text:
The Jury
Labour has £28 billion worth of unfunded spending commitments - Shapps
By Paul Goodman
Follow Paul on Twitter.
Attack-mails from Grant Shapps and his sorcerer's apprentices in CCHQ's kitchen seem to be arriving in my in-box at a rate of approximately one a minute. I'm not going to report each time the Party Chairman announces a new attack website, but here's today's, timed for the start of Labour's Conference, which gives a sense of how much the Tory assault operation has improved.
Sunday, September 22, 2013 in CCHQ, Economic policy, Party conferences, Tax and spending | Permalink | Comments
CCHQ|Economic policy|Party conferences|Tax and spending|
Watch Sajid Javid
It's no surprise to see Conservative attack dog Chris Grayling sinking his fangs into Labour's spending pledges in today's Sunday Telegraph. By the same token, it wouldn't be a shock to see Conservative attack dog Michael Gove unleashed on Ed Miliband's vulnerabities (I leave it to the reader to decide exactly what and where these are). After all, Grant Shapps and his apprentices in CCHQ's devil's kitchen cannot be expected to carry out every assault themselves.
But who's this popping up behind the Sunday Times paywall? Why, none other than the relatively lowly figure of Sajid Javid, MP for Bromsgrove - and number five in the Treasury team, the bottom figure in the ranks. Javid warns that Miliband has a £27 billion hole in his spending plans. Watch for that figure to rise as this week's conference goes on.
And watch out for Javid, too. That so junior a Minister in the Government pecking-order is trusted to work at the same level as Cabinet Ministers such as Grayling says much about him - and how highly the Party leadership rates him. The Economic Secretary to the Treasury is a very modern success story.
The son of a family of Pakistani origin, he was brought up for a while in "Britain's most dangerous street", went first a Bristol comprehensive, then to Exeter University, and onwards to Chase Manhattan - where he became the youngest Vice-President in the history of the bank. Elected to the Commons in 2010 and already a Minister, he will be promoted before 2015.
The move may stir suspicions of tokenism. It shouldn't. You don't get to a senior level at Chase Manhattan by being a slouch. Javid is very bright, straightforward, sharp and, for that matter, right-wing: he pushed earlier in this Parliament and on this site for a debt ceiling. My only question is whether he is, well, political enough: business people and politics don't always mix.
This is presumably why George Osborne - whose previous PPS, Greg Hands, is very political indeed - talent-spotted Javid and made him his PPS. (The Bromsgrove MP had previously served John Hayes in the same position.) Javid will be learning some of the political tricks of the trade in the Treasury, not to mention gaining experience of Whitehall's most senior department. You will hear more about Sajid Javid in the months to come. Which is why I say: watch him.
Sunday, September 22, 2013 in Economic policy, Frontbench, Tax and spending | Permalink | Comments
Economic policy|Frontbench|Tax and spending|
Politics is about more than maths - Conservatives must make the moral case for welfare reform
By Harry Phibbs
Follow Harry on Twitter
At last we have a clear Labour Party policy in place for the 2015 General Election.
They have given a clear pledge to reinstate the spare room subsidy. The Conservatives will challenge them on how they would pay for this. That is a reasonable challenge. As I noted on Thursday - and if the early figures from Barnet are anything to go by - the savings will be far more than estimated. Well over a billion instead of around half a billion. This is because many of those affected are being prompted to take jobs and come off benefits altogether.
On the other side of the ledger Ed Miliband's claim to pay for it - even if it were a mere half billion price tag - with a £145 million Stamp Duty hike on pension funds is also vulnerable to scrutiny.
The short term politics of Mr Miliband's spare room subsidy announcement are understandable. This has been the big campaign of the year for the trade unions and left wing activists.
Labour's media allies - in the BBC and also such papers as The Independent and the The Mirror - have been denouncing the policy with great prominence. This has had some impact on public opinion. Then there have been Conservative taunts - led by David Cameron at PMQs - about Labour's failure to say what they would do on the subject.
Certainly Mr Miliband needed to clarify his stance on a number of policy issues. However on this one his announcement is a sign of weakness rather than strength. It is also imprudent to have made it at this stage. Labour has seized on the rise of rent arrears, but what will they be in a year's time? Labour has said that many have found difficulty finding a property to downsize into. Can they rely on this continuing?
Continue reading "Politics is about more than maths - Conservatives must make the moral case for welfare reform" »
Saturday, September 21, 2013 in Housing | Permalink | Comments
Housing|
Introducing...UKIP's White Company
Guido has the better headline: "It'll be All White On The Night."
And as he acknowledges the spot was originally our very own Mark Wallace's.
Friday, September 20, 2013 in UKIP | Permalink | Comments
UKIP|
The lesson of Damian McBride's memoirs is that Labour is the Nasty Party
In 2001 or so, I wrote a speech for Iain Duncan Smith that went well enough, and was drafted on the back of it into his team for Prime Minister's Questions prep. The other three members were David Cameron, George Osborne and Boris Johnson (and I should say in passing that those first two were infinitely better at the task than I was). I thus spent part of each week, for the best half of four years, with the duo that leads the Conservative Party.
I never saw them tip the wink at their underlings to "destroy" a senior Shadow Minister, or leak details of another's alleged "drinking, fighting and carousing", or tip off newspapers about their rivals "drug use, spousal abuse, alcoholism and extra-marital affairs" - all conduct that Damian McBride writes of in his memoir, serialisation of which opens in the Daily Mail today. There are three possible explanations for this (assuming that Tory MPs as well as Labour ones are vulnerable to drinking, fighting, carousing, drug use, spousal abuse, alcoholism and extra-marital affairs which, since human nature is a given, is a reasonable presumption).
The first is that I'm incapable of seeing what goes on at the end of my nose. The second is that Cameron and Osborne did all this and more when I wasn't around. The third is that it didn't happen - or at least, to nothing like the same degree. Call me sentimental, self-deceived or a liar, but I'm sure the explanaton is the third. You don't get to the top of politics without being ruthless - and both are as much so as any politician I worked with during my ten years in the Commons. None the less, I can't imagine either discussing plans to set up a paper called, say, "Blue Rag" to smear a woman Labour MP with fictitious tales - as McBride did in relation to Nadine Dorries.
Continue reading "The lesson of Damian McBride's memoirs is that Labour is the Nasty Party" »
Friday, September 20, 2013 in Parliamentary Conservative Party, Team Cameron, Things people are wrong to think about the Conservatives | Permalink | Comments
Parliamentary Conservative Party|Team Cameron|Things people are wrong to think about the Conservatives|
Yes, it's Mitchell Is Innocent Day on ConservativeHome
In my ToryDiary of earlier today about Andrew Mitchell case, and the failure of Operation Alice to report a year after it was set up, a long list of articles is enclosed supporting the MP.
Some of them are very fine, all of them make good points, and we're going to make it Mitchell Is Innocent Day on ConservativeHome.
One will be posted on the site each hour until close of play. In order to avoid having two threads on the same subject, we will close the one below shortly.
Thursday, September 19, 2013 in Frontbench, Law and order | Permalink | Comments
Frontbench|Law and order|
Andrew Mitchell should be returned to the Cabinet at the first opportunity
