text:
MAST YEAR
Reflections on a Year of Plenty
There's a good bit of speculation that 2015 may be a mast year for many oaks. "Mast" is the fruit of forest trees, like acorns or nuts, but unlike traditional agricultural crops which have a (somewhat) predictable yield each year, forest trees have highly variable fruiting. Some years, oaks only produce a handful of acorns, but in mast years, the trees produce a ridiculous abundance of nuts. Over vast regions of the country, almost all of the oaks of a single species (and sometimes more than one species) prepare to produce the crop of a decade.
In Old Town, Alexandria, my walk from the metro has become as treacherous as the "black ice" of winter. The red oaks of King Street shower the sidewalks with small, perfectly round acorns like thousands of ball bearings. Ankles and knees: beware! When the wind blows, acorns pop on the hoods of parked cars like dried corn in a skillet.
Since medieval times, farmers have taken advantage
of mast years to feed livestock
In the forests, the impact of these boom and bust cycles ripples throughout the entire ecosystem. Bumper crops of acorns produce a feast for all kinds of birds and mammals. Throughout history, farmers have taken advantage of mast years to feed their livestock. In the wild, populations of Acorn Woodpeckers (Melanerpes formicivorus) on the West Coast of North America spike during mast years. And when one population spikes, it creates a domino effect through the whole system. Researchers at the Institute of Ecosystem Studies documented a surge in mice and deer during masting years. This in turn produces an uptick in ticks who feed on deer and mice. And because ticks produce Lyme disease, the incidences of it in human populations increases. Mice pillage ground-nesting birds such as some veery and warblers, so following mast years, these species decline. But increases in mice also result in a decrease of gypsy moth (Lymanthria dispar), a notable pest which defoliates a significant percentage of the eastern forest. Scientists call this chain of events a "trophic cascade." The result can literally change the community composition of an entire ecosystem for years.
Why do trees mast? Some scientists speculate that trees deliberately develop an abundance to satiate seed eaters who might otherwise eat all the available acorns. The resulting leftovers increases the odds for germination of a next generation of oaks. Likewise, lean years help to keep populations of seed eaters so low that there are not enough to eat all the seeds during subsequent years. In a Machiavellian scheme, trees satiate animals one year only to starve them the next.
Masting may also be a way of balancing a tree's limited resource. Producing a large seed crop takes a lot of energy. During mast years, trees shift energy into flower and seed production; the next year, seed production tends to be very low, but the trees grow more. There is an inevitable tradeoff between reproduction and growth.
My walks down acorn-littered sidewalks have me thinking about my own cycles of preparation and production. After several years of chaining myself to a desk at nights and early in the mornings, I have emerged with a book. The years spent in development with Claudia only heighten my relief and pleasure in having it out in the public. Writing a book is so different than a blog post; it lacks the immediate gratification of sharing an idea online with peers. But that long season of waiting has resulted in an extraordinary season of abundance.
Path through dune in Cape Cod near Newcomb Hollow Beach
For me, this has been a year of plenty. Not only in terms of my own work, but also in the relationships I've developed, the rich conversations I've had, and the wealth of knowledge shared with me. Travel has taken me to many wonderful places. In Dublin this past winter, I felt the palpable energy of a new generation of designers and gardeners eager to innovate and adapt. In Des Moines, I witnessed a small but mighty botanical garden creating genre-blurring plantings. In Portland, I toured some of the most idiosyncratic and expressive gardens I've ever seen; gardens that challenged me to rethink the way I approach place-making. I've driven across the dry savannas of north central Texas, traveled through the rolling fields and forests of the Brandywine Valle, wandered the boulder fields of the Alabama piedmont woodlands, and explored the craggy coastlines of the Massachusetts Cape. We are spoiled with so much beauty, so much life. I've sat in kitchen tables and broken bread with thoughtful, kind, and fascinating people—all united by a love of plants.
Meadow at Mt Cuba Center this November
This is my mast year. To all of you who have invited me, opened your gardens and kitchens, and shared with me pieces of your life, I thank you. You've stretched my mind, and you've stretched my heart. I am certainly not worthy, but I am so grateful.
Source: Koenig, Walter and Johannes Knops. "The Mystery of Masting Trees." The American Scientist. Volume 93. July-August 2005
Labels: acorn woodpeckers, acorns, mast year, Planting in a Post-Wild World
ONE IDEA, ONE VOICE
A Behind the Scenes Look at Co-Writing a Book
Like many of you, I garden and I write about gardening. Both of these are essentially solitary acts. As a blogger, I get to do and say what I am interested in. But I have spent the past few years doing something very different: writing with someone else. It was a process unlike anything I've ever done. So I thought I'd share an honest account of that collaboration, revealing both the ups and downs of the process.
Our culture holds collaboration as a virtue. Working together toward a common goal is a parable preached by preschools and MBA programs alike. But actually doing it—sitting down with someone and then developing, for example, a 316-page manuscript focused on a marketable idea—is quite another thing altogether.
So the celebration of having an accepted book proposal was short-lived. The euphoria quickly melted into doubt. Wondering whether I could pull off a book on my own was worry enough. But seamlessly melding two viewpoints and voices into a single message was something I've never done before.
Of course, I had a great partner. Claudia's big ideas and hands-in-the-dirt experience were huge assets. And her passion is contagious. I found myself looking forward to talking to her every week. We logged hours on Skype. I'd fill notebooks with thoughts; mental kindling that set my mind on fire.
But starting was hard. One of the beliefs that initially paralyzed us is the idea that you need permission to do anything. In co-writing, civility is certainly a virtue, but politeness can be a waste of time. Clear writing results from a strong point of view and logic; yet our fear of offending the other left us with little resolution on complicated points. We would end long Skype conversations courteously, but without firm resolutions. It left us mushy ground to launch our next week of writing.
Plants are social. The layered structure of naturally occurring plant communities was the inspiration for the book. Photo by Claudia West.
And it took us many months to get into a rhythm. Initially, we both tried to write pieces of the same chapter. But our styles were so different, the early drafts were a total mess. I was verbose; Claudia was brief. I wrote in paragraphs, feeling my way through arguments as I wrote. Claudia worked from clear outlines that progressively expanded into narrative. I would spend hours polishing a paragraph without knowing what was coming next. Claudia could quickly develop content, but had a hard time expanding this into a narrative.
So we changed course. What ultimately worked best was that we'd both hammer out a basic outline. Claudia would free-form several pages of bullet points about a single topic. I would organize them into an argument and rewrite them in a draft form. Then we'd both tweak the drafts. We each had separate roles, but we also each controlled the content at several points. It was an iterative process that allowed us each to shape the idea in the way what we did best.
We struggled the most with the big idea. Our first proposal was for a book called Native Planting Design. While there were several regional books on native planting, we wanted to write the definitive resource on designing with natives from an international perspective. But several chapters into that book, we realized that the concept didn't work. For us, where a plant came from was less useful than how they fit together in communities. So four months before our completed manuscript was due, we scrapped that idea and started over. Throwing away tens of thousands of words was painful. Getting Timber Press to agree to a new angle (and re-vet the book through several layers of approval) was even more painful. But in the end, we all agreed on the new direction.
