H 9RS.
Please submit Abstracts to Lorraine Frew at secretary@britishandrology.org.uk by Monday 1st July 2019 stating if submission is for consideration for oral presentation, poster presentation or both.
Please follow the steps below to successfully ..
ESHRE Campus Symposium on Male factor infertility: the broad picture is now open for registration and abstract submission. The meeting will take place in March 2019, Belgium and aims to provide broad coverage of the multitude of causes of male subfertility and paternal effects on offspring health.
For many years now there has been sporadic discussion around the idea of a unified professional society to cover all aspects of reproductive science and research. We believe that there would be many advantages to a unified society that would allow us to better represent scientists on the national stage, streamline/reduce costs whilst increasing efficiency, improve the knowledge and skill base available overall, improve the quality and quantity of research undertaken, unify training schemes and improve patient care.
It has become increasingly obvious that there is duplication and repetition ..
Obituaries: Brian Setchell (1931-2018) and Guido Verhoeven (1945-2018).
It is with the greatest sadness that we report the recent deaths of two of Andrology's greatest pioneers, Brian Setchell (11th July) and Guido Verhoeven (19th August). Two very different characters from opposite sides of the world (Brian from Adelaide, Guido from Leuven), who investigated andrology from very different angles, but both outstanding scientists who shaped the course of andrological research and had big influences on the thinking and careers of the two of us. Andrology can ill afford to lose such giants of the field, whose ideas so influenced ..


"How long has it been since you had any sleep?" He looks at her, the strongest woman he's ever met. So unlike Vasquez, with her muscles and her big mouth, so unlike every other female private he has met. All the women in his life were so much different from her, Ripley as she only told him her last name. Confronted with her worst nightmare, she doesn't run for the hills, no, she braces herself and confronts the problem, head-on. In the background, he can hear Hudson lamenting Game over man, game over! but he tunes the words out.
She turns to look at him, face set in pure determination. "You won't let us end up like those others, will you, Hicks?"
"When the time comes..." It won't come, not ever. She's too strong to be defeated by those monsters. They'll crumble under her determination, under her strong will, just like him. She doesn't need his protection. He needs hers. "I'll do us both," his voice is nothing but a whisper, but he means it.


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The U.S. Tax Court upholds deduction for the charitable contribution of façade easements to preserve historical architectural elements of petitioner's property.
This entry was posted in Federal and tagged Conservation Easement, Facade Easement, Qualified Appraisal, Tax Court by admin. Bookmark the permalink.


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Trump's Running Mate Backs Away From Total Ban On Muslims Entering U.S.
October 06, 2016 19:33 GMT
U.S. Republican presidential candidate Donald Trump (right) and his running mate Mike Pence. (file photo)
The running mate of U.S. Republican presidential candidate Donald Trump says Trump has backed away from his call for a total ban on Muslims entering the United States.
Vice presidential running mate Mike Pence said on October 6 that the provocative proposal was "not Donald Trump's position now."
In December, after an Islamic State-inspired mass shooting in California by a Muslim couple, Trump called for a "total and complete shutdown of Muslims entering the United States."
In recent months, Trump has said he would suspend immigration from countries where Islamist militants are active.
But he has been vague about whether he was narrowing or expanding his original policy position.
Pence said during television interviews on October 6 that, if elected on November 8, Trump would suspend immigration from "countries that have been compromised by terrorism."
Asked if this amounted to a ban on Muslims, Pence told MSNBC's Morning Joe program: "Of course not."
Based on reporting by Reuters, AP, AFP, and MSNBC
Trump Moderates View On Putin After Running Mate Calls Him A 'Bully'
Kremlin Deplores Use Of 'Russia Card' In U.S. Presidential Campaign
Pence: U.S. 'Should Use Force' In Syria If 'Barbaric' Aleppo Attack Continues
Trump Says Russia Broke Syrian Deal; Has No Respect For Obama
Story Alerts Region Widget-GR-1878
Mug Shots To Bug Shots: A Former Romanian Cop Becomes A Celebrated Wildlife Photographer