It is a year today since Operation Alice, the investigation by the Met into the Andrew Mitchell affair, was launched: 30 police officers were apparently put on the case. Yet it has failed to produce a report: 12 months is apparently insufficient time to probe an incident lasting some 45 seconds. Here are some more figures relating to the case. Six people are reported to have been arrested, four of them police officers, four of them from the Diplomatic Protection Unit. Four members of the unit are undergoing disciplinary proceedings. Three members of the Police Federation are being investigated by a separate inquiry for alleged misconduct over comments they made to the media.
Now let's turn from figures to facts - and the meticulous investigative journalism of Michael Crick. A witness who e-mailed his MP backing up the claims about Mitchell in the police log said later when questioned by Crick that he "wasn't a witness to anything". He had also failed to tell the MP that he is a serving police officer. As Crick also reports, "according to the leaked police logs there were "several members of the public present - around the gate - they heard the altercation and were 'visibly shocked'. What this CCTV shows is that there are no crowds of people watching and listening".
Viewers of the footage will decide for themselves whether - as Mitchell wheels his bicycle towards the pedestrian entrance to Downing Street without visibly engaging with an accompanying policeman - he actually said the words attributed to him: "best learn your f*****g place. You don't run this f*****g Government. You are f*****g plebs". I agree with Crick that the tape "doesn't really seem to support this version". But whether one shares this view or not, the facts of the case are clear. There is no evidence that Mitchell said the words attributed to him other than the police log. That log has been proved to be not fully accurate. And an account backing it up has proved to be false.
Continue reading "Andrew Mitchell should be returned to the Cabinet at the first opportunity" »
Nick Clegg turns up the volume
Nick Clegg didn't have anything terribly interesting or new to say in his speech this afternoon but the tone was more assertive. Usually the Liberal Democrat politicians avoid being messianic. They like to project a let's be reasonable, split the difference, would you like a cup of tea message.
The pitch is to be nice and trying to vary that by assuring the audience that they can also be jolly tough tends to sound contrived and embarrassing.
Here was an unaccustomed effort within the Lib Dems to build up a leadership cult. They were practising power worship. Mr Clegg accommodated the power worshippers. Thus there were a few insidery anecdotes - something about sorting out the furniture when he first became Deputy Prime Minister and also something about meeting Andy Murray.
Then there was plenty of of "back story" - his upbringing, lots about his wife and children and the values they believed in. All the American stuff which is now familiar to our politics too.
Amongst all this Mr Clegg listed policies that the Government had brought in that he wanted to claim credit for he gave a list of policies which he claimed to have stopped:
Sometimes compromise and agreement isn't possible and you just have to say "no". Inheritance tax cuts for millionaires - no. Bringing back O' levels and a two-tier education system - no. Profit-making in schools – no. New childcare ratios – no. Firing workers at will, without any reasons given – no, absolutely not.
Regional pay penalising public sector workers in the north - no. Scrapping housing benefit for young people – no. No to ditching the Human Rights Act. No to weakening the protections in the Equalities Act. No to closing down the debate on Trident. Had they asked us, no to those 'go home' poster vans.
No to the boundary changes if you cannot deliver your side of the bargain on House of Lords reform. And if there's one area where we've had to put our foot down more than any other, have a guess. Yep, the environment.
It's an endless battle; we've had to fight tooth and nail; it was the same just this week with the decision to introduce a small levy to help Britain radically cut down on plastic bags.
They wanted to scrap Natural England, hold back green energy. They even wanted geography teachers to stop teaching children about how we can tackle climate change. No, no and no – the Liberal Democrats will keep this Government green.
There is a lots of nonsense in this section, of course. For example the proposal on Inheritance Tax was to cut it for everyone but millionaires - raising the threshold to £1 million. Most people would have been pleased that had taken place. Most people would probably support most of the other measures that the Lib Dems are boasting about stopping. However they are not interested in what most people think - only the 25 per cent who are potential Lib Dem voters.
On free school meals Mr Clegg said:
If you want to know what I really believe in you will find it in these policies. Using the muscle of the state to create a level playing field when it counts most – when boys and girls are still forming their views, their characters, their hopes and their fears.
That's why I'm delighted to tell you that we are now also going to provide free school meals for all children of infant school age.
From next September we'll give every child in Reception, and Years 1 and 2 a healthy lunch every day – saving families more than £400 per year, per child.
And, for the Liberal Democrats, this is a first step: my ambition is to provide free school meals for all primary school children. Another reason we want to get into Government again next time round.
The Conservatives, on the other hand, have made it clear that their priority is to help some families over others, with a tax break for married couples. A tax break for some, funded through the taxes of everybody else - that tells you everything you need to know about their values.
But extending free school meals helps some families over others. It helps the rich - who will no longer have to pay for them - over the poor - who were getting them anyway. There might be a case to be made for encouraging a proper hot meal at school rather than a packed lunch. But it is silly to claim the new policy as egalitarian.
Still what comes across from this week is Nick Clegg and, on the whole, the Lib Dems generally like being in power. The modesty has been junked.
There might well be Conservative or Labour MPs who would prefer opposition to a Lib Dem coalition. However for all the stick tehy have taken the Lib Dems will be keen to get another deal if they have a chance.
Wednesday, September 18, 2013 in Liberal Democrats | Permalink | Comments
Liberal Democrats|
Who is winning the Coalition? Us or the Lib Dems?
By Mark Wallace
Follow Mark on Twitter.
Now that both parties are fighting to take credit for the coalition's achievements, rather than seeking to blame each other for its impact, it seems an opportune moment to ask: who is winning the Coalition? Do the Lib Dems or the Conservatives enjoy more success in Government?
Let's tot it up, match by match, across thirteen key policy areas:
With PCCs introduced, an immigration cap in place, the concept of regional immigration limits rejected, spending cuts to the police but crime falling regardless and even the now-famous "Go Home" vans, the Home Office is a round victory for the Conservatives. The Lib Dems will be happy about the scrapping of ID cards, but it's worth remembering that this was Tory policy at the election, too.
Blues 2 - 0 Yellows
Both parties described themselves as localist in the run-up to 2010, but the plan the Government have implemented is almost entirely Eric Pickles'. Spending transparency, guaranteed referenda for council tax increases over 5 per cent and relaxed planning regulations all point to a Conservative win.
It's a little hard to say how the different parties have fared in the Justice department. The failure to fulfil the Tory pledge for automatic jail sentences for carrying a knife illegally and the fact the Human Rights Act still has not been replaced by a British Bill of Rights are certainly points against the Conservatives, but they were respectively scored by Ken Clarke and a Commission set up by the Prime Minister, so count as own goals. Since he took over as Justice Secretary, Chris Grayling has been pushing ahead more productively with cuts to legal aid, reform of the courts system and a new, more accountable prison regime. The Lib Dems have had barely a look-in, but the own goals go on their tally - we can expect a better rematch later in the Parliament.
Constitutional Reform