What held us together was a single-minded obsession about the same inspiration: plant communities. The social nature of plants had been almost entirely forgotten by traditional horticulture. Yet I could not even walk down my urban street without being confronted intricately interwoven carpets of weeds. I'd bend over to examine an upright spike of green foxtail, nested in a bed of Indian goosegrass, coming out of a mat of spotted spurge. Though the plants were different, the same scene was happening in the native meadow and forest floor. It was so seemingly obvious, so ubiquitous, that writing a book on the subject sometimes felt like proclaiming that the sky was blue or water wet.
The patterns and legibility of long established plant communities motivated me. Photo by Mark Baldwin
And yet we came to these inspirations from different points of view. For me, native plant communities were design exemplars, compositional allegories waiting to be explored. My hikes through the grassy balds of the southern Appalachians, or the granite outcrops of Georgia's monadnocks, or riverside prairies of the Potomac Gorge told a story of patterns and structure. Though the structure is often blurred and the patterns overlapping, the arrangements of plants within these communities are for me a triumph of legibility over chaos. I could not pass a weedy median or walk through an old growth forest without filling my mind with mental notes of new combinations, new matrixes, new X's and O's to put together on the next plan. I came to the book wanting to tell the story of design. And to confess to my own ideological bent, I believed deeply in the potential of our native plants, but the lack of good design examples that was holding them back.
For Claudia, it was the layering of plant on top of plant—the gorgeous morphological diversity of plants above and below ground—that was the story to tell. Claudia wanted to weave the science of plant interaction and ecological niches (the natural story) together with the history of the German perennial movements (the cultural story). Claudia's experience in Germany immersed her in the world of Karl Foerster, Richard Hansen, Wolfgang Oehme, Cassian Schmidt, Bernd Hertle, and Norbert Kuhn. Germany's emergence from the desolation of World War II produced a renaissance of thinking about how perennials could be viable plants for covering much of the country's public landscapes. Unfortunately, our book only covers a small amount of this fascinating history (Timber Press wanted us to focus on the larger narrative). But hopefully, Claudia will write and speak more about this in the future (her talk this summer on Karl Foerster at PPA in Baltimore was a big hit).
Claudia and me at a recent talk in Oxford, MD. Photo by Susan Harris
In the end, it was the power of the idea—and a trust in each other as colleagues and friends—that got us through the grueling process. That idea was big enough to hold together both our points of view. It's a big tent idea: I'm confident it will support many, many other expressive variations. Whether the book is a flop or success, the collaboration itself was one of the most rewarding experiences of my professional life. It blew open my thinking about plants, and has set my thinking onto much broader horizons. I am grateful for the experience.
Planting in a Post-Wild World is available anywhere books are sold. You can find it online here at Amazon or here at Timber Press.
Labels: Claudia West, native plant communities, Planting in a Post-Wild World, resilient planting
THE COLLABORATION: TEAMING WITH CLAUDIA WEST
It has been a long time since I've written here. I have missed it immensely. And I have missed you.
I am writing to say that I am back. I am returning to write refreshed and re-energized by a much needed sabbatical in which I wrote a book. I may not write the frequency of my earliest posts, but when I do, I'll try my best to make it worthwhile.
I want to share a bit about the project that has absorbed me for the last two years. Several years ago, Timber Press approached me about submitting a book proposal. I said no initially (overwhelmed with a new baby and home renovation), but when they asked again, I was ready.
Claudia West
A few months prior, I had run into Claudia West at a conference in which we both spoke. She gave a talk about the color ranges of native plants that blew me away. It was wonderfully researched and rooted in science; but it was her ability to synthesize a lot of little details into a big picture that totally changed the way I thought about plants. I drove home looking at the landscape around me as if the scales had fallen off my eyes. I wanted more.
I had met Claudia many years before when I was working with Wolfgang Oehme at OvS. Claudia grew up on a family nursery in eastern Germany. Wolfgang was a family acquaintance. When Claudia was finishing school, she came to the U.S. to work at one of Wolfgang's favorite perennial nurseries: Bluemount located outside of Baltimore (unfortunately, now closed). One of the great things about working at OvS was Wolfgang's weekend tours. Wolfgang would invite all the young staffers (plus members of his posse—a random assortment of people who sought him out to learn from the master) up to Baltimore to look at his projects tucked all over the city. His garden tours were an odd mix of joyful discovery and grueling 10 hour forced marches (we never stopped for food or drink). But seeing plants in the landscape was a great way to learn them, and the tours bonded the participants. I got to know Claudia through these epic events.
Claudia West with the late Wolfgang Oehme. Image by Rick Darke
Many years passed. Claudia became a landscape architect in Germany and then came back to the mid-Atlantic, eventually making her way to North Creek Nurseries, one of the preeminent perennial and grass nurseries in the country. Infused with ideas from German mentors and her rich knowledge of American native plants, Claudia's unique approach to design and mixed perennial planting developed, particularly as she experimented with real sites. Claudia's current role at North Creek is expansive. She runs the ecological landscape division, the fastest growing branch of North Creek that grows perennial plugs for direct installation in the landscape. Most perennial plugs are sold as liners to wholesale nurseries to be potted up as quarts or gallons. But North Creek's landscape plugs are especially long, allowing them deeper roots that can be planted directly. Claudia not only sells, but she designs and installs dozens of plantings a year. This provides her with a real world laboratory to constantly trial her ideas and designs.
Claudia West in her element laying out plants for a trial garden at North Creek Nurseries. Photo courtesy of North Creek Nurseries
While Claudia made her way back to the U.S. from Germany, I was making a transition of my own. I joined Rhodeside & Harwell in 2009 out of a longing to design more public scale parks, urban sites, streetscapes, and historic landscapes. While I loved creating gardens, I had a sort of Olmstedian itch I needed to scratch. I wanted to do more than just shrub up the estates of the uber-wealthy or the private landscapes of developers. I love plants, but I also love cities and wanted a practice that fully engaged in the issues of the urban realm. The shift from mostly private work to mostly public work was difficult, particularly when it came to planting design. No longer could I rely on trained gardeners to keep plantings perpetually maintained. Now I was dealing with sites that would be planted and minimally maintained. It required a different kind of planting. And a deeper knowledge of plants naturally interact with each other and their sites.
So when Timber Press contacted me about a book, I knew immediately that I wanted to work with Claudia. We were both dealing with the same challenges. We knew intuitively that there were plants that thrive in any site, but we both wanted to understand how to arrange plants in compositions that simulated the function and beauty of naturally occurring plant communities. We were both highly aware of the problems that many native plantings had in getting established. This was our starting point.
Next post: Writing a Book Together
The book will be released this month!
Labels: Claudia West, Planting in a Post-Wild World, wolfgang oehme
If you liked this post . . .
Thomas Rainer
Thomas Rainer is a horticultural futurist fascinated by the intersection of wild plants and human culture. A landscape architect by profession and a gardener by obsession, Thomas has worked on projects such as the U.S. Capitol grounds, the Martin Luther King, Jr. Memorial, and The New York Botanical Garden, but is happiest puttering in his small garden in Washington, D.C.