First and foremost, I hope everyone had a great holiday season with your family. My belated wishes to you for a HAPPY NEW YEAR!!!
It's hard to believe that I am a little over halfway done with my term as your president, and it has been a busy and productive first half. I want to share with you some of the highlights and positive results that we as an organization can be proud of.
The LP Board passed and is implementing the first 5 Year LP Strategic Plan.
Held our 1st New Alumni Orientation and Social to help everyone understand how to best get involved.
Held our Board Leadership Retreat and the Annual Past President's Lunch.
Creation of the LP Mentor / Mentee Program reinforcing our added focus on enhanced leadership development of our program with the help of 40 Alumni enriching this year's experience for the Class members as well as the Alumni based on feedback I've received.
Successful selection of the Class of 2019. The class is top notch and really have come together as a cohesive force for change moving forward. The Class has already gone beyond everyone's expectations by deciding to do some service projects on their own. Look for a strong Spring as they perform other projects to make our community stronger.
Developed and implemented a new skit format for the Class Retreat followed by a social with alumni bingo, photo booth and one of the best turnouts from our alums to welcome our new class to our organization.
Leader Reader improvements based on Alumni requests. One, the Leader Reader now offers a print version as well as the online version. Two, the Leader Reader is now in the "News" drop-down menu on our website so you can easily find past issues.
Our LP Program Days remain strong with over 100 alums volunteering to help implement this critical function for LP. The days continue to exceed everyone's expectations and they continue to improve year to year.
Successful implementation of our Youth Leadership program partnership with the YMCA.
Launched new Leadership Pinellas Bookshelf to share what LP Alumni are reading each month in our Leader Reader.
Successfully implemented a cross-functional marketing team for more effectiveness.
Created an easy way for Alumni to refer people to Leadership Pinellas online with ReferLP.com and implemented a follow-up system to keep them informed as recruitment events occur.
Record turnouts for our LP debrief socials that are averaging over 60 people each time.
A sold-out Thursday night LP branded VIP Clearwater Jazz event that will hopefully be returning next year.
Festive holiday party mid-county at the waterfront rooftop venue at Bubba Gump with great attendance. Much fellowship and holiday cheer were shared.
New LP Snapshot Program developed and will fill a need for a taste of what our full program offers.
A wide variety of LP socials offered for opportunities to connect throughout the year.
Continued partnership with SPC offering Leadership Institute.
Revamped our LP sponsorship offerings to better acknowledge them including the video series – Lessons in Leadership.
Involved LP past presidents to improve the transfer of institutional knowledge this year.
All of this while operating under budget and building up our financial strength.
So, as you can see your LP leadership team has been very busy and the feedback we keep hearing from you, our members, is positive and that we are on the right track.
So, what is next? Now we can use your help to focus on two things: start thinking about who you know that would be a great member in next year's LP Class of 2020 (use ReferLP.com) and start thinking about who you'd like to see serve in our LP leadership roles. The Nomination process will open up for LP Alumni to serve on our LP Board as well as Officers for 2020.
Finally, look for more social events, recruitment events and more in the new year.
I can't thank you enough for your support and all you do to make Leadership Pinellas the strong organization it is.


First thing when I woke up this morning I see Greg brushing his teeth, fully dressed. At 7:30am on a Saturday. Hmmmm. What's up?
He tells me that his dad will be here in 2-3 hours to get him, he's moving home (to Arizona) today.
He wasn't mean about it or anything.
Butch did a silent Victory dance on the porch when I broke the news to him.
I will be spending the day moving all of the crap that belongs to the children that's been stored in my room since Feb, back in there. Cleaning is very therapeutic for me, so I'm actually looking forward to it.
And on a totally unrelated sidenote - I jogged 10 straight laps around our track last night! I'm super excited because I've NEVER done that before!!