The Lib Dems had a good sequence of play early on - for a while it looked like they might romp home. They certainly secured the referendum on AV which they had demanded, but then the electorate overwhelmingly rejected the plan. Lords reform briefly came onto the agenda, before being torpedoed by Tory backbench opposition. In revenge, Clegg sank the boundary reform the Conservatives desperately need to iron out structural bias in the election system. Both sides lose out - a no-score draw.
It's fair to say Michael Gove has emerged victorious on almost every measure in Education. The academies scheme has been dramatically extended, Free Schools are springing up and new, more rigorous exams are in place. The flagship Lib Dem policy of the Pupil Premium has been implemented, but their promise to aboilish tuition fees has been entirely reversed.
Both parties supported High Speed 2 in 2010, and despite heavy fire from all sides it remains Government policy. The Lib Dem policy of introducing road pricing has been rejected, and replaced by reductions and freezes in fuel prices, driven by Rob Halfon. Clegg and Cameron both promised that Heathrow would not be expanded, and they've got their way - with Lib Dem support for the policy helping to overwhelm any Tory suggestions it be revoked.
The decision to hold a Strategic Defence Review rather partially removed this department from the realm of pure party politics early on in the parliament. However, the Lib Dems regularly boast that they have managed to delay any decision to replace Trident until at least 2015, while the Conservatives have successfully slimmed down the MoD's size and balanced its budget for the first time in years. A score draw.
Chris Huhne, and later Ed Davey, have dominated these policy fields from DECC until Owen Paterson gave DEFRA more Tory bite in the last year. The Green Deal is in place (and splashing money everywhere), wind farms are still going ahead despite the Tories wishing to implement a moratorium and the Green Investment Bank has got the go-ahead. Shale gas has now been given the green light, but only after lengthy delays thanks to Lib Dem opposition.
Blues 1 - Yellows 5
Tax and Spend
Both parties agreed on the need for austerity after the Brown years, but we should note that the Lib Dem manifesto proposed £15 billion of spending cuts, delayed until 2011-12. Austerity has been larger than that, and began immediately. While Clegg and Alexander's presence in the Quad has certainly reduced the fiscal tightening somewhat, Government policy looks closer to Osborne's position than theirs.
On tax, it's a different story. The 50p rate is gone, but it is now 45p rather than the 40p many Tories would have preferred. The income tax threshold is rising to £10,000, following a Lib Dem manifesto pledge - though it's not a policy many Conservatives are uncomfortable about. It's fair to say Osborne's enthusiasm for tax cuts (for example on Inheritance Tax) has been sizeably hindered by his coalition partners.
Goals for each side, but level pegging so far.
Like Eric Pickles, Iain Duncan Smith went into the 2010 election with a coherent plan and a deep personal dedication to his brief. As a result, he's got his way on the bulk of his proposals. The two parties have collaborated to protect the Universal Credit scheme from Treasury attempts to axe it or scale it back. It says a lot that the Lib Dems' main impact on the DWP has been to veto IDS' offers to make even more savings from his budget.
Business and Banks
Vince Cable has long touted his Department as the heartland of Lib Dem opposition to Conservative leadership of the coalition. He's certainly managed to get the Government to adopt his industrial strategy, and blocked the Beecroft reforms to workplace regulation. But he has also had to accept the abolition of the Regional Development Agencies and the Conservative-driven cuts to red tape. The decider is the Government's decision to accept the Lib Dem policy to break up the banks.
To say the Health and Social Care Act proved controversial is an understatement. Various of the policies within it are drawn from the Conservative 2010 manifesto, although Lib Dem opposition forced the Government into a "listening period" and resulted in several changes to the legislation.
This always seemed likely to be the sticking point of the Coalition. Clegg has prevented Cameron from offering an earlier referendum, and the Conservatives have been forced to use a Private Member's Bill to pursue their policy post-2015. However, the Lib Dems so far have been too afraid of public opinion to vote against the Wharton Bill, resorting to wrecking attempts in the Committees. The In/Out referendum is on the way, but Yellow blocking tactics have left the Blues open to attack by UKIP.
Scores so far
Here are the overall scores from the first half of the Parliamentary season. Of 13 matches, there have been 7 Blue victories, 3 Yellow wins and 3 draws. 25 goals for the Conservatives and 19 for the Liberal Democrats leaves the goal difference at +6 for the Blue team.
The contest is only going to become more hotly contested - as can be seen by Nick Clegg's attempt to take the credit for Rob Halfon's ideas today - so we will continue to watch every match and report back.
Wednesday, September 18, 2013 in Constitution and democracy, Economic policy, Education, Electoral reform, Energy, Environment, Europe, Foreign affairs, George Osborne, Health, Housing, Immigration and asylum, Law and order, LibDem-Tory relations, Liberal Democrats, Local government and local elections, Localism, Tax and spending, The Coalition, Tory 2010 manifesto, Welfare reform | Permalink | Comments
Constitution and democracy|Economic policy|Education|Electoral reform|Energy|Environment|Europe|Foreign affairs|George Osborne|Health|Housing|Immigration and asylum|Law and order|LibDem-Tory relations|Liberal Democrats|Local government and local elections|Localism|Tax and spending|The Coalition|Tory 2010 manifesto|Welfare reform|
EXCLUSIVE: CCHQ declares Conservative Party membership to be 134,000
I asked on this site in early August why the Party wouldn't declare a membership figure, and ran the editorial asking the question every day for a week - a first for this site. The answer was plain. 253,600 members voted during the 2005 leadership election, and Downing Street didn't want headlines declaring that since David Cameron won it membership has fallen by roughly half. These are certain to follow the figure that senior CCHQ sources have disclosed to ConservativeHome - 134,000 constituency members, which is a bit over that halfway mark. So how reliable is that headline total? And why has CCHQ changed its mind about releasing it?
This site has seen an individual constituency breakdown of the 134,000 figure, but has not had the time to examine it closely: we will do so during the next few days. (The Party claims that the total membership figure is 174,000.*) There are three main reasons for the decision itself.
Continue reading "EXCLUSIVE: CCHQ declares Conservative Party membership to be 134,000" »
Tuesday, September 17, 2013 in CCHQ, Party democracy and membership | Permalink | Comments
CCHQ|Party democracy and membership|
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Home » Falls the Shadow (Kobo eBook)
Falls the Shadow (Kobo eBook)
By Stefanie Gaither
Cate's sister may be a clone, but that doesn't make her a killer. Does it? Murder, morality, and a slow-burning romance fill the pages of this futuristic thriller "for die-hard fans of Divergent and The Hunger Games" (Kirkus Reviews).
When Cate Benson was a kid, her sister, Violet, died. Two hours after the funeral, Cate's family picked up Violet's replacement like nothing had happened. Because Cate's parents are among those who decided to give their children a sort of immortality by cloning them at birth—which means this new Violet has the same face. The same perfect smile. She even has all of the same memories as the girl she replaced.
She also might have murdered the most popular girl in school.
At least, that's what the paparazzi and the anti-cloning protestors want everyone to think: that clones are violent, unpredictable monsters. Cate is used to hearing all that. She's used to defending her sister, too. But Violet has vanished, and when Cate sets out to find her, she ends up in the line of fire instead. Because Cate is getting dangerously close to secrets that will rock the foundation of everything she thought was true.
Publication Date: September 15th, 2014
Hardcover (September 16th, 2014): $18.99