Thomas thinks you should use more natives, plant more daringly, and loosen up that landscape, for crying out loud.
talks!
grounded design is on the road. Click here to see Thomas' speaking schedule or learn how to book a talk with Thomas
I believe:
Good design matters.
The quality of our environment affects our health and spirit.
Gardens are points of connection, grounding, and continuity.
Well loved spaces amplify living.
Nature should be interpreted, not imitated in designed landscapes.
Planting design should be bold, daring, and uncompromising.
We can reclaim biodiversity and habitats within human landscapes.
A good day ends with dirt under my nails, grass stains on clothes, and dreams of the next garden.
"(Thomas' lecture at NYBG) was a turning point for the next generation of garden designers that take into consideration both the art and ecology of great garden making. Thomas has a new contemporary voice."
"How about stopping by Mr. Rainer's influential garden blog, Grounded Design, where he has taken to speaking apostasy against the dogma of green landscaping." The New York Times
"Thomas, perhaps the first theoretical horticulturalist of the social media generation, has a true blogger's ease with the first person voice."
"If I only had time to read one blog, this would be a serious contender."
"So often I read your posts twice, even three times because they're THAT good."
"I came across your blog recently and have read almost every post top to bottom in a frothing frenzy."
"I love gardening and I love good writing and this blog is the best fusion of the two I've seen on the web! Wow!"
"This is one of the best blogs I've ever read. You are a man after my own heart. I wish I had written this."
"The most exciting blog discovery in a long time." Garden Rant
"As a general rule, I don't tell people what to do, or what websites to visit, but this is a 'must read' blog. I've been in this field over 40 years . . . I rarely read anything about gardens, gardening, or design that I don't know. When I see there's a new post on Thomas Rainer's blog, I get excited . . . I've yet to be disappointed."
"Every time I read a post, I want to shout 'YES! YES! You are so right!!'"
"Your blog is the one I look most forward to: always engaging, always thought provoking."
"Sublime commentary. Gorgeous photos."
"The writer combines his vast knowledge of landscape culture and his gift as a writer to produce fresh, innovative, attention-grabbing, and at times inspiring posts--post after post."
"I browse through many gardening sites, but this one has very quickly become my favorite."
"these words are superb . . . anointed . . . "
"I enjoyed it so much we read all the way back to the first posting, and then subscribed."
"The good earth viewed by a visionary pair of eyes. "
"Thomas doesn't write every day or even every week -- he is, after all, a busy landscape architect -- but you won't want to miss any of his posts. It's one of the most relevant and fascinating and informative blogs on the subject of landscape design and/or architecture that's out there. You will not be disappointed." Garden Design Online
"I love your blog--it is like reading an excellent garden book! Only better, if that is possible."
"An exciting convergence of landscape design and art, narrated by a visionary gardener-poet. By far, this is my favorite gardening blog."
"This is no mere garden blog. With each posting, he takes the reader on a journey from which few would want to return."
"The posts are exceptionally well written, and I almost always come away from them heady with new ideas and new ways of seeing."
"I just LOVE Thomas Rainer's blog, Grounded Design. It's not that he just writes great things about gardening. It is HOW he writes that really has me hooked. There is nothing boring or superficial about this blog. Rainer digs deep into the human aspects of gardening." Metro DC Lawn & Garden
"These really are the best articles we've read in ages."
Winner of Horticulture Magazine's "Best Gardening Blog"
blow your mind quote of the moment:
"It is through our strong sense of mortality that ephemeral beauty is so keenly savored." Christopher Lloyd
GardenDesignOnline
Happenings: August 2019
Nature Scenes Reduce Anxiety. How about Gardens?
Planting The Summer Pots
Noel's Garden Blog
View from Federal Twist
Rediscovering the value of plants in landscape architecture by Giacomo Guzzon
Perennial Meadows
Perennial Border One Year Old
Rhone Street Gardens
A Lucky Shot!
Ecological Gardening
Gardening as a Political Act of Necessary Beauty
The Gardener's Eye
The Late Summer Gardens of Southern England 2019
blackwalnutdispatch.com/
It's February 4 and 62 Degrees
John Grimshaw's Garden Diary
Plant of the Year 2017: Narcissus 'Thalia'
Garden Guru
The Most Beautiful Landscaped Flower Garden in Thailand.
Restoring The Landscape With Native Plants
Beneficial Insect Profile - Lacewings
LANDSCAPES WORTH VISITING
The New York Botanical Garden
Dumbarton Oaks, Washington, D.C.
The Highline, NYC
The U.S. Botanical Garden, D.C.
Mount Cuba Center, Delaware
The Adkins Arboretum, Eastern Shore
Longwood Gardens, Pennsylvania
Chanticleer, Pennsylvania
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text:
Personal identity and applied ethics : a historical and philosophical introduction
Andrea SAUCHELLI
Research output: Scholarly Books | Reports | Literary Works › Book (Author) › peer-review
Soul', 'self', 'substance' and 'person' are just four of the terms often used to describe the human person. Cutting across metaphysics, ethics and religion the nature of personal identity and the self is a fundamental and long-standing puzzle in philosophy.
Personal Identity and Applied Ethics introduces and examines different conceptions of the self and personal identity and considers the implications of these for applied ethics. A key feature of the book is that it considers a range of different views of the self; philosophical, religious and cross-cultural, including perspectives from non-Western traditions. Within this comparative framework Andrea Sauchelli examines the following topics:
- Early views of the soul in Plato, Christianity and Descartes
- The Buddhist 'no-self' and the self as a fiction and Hume on the self Confucian ideas of the self and the importance of self-cultivation as constitutive of the self
- Locke's theory of personal identity as continuity of consciousness and memory and objections to Locke's argument by Butler and Reid as well as contemporary critics
- The theory of 'animalism' and arguments concerning embodied concepts of personal identity
- Narrative theories of personal identity and moral agency Personal identity and self-knowledge
- Personal identity and important issues in applied ethics, including abortion, euthanasia and the idea of life after death
- Implications of life-extending technologies for the self and personal identity.
Throughout the book Andrea Sauchelli also considers the views of important recent philosophers of personal identity such as Sidney Shoemaker, Bernard Williams, David Wiggins, Derek Parfit, Galen Strawson and Christine Korsgaard, placing these in helpful historical context.
The addition of chapter summaries and annotated further reading make this a refreshing, approachable introduction to personal identity and applied ethics. It is an ideal text for courses on personal identity that consider both western and non-western approaches and that apply theories of personal identity to applied ethics. It will also be of interest to those in related subjects such as religious studies and history of ideas.
Oxon
This project was supported by a Grant from the Research Grants Council of the Hong Kong Special Administrative Region, China (Project No. LU23400314).
Publisher's page
Fingerprint Dive into the research topics of 'Personal identity and applied ethics : a historical and philosophical introduction'. Together they form a unique fingerprint.
Philosophical Introduction Arts & Humanities
Personal Identity Arts & Humanities
Applied Ethics Arts & Humanities
Self-identity Arts & Humanities
Moral Agency Arts & Humanities
Theory of Narrative Arts & Humanities
Sydney Shoemaker Arts & Humanities
Christianity Arts & Humanities
Personal Identity, Survival, and Human Enhancements (個人同一性,生存和人類改善工程)
SAUCHELLI, A.
SAUCHELLI, A. (2017). Personal identity and applied ethics : a historical and philosophical introduction. Routledge. https://doi.org/10.4324/9781315644288
SAUCHELLI, Andrea. / Personal identity and applied ethics : a historical and philosophical introduction. Oxon : Routledge, 2017. 244 p.
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SAUCHELLI A. Personal identity and applied ethics : a historical and philosophical introduction. Oxon: Routledge, 2017. 244 p. https://doi.org/10.4324/9781315644288