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Home / News / News / AHO outraged by kidney trafficking business in Egypt
Through interviews and documents obtained by Al Jazeera, the investigation exposes officials who have been giving out false papers for personal gain to facilitate organ trafficking.
The organ-trafficking ring preyed on poor Yemenis willing to travel to Egypt and sell a kidney in a desperate bid to gain income that would keep them going, at least for a while.
One of these Yemenis was Ahmed*, who was told in 2014 by a friend that he could get $5 000 for one of his kidneys. He agreed, and before he knew it, he was on a plane to Cairo.
Ahmed* sold his kidney for $5 000 in Egypt in 2014 [Al Jazeera]
At the time, Yemen was not yet home to the world's worst humanitarian crisis and the destructive war that has left 80 percent of its population in need of humanitarian assistance.
But it was already the poorest country in the Middle East with half the population living below the poverty line.
In Yemen, selling your organs is not illegal. However, it is illegal in Egypt, where three donors Al Jazeera spoke to, and hundreds of others who told their story to a Yemeni NGO, went to sell their organs.
Recruited by a broker
The trafficking ring found its donors through brokers in Yemen who would find willing individuals and connect them with brokers in Egypt to arrange their travel, accommodation, and surgeries.
The brokers get involved for different reasons. One Egyptian broker Al Jazeera spoke to became involved after his brother needed a kidney and bought one from a Yemeni donor.
"After the operation, [the Yemeni donor] went back home and we stayed in touch … he started telling me he could find others willing to donate if I knew of anyone who needed transplants."
The Yemeni broker Al Jazeera spoke to was initially recruited to be a donor but was not compatible with any of the ring's clients.
The Yemeni broker began recruiting others to donate when he found out he was incompatible with the ring's clients [Al Jazeera]
Instead, he was asked to find others in Yemen who would be willing to sell a kidney and was told he would make a $1,000 commission on every donor he recruited.
Nabil al-Fadhil, head of the Yemeni Organization for Combating Human Trafficking, told Al Jazeera that his organisation verified some 1,000 cases of organ sales, but they were certain that there were tens of thousands.
Nabil al-Fadhil, head of the Yemeni Organization for Combating Human Trafficking [Al Jazeera]
"Of the thousand we interviewed, 900 had sold their kidneys – then came back to Yemen as brokers looking to find new victims," al-Fadhil said in an interview at the end of 2018.
Egyptian hospitals implicated
Patients in need of a kidney would get in touch with the network, which maintained a pool of candidates to act as donors.
Once a compatible donor was found, the surgery would be performed almost immediately and the donor would be flown back to Yemen with little to no time to recover, increasing the chances of health complications and making it difficult for a donor to return to any sort of labour-intensive work.
Several hospitals across Egypt have been accused of operating on these donors, and the government has busted prominent doctors and institutions working in trafficking rings over the past five years.
"We work with public and private hospitals," the Egyptian broker confirmed to Al Jazeera.
In al-Fadhil's records from 2014, one hospital kept coming up, one that saw no arrests in spite of his notifying anti-trafficking organisations in Egypt: Wadi El Neel Hospital in Cairo.
It is one of 48 hospitals licensed by the Egyptian government to perform transplant procedures and Al Jazeera sources in Egypt say it is referred to as the Mukhabarat (or Intelligence) Hospital by many Egyptians.
"The Mukhabarat Hospital is used for Yemeni [donors] only, and the receiving patients are Saudis and other foreigners," the Yemeni broker told Al Jazeera.
Al Jazeera reached out to the hospital and spoke to an individual who presented himself as a manager there.
He denied the accusations, citing Egyptian law: "If the patient is Yemeni then the donor must be Yemeni, with a passport accredited by the embassy, and the embassy's approval to donate. This law has been in place for years. Everything but that is nonsense." In Egyptian hospitals licensed to perform transplant surgeries, donors are also required to testify that they are donating by choice, either in writing or on camera, which all three of our Yemeni donors did.