redpajama_set_name: RedPajamaCommonCrawl


Ornellaia Bolgheri Superiore 2013 (750ML) - PJ Wine, Inc.
Aged for 18 months in barrique (70% new and 30% once-used). After bottling, the wine aged a further 12 months prior to release.
In 2005, Marchesi de' Frescobaldi, following the sale of Robert Mondavi Corporation to Constellation Brands, acquires the remaining 50% share. Marchese Ferdinando Frescobaldi is appointed chairman.


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Houston Texans vs. Arizona Cardinals: Matchups, predictions as the Cardinals look to stay perfect
In the Week 7 Houston Texans vs. Arizona Cardinals matchup, can Arizona remain perfect, or will Houston spring a major surprise?
Houston Texans offense vs. Arizona Cardinals defense
Davis Mills vs. Cardinals defense
Texans skill players vs. Cardinals secondary
Texans offensive line vs. Cardinals defensive line
Arizona Cardinals offense vs. Houston Texans defense
Kyler Murray vs. Texans defense
Cardinals skill players vs. Texans secondary
Cardinals offensive line vs. Texans defensive line
Betting line and game prediction
This Sunday's Houston Texans vs. Arizona Cardinals matchup appears to be a mismatch based on what we have seen on the field so far. However, the NFL does not always go to script. Let's examine whether there is any realistic chance of an upset as the Texans and Cardinals face off in Arizona.
It has been a mixed season for the Texans' offense. In the first two weeks, Tyrod Taylor appeared to have found some rhythm quarterbacking the offense. But after Taylor was injured in Week 2, the offense struggled mightily in Davis Mills' first two starts. The good news is that things have started to change in the last couple of weeks, at least in terms of getting the offense moving down the field.
No one expected the Texans' third-round selection to lead this offense to many wins once Taylor went down. However, Mills has demonstrated some progress in the past two weeks.
His performance against the Patriots' defense made the NFL world sit up and take note. Last week against the Colts did not go to plan, but it was still a significant improvement over Houston's Week 4 loss to the Bills.
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Mills has completed 69.4% of his passes in the last two weeks. In doing so, he has passed for 555 yards at an average of 7.7 yards per attempt. Those numbers demonstrate the potential he has at the helm of this offense. Unfortunately, the consistency has simply not been there, which remains a concern heading into this matchup.
In the Cardinals' defense, Mills is facing a unit that allows an average of just 5.9 passing yards per attempt and only 9 passing touchdowns while reeling in 6 interceptions. All three of those numbers place them in the top 10 in the league this season. This is going to be an extremely tough matchup for Mills against a very comprehensive Cardinals defense.
Advantage: Cardinals
When we talk about the Texans' skill players, it is really all about Brandin Cooks. Cooks leads the team with 57 targets, while no other Houston pass catcher has more than 18 targets. In the past two weeks, Chris Moore and Chris Conley have emerged as secondary targets, but they have just 22 targets combined this season.
That lack of clear secondary weapons is tough when going up against a top-10 pass defense in terms of opposing completion rate (62.6%). If the Cardinals look to double team Cooks, the Texans will need to lean on those secondary options.
Arizona cornerback Byron Murphy has allowed just a 52.8% completion rate for 310 yards and a touchdown on 36 targets. He has been somewhat susceptible to the big play, which may make the Cardinals hesitant to have him shadow Cooks.
The No. 2 cornerback on Arizona's roster is Robert Alford, who has allowed just a 56.7% completion rate with 135 yards and 2 touchdowns on 30 targets. He has been less susceptible to the big play and may be the better player to line up opposite Cooks in this matchup.
With two CBs that have posted good numbers this season, the Cardinals have a clear edge here, especially if they can limit Cook's effectiveness.
Not much was expected of Houston's offensive line entering the season, and they have managed to match those low standards. Football Outsiders' offensive line metrics place the Texans' OL as the worst unit in the league in terms of run blocking.
However, this matchup could be fairly close to even in the run game. The Cardinals' defense has struggled against the run this season, with opponents averaging 5.2 yards per rushing attempt. Only one team in the league has allowed more rushing yards per attempt than Arizona this season.
The Texans' OL has been better in pass protection than run blocking. Their 7.1% sack rate allowed is closer to the league average than the worst teams in the league but is still below average.
That is a concern when facing a Cardinals defense that is top 10 in both pressure rate (26.9%) and sack rate (7.7%). These two lines might be similar in terms of the run game, but the Cardinals' defense appears to be the superior unit when it comes to the passing game. However, the Cardinals will be without Chandler Jones, who was not activated from the COVID reserve list in time for the game.
The Cardinals' offense has been extremely impressive in 2021. They rank fourth in the league in points per game and seventh in yards gained. Can the Houston defense slow down a unit averaging over 30 points per game, or will the Cardinals continue on their march?
We have seen an impressive opening to the 2021 NFL season from Kyler Murray. He has thrown 14 touchdown passes at a rate of 7.2%, compared to 4 interceptions at a rate of 2.1%. However, the most incredible part of his play has been leading the league in completion rate at 73.8% while also ranking third in passing yards per attempt.
There is no reason he should struggle when facing a Texans team that allows 7.6 passing yards per attempt, the fourth-worst in the league. The only reason that teams have not been throwing for more yards against the Texans is that they have been racking up yards on the ground.
This matchup should not be a serious challenge for Murray. As long as he plays his game and doesn't take unnecessary risks, he should be able to have a more than comfortable game in Week 7.
The Cardinals have a lot of talent at their disposal, and their offense has a lot of different skill sets. The balance in targets has been a delight to see, with five pass catchers seeing between 28 and 38 targets each. With 6 touchdowns, DeAndre Hopkins continues to be the star, and A.J. Green is providing a perfect foil as he revitalizes his career.
The real delight has been the development of Christian Kirk. He has pulled in 26 of his 31 targets for 358 yards and 3 touchdowns. Kirk and Rondale Moore have secured 50 of the 59 targets thrown their way. That kind of reliability from your third and fourth receiving options makes a quarterback's life much easier.
On top of those four receivers, the Cardinals have had solid production in the receiving game from Chase Edmonds. They also traded for Zach Ertz to replace the injured Maxx Williams. This group might just be the best combination of six pass catchers anywhere in the NFL.
The Texans have been perfectly adequate in terms of their coverage. They are allowing a close-to-league-average 66.8% completion rate, with just 9 touchdowns compared to 6 interceptions. The problem is that they are susceptible to giving up the big play, allowing 8.3 yards per passing attempt.
From the perspective of the individual players in the secondary, Justin Reid has impressed, picking off 2 passes on 13 targets. Terrance Mitchell has posted solid numbers, but Desmond King II and Vernon Hargreaves III have both struggled.
When facing the Cardinals, teams need their entire secondary to play well to cover all their options. That is simply not the case for the Texans. Even if Houston can restrict a couple of Arizona's receiving options, the Cards will have other places to turn in the passing game.
The Cardinals' offensive line has been a below-average group this season, especially in the run game. That has translated to their running game being just average this year. However, this week they face a Texans run defense that is in the bottom five of the league in 2021.
In terms of pass blocking, the Cardinals line has put up average numbers. However, some of their deficiencies are hidden by having the ultra-mobile Murray playing QB. This week, they should find it slightly more manageable. The Texans are one of the worst units in the NFL in pressure rate (19.4%) and are below average when it comes to sacking the QB (5.1%).
Neither unit will likely be dominant in this matchup. However, with the X-factor of Murray under center, the Cardinals' line should feel more than comfortable with what the Texans will throw at them.
Advantage: Push
Once again, the Texans will be underdogs by a significant amount this week. Given that they have lost by 28 or more points in two of the last three weeks, a spread of 17.5 points might not be enough. The Cardinals are the better team in almost every area.
Texans vs. Cardinals Prediction: Cardinals 30, Texans 13


Guruvayur Sri Krishna Temple is a Hindu temple dedicated to the Hindu god Guruvayurappan, located in the town of Guruvayur in Kerala, India.
Open to Hindus only, this Kerala-style temple is dedicated to Lord Shiva & conducts 3 daily poojas.
Mammiyoor temple or famously known as Mammiyur Mahadeva Kshetram is a Shiva temple situated in Guruvayoor, Thrissur district of Kerala, India. Every devotee who goes to Guruvayur Temple is supposed to go to Mammiyoor also, as the ritual goes.
Around 1000 steps up Chamundi Hills leads to this tall Hindu temple with rows of intricate carvings.


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Services check in time after 2:00 pm. onwards check out time 12:00 am. Daily housekeeping between 10:00 am.- 5:00 pm.
Type This room is awesome! Featuring mixtures of peaceful colors and creative designs, Spacious, Clean and fun atmosphere for great peaceful sleep.
Type This room is awesome! Featuring mixtures of peaceful colors and creative designs, Spacious, Clean and fun atmosphere for great peaceful sleep,Good Sofa Big Balcony.