redpajama_set_name: RedPajamaCommonCrawl


text:
Sick of Fitbit? Fossil could be about to unleash a rival smartwatch
The sequel to the Fossil Sport could be on its way. That's what the discovery of a Bluetooth listing suggests, but since the original only came out in November 2018, there could still be a little bit of a wait before the Fossil Sport 2 arrives.
A new Fossil Sport 2 has been uncovered via the certification board for Bluetooth – Bluetooth SIG. The product was listed on July 1 as a Bluetooth device from Fossil – this doesn't necessarily guarantee it's the Fossil Sport 2, but there is a key hint on the listing.
Related: Amazon Prime Day wearables deals
Gadgets & Wearables reports that the device has the name DW10F1 on the Bluetooth SIG listing. The Fossil Sport from last year had been listed as the DW9F1. While this is far from a guarantee that the DW10F1 is the Fossil Sport 2, it seems fairly likely.
Beyond this information and the assumed name, we know very little about the Fossil Sport 2. The Fossil Sport features the Qualcomm Snapdragon Wear 3100, and the sequel is expected to do the same.
Hopefully, the Sport 2 will come with some new and enhanced features elsewhere though – both in terms of hardware and its utilisation of Wear OS.
Whether this is the Fossil Sport 2 or not, there's a chance that the device will be announced very soon. That's because the original Fossil Sport was announced just a month after it was listed as being Bluetooth SIG certified.
Related: Best smartwatch
The Trusted Reviews take on the Fossil Sport was less than glowing: "The Fossil Sport's lacklustre battery life and buggy performance undermine this otherwise sports-friendly smartwatch". However, the smartwatch did receive a solid three-star rating.
Fossil smartwatches haven't exactly taken the world by storm. Figures reported in May of this year showed the number of smartwatches shipped by the company had actually declined from Q1 2018 to Q1 2019.


The perfect set for day in the spotlight. The top neckline and hem are lined with an elegant scalloped edge while the lace pencil skirt is classy and comfortable. Pair the top with high-waisted jeans or a leather jeaket to take this set from day to night!


text:
The Illinois Department of Employment Security (IDES) is the code department of the Illinois state government that administers state unemployment benefits, runs the employment service and Illinois Job Bank, and publishes labor market information. , Jeffrey D. Mays was the Director of Employment Security.

Structure
The board of review consists of 5 members, 2 of whom are representative citizens chosen from the employee class, 2 of whom are representative citizens chosen from the employing class, and one of whom is a representative citizen not identified with either the employing or employee classes.

The Employment Security Advisory Board is composed of 12 persons, 4 of whom are representative citizens chosen from the employee class, 4 of whom are representative citizens chosen from the employing class, and 4 of whom are representative citizens not identified with either the employing class or the employee class.

See also
 Illinois Department of Labor

References

External links
 Official website
 TITLE 56: LABOR AND EMPLOYMENT of the Illinois Administrative Code

Employment Security

redpajama_set_name: RedPajamaWikipedia


text:
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 ActiveScaffold
 (c) 2007 Richard White <rrwhite@gmail.com>

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redpajama_set_name: RedPajamaGithub


Made with Chocolate Chunk Cookies, a vampire's bite has never been so sweet!
Hosting a crowd this Halloween? We've got you covered. Not only are Chick-fil-A's Chocolate Chunk Cookies scary good, they help make for a Pinterest-worthy Halloween treat.
Order a small cookie tray from the Chick-fil-A catering menu to serve 12, or a large tray to serve 24. Then follow the steps below to add marshmallow teeth for an easy vampire-themed treat!
•	Cut cookies in halves.
•	Fill icing decorating bags – one with red icing and one with white icing. If you do not have icing decorating bags, fill a sandwich bag with icing and cut a small hole in one corner.
•	Run a line of red icing along the top and bottom of round cookie edges. Add more red icing as needed to keep cookies intact.
•	Place marshmallows in a line between icing layers and close cookies.
•	Using the second icing bag, run a line of white icing to resemble fangs to the left and right of the two front teeth.
•	Sink your fangs in and enjoy!
For other festive Halloween treats to spice up your table this season, check out our Fruit-Ka-Boos, easily made with a Chick-fil-A fruit tray, and our Chick-fil-A Candy Corn Lemonade!


I think much worse. The years after I left, it got worse. But just because other people are doing it, doesn't make what I did right. Back when I was (running Stratton), it was the total Wild West on Wall Street. That was my rationalization: Everyone's doing it. Bull. ... Just because everyone else is doing something wrong, doesn't give you (permission). That was a huge error on my part.
It was going on and got much worse leading up to the GFC (global financial crisis). The whole industry was running amok.
You've remade your career as a motivational speaker. What's different in your message on this new tour?
The big difference is that I'm giving all the profits away (to Stratton Oakmont's financial victims). ... One of my messages is that success without ethics and integrity is not success. For me, a lack of ethics cost me everything. You don't cut corners to get rich. It takes a little longer when you're playing by the book, but you're building a foundation on concrete, not sand.
What's your biggest regret in the collapse of your personal life and your company?
My biggest regret is that people lost money when the company collapsed. Any of the behaviors that led me to allowing the firm to fail, I would change those. I wouldn't choose to live that again. My personal life, my insanity, the drugs … that was my life. It was part of my journey. My personal recklessness, I wouldn't change, just because (living with regrets) is not a healthy way to look at life. My drug addiction affected me, my family … but I wouldn't change it. But I would not advise someone to live like that because it was horrible.
It was a huge wake-up call to lose everything. That sort of cataclysmic event makes you realign your values … This lifestyle is so much better than my old value system.
Where did Stratton Oakmont go astray?
The company was absolutely 100 percent on the up-and-up (when it started). … It wasn't a Bernie Madoff thing, where I started out (to deceive investors). It took about a year for it to spiral out of control. I chose the wrong mentor, I crossed the ethical line. You start doing a little rationalization and before you know it, you get desensitized.
There's still greed on Wall Street. … There's a very fine line between greed and ambition. You can make money, but not at the expense of other people.
There have been media reports criticizing your California lifestyle and statements by the Brooklyn DA's office that you're not doing enough to pay back the $110 million owed to more than 1,500 victims of Stratton Oakmont.
It's ridiculous. I've paid more than anybody in my position has. The government's view is completely incorrect, based on a flawed assumption, on their part, that I owe 50 percent of my income for life. That is completely untrue. In fact, two months ago, the judge ruled 100 percent in my favor, saying that I am not obligated to pay 50 percent of my income for life. .... I currently pay $10,000 a month, which was a number my lawyer worked out with the government, and on top of that I am voluntarily turning over all of my book and movie royalties, and also all my profits from the U.S. tour.
When it comes to investing, especially in the world of penny stocks, how would you advise people to avoid people like you?
Good question. Honestly, I'm really reticent to advise people to invest in any stock, unless you know the person recommending it to you really well. In addition, you can Google anything nowadays, so you should do your own research, too. Don't just rely on someone else telling you what to invest in.