'Yemeni embassy's involvement'
All three donors claim they sold their organs to non-Yemeni nationals.
"They found a woman from the UAE who needed a kidney, so we did the blood and tissue tests, and found that we were a match. So, I went in for the surgery … Afterwards, she asked me how much I got, I said $5,000. She told me that she had paid $50,000," Ahmed* told us.
Besides having to be of the same nationality, the donor and recipient of an organ must be related, according to the Yemeni embassy in Cairo.
Brokers claim that the Yemeni Embassy in Cairo facilitated the organ trafficking trade by processing false papers [Al Jazeera]
Proof of relation is signed off on by the Yemeni Ministries of Foreign Affairs and Justice, but it is the responsibility of the embassy that receives the paperwork and coordinates with the Egyptian Ministry of Health to finalise approval for a transplant
According to the Yemeni broker Al Jazeera spoke to, they were quite accommodating – for a price.
"The embassy announced it was illegal to donate an organ unless it was to a family relation and the relationship would have to be approved by the embassy.
"There were 15 or 20 people waiting [to donate] but they stopped them. So, the network sent me to Yemen to get the necessary paperwork to prove a relationship." the broker told Al Jazeera.
"I made a deal with a judge to pay him 80,000 Yemeni rials ($320) per case, and he'd get it signed by the Ministry of Foreign Affairs. I had done three when they got in touch and told me to stop because they'd found someone at the embassy who could approve the requests for $500 each," he explained. According to the Egyptian broker, cooperation by Yemeni officials was instrumental to the process. "To be honest, our work would be impossible without cooperation with government entities there (in Yemen) that makes bringing Yemenis over to Egypt much easier for us."
Al-Fadhil said he had come to suspect the embassy's involvement.
"There were laws in Egypt being broken, and our embassy could have acted, but they just denied it … the embassy is still involved to this day because this business makes them a lot of money," he said.
After repeated efforts to contact the embassy, Al Jazeera received a response from the media attache, Baleegh al-Mukhlafi, who said: "The only thing the embassy does is to address medical authorities after the documents required by the [Egyptian] Ministry of Health and the courts have been completed."
The embassy denied any other form of involvement.
Yemenis trapped in Egypt
There are now many Yemenis already in Egypt who are resorting to selling their organs to make ends meet, says al-Fadhil.
They came to Egypt to escape the violence in Yemen and are unable to return because of the worsening situation and because of the closure of Sanaa airport.
There was a decrease in overall cases in 2014 and 2015 when the Egyptian government began denying entry to Yemeni citizens, but there are still many Yemeni refugees trapped in Egypt.
"Yemenis who went to Egypt when the war broke out are now stuck there and have been forced to sell their kidneys out of desperation. We've recorded more than 200 such cases," al-Fadhil told Al Jazeera.
What al-Fadhil and others working to end this trade would like to see is a change in government policies that would end this trade. However, given the state Yemen is in today, it is unlikely that any significant changes will be made. Anti-trafficking organisations, like most other NGOs, are struggling to continue operations in the war-torn country.
"We still face threats and a lot of pressure. This is probably going to be my last interview because we're living in a country where even humanitarian work is prohibited."
A few months after our interview in 2018, al-Fadhil's organisation was shut down by Houthi forces and he was forced to leave Yemen.
"There's no way we can actually work to stop this when we're in the middle of war and destruction and poverty and people can barely afford food.
"There's no solution except to stop the war, rebuild the country, hire people … that's the only solution . . . and it's just not possible." — AL JAZEERA NEWS.
Welcome by the Founder and President Graciano Masauso >
Cardiovascular diseases (CVDs) >