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Fiji's largest telecoms group Amalgamated Telecom Holdings (ATH) has published its audited financial results and annual report for the financial year ended 31 March 2014 (FY 2013/14) in which it posted consolidated group revenue growth of 4% to FJD281 million (USD151 million), up from FJD270 million in FY 2012/13, due to 'strong and continued growth' in fixed/mobile internet and data services. The fixed line, wireless and broadband group's consolidated net profit swung to FJD14.5 million in the twelve-month period, compared to a net loss of FJD15.9 million in the previous financial year, while ATH recorded consolidated EBITDA of FJD93.1 million in FY13/14, up from FJD26.2 million year-on-year. ATH chairman Ajith Kodagoda, commented on the annual report, which was released by the South Pacific Stock Exchange yesterday: 'Our financial performance has been robust despite the intense competition faced in the telecommunications sector. The result this year has come about from some hard decisions including the refreshing of infrastructure and the continuing restructure undergone over the past four years … Our forward-looking investments in next-generation technology and network infrastructure are ushering in the future of telecommunications to Fiji.' Among recent important developments at the group, in August 2013 ATH completed its takeover of Fiji International Telecoms Limited (FINTEL), raising its stake from 51% to 100% by acquiring shares previously held directly by the government, while in December 2013 ATH's Vodafone Fiji-branded wireless division commercially launched its LTE mobile broadband network (claiming a first in the South Pacific). In events following the end of the FY13/14 fiscal year, in May 2014 ATH's PSTN division Telecom Fiji Limited (TFL) launched its 'Connect Infinity' fibre-to-the-home (FTTH) service, and a month later the UK's Vodafone Group exited the group by selling a 49% stake in Vodafone Fiji to Fiji National Provident Fund.


For interior paint color design for small playroom and bedroom are very varied. The child's bedroom using their favorite colors. Even the girls who like cartoons such as Barbie, then the child will ask his room is decorated after the color identical to the color of Barbie. Playroom and bedrooms will usually use colors that are soothing. Most master bedroom using a beige or white. However, the season currently cover the walls of the rooms were attached to the walls of the room or some are created naturally by using paint.
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16 Channel Microprocessor Based Temperature Scanner, linearised for PT100 & 3 T/Cs (J,K,R) with cold junction compensation.
Scan rate settable from front panel up to 99sec/channel.
Number of channels user selectable.
Configuration lock at rear to lock the number of channels and configuration.
Non-volatile memory to save settings.
Aesthetically designed front panel with membrane switches.


Creator: Unknown. March 10, 1860.
March 9, 2015, 6:18 p.m.
The Weekly Anglo-African. (New York [N.Y.]), Vol. 1, No. 34, Ed. 1 Saturday, March 10, 1860, newspaper, March 10, 1860; New York, New York. (https://texashistory.unt.edu/ark:/67531/metapth596306/: accessed April 20, 2019), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; .


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Like Devil May Cry 4 on Facebook
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$19.99 Download to Xbox 360


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module Rockstar
  Version = File.open(File.join(File.dirname(__FILE__), "../../VERSION"), "r").read.strip
end

redpajama_set_name: RedPajamaGithub


New Direction. Real Career. Better Life.
Since 1995 Career Quest has provided ambitious students with new opportunities in career education. Our campuses are conveniently located in Bay City, Jackson, Lansing and Mt. Pleasant, Michigan.
Our dedicated staff and faculty are committed to helping you succeed. We realize that your education doesn't end in the classroom. As you approach graduation, our Career Services will help you put together a resumé, portfolio and provide interview coaching. You'll also have access to free tutoring to help you prepare for certifications that are important to employers.
The Career Quest learning experience is hands-on. Students in every program practice with tools and technologies required in real-world applications. Our instructors bring proven experience and skill to the process and genuinely enjoy sharing their knowledge.
Our goal is to get you certified and successfully place you in the job market.
Health care providers need a strong, qualified administrative team to function properly.
If you are interested in a career that helps people properly receive the health care services they need, consider Medical Billing & Coding training from Career Quest Learning Centers.
Our 8-month* Medical Billing & Coding program will teach you how to perform important tasks including electronic medical recordkeeping as well as medical coding and billing. You'll also learn basic anatomy, physiology and medical terminology along with government regulations such as OSHA and HIPAA. Our dedicated instructors understand the importance of these tasks and will help you learn the skills needed to become an integral part of a health care team.
You'll also perform a real-world externship that allows you to apply your skills in a medical setting.
Most medical billing and coding professionals work full time and can work in a variety of settings, such as physicians' offices, hospitals and more.
According to the Bureau of Labor Statistics Occupational Outlook Handbook, employment for healthcare support occupations is expected to rise 28.1% between 2012 and 2022. That's much faster than the average for all occupations and accounts for 1,155.8 new jobs during that time frame.
Find a career that allows you to make a difference in the lives of others.
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*To qualify, applicants must have earned a High School Diploma or GED from a recognized school.
**Certifications are subject to change at any time at the sole discretion of Career Quest.
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In the Medical Assistant program, you can learn to assist physicians during examination and treatment. These skills will allow you to perform a variety of laboratory and clinical procedures.
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*Certifications are subject to change at any time at the sole discretion of Career Quest.
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*To qualify, applicants must have earned a High School Diploma or GED from a recognized school and be able to provide documentation of successful completion from a regionally or nationally accredited diploma level program related to this associate degree.
Phlebotomy is a fancy term for drawing blood. Phlebotomists, also called phlebotomy technicians, work in hospitals, clinics and other care settings, drawing patient blood for testing and disease diagnosis.
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At Career Quest Learning Centers, you can become proficient in a high-demand field: Certified Nurse Aide. Greater need for services and rapidly evolving healthcare regulations mean more opportunity for employment in this exciting area. Your knowledge will put you in a strong position to help get the job you want and advance your career and your life.
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All cultures are dehydrated for safe shipping and will not be adversely affected during transit time. This allows us to confidently ship throughout the United States and Canada any time of year.
However, leaving your cultures to sit in a hot mailbox for days can certainly cause problems. We send a tracking number with each order and encourage you to retrieve your package as quickly as possible upon delivery.
Cultures can be stored in the fridge or freezer to extend their shelf life until you're ready to activate them. If you ever have any concerns about the viability of your cultures after activation, please don't hesitate to contact us using the Submit a Request button above.