In November 2007, Arthritis Consumer Experts (ACE) developed and administered an internet-based survey to gather information on the healthcare and treatment needs of people living with arthritis.
Timely access to treatment and care is critical for people living with arthritis. Research shows that delays in accessing appropriate treatment and care can result in higher rates of disability, increased joint damage, increased pain, and significant reduction in quality of life.
While research provides us with important information on these issues, too often it does not ask people living with arthritis where they feel their care and treatment issues are not being addressed. That is why ACE asked its members and JointHealth™ monthly readers-people living with arthritis-to share their views about arthritis treatment and care.
The length of time it took to receive this diagnosis from the first visit to a health care professional for their symptoms.
The number of health care professionals individuals saw before receiving their diagnosis.
Here are the results: For respondents living with osteoarthritis, 57% received a diagnosis within less than one year. 22% were diagnosed between 1-3 years, 13% between 4-6 years and the remaining 9% waiting between 7 and 10 years.
For respondents living with inflammatory types of arthritis, 57% received a diagnosis in less than one year and 20% in 1-3 years. While this may seem like an acceptable period of time for diagnosis, it is important to look at the differences in diagnosis times between the types of inflammatory arthritis diseases as there are valuable findings that emerge.
For example, while we can see in the chart below that 58% of people living with rheumatoid arthritis received their diagnosis in less than one year, only 26% of people living with ankylosing spondylitis and 38% of people with lupus were able to get a diagnosis in this time frame.
Even more troubling is the percentage of respondents who had to wait more than 10 years to be diagnosed with their disease, including 23% of people living with ankylosing spondylitis and 23% of people living with lupus. This stands in stark comparison to only 2% of those respondents living with rheumatoid arthritis.
The lengthy delays in getting a diagnosis for people living with ankylosing spondylitis and lupus are highly problematic because of the impact on accessing treatment and care. Research has proven that starting treatment for inflammatory arthritis in the early stage of disease onset is the best way to prevent irreversible joint damage. In fact, we now know that there is a small window of time, at the outset of the disease process, when proper treatment can actually prevent joint damage.
Unfortunately, many people with arthritis in Canada are not receiving the best treatment possible. Recent research conducted by Dr. Diane Lacaille found that only 43 percent of the people diagnosed with rheumatoid arthritis in British Columbia received disease modifying anti-rheumatic drugs (DMARDs), a class of medications considered "essential" to preventing joint damage and controlling disease in the early going.
The issue of timely diagnoses has a significant impact on the lives of people living with arthritis in terms of managing their disease, and also has a considerable impact on the health care system. When we asked people how many health care professionals they saw before receiving their diagnosis, there were important differences between different arthritis disease groups.
The majority of respondents living with rheumatoid arthritis and osteoarthritis saw no more than two health care professionals to get a diagnosis, with only 25% and 20%, respectively, seeing more than three health care professionals.
In contrast, those respondents with psoriatic arthritis, ankylosing spondylitis and lupus were more likely to see three or more professionals before being diagnosed, 51%, 62% and 65%, respectively. In addition, for respondents with lupus and ankylosing spondylitis, 17% and 19% respectively saw more than 6 health care professionals before receiving a diagnosis.
The need to see more than three, and in some cases many more than six, health care professionals to receive a diagnosis negatively impacts the health of people living with arthritis and adds unnecessary costs to a health system already suffering from cost pressures.
In addition to the top three, individuals also reported using self-management programs (27%), registered massage therapy (23%), physiotherapy (22%), house cleaning services (14%) and medicinal marijuana (3%).
The findings regarding treatment are similar to what research has shown that people living with arthritis use to manage their disease. While appropriate treatment with prescription medications is a key tool for people living with arthritis, in particular inflammatory arthritis, it is encouraging to see so many respondents say they use exercise. Research tells us that exercise is a key aspect of arthritis treatment. It helps to keep the muscles strong, protecting the joints and is also an important way to maintain a healthy body weight6. In addition to those benefits, exercise is beneficial for mental well-being and can be a good way to socialize with friends and family.
When we look at this data by disease groups, focusing on osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis, we see that with the exception of respondents with ankylosing spondylitis who listed massage therapy as something they need but are not receiving due to cost (31.7%), exercise therapy was the top answer for these respondents. This is an important finding and one that needs to be addressed by policy makers, health care providers and people living with arthritis. As exercise is central to managing arthritis diseases, barriers to exercise-such as cost-need to be removed.
In addition to the top five treatments, tools and therapies people reported needing but not receiving due to cost, 19% of respondents indicated not receiving their needed prescription medications due to cost. This is an alarming finding because research has shown that appropriate treatment of certain types of arthritis with prescription medications are one of the most important methods to managing the pain, joint destruction and disability of arthritis.
As well, this finding sheds light on the problems that exist in provincial and territorial drug plan reimbursement programs. On further inspection, important geographic differences emerge. For example, 20.9% of people with rheumatoid arthritis in BC responded that they need prescription meds that they are not currently receiving due to cost. This compares with only 7.7% of Ontario respondents with rheumatoid arthritis.
Similar findings appear in respondents living with psoriatic arthritis and ankylosing spondylitis. In British Columbia, 27.3% respondents with psoriatic arthritis are not currently receiving prescription meds they need due to cost and 22.2% of people with ankylosing spondylitis need prescription meds that they are not currently receiving due to cost. While we can only speculate, one of the reasons for these findings may be related to the differences in medication coverage across Canada.
As we noted in our 2007 September/October issue of JointHealth™ monthly, formulary reimbursement listings for arthritis medications vary widely across the country. For example, people living in Manitoba with ankylosing spondylitis have no access to provincial reimbursement for biologic response modifiers; people in Ontario with the same disease have financial coverage from the province for two biologic medications.
Far too often, the voices of people living with disease are not included in research. Yet, we know that patients' voices and experiences provide a unique and important contribution to the body of knowledge on arthritis. That is why Arthritis Consumer Experts is committed to gathering your views through surveys such as the one reported above.
Thank you to everyone who participated in the JointHealth™ Survey on Arthritis Treatment and Care. Your participation helped to ensure that the voices of people with arthritis are heard by researchers and health policy decision-makers.


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Ambulyx lahora är en fjärilsart som beskrevs av Butler 1875. Ambulyx lahora ingår i släktet Ambulyx och familjen svärmare. Inga underarter finns listade i Catalogue of Life.

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Playmobil is joining Hamleys to host its summer roadshow, travelling to six toy stores located in the UK.
Kicking off this July, the Playmobil roadshow began its tour of the Hamleys store in Glasgow before heading to the Trafford Centre in Manchester for this weekend.
The next stop will see the roadshow travel to St David's Centre in Cardiff over the weekend of July 15th and 16th, Lakeside in Essex on July 22nd and 23rd, Regent Street, London, on July 29th and 30th.
The tour will come to a close in Hamleys Dundrum on Saturday 5th and Sunday 6th August.
"Our partnership with Playmobil grows from strength to strength every year. The roadshow event travels the length and breadth of the country visiting six of our flagship stores in major cities in the UK and Ireland," said Grant Yuill, senior marketing manager from Hamleys.
During each event, guests will be able to meet the Twinkle Playmobil Fairy, take part in games, a colouring competition and more.
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By Josh Jackson | June 8, 2019 | 5:24pm
Movies Reviews I Am Mother
The sci-fi and post-apocolyptic bottle movie is becoming a genre all of its own. Since Duncan Jones turned a $5 million budget into one of the thought-provoking sci-fi Moon, filmmakers have realized you can say a lot and still make it look good with just a futuristic bunker and a clever concept.
I Am Mother, Netflix's latest sci-fi offering, has both those things. Almost all of the film takes place inside a secure facility where a robot named Mother (voiced by Rose Byrne) raises a human child simply named Daughter (Clara Rugaard). Mother has provided an idyllic upbringing for the girl, who represents the hope for humanity with thousands more embryos ready to become her little brothers and sisters. She learns everything from engineering to medicine to ethics (that latter subject key to the questions the film will eventually raise).
Grant Sputore's Australian/American production is constructed around plot twists as much as characters, and while some of them are exactly what any sci-fi fan was probably expecting, there's enough original thought to keep the tension level high. Everything Daughter knows is thrown into question by the arrival of a nameless woman (Hilary Swank) whose description of the outside world doesn't match Mother's. (There's definitely a little 10 Cloverfield Lane going on here.)
Daughter must balance her loyalty to Mother, to her future siblings and to her species, all while trying to uncover the truth. The film's most familiar sci-fi tropes about our future robot overlords have been examined in more interesting ways before. Still, I Am Mother offers just enough of a twist on an old futuristic tale to be enjoyable, and its small cast buoys the film above most small-budget sci-fi. And Mother herself joins a long list of memorable movie A.I. like Gerty and Hal, with a personality all her own.
Director: Grant Sputore
Writer: Michael Lloyd Green
Starring: Clara Rugaard, Hilary Swank, Rose Byrne
Release Date: June 7, 2019 (Netflix)
More from I Am Mother
I Am Mother By Josh Jackson June 8, 2019