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To many New Yorkers, the Upper East Side is a clubby, outsiders-beware territory, where immaculately uniformed doormen and snooty co-op boards guard the gates for billionaires and their personal trainers; a sometimes heartless province where poodles get manicures but maids get minimum wage.
But for Richie Spagnole, who lived for a decade on the streets of the city's richest neighborhood, the Upper East Side was a place of astounding generosity. Store owners handed out bagels in the morning, chicken wings for dinner and sausage pizza for snacks. His pleas for money, he says, were often met with $50 contributions. In winter he wrapped himself in donated down coats. On frigid nights, he slept in the boiler rooms of tenement buildings. He brushed his teeth and washed his armpits there, too.
When Mr. Spagnole had had enough of crack cocaine and of being homeless, it was a local institution, the family-owned Rosedale Fish Market on Lexington Avenue and 79th Street, that offered him a job as a deliveryman. And not only did Rosedale hire him; the market's general manager found him an apartment and paid the first month's rent and security deposit out of her own pocket -- an act she modestly confirms only with prodding.
Mr. Spagnole is a man of energy and humor, so it is easy to imagine him as a charming panhandler. It is more of a stretch to understand how he became homeless in the first place. By his own account, he came from a good family. His mother was a rhythm-and-blues singer, and his stepfather was a bartender. They lived in a house on East 123rd Street. When he was 17, his stepfather was hit by a car, and Mr. Spagnole quit school to help out. He went into the military briefly, but was discharged soon after. He married at 19 and had a daughter, but was swiftly divorced. ''I was immature then,'' he confesses.
He was drifting between jobs -- cameraman, printer's assistant -- and struggling with a drug habit that landed him in a methadone program. When his mother died, he went to live at East 113th Street to take care of his stepfather, who was now living in public housing. He stayed for 12 years, but he was never put on the lease. In the summer of 1989, his stepfather became so ill he had to be institutionalized. Mr. Spagnole came home on Aug. 22 and found himself padlocked out.
At first he went to the homeless shelter on Wards Island, he says, but when he went to sleep the first night another resident set his pants on fire. Hetamped out the blaze, but swore never to go back. He then decided to settle on the Upper East Side because he knew it was a fancy neighborhood and expected it to be safe.
In his first days he tried collecting bottles, but decided the payoff was too small for the work. So he began panhandling and soon was raking it in, sometimes at the dizzying rate of $2,000 a week, he said. The money disappeared dizzyingly too, as it financed binges of drugs and women in his old neighborhood and the occasional $39-a-night motel or change of clothes.
Many of the specifics of his stories from his days on the streets cannot be verified, but restaurant owners from around the neighborhood still remember him warmly from his days as a beggar.
Being helpful was part of Mr. Spagnole's come-on. He told restaurant owners that he would not beg in front of their places during the day and would keep an eye out for thieves at night if they would just donate leftover food. He also did favors like clearing snowy sidewalks with shovels ''borrowed'' from local buildings. For the employees of one restaurant he was the lookout, watching for the police while they gambled inside.
Shop owners rewarded him, he says, with chicken wings by the bagful and enough moo shu pork and tacos to feed himself and some of the other guys on the street.
But Mr. Spagnole's biggest asset was charm and the funny comeback. One day when he was begging in front of a swanky Park Avenue address, a large, richly dressed man responded to his request for change by turning his pockets inside out and saying he had no money. ''Too bad,'' Mr. Spagnole said sympathetically and took a dollar from his own pocket and handed it over. The man came back an hour later with a $100 bill, an amount he gave Mr. Spagnole maybe a dozen more times over the years.
Mr. Spagnole's escapades were not always benign. He and a partner once stole a new bathtub from one building, sold it to a superintendent of another building, then stole it again and sold it again. And then there was the man who frequented Sam's Place, a bar that was on Third Avenue, who would never give Mr. Spagnole any money. So he placed a beer bottle under the wheels of the unwilling patron's red Rolls Royce and waited. When the man left the bar and got into the car, Mr. Spagnole stopped him, pointed out the bottle and received a $50 tip for saving the tires.
At one point in his street career, in 1993, he was arrested for stealing liquor from a local bar and spent eight months in jail. And in 1994, Mr. Spagnole said, he was arrested for stealing bicycles and spent 20 months in a detention camp. In both cases, he gave the police false names. (He says he did it to protect his family from shame.) A check of Mr. Spagnole's records with the Manhattan District Attorney's office did not reveal additional arrests, but it did not rule out the possibility that he was incarcerated for additional crimes under yet another alias. Those are moments he is not proud of, he says, but there were also moments of redemption. Like the time he saw a woman who was a regular donor being mugged at knifepoint. He went to her defense, and she escaped unharmed. An hour later her husband found him as he was bedding down for the night on a nearby stoop to give him $1,000. ''When you are on the street 24/7 you see lots of things,'' he explains.
Yet life on the street could be relentlessly hard. Late one evening during his first year as a homeless man, Mr. Spagnole was beaten by a gang of youths who crushed his nose and knocked out his top teeth. Eventually, he grew savvy and learned which landlords would look the other way when he broke into their boiler rooms to sleep on frigid nights or to wash up every few days.
In warm weather he often slept on the pavement. He carried nothing but what he wore. ''I never was one of those homeless guys carrying around sacks,'' he says a bit disdainfully.
In the winter of 1998-99, exhausted by the grind, he decided he would get off drugs and save some money. He went back to the Wards Island shelter and lucked into a room with just two other men. Then, one day as he was panhandling in a favorite spot on Third Avenue at 79th Street, he got another lucky break.
Mr. Spagnole had received tenuous promises of work before, but here was a concrete offer. He jumped at the chance even though, as he says, he would ''have to take a pay cut.'' The early days were touch and go as he struggled with the work, which was tough on his legs, and he struggled with his addiction. He was even thrown out of the shelter for being in a fight. He would not have made it through, he says, without help from Ms. Mecir and Mr. Neuman.
Eventually they found a $600 apartment. Ms. Mecir and her husband paid the first month's rent and deposit from their own pocket.
Mr. Spagnole rewarded their trust, Ms. Mecir said. After his first day at work, she recalled, he returned to the store 20 minutes after leaving, this time with a haircut, and said, '''I just wanted to show you how I spent my first day's pay.''' He never missed work, he never complained even when the deliveries were on the far side of town, and he won customers over with his charm and free tastes of Rosedale's signature fresh tuna salad.
Work and shelter would have been enough, of course, but Rosedale gave Mr. Spagnole another gift. He had lost touch with his daughter, Lelia Spagnole Negron, when he became homeless. The last time she saw him, she remembers, she was 15 and he had come to her home at her mother's behest to warn her against a slightly older man from the neighborhood who was walking her home from the train station.
During their first years apart she had tried searching for him but eventually gave up when she heard through friends that he was homeless. She married Pete Negron, that tall stranger whom her father had been worried about, and had two boys. She said she often wished the two could have met because they had so much in common, right down to loving the Yankees. But Mr. Negron, an asbestos removal specialist for the Port Authority, died in the September 11 attacks.
It was in part the lack of a man in her boys' lives that made her plug her father's name into an Internet search engine in January 2002. Rosedale's address came up. She left a message at the store, and he called back the next day at 9 a.m. ''Stay there, Dad, I am coming to get you,'' she yelled into the phone.