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Home > Conferences and Symposia > Young Historians > 2021 > 1
Young Historians Conference 2021
Session 1: Panel 2: Presenter 3 (Paper) -- Nonbinary Significance: Roles and Perceptions Throughout History
Minami S. Powers, Grant High SchoolFollow
5-19-2021 1:20 PM
Gender-nonconforming people -- History, Gender-nonconforming people -- Cultural aspects, Gender nonconformity -- Cultural aspects, Sexual minorities -- History
Nonbinary people existed in many different cultures and often held special or important roles before their presence was decimated by colonization. Despite this, nonbinary people are still around today, whether with a cultural aspect to their identity or not. In this paper, three cultural examples are given. The hijra of India have been around for a long time, and are considered able to bless people. The British came and enacted laws that led them to be majorly stigmatized, and today they are still struggling to gain acceptance. Similarly, in Indonesia, the bissu have been priests for hundreds of years, and then when Islam came into the area, they were almost eradicated. They now are trying to survive by coexisting with Islam. Finally, many Native American cultures have had a nonbinary gender with a spiritual aspect. When Westerners came to America and the culture was systematically taken apart, the gender systems were almost lost as well. Today, nonbinary people in all cultures still face many different challenges, but they are also gaining visibility and acceptance.
History Commons
May 19th, 1:20 PM May 19th, 2:35 PM
Young Historians Conference
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Home News & Events
Chicago Innovation Award
Southwest Capital Bank Expands ATM Channel with the Help of Cummins Allison
April 4, 2017, Mt. Prospect, IL – Southwest Capital Bank, located in Albuquerque, New Mexico, installed 35 cash-dispensing ATMs from Cummins Allison, the leading innovator and provider of coin, currency and check processing technology as well as ATMs, to increase its presence at convenience stores located throughout the state of New Mexico.
"We're constantly searching for additional ways to bring more convenience and access to our customers," said Richard Torrez, customer support manager, Southwest Capital Bank. "The Southwest Capital Bank-branded ATMs meet our customers' cash access needs in a way that works best for them – in the conveniently located stores that are already part of their lives," said Torrez. "In addition they meet the needs of many types of non-customers including travelers in need of spending cash."
Superior experience
Southwest Capital bank started working with Cummins Allison when they replaced two of their six bank branch ATMs. "We had an extremely positive experience with them so when one of our small business customers approached us looking for a new ATM fleet because their existing ones were frequently out of service, we reached out to Cummins Allison."
"We were looking for cost-effective ATMs that were not only reliable but fulfilled our modern brand image," said Torrez. "We were impressed by the look and the uptime, and, for any bank, keeping ATMs up and running means increased revenues," said Torrez.
All 35 ATMs were installed in less than two weeks. "It's the relationships, the customer service and attention to detail that Cummins Allison offers that had the ATMs up and running well before scheduled," said Torrez.
Customer-centric provider
Once a financial institution has made the decision to replace or add to its ATM fleet, it's critical to select the technology that best meets their needs. Equally important is choosing a partner that is focused on delivering superior service and support throughout the entire process.
"When choosing technology like this, the sea of 'sameness' is ever present, but what really differentiated Cummins Allison from other providers is the level of service and care I received from them," Torrez commented. "From the beginning to end, I have nothing but positive things to say. They picked up the ball and never dropped it."
"Any technology roll-out of this size requires seamless collaboration between customer and ATM partner," said Bob Gibson, vice president, branch operations, Cummins Allison. "Successful deployment of this significant ATM installation demonstrates our ability to scale with our customers' needs and demonstrates our commitment to helping Southwest Capital Bank expand its brand presence."
For more information on Cummins Allison's ATMs visit: www.cumminsallison.com/atm
About Southwest Capital Bank
Southwest Capital Bank is among the very few family owned banks in the nation and prides itself on a history of long-term relationships. The familiar, conservative leadership of the Levenson family means continuity and stability for their customers—many of whom come from families that have themselves been part of the New Mexico landscape for generations. Being a family bank in a place where family comes first, they know what it's like to work together, struggle together, and prosper together. They understand what it is to have a business and a family in New Mexico.
About Cummins Allison
Cummins Allison is the leading innovator and provider of check, currency and coin handling solutions, as well as full-function ATMs. Our world-class sales and service network includes hundreds of local representatives in more than 50 offices in North America, 6 wholly-owned subsidiaries and is represented in more than 70 countries around the world. For more information about our award-winning solutions, visit www.cumminsallison.com.


There is a very rich history of sports in Egypt and a long history of gambling. It therefore makes sense that there would be a long and rich history of sports betting there. These days, Egypt is a predominantly Muslim nation and is subject to some unique laws. In essence, Egyptian residents are prohibited from gambling. While there are many casinos operating throughout the country, only non-residents may gain entry. For years, the only real legal gambling has been state-run lotteries which have offered sports betting as part of their repertoire. More recently, Egyptians have faced no interference when they place bets at internet betting sites.
Internet betting is not regulated in Egypt which means that there are no legal online wagering sites operating within its borders. However, there are plenty of foreign betting companies who take bets from Egyptian customers. With over 91 million residents, Egypt represents a very lucrative market and online bookmakers are doing their best to get a piece of it. At least for now, Egyptian punters will be able to continue placing their bets with online bookies.
What are the Best Sports Betting Sites and Bookmakers for Egypt?
Egyptians have a lot of choices when they are searching for an online bookie. The most respected brands in the world are offering their services to this huge market. These top-rated sportsbooks offer competitive odds, a wide variety of sports markets, and the latest options like mobile betting and live streaming. They also offer a safe and secure experience by operating to the highest industry standards. Pinnacle, and Marathonbet are a few of the most highly regarded bookmakers in the industry and an increasing number of Egyptian punters are placing bets with them every day. Other top brands that Egyptians trust are SportingBet, Intertops, Betsson, and Bwin as well as Paddy Power, Vernons, and Nordicbet.
These are just a few of the best bookmakers for Egyptians. To find more, go to Gambling Judge's sportsbook database and read the reviews. You can also cash in on some pretty sweet deposit bonuses while you're there.
What are the Most Popular Sports in Egypt?
Egyptians love a variety of sports. Racquet sports like tennis and squash are played by many. Weightlifting, boxing, and wrestling are also widely followed as are roller hockey, handball, and basketball. The biggest and most popular sport is soccer. Soccer is watched by very large audiences and it is one of the most wagered on sports.
Is Online Sports Betting Legal in Egypt?
Sports betting is one of the few forms of gambling that Egyptians are allowed to participate in. Internet gambling is not regulated in Egypt and citizens have been free to wager on sports through foreign operated online operators.
Are there any Sports Betting Bonuses and Free Bets for Egyptian Players?
The Egyptian online betting market is massive and there are many online bookies fighting for customers. This translates into great news for Egyptian punters. Many of these sportsbooks are offering some very tantalizing bonuses to new and existing clients. BetVictor is offering new customers a €25 free bet. Ladbrokes and 12bet, will give you a €50 free play while Efbet is offering free €100 bets.
Perhaps you would like a cash bonus? You can claim €50 in cash at BetMotion and NetBet. Noxwin, Exclusivebet, RedKings and BetAdonis will give your account an instant €75 boost. You can get €100 in cash when you join SLbet. If you are looking for the biggest cash bonuses then you should look into ComeOn where you can get €300.
These bookmakers don't stop with welcome bonuses. Most of these bookies are continuously offering their existing clients a wide range of bonuses and incentives. Go to Gambling Judge's sportsbook promotions section to find many more wonderful bonuses. We bring you the latest offers from the best bookmakers on the internet.


Randy's Random is a collection of memes — online, a meme is a brief mental object usually expressed graphically to express an idea in a fun or thought-provoking way. The topic? That's what's pretty much random: whatever catches Randy's eye that he thinks you'll enjoy.
Look for new posts 2-3x/week, and you can use the form at the upper right to subscribe to notifications to get an email alert of new posts (which, of course, also come out 2-3x/week). You're also welcome to use the Share buttons under each post, and comments on posts are handled by Facebook — yes, you need to be logged in to Facebook to comment.
New to the Site? You might enjoy the "Random Post" button in the navbar, and/or the list of "Most-Shared Posts" in the sidebar.