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Personal Loan Deoghar, 20 January 2020 from Punjab & Sind Bank
Wedding Loan from Punjab & Sind Bank in Deoghar
Deoghar, considered to be a holy city, is a part of the Indian state of Jharkhand. It functions as the administrative headquarters of the Deoghar District. It is located in the Santhal Parganas division of harkhand. This city is known for the famed Baidyanath Dham Temple which is one of the 12 Jyotirlinga shrines in India. The city has mythological origins and houses famous mythological temples. Thus Deoghar attracts a lot of tourists and devotees. The famous educational institutions in the city are Deoghar College, Deoghar Ramakrishna Mission and the campus of Birla Institute of Technology. The city has over 2 lakh residents who speak in Hindi. Other popular tourist destinations in and around the city are the Tapavan, the Trikut Parvat, Naulakha Mandir, Nandan Pahar and Sri Sri Thakur Anukul Chandra Satsang Ashrama.
Low interest rate Wedding Loan in Deoghar, 20 January 2020 from Punjab & Sind Bank
The Punjab and Sind Bank was established on 24th June 1908 with an idea to uplift the weaker section with the far-sighted vision of luminaries like Sir Sunder Singh Majitha, Bhai Vir Singh, and Sardar Tarlochan Singh. As on 31st March 2015, the net worth of the bank is Rs. 4812 crore. A Punjab & Sind Bank branch was established in London in the 1960s. In 1991, the Bank of Baroda acquired the Punjab & Sind Banks London branch on the request of the RBI based on the Punjab & Sinds involvement in the Sethia fraud. The Bank confirmed to have a network of 920 branches or extension counters and 63 ATMs spread across the country as of July 31, 2010. Notably, they have 49 specialized departments, out of the 920 offices. The government owns Punjab & Sind Bank, and it is based in New Delhi. Its 623 offices are in Punjab state out of 1554 branches spread all over India. The Punjab & Sind Bank sponsored a regional rural bank known as Sutlej Gramin Bank. The products of Punjab and Sind bank includes Debit Card, ATM, Internet Banking, Mobile Banking, SMS Banking, BHIM, UPI, POS Machine, AADHAR PAY and BHARAT QR.


"Is There Anything Wrong in That?" Words by Herb Magidson, music by Michael H. Cleary (1928). Recorded by Elsie Carlisle with accompaniment by Jay Wilbur's Orchestra in London c. February 1929. Dominion A. 83 mx. 1148-2.
In "Is There Anything Wrong in That?" the singer repeatedly expresses hesitance, doubt, and more than anything, ignorance with regard to basic questions of morality. She explains, "I can't tell the bad things from the good," and "I can't tell the naughty from the nice." Her misdeeds appear to consist of taking gifts in exchange for sexual favors; she also seems to use her attractiveness to facilitate the theft of a fur-lined coat and a Cadillac!
The most familiar recordings of this song are by Helen Kane and Annette Hanshaw, both of whom use the persona of a Bronx-accented baby vamp. Their exaggerated little girl voices complement their bogus claims of ignorance and innocence. Elsie Carlisle, by contrast, uses an adult voice, so the comic effect is more subtle. Elsie sings mostly in a parlando style, where the delivery of the lines is close to natural speech. Her more natural intonation gives her leeway to emphasize the lyrics' ridiculous statements.
"Is There Anything Wrong in That?" was recorded in 1928-1929 in America by Helen Kate, Beth Challis, Annette Hanshaw, Ermine Callway (with the Seven Blue Babies), and Helen Charleston (with Ken Murray). In Britain it was recorded in 1929 by Lily Lapidus and The Rhythmic Eight.


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Cabinet committee formed to probe cypher 'stolen' from PM House
Last modified on 10 PM-30 Sep,2022
File photo The Federal cabinet
The Federal cabinet was on Friday informed that a copy of the diplomatic cypher carrying the details of the US's purported threat to ex-premier Imran Khan's government was "missing" from Prime Minister House records.
The cypher, based on then-envoy Asad Majeed's meeting with State Department official Donald Lu, has been at the centre of PTI's claim that the US conspired with elements within Pakistan to dislodge Imran from office.
A handout issued after a meeting of the cabinet declared that the "theft" of diplomatic cypher records is an "unforgivable crime" and violation of the Official Secrets Act, 1923.
After detailed deliberations, the cabinet formed a special committee which will determine the legal action to be taken against all those involved, including the ex-premier, ex-principal secretary to prime minister and senior ministers.
"The cabinet committee will consist of the representatives of the coalition parties in the government, along with ministers," the handout added.
The cabinet was told that the act was an "unpardonable crime" against the state which was tantamount to prioritising political interests over key state interests.
The meeting participants were informed that the record of the receipt of the cypher was available with the relevant department, but the diplomatic cable was missing.
"According to the law, this document is the property of Prime Minister House," the statement said.
With regard to the audios, the cabinet was told that the audios purportedly featuring Imran and his aides exposed "the criminal conspiracy of the former government", while the cypher was given "fictitious meanings for political mileage and subsequently it was stolen after fraud, forgery, fabrication."
The cabinet also strongly condemned the "harassment and intimidation" of Information Minister Marriyum Aurangzeb by the PTI workers in London. The meeting noted that there was no room for such a behaviour in Islam or even in Western civilisation.
The members appreciated "exemplary patience and bravery" shown by the minister.
The controversy surrounding the no-confidence motion against the former premier Imran Khan took a dramatic turn when the embattled PM brandished a letter at a rally on March 27 — days before his ouster — claiming it contained evidence of a "foreign conspiracy" hatched to topple his government.
Imran had kept mum about the contents of the letter when he first unveiled it but he spilled the beans days later by naming the United States when the exit of his government appeared imminent.
Imran's allegation that the US spearheaded his exit from power was based on a cypher received from Pakistan's Ambassador to the US, Asad Majeed, in which the envoy had reported about a meeting with Assistant Secretary of State for South and Central Asia Affairs Donald Lu.
Majeed had reportedly said that Donald Lu warned that Imran Khan's continuation in office, who was set to face a vote of no confidence, would have repercussions on bilateral relations.
The US was said to be annoyed with Imran over his "independent foreign policy" and visit to Moscow.
The Pentagon and the State Department have repeatedly rejected the accusations, saying there was no veracity to it.
The National Security Committee (NSC), which includes all services chiefs as well as the head of Pakistan's top intelligence agency, took up the matter on March 31 with then premier Imran Khan in the chair. The forum decided to issue a "strong demarche" to a country that it did not name over what it termed as "blatant interference in the internal affairs of Pakistan".
It had also termed the interference "unacceptable under any circumstances" and said the language used in the communique was undiplomatic.
While the forum had stopped short of calling the interference a conspiracy at the time, another meeting of the NSC was held on April 22 with newly elected premier Shehbaz Sharif in the chair, and which included the same military chiefs who attended the March 31 session.
During its second meeting, the NSC statement said it "reaffirmed the decisions of the last NSC meeting" and explicitly went on to add that it found no evidence of a foreign conspiracy.
PM Shehbaz apologises to nation for massive power outage
Imran Khan wants PM Shehbaz to take trust vote