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Morávia-Silésia (tcheco: Moravskoslezský kraj, "região Morávia-Silésia") é uma região da República Checa. Sua capital é a cidade de Ostrava.

Distritos
A região de Morávia-Silésia está dividida em 6 distritos:

Municípios com competência estendida

Desde 1 de janeiro de 2003, a região está dividida em 22 municípios com competência estendida que assumiram a maior parte da administração das antigas autoridades distritais. Alguns destes estão subdivididos em Municipalidades com Autoridade Local Delegada. Eles são extraoficialmente chamados de pequenos distritos (). São eles:

 Bílovec
 Bohumín
 Bruntál
 Český Těšín
 Frenštát pod Radhoštěm
 Frýdek-Místek
 Frýdlant nad Ostravicí
 Havířov
 Hlučín
 Jablunkov
 Karviná
 Kopřivnice
 Kravaře
 Krnov
 Nový Jičín
 Odry
 Opava
 Orlová
 Ostrava
 Rýmařov
 Třinec
 Vítkov

Ligações externas
 Website oficial

Silésia

redpajama_set_name: RedPajamaWikipedia


Business Modeling a business process is an essential part not only of any software development process, but any business development process as well. It enables the analyst to capture the broad outline and procedures that govern what it is a business does: the significant events, inputs, resources and outputs associated with business process. By connecting later design elements (such as Use Cases) back to the Business Process Model through Implementation Connectors, it is possible to build up a fully traceable model from the broad process outlines to the functional requirements.
Business Process Modeling should not be misinterpreted as Business Model Canvas. The last one is a descriptive method to visualize how any business unit generates profit – and that can be considered as a static reflection of the actual business situation.
With regards to Business Process Modeling, we would like to underline: that Modeling Technique is suggested as a continuous activity based on Business Process Analysis and Business Process Modeling, which ideally must be synchronized. Referring to those prerequisites, Business Process Modeling is mainly focused on construction of an optimized Business Process as an efficient result.
Moreover, we should state that Business Process Modeling might be applicable to any business functional zone – Supply Chain Management, Marketing, Sales, Production etc.
Business Process Modeling activity should reflect both enterprise mission and vision.
For instance, the business processes of an online retailer would include marketing, sales, order fulfillment, inventory management, and government reporting.
An important part of enterprise Business Process Modeling is the identification of the offerings (services and products) the organization provides to the customers.
o What is being provided?
o Is there any plan to stop providing any of the services or products?
o What is the process of doing that?
Some models are good for logical process modeling, where the focus is on what must be accomplished (but not how); others are well-suited for physical modeling, where the focus is on how the processes are accomplished. Some models can be used for either.
It is essential to explore existing business processes within the organization, and to identify critical business rules that should be captured. Nevertheless, the only fundamental idea but not the deep details must be analyzed.
o or an already existing Business focusing on Business Processes optimization.


Welcome to my mostly weather blog. I hope you enjoy getting to know me on a more personal basis through my posts, pictures and other related media.
I'm back at News 4 Tucson after three years of reporting the weather in the Pacific Northwest.
I worked for KOIN Local 6 in Portland, Oregon as a Meteorologist. I came to KOIN from Tucson, Arizona where I worked at KVOA for 4 years. I have also worked in South Florida and Northern Minnesota. By now you can imagine the very different types of weather I have encountered.
I was born in Salem, Massachusetts and was raised in Ann Arbor, Michigan. I have lived in 10 states and have been to 42.
Aside from the weather I enjoy listening to and playing music, reading, watching movies and traveling.
A few things you might be most surprised to find out about me are that I am a Dead Head, a fanatical Michigan fan and if you challenge me I may verbally name all 50 states in under 12 seconds.
Hi Matt! Could you possibly be the Matt Brode from Ann Arbor? Used to be Marc Hoffmann's friend? I was just talking about you!
A belated reply to you Wendy. God bless you and Marc's memory, he was one of a kind.
Happy New Year, Matt! We leave in one week for FL, & can't wait! Temps in N. MI will be in the single digits by next weekend. Will you & your wife be in FL this winter?
MATT! I finally had to ask KOIN why I haven't seen YOU forecasting ….and got that "update"…..HOPEFULLY, you're forecasting in a venue we can watch here in Portland….. Hope you'll tell us… We always enjoyed seeing YOUR forecasts….you are a great meteorologist….and do the science well.
Nice to see you back in Tucson.
Hey Matt, r u a drinker? Wanna go throw some back? We'll call a taxi since we don't want to drink and drive ya know!!
We don't usually watch the afternoon news but did today. We were surprised to see you back in Tucson. What's up with that? Did you not care for Portland or the PNW? We, like you, have moved quite a bit, and traveled to many states. We are considering a move to Portland right now. Just wondering why you decided to move back. I love Tucson but it's time to move on. I want to try a few more states before my final dirt nap – don't mean to be too morbid.
So glad your back on my TV. I missed your lively forecasts, and that great smile of yours. I can't help but smile with you.
Smile, smile, smile. Thanks Tina!
We always watched you in the mornings with Josh Benson and are glad to see you back at KVOA. Go Blue!
Thank you Lorraine. I'm thrilled to be back.
I suggest an alternative explanation of the dew point humidity.
This is the temp. You would have lower a "box" of air to get the moisture to rain out.
Matt, I just posted a unique Night Blooming Cereus photo from last night to the Weather Gallery. Hope you can use it.
Keep an eye on NASA' s site. Tonight around 7:35 p.m. the ISS flew directly over what I believe was hurricane Julio. It had a definite eye. Hopefully NASA will release an image or video.
You mentioned that you needed firewood. You could contact my son Mark at Mark's Tree Service at 886-6860. He has a lot of firewood in various kinds of wood. I like your weather reports. Have a great Thanksgiving.
Hi matt, wanted to send you a good picture I took from my home today of Catalina mts but couldn't find a place to send it to. Nice pic of the snow on them.
i read your biography, do you have any roots around Harrisburg PA> ?
"Where the Caribbean meets the Atlantic" is an amazing picture. Thanks for sharing.
Are you on vacation? Have not seen you recently on KVOA at night. Hope you are still there. We miss Rebecca Taylor.
Good morning Matt Brode, I was reading your post this morning ( A surprise asteroid came "relatively" close to Earth today). I just write to infom you that a giant METEORITE has exploded and landed in some villages in Africa and I believe NASA might not aware of it because of the location.