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Case ReportE-INTERVENTIONAL
Medicare Physician Payment Rules for 2011: A Primer for the Neurointerventionalist
L. Manchikanti and J.A. Hirsch
American Journal of Neuroradiology June 2011, 32 (6) E101-E104; DOI: https://doi.org/10.3174/ajnr.A2653
L. Manchikanti
J.A. Hirsch
SUMMARY: Physicians generally have been affected by significant changes in the patterns of medical practice evolving over the past several decades. The Patient Protection and Affordable Care Act of 2010, also called ACA for short, impacts physician professional practice dramatically. Physicians are paid in the USA for their personal services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula based payment, mostly based on the Medicare payment system. Physician services are billed under part B. The Neurointerventional practice is typically performed in a hospital setting. The VA system is a frequently cited successful implementation of a government supported health care program. Availability of neurointerventional services at many VA medical centers is limited. Since the inception of the Medicare program in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, the payment systems compensated physicians on the basis of their charges. In 1975, just over 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in medical economic index. The involvement of medical economic index failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991. In 1992, the fee schedule essentially replaced the prior payment system that was based on the physician's charges, which also failed to curb the growth in spending. Thus, in 1998, the sustainable growth rate system was introduced. In 2009, multiple unsuccessful attempts were made by Congress to repeal the formula. The mechanism of the sustainable growth rate includes three components that are incorporated into a statutory formula: expenditure targets, growth rate period and annual adjustments of payment rates for physician services.
Physicians in the USA have been affected by significant changes in the pattern(s) of medical practice evolving over the past several decades. These changes include new measures to: 1) curb increasing costs, 2) increase access to patient care, 3) improve quality of healthcare and 4) pay for prescription drugs.1–5 Escalating healthcare costs have focused concerns about the financial impact of healthcare and solvency of Medicare. Neurointerventionalists (NIs) practice in a space where there are limited numbers of randomized control studies to support some of our most basic treatments. Changes in Medicare will necessarily impact on the practice of NI.
The historic enactment of affordable healthcare, the Patient Protection and Affordable Care Act of 2010, also called ACA for short, has changed the entire landscape of the practice of medicine in the USA.2,6–8 ACA has far reaching goals, including insuring 34 million more Americans.
Medicare paid over US$60 billion in 2008 and US$64 billion in 2009 for physician services. On 29 December 2010, Centers for Medicare and Medicaid Services (CMS) issued an emergency update to the 2011 Medicare physician fee schedule, which reduces the conversion factor from December 2010 $36.8729 to CY 2011 conversion factor of $33.9764—a 7.9% reduction.9 This essentially is lower than the fee schedule of 2008, 2009 or 2010.9–12
Manchikanti et al1 recently published an article on the impact that the new Medicare rules will have on interventional pain management. Given the similarities of NI procedures to elements of interventional pain management, this brief communication was undertaken.
Physician Services Payment System
Physician services include office visits, surgical procedures and a broad range of other diagnostic and therapeutic services. Physician services are billed to part B (under physician fee schedule), for which Medicare paid approximately US$64 billion in 2009, accounting for 13% of total Medicare spending.13
All services—surgical and nonsurgical—are classified and reported to CMS according to the Healthcare Common Procedure Coding System, which contains codes for about 7000 distinct services.14 Currently, approximately 80% of beneficiaries obtain covered services through the original Medicare program, also referred to as fee for service (FFS) Medicare. The remaining 20% of beneficiaries are enrolled in managed care organizations, under Medicare Advantage (MA) organizations. Under the FFS program, beneficiaries obtain services through providers of their choice, and Medicare makes payment for each service rendered or for each episode of care, whereas under the MA program, the entities which insure Medicare beneficiaries assume the risk for providing all covered services in return for a fixed monthly per capita payment. Furthermore, in the FFS program, the deductible is US$100 per enrollee with a 20% co-pay, whereas in the MA program, the deductibles can range up to US$6700.15 Overall, Medicare enrollees in 2010 were approximately 44 million. Of these, in 2010, MA plan enrollment was approximately 12 million.
Evolution of Physician Payment System
In the USA, physician payment includes the overhead expenses for maintaining an office and providing the services. The payment system is highly variable in the private insurance market; however, governmental systems have a formula based payment, mostly based on the Medicare payment system.
Since the inception of Medicare programs in 1965, several methods have been used to determine the amounts paid to physicians for each covered service. Initially, payment systems compensated physicians on the basis of their charges and allowed physicians to balance their books by billing beneficiaries for the full amount above what Medicare paid for each service. In 1975, just 10 years after the inception of the Medicare program, payments changed so as not to exceed the increase in the medical economic index (MEI).16–18 Despite the incorporation of the MEI, the policy failed to curb increases in costs, leading to the determination of a yearly change in fees by legislation from 1984 to 1991.16–18
In 1992, the fee schedule replaced the prior payment system. This system was replaced by the sustainable growth rate (SGR) system in 1998. In 2009, multiple attempts were made by Congress to repeal the formula. The House of Representatives passed such a bill, but replaced it with another formula which is considered the same or more onerous than SGR,19 which never became law.
Resource Based Relative Value System
Since 1 January 1992, Medicare has paid for physicians' services based on national uniform relative value units (RVUs), based on the relative resources used in furnishing services. The national RVUs are established for physician work, practice expense (PE) and malpractice expense (ME).11–14
Since the initial implementation, RVUs have been refined several times. The first 5 year review of the physician work RVUs was effective in 1997; the second 5 year review was effective in 2002. The third 5 year review of physician work RVUs was effective on 1 January 2007. As part of the 2007 final rule, the CMS implemented a new methodology for determining resource based practice expense relative value units and are transitioning it over a 4 year period.
Sustained Growth Rate Formula
The SGR includes three components that are incorporated into a statutory formula: first, expenditure targets, which are established by applying a growth rate (calculated by a formula) to spending during a base period; second, the growth rate period; and third, the annual adjustments of payment rates for physicians' services, which are designed to bring spending in line with expenditure targets over time.
The relative value of a physician fee schedule is based on three components—physician work, PE and MEIs that are used to determine a value ranking for each service to which it is applied. On average, the work component represents 52.5% of a service's relative value, the PE component represents 43.6% and the ME component represents 3.9%.20
The volume and intensity of services have increased on average by about 4.5% from 1997 to 2009. Since 2002, spending (as measured by the SGR method) has consistently been above the targets established by the formula.1,20 The SGR reductions in payment rates for physician services resulted in a cut of 4.8% in 200221 with additional proposed cuts of 4.4% in 2003.22 In 2003, Congress responded by increasing payments for physician services by 1.6% instead of the projected 4.4% cut.23 In 2004 and 2005, the Medicare Modernization Act replaced the scheduled rate reduction with an increase of 1.5%. In 2006, the Deficit Reduction Act held 2006 payment rates at their 2005 level, overriding an additional impending 4.4% reduction.24 In 2007, Congress again approved holding the 2008 payments at the 2005 level, thereby avoiding a proposed additional 5.1% reduction.25 From 2008 to 2011, repeated temporary measures were also undertaken.11,26–28
Medicare Advantage Programs
The MA programs provide Medicare beneficiaries with an alternative to the FFS Medicare program. It enables them to choose a private plan to help provide their healthcare. Those private plans can use alternative delivery systems and care management techniques. They also have the flexibility to innovate.
MedPAC's report to Congress stated that 9.9 million Medicare beneficiaries were enrolled in MA plans as of November 2008 and payments to MA plans continue to exceed what Medicare would spend for similar beneficiaries in FFS; MA payments per enrollee are projected to be 114% of comparable FFS spending for 2009. All in all, it appears that the MA program continues to be more costly than the traditional program.
Relative Value Determination of Physician Services