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Q: How to enforce constraints between template and template template parameters in C++17 I have the following code that compiles (GCC7, C++17):
template<typename T>
struct NDArrayHostAllocatorNew
{
    static T* allocate(std::size_t size) {
        return new T[size];
    }

    static void deallocate(const T* ptr){
        delete [] ptr;
    }
};

template<typename T, template<typename TT> typename Alloc>
class NDArrayHost
{
public:
    typedef Alloc<T> allocator_type;
    NDArrayHost(std::size_t size);
private:
    T* m_data;
};

template<typename T, template<typename TT> typename Alloc>
NDArrayHost<T, Alloc>::NDArrayHost(std::size_t size)
{
    m_data = allocator_type::allocate(size);
}

Here are my questions:

*

*If I use T instead of TT I get an error that one T shadows the other. OK fair enough, but in my case, I want T to be the same with TT. How can I enforce that? I guess I could use std::enable_if and std::is_same somehow? But in that case the code will become too hairy. Is there any less hairy solution for this?

*I barely see code with template template parameters. Am I doing something that is not considered a good practice?

*I don't really like the syntax of this solution. Is there a better way to do the same but with cleaner/simpler code?

*While the code with the template template parameters is big ugly, it is quite obvious to understand what this code does: It just allows the user to specify his/her own mechanism to allocate memory for NDArrayHost objects. Although this qualifies for a whole different/separate question: if you think that I am approaching the problem completely wrong, feel free to point me to a better solution (as long as is not very complex like Thrust.

A: On way is to declare the base template in terms of types T and Alloc and then only provide a legal partial specialisation.
#include <cstddef>
#include <memory>

template<typename T>
struct NDArrayHostAllocatorNew
{
    static T* allocate(std::size_t size) {
        return new T[size];
    }

    static void deallocate(const T* ptr){
        delete [] ptr;
    }
};

/*
 * declare the base template in terms of T and allocator
 */
template<typename T, typename Alloc>
class NDArrayHost;

/*
 * only provide legal specialisations
 */
template<class T, template<class> class Alloc>
class NDArrayHost<T, Alloc<T>>
{
public:
    typedef Alloc<T> allocator_type;
    NDArrayHost(std::size_t size);
private:
    T* m_data;
};

template<class T, template<class> class Alloc>
NDArrayHost<T, Alloc<T>>::NDArrayHost(std::size_t size)
{
    m_data = allocator_type::allocate(size);
}

We could if we liked, add a specialisation to provide a diagnostic if the T's don't match:
/* specifically disallow illegal specialisations */
template<class T, class U, template<class> class Alloc>
class NDArrayHost<T, Alloc<U>>
{
    static_assert(std::is_same<T, U>(), "meh");
};

Testing...
int main()
{
    NDArrayHost<int, NDArrayHostAllocatorNew<int>> h(10);

    // fails with static assert
    // NDArrayHost<int, NDArrayHostAllocatorNew<double>> h2(10);
}

redpajama_set_name: RedPajamaStackExchange


ProLogis [stock PLD][/stock] injected good news into a struggling commercial real estate (CRE) market by raising $840m from asset sales and property fund contributions for the second quarter of 2009. As part of an effort to cut global debt, ProLogis, which leases industrial space to manufacturers and retailers, sold 136 CRE properties from Seattle to Washington DC, in 28 separate transactions. From the sales, ProLogis raised $561m, and they expect to earn an extra $96m in the second half of this year.