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Q: difference between send() and sendTo() in C for a UDP network implementation I'm trying to implement a UDP network between a client and a server but in many implementations, they use either send() or sendTo() I tried looking in the man pages but I didn't really understand the difference other than that the sendTo() takes in more arguments which makes it look rather useless compared to send(). If you could bring any clarity on this matter I would be happy to hear :)

A: The sendto function is the one that's generally used for UDP sockets.  As UDP is connectionless, this function allows you to specify the IP and port that each outgoing packet is sent to.
You can however also use send if you first use connect.  The connect function can be used to specify the destination IP and port for all packets sent using send.  It also restricts the packets you receive to just those from that IP/port.  The connect function may be called multiple times to change the associated remote IP/port, or to remove the association.
In general, I would recommend sticking with sendto as it gives you more flexibility over who you're sending to.

redpajama_set_name: RedPajamaStackExchange


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ORMC to provide vaccinations Wednesday
Peru president survives impeachment vote amid virus turmoil
by: CHRISTINE ARMARIO and FRANKLIN BRICEÑO, Associated Press
Peru's President Martin Vizcarra greets reporters after addressing Congress in Lima, Peru, Friday, Sept. 18, 2020. Vizcarra's job is on the line Friday as opposition lawmakers push through an impeachment hearing criticized as a hasty and poorly timed ouster attempt in one of the countries hardest hit by the coronavirus pandemic. (AP Photo/Rodrigo Abd)
LIMA, Peru (AP) — Peruvian President Martín Vizcarra easily survived an impeachment vote Friday night after opposition lawmakers failed to amass enough support to oust the leader as the country copes with one of the world's worst coronavirus outbreaks.
The decision came after long hours of debate in which legislators blasted Vizcarra but also questioned whether a rushed impeachment process would only create more turmoil in the middle of a health and economic crisis.
"It's not the moment to proceed with an impeachment which would add even more problems to the tragedy we are living," lawmaker Francisco Sagasti said.
In the end, only 32 lawmakers voted to remove the president, while 78 voted against and 15 abstained. A two-thirds majority was needed to oust Vizcarra.
The political feud was sparked by the release of several covertly recorded audios that Vizcarra's detractors contend show he tried to obstruct an influence peddling probe. And despite the failed vote, that conflict was likely to continue, afflicting the president's ability to carry forward his anti-corruption agenda could be indefinitely stymied.
"In the overall scheme of things, Vizcarra has won this round, but winning is a very relative term," said Jo-Marie Burt, a senior fellow with the Washington Office on Latin America.
The political turmoil rocking Peru has briefly distracted attention from the pandemic, which has left hundreds of thousands sick in the South American nation with the highest per capita COVID-19 mortality rate around the globe.
At the center of the ordeal is Vizcarra's relationship with a little-known musician known as Richard Swing and nearly $50,000 in questionable contracts that the entertainer was given by the Ministry of Culture for activities like motivational speaking.
A covert audio recording shared by Edgar Alarcón — a lawmaker himself charged with embezzlement — appears to show Vizcarra coordinating a defense strategy with two aides, trying to get their stories straight on how many times the musician had visited him.
In remarks before Congress on Friday, Vizcarra asked for forgiveness for the upheaval that the audios have generated but insisted he committed no crime. He called for a proper investigation and urged lawmakers not to aggravate Peru's already precarious situation by rushing through an impeachment proceeding.
"Let's not generate a new crisis, unnecessarily, that would primarily affect the most vulnerable," he said
During a long day of debate, many lawmakers expressed frustration with Vizcarra, denouncing his apology as a weak attempt to make amends and demanding a thorough investigation. But numerous legislators also said they couldn't support an impeachment that itself was rushed and full of flaws, held before an official probe reaches any conclusions.
"This doesn't mean we're handing over a blank check," one lawmaker warned.
Vizcarra became president in 2018 after Pedro Pablo Kuczynski resigned the presidency under pressure by Congress after the discovery of about $782,000 in undisclosed payments to his private consulting firm by Brazilian construction giant Odebrecht, which is at the center of a regionwide corruption scandal.
Odebrecht has admitted to paying some $800 million in bribes to officials across Latin America, and nearly every living former Peruvian president has been implicated in the scandal.
Vizcarra, at the time a vice president serving as Peru's ambassador to Canada, is an engineer by training and was considered an unknown political novice. But he has managed to become a highly popular president, recently getting a 57% approval rating in a poll despite Peru's severe economic fallout from the COVID-19 crisis and the high infection rate.
Many Peruvians see him as a frank-talking leader who has taken on corruption, dismissing Congress last year in a brash move cheered by citizens as a victory against a dishonest class of politicians and pushing through initiatives to reform how judges are chosen and bar politicians charged with crimes from running for office.
"He's the only president who — without a lot of power — has faced off against those shameless people," said Pedro Quispe, a retired teacher out selling face masks on a recent day.
Steve Levitsky, a Harvard University political scientist, said Vizcarra has made "some modest steps forward" when it comes to corruption.
"He hasn't been able to carry out all the political reform that he and his allies hope to," Levitsky said. "But corruption in middle-income countries is never eliminated in a single presidency."
Vizcarra tried to halt the impeachment by filing a lawsuit with the Constitutional Tribunal, but magistrates ruled Thursday that the process could proceed, under the belief that lawmakers would not actually be able to oust him.
While analysts criticized the rushed procedure in which the impeachment proceeding was initiated within hours of the audio's release, many agreed the president owed Peruvians an explanation.
Vizcarra didn't delve into details in his statement Friday, though he did point to inconsistencies in statements by a former aide who made the audios and said the only proven misconduct is having been illicitly recorded.
To what degree the scandal could taint the seven months he has left in office remains to be seen. The president has no majority in Congress, a pandemic still to deal with and an economic contraction that has thrown millions into poverty.
His presidency, it appears, will be book-ended by crises.
"He is very isolated, very alone," Burt said. "I really don't think anyone is winning in this situation."
Associated Press writer Christine Armario reported from Bogota, Colombia, and AP writer Franklin Briceño reported in Lima, Peru.
ODESSA, Texas (Nexstar) – Odessa Regional Medical Center will have vaccines available today.
According to a release from the hospital, ORMC received about 400 doses of the Moderna vaccine this week. They plan to distribute around 100 of those to frontline workers and the remaining vaccines will be available to the public.
Todd Boulanger – President Trump granted a full pardon to Todd Boulanger. Boulanger is an lobbyist who pled guilty of one count to commit honest services fraud in 2008.