Three types of resources, physician work, PE and ME, are estimated for each service as RVUs.27,28 The total RVUs for a service measures its resource used relative to the resource use of all other physician services in the fee schedule. The Medicare payment for a service is the product of its RVUs and conversion factor that translates the RVUs into dollars.
An example of the impact of the current RVU payment system is the widespread belief that evaluation and management services are undervalued, which has held down the income of physicians in primary care relative to other physician specialties.29
The two largest components of the fees, physician work and PEs, comprise about 95% of Medicare physician payments.12,27 Even though the data and methods for estimating the work and PE resources for each physician service have been updated and improved, annual changes to the fee schedule still raise comments about the accuracy of the RVUs.27 Consequently, questions persist about the adequacy of the data, the transparency of the processes, the involvement of medical specialty societies, CMS oversight and the standards against which the estimates are valued.27
Medicare Spending on Physician Services
Medicare spending for FFS per beneficiary for physician services has increased annually. In the decade between 1998 and 2008, Medicare spending per FFS beneficiary on physician services increased by more than 75%.30 It has been stated that even though the physician portion of the Medicare spending is declining, growth and spending on physician services is one of several contributions to part B premium increases over this time period.30 Overall, over the first 12 years of the SGR policy (1997–2008), Medicare spending for physician services—per beneficiary—increased by 90%. Growth in the volume of services provided contributed significantly more to the rapid increase in Medicare spending than payment rate updates. Both factors (updates and volume growth) combined to increase physician expenses. It has been stated that the number of physicians providing services to beneficiaries has kept pace with growth in the beneficiary population from 2001 to 2006, with the number of physicians per 1000 beneficiaries being maintained relatively steady at a little more than 14.30
The most recent publication from MedPAC provides data on national healthcare and Medicare spending. Medicare spending among FFS beneficiaries grew strongly in most sectors from 2000 to 2005. The rate of growth slowed in 2006–2008, reflecting a decline in FFS enrollment, as many beneficiaries changed their enrollment to an MA plan.13 Physician payments were number 2, just behind hospital inpatient but above postacute care hospital outpatient, inpatient psychiatric hospital and ambulatory surgery center payments. However, Medicare spending per beneficiary in FFS Medicare increased steadily in most sectors from 2000 to 2008.13 This trend contrasts with a slowing and aggregate spending in FFS Medicare from 2006 to 2008 caused by a decline in the number of FFS beneficiaries.
The Future of Healthcare in the USA
Medicare spending during this time has also grown as a share of economy from less than 1% in 1965 to about 3% in 2008, with projections suggesting that Medicare spending will make up 4% of GDP by 2019. Further, in 2008, all public spending made up about 47% of the total healthcare spending and private spending made up 53%, which is expected to reverse by 2019, with the public share of 52% and the private share of 48%. However, with enactment of ACA, these projections may be quite off and public spending may increase to as much as 60%–70%.1,2,6–8
Not surprisingly, as most private insurers adapt principles from Medicare, rates of growth in per capita spending for Medicare and private insurance over the long term have been quite similar. Medicare spending has grown nearly 13-fold, from US$37 billion in 1980 to US$468 billion in 2008, which includes benefit payments and administrative expenses; however, benefit payments alone increased to US$491 billion in 2009 with inpatient hospital services by far the largest spending category (27%), followed by managed care (22%), physicians (13%), outpatient prescription drugs provided under part D (12%) and other FFS setting (8%).13 Inpatient hospital payments, as well as FFS, actually reduced from 1999 to 2009. Inpatient hospital expenses were 41% in 1999 whereas they were 27% in 2009 due to a shift of multiple services into outpatient settings. However, physician fee schedule constituted 16% of total spending of US$280 billion in 1999 reduced to 13% in 2009 spending of US$491 billion. The physician payments constituted 14.2% of total Medicare benefits in 2007.13,30 One of the discrepancies may be that managed care payments constituting 22% of the payments enroll less than 20% of beneficiaries. Medicare spending for services is illustrated in Fig 1 with physician fee schedule with 16% of expense in 1999% and 13% in 2009.13
Fee for service (FFS) program spending is highly concentrated in a small group of beneficiaries (2006).13.
Medicare FFS spending is concentrated among a small number of beneficiaries, as shown in Fig 1. In 2006, the costliest 5% of beneficiaries accounted for 39% of the annual Medicare FFS spending and the costliest quartile accounted for 83%.13 By contrast, the least costly half of beneficiaries accounted for only 4% of FFS spending. Costly beneficiaries tend to include those who have multiple chronic conditions, those using inpatient hospital services, those who are duly eligible for Medicare and Medicaid and those who are in the last year of life.
Physician Payment Schedule for 2011
The final schedule for physician payments was issued on 24 November 2010.11 This was based on a 28% cut of SGR. However, CMS issued emergency update of CY2011 Medicare physician fee schedule data base on 29 December 2010.9
Due to multiple revisions and additions of RVUs, the conversion factor associated with the CY2011 final rule has been revised. Legislative changes subsequent to issuance of 2011 final rule have led to further revisions of the values published in the 2011 final rule correction notice, including a change to the conversion factor. Thus an emergency update has been issued by CMS.9
Changes to the Fee Schedule in 2010
On 2 March 2010, the Temporary Extension Act of 2010 was signed into law which extended through 31 March 2010, the 0% update to the physician fee schedule that was in effect for claims with dates of services from 1 January 2010 to 28 February 2010. In addition, on 15 April 2010, the Continuing Extension Act of 2010 was signed into law extended through 31 May 2010, the 0% update to the PFS that was in effect for claims with dates of services from 1 January 2010 to 31 March 2010; the provisions were retroactive to 1 April 2010.
On 25 June 2010, the preservation of access to care for Medicare beneficiaries and Pension Relief Act of 2010 was signed into law.31 This law required application of a 2.2% update to the physician fee schedule for claims with dates of services from 1 June 2010 to 30 November 2010. As a result of this change, the physician fee schedule conversion factor to US$36.8729 for services furnished during this time period.
On 30 November 2010, President Obama signed into law the Physician Payment and Therapy Relief Act of 2010.9 As a result of the Physician Payment and Therapy Relief Act of 2010, a new reduced therapy fee schedule amount (20% reduction on the PE component payment) was enacted. On 15 December 2010, President Obama signed into law the Medicare and Medicaid Extenders Act of 2010.9
Medicare and Medicaid Extenders Act of 2011
The important part of the physician reimbursement is physician payment update in this regulation passed on 15 December 2010.9 This averts the negative update that would otherwise have taken effect on 1 January 2011, in accordance with the final rule. The Medicare and Medicaid Extension Act provides for a 0% update to the physician fee schedule for claims with dates of service 1 January 2011 to 31 December 2011. While the physician fee schedule update will be 0%, other changes to the RVUs, including misvalued code initiative and rescaling of the RVUs to match the revised MEI rates, are budget neutral. To make those changes budget neutral, CMS made an adjustment to the conversion factor. The revised conversion factor to be used for physician payment as of 1 January 2011 is US$33.9764 with a 7.9% reduction.
The USA is facing widespread challenges to its healthcare system. A historical reform has been passed by Congress and signed into law whose survivability is not quite known yet. However, the ACA effects are already felt at multiple levels. NI is a young evolving specialty with limited level 1 data to support its treatments. With the increasing focus on evidence based medicine and comparative effectiveness research, our specialty will likely be forced to deal with many challenges. With approximately 50% of US based healthcare paid for by the public sector, it is clear that NI specialists benefit from a familiarity with Medicare.
Provenance and peer review
Not commissioned; externally peer reviewed.
The manuscript is a brief version of Medicare Physician Payment Systems: Impact of 2011 Schedule on Interventional Pain Management published in Pain Physician 2011;14:E5–33. This version is published with the consent of all of the authors and the permission of the journal Pain Physician.
Reproduced from [J NeuroIntervent Surg, Manchikanti L, Hirsch JA., doi:10.1136/jnis.2011.004937, 2011] with permission from BMJ Publishing Group Ltd.
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You are going to email the following Medicare Physician Payment Rules for 2011: A Primer for the Neurointerventionalist
L. Manchikanti, J.A. Hirsch
American Journal of Neuroradiology Jun 2011, 32 (6) E101-E104; DOI: 10.3174/ajnr.A2653
The Independent Payment Advisory Board: impact on neurointerventionalists
Physician payment outlook for 2012
Physician Payment Reform: Getting What We Pay For


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