Browse > Home / Medicare, Medicaid & Private Payor Updates / Providers Need to Review Their Private Payor Contracts Before Signing!
(August 14, 2013): In today's reimbursement environment, solo physicians and physician practice groups are witnessing a steady decline in reimbursement rates. Unfortunately, their overhead costs and obligations due to the imposition of Electronic Medical Records, HIPAA Privacy, OSHA and a litany of other regulatory requirements are making more and more difficult to remain profitable each year. Health care providers have long accepted the fact that they have very little leverage when it comes to negotiating contracts with Medicare, Medicaid and other government health benefits programs. Nevertheless, that is not necessarily the case when dealing with private payor contracts. The purpose of this article is to discuss several of the issues you need to consider before you enroll or extend your participation as a provider in a private payor plan.
When is the last time you sat down and carefully reviewed a proposed private health plan prior to merely signing the last page and sending it in for processing?
We recognize that it is likely to take a considerable amount of time for you to review and understand what is expected of you as a participating provider. In recent years, we have noted that many private payor plans only provide a written copy of the basic contract information for your review and consideration. It is very common for payors to now maintain portions of their plan on their website for a provider's review. At first blush, you may think that this facilitates the review process. Think again. Providers have often complained that they have had a difficult time looking up important information (such as reimbursement rates) directly associated with their payor contract. Some providers have encountered broken links and / or pages that no longer exist when trying to look up specific terms of their contract with the payor.
You are likely signing multiple private payor contracts each year. Once executed, you and the payor plans will be required to adhere with the obligations set out for each respective party to the agreement. As you review your private payor contracts, you will likely note that there is no provision which allows you to bill "insurance only" and fail to try and collect any copayments or deductibles that may be due.
Medical necessity and coverage requirements may vary from plan to plan. While there is arguably a right way and a wrong way to assess whether a specific care and treatment regimen would be "medically necessary," you may find that a plan appears to confuse issues of medical necessity with those relating to "coverage." For example, one private payor contract may cover the administration of a certain chemotherapy drug if a patient is diagnosed with a specific type of cancer, while another contract policy may conclude that the use of the same chemotherapy drug for patients with this type of cancer is not medically necessary (or is non-covered) because it would involve using the drug in an off-label fashion. As a participating provider, it is your job to know what each private payor contract and policy covers.
In the healthcare environment today, costs continue to rise while provider reimbursement rates are in decline. The introduction of the Resource Based Relative Value Scale (RBRVS) and Medicare's adoption of a national fee schedule have also impacted a practice's ability to generate additional income from insurance plans by simply raising what it charges for services. Physicians and practices are now scrambling to assess their options when it comes to maintaining profitability. As any business owner can attest: Profitability is the only way to ensure Viability.
Physicians and multi-disciplinary practices may not realize it, but they have quite a bit of leverage when it comes to negotiating fees with private payor health plans. So what's the problem? Unfortunately, an informal survey we conducted found that most health care providers: (1) Were not aware that private payor contracts were subject to negotiation, (2) Didn't feel comfortable engaging in the negotiation process, or (3) Had no real frame of reference to use if they were to try to negotiate with a private payor. Regardless of your reason(s) for not seeking to negotiate with a private payor, if you use the right approach and are equipped with the right information, negotiating your way towards higher reimbursement rates can be a successful process.
Physicians and multi-disciplinary practice groups may consider the large insurance companies – Blue Cross, Blue Shield; United Healthcare; Aetna; CIGNA; etc. – as daunting obstacles, unwilling to negotiate with the sole practitioner or small physician practice group. But consider this: today's healthcare market reflects a massive shortage of certain providers. As a result, the fee negotiation process, often considered to be very adversarial, should be considered as a mutually beneficial partnership between physicians and health plans in which they desire to serve as a participation provider.
Before you attempt to negotiate more favorable rates with a private payor plan, physicians and small practice groups should consider the following?
Who will represent me or my practice in the reimbursement rate negotiation process?
Do I feel comfortable negotiating my contract? Alternatively, is our office manager capable of representing our interests in the process?
What types of data and bargaining methods would be useful when trying to negotiate a reasonable contract with private payors?
The answers to these questions will allow the solo physician or practice group to stay in business and continue to provide quality healthcare to their patients.
Hospital-based physicians may be the lucky ones. They have a little more leverage in the negotiation process. For instance, a physician performing services at a hospital is generally paid the health plans' usual, customary rates for that location. What happens when a physician asks for an increase in reimbursement rates, but the health plan carrier declines his requests?
In response, the physician may cancel his contract and begin working non-contracted with the plan. He knows that the plan's patients are going to come to the hospital regardless of whether he has a contract with the private insurer or not. The physician can now bill the patient for 100% of his fee schedule. While the health plan will pay what it believes is appropriate, the remaining balance then is owed by the patient. The patient now becomes the physician's best advocate.
The patient's complaints move up the insurance chain, and the problem ultimately ends up with the carrier. This may force the carrier into the negotiation process to give the physician a better reimbursement rate. In this situation, the physician has had the upper hand.
Unfortunately, the negotiation process is not easy and can be a frustrating process. In fact, it is more difficult for independent physicians, i.e., those who rely on the third-party carrier to direct its members to the physician's practice. They are at the whim of the insurer and do not have substantial bargaining power at the outset. As a result, the physician must be proactive and make an argument using business data.
Unfortunately, physicians are reluctant to make the next step. It takes time, diligence, and preparation and physicians are already pressed to do their job and provide quality care. But remember: the carrier is not going to grant you better reimbursement rates unless you make the argument and demonstrate that you deserve it. Thus, solid data and a well-reasoned argument must be brought to the negotiating process.
Before renegotiating your reimbursement rate, know where you stand. If your payor's fee schedule results in payments that are less than what Medicare typically pays, you already have a strong argument for increased reimbursement rates.
Determine whether the insurance payer maintains your fee schedule based on a percentage of a given year of the RBRVS (let's say, 120% of 2010 RBRVS). Find out if, and when, the payer updates its fees. You should also consider what components of the RBRVS the carrier uses (e.g., geographic practice cost indices (GPCI) adjustment, site of service differential, etc.).
A majority of practitioners derive their revenue from office-visit, hospital and preventive-medicine codes. These will be the first codes to identify.
Just as important, you should determine the frequency of each CPT code, i.e., the number of times the service has been provided over a 12 month period. Certain codes may not, individually, be significant revenue generators; but if your practice consistently bills for them, they are a vital bargaining tool to identify.
For example, if you determine that evaluation and management (E/M) constitutes 75% of what the practice does, you might try to negotiate a lower reimbursement on other procedures to increase reimbursement for E/M services. In the long run, you'll gain more by accepting less.
The easiest way to assemble this data is through your electronic billing system.
Medicare and/or Medicaid may, individually, comprise the bulk of your practice's business. However, they use established fee schedules and do not negotiate.
Thus, prioritize your top three to four private carriers that make up the bulk of your reimbursement. Collectively, they may represent the largest percentage of the practice's income and will be easier to negotiate fees.
Step 4: Determine Your Reimbursement for Each Code.
Review the Explanation of Benefits statements from your top payers and assess how much they "allow" – but not how much is "paid" – for each of your top billing codes.
Then calculate each payers' reimbursement rates as a percentage of Medicare's reimbursement rates.
For instance, a health plan may indicate that it pays 120% of Medicare's rate for a certain code. You can calculate Medicare's current rates for your geographic area on the "Medicare Physician Fee Schedule Look-Up" tool at http://www.cms.hhs.gov/physicians/mpfsapp/step0.asp.
You should also determine the current relative value units (RVUs) Medicare assigns to each code. Because many health plans now incorporate RVUs in the payment process, it is important to understand what they represent. Under Medicare's RBRVS, each service is assigned RVUs based on the physician effort, practice expenses and malpractice risk involved.
Step 5: Review Your Reimbursement Rates for Each Code.
Analyze your current fees for each CPT code on your list against your fees as a percentage of Medicare's rates.
If you determine that the insurance carrier is reimbursing some of your charges in full, this may mean your fees are too low. If so, the payor may be willing to pay more. You could also consider raising those fees or, alternatively, standardizing all of your fees at practical and reasonable percentage of Medicare (e.g., 130%).
If your payers seem to pay more for procedures or diagnostic studies, another approach is to establish a tiered fee schedule. For example, your schedule could set E&M services at 130% of Medicare while charging 150% of Medicare for other services.
Step 6: Organize the Data and Analyze Your Position.
Compiling this data will help you identify which codes or health plans should be targeted for negotiating higher reimbursement rates.
At first, focus on the codes with the highest volume and dollar value. These codes will yield the most return for negotiating efforts.
If one health plan's rates are clearly lower, or if one code is reimbursed at a lower percentage of Medicare than the others, these determinations will also be clear targets for negotiation.
For instance, if one of your health plans pays 95% of Medicare for preventative services and 130% of Medicare for lab services, you could use that as a negotiating tool. Disease prevention is a vital part of most health plans; they should provide proper incentives to do so.
After considering these issues, ensure that you develop target reimbursement rates for your negotiations.
Once you have completed an analysis of fees being paid, you should now move to negotiate with the health plan carrier. First, you should identify an important payor contact. This usually is your provider representative. Although this individual may be incentivized to keep your reimbursement rate increases to a minimum, he or she can be a very helpful contact. This person will likely be the person that ensures that your proposal gets into the right hands.
You should then prepare and send a formal health plan proposal letter. In this letter, differentiate yourself from your competitors and demonstrate the strengths and assets of your practice. Specify what your practice brings for the payor and how you are the better provider for the health plan members. Ensure you point out several key factors if they exist: Is your particular field or specialty in high demand, unavailable in certain geographic areas, or not provided by your competitors? If so, these factors can be significant tools in the bargaining process and can be vital in securing higher reimbursement rates.
Hopefully your diligent work has paid off and you receive an offer from the health plan carrier. Once you do, make sure you request and review the complete agreement. This will allow you to ensure that your entire offer (i.e., rates and contract language) are acceptable to the unique needs of your practice. If necessary, you should draft revisions to specific terms or language within the contract. Make sure you prepare additional letters to your payor and specifically reference what language may be problematic. Ensure that you also note why you are objecting and propose alternative language that will be feasible to both entities. Continue this process until both you and the health plan carrier are satisfied and in agreement.
Analyze your fee schedule and your health plans' reimbursement rates. This will help you reveal and overcome any payment inequities.
Review your fees annually and make sure you set them at a reasonable rate (e.g., at 130 percent of Medicare's rates).
Even if you're only to gain a small increase for just a few codes, this increase can generate enough income for your practice to keep you profitable.
Don't forget – annual increases in the overall costs of healthcare are increasing demands to depress future provider reimbursement rates. Annual adjustments may not be sufficient to allow a practice or a physician to stay viable. As a result, unless the physicians are willing to work harder – or work for less – they must make the adjustments now in order to capture the revenue. Negotiating for increased reimbursement rates will take the work, but it is not a process that is not manageable. With the right tools and information, you can be prepared to effectively make your case for higher rates. Do you need assistance with your contracts? If so, give us a call.