"You Must Believe in Spring"
It amazes me that Bill Evans...just a few short years from his death was playing better and more beautifully as he got older. This Shm-Sacd is a perfect example. In my opinion it ranks as what may be his best playing ever.
I consider this Warner disc to be a Dvd-Audio but I still give it 5 stars because both the music and the sound is awesome. It is so impressive how ones emotions change from the different note-structures Evans plays. Evans note selection is much more complex here.
A person can go through the gamut of his/her emotions pretty quickly listening to this album. Evans piano playing on this album is so musical and liquid...how he can bunch notes together so suddenly and then play other tonal colours....then slowing down the tempo....is truly amazing here.
This disc must be played very loudly and the sound is wonderful. Sonically this disc cant compete with the other tape to Dsd discs but it still impresses never the less.
The original album had 7 tracks but this Shm-Sacd has 10. The 3 bonus tracks are different in feel and dont completely relate to the first 7 on the same emotiional level but it does make for great listening and a longer playing time.
Evans......hopelessly hooked on heroine and according to one friend.... committing the longest suicide in history manages to achieve masterful piano artistry of the highest calbre. A TRUE ARTIST.
A truly great album and Shm-sacd.
Anyone interested in the artistry of Bill Evans would do well to purchase this incomparable SHM~SACD. With Eddie Gomez on Bass and Eliot Zigmund on drums, Evans plays two originals, B Minor Waltz (for Elaine) and We Will Meet Again (for Harry) and Jimmy Rowles The Peacocks, Michel Legrand You Must Believe in Spring," the unlikely Theme From Mash and Warner has generously added three bonus cuts.
The trio sizzles in a recording engineered by Al Schmitt and mastered by Doug Sax and produced by Helen Keane and Tony LiPuma.
I only wish that Bill Evans classic "Quintessence" with the transcendent A Child Is Born would also be released in the SHM~SACD format.
Again, I welcome Warner Japan to the SACD format and am hoping that they continue to release other jazz classics and while we're at it, how about some Van Morrison?