text:
Maine schools must provide a safe environment for all students, including transgender students. Those who have a gender identity different from the sex they were assigned at birth are not being given enough protection, let alone the type of welcoming atmosphere that encourages learning.
Some schools have shown leadership by working closely with transgender students and their parents to ensure their needs are met. They have encouraged the creation of student groups to celebrate diversity and made clear that derogatory language is unacceptable. But too many schools have not taken steps to end verbal and physical harassment.
A continuing legal battle over an Orono school prohibiting a transgender child from using the girls bathroom has drawn attention to the experiences of transgender students in Maine. The case has highlighted how little public understanding there is of the best ways to support transgender students' education.
Nearly nine out of 10 transgender students experience verbal harassment at school because of their gender expression, according to a 2009 study released by the Gay, Lesbian and Straight Education Network. More than half experience physical harassment, and more than a quarter experience physical assault. The attacks often result in transgender students missing more school and receiving lower grades.
More enlightened policies and protection — similar to those that help to improve school climates for gay students — will require schools to be proactive. Leaders should not wait until an act of discrimination occurs to change the rules. The Maine Human Rights Commission's draft guidance on sexual orientation policies is a good place to start.
Ensuring equal treatment means addressing certain issues. Here are some of many ways schools can make sure they treat transgender students with respect:
• Language. Students and teachers' language sets a school's tone. Adults should correct students who say "that's so gay" or use other ostracizing phrases or words. Harassment — including cyberbullying — on the basis of sexual orientation is illegal. Sexual orientation is legally defined in Maine statute as a person's "actual or perceived heterosexuality, bisexuality, homosexuality or gender identity or expression."
• Positive representation. Schools should not make the gay or transgender experience invisible. One way to do this is to establish gay/straight alliances or offer diversity programming. When students see administrators and facility supporting gay and transgender students — or even acknowledging their existence — they know bullying isn't tolerated.
• Bathrooms. Transgender students should have access to bathrooms that respect their gender identity, though for some this could mean single-stall bathrooms. It is not OK to force transgender students to use rooms that correspond to their assigned sex at birth.
• Names. Forms should have a space for a "given name" and a "chosen name," and school IDs should reflect the chosen name. (The policy also could be helpful for students with divorced parents, who go by a different last name than their legal one). Staff should refer to students by the names and pronouns they desire. If a student hasn't authorized disclosure of information that reveals his or her transgender status, school staff must not disclose it.
• Housing. At residential high schools and on college campuses, having a floor or wing of a dorm that is designated as friendly to gay, lesbian, bisexual and transgender people — and their allies — helps keep students safe.
It's not known how many people are transgender, but the National Center for Transgender Equality estimates it's between 0.25 percent and 1 percent of the population. Feelings about one's gender are usually set early in life and do not change — though establishing a gender identity can be a dynamic process. Students cannot be asked for "proof" of being transgender, and no medical diagnosis, surgery or hormone replacement therapy is necessary to be transgender.
What is necessary is for educators, legislators and neighbors to be more understanding of transgender students, ensure they are treated with respect and create the type of environment most conducive to learning.


text: Allstate Insurance Company of Canada Makes Best Employers in Canada List Again! Markham, November 7, 2013 - For the second year in a row, Allstate Insurance Company of Canada has been named as one of the best employers in the country, according to the 2014 Best Employer study conducted by global Human Resources consulting firm Aon Hewitt. The annual study identifies the 50 best organizations with the highest employee engagement, which is determined by leadership, rewards, workplace culture, values, productivity and the support of performance and development. "We are honoured to once again be recognized as one of Canada's best employers," says John O'Donnell, president and CEO of Allstate Insurance Company of Canada. "Making this list a second time is proof that the work we're doing at Allstate to foster a strong and positive corporate culture and healthy work environment has taken root. I'm proud of the recognition our employees have garnered by earning this award. This is an accolade that belongs to every Allstate employee." According to Aon Hewitt, the level of engagement in a company is measured through its employee behaviour. They capture this information by determining if employees speak positively about the organization to others, whether they are committed to remaining with their current employer, and whether they are motivated by their organizations' leaders, managers, culture and values to do the very best job possible to contribute to business success. "The results of this national study more than anything speaks to how Allstate employees feel about working for this organization," says O'Donnell. There are three components used to determine the rankings: a survey completed by a minimum number of employees based on the organization's size (in Allstate's case, 944 employees responded to the survey); the leadership team is surveyed to measure how closely the leadership and employee goals and fundamental values are aligned; and the Human Resources team is canvassed on policies and practices. For more information on the study, visit www.hewitt.com/bestemployerscanada. About Allstate Insurance Company of Canada Allstate Insurance Company of Canada is one of the country's leading producers and distributors of home and auto insurance products, serving Canadians since 1953. The company strives to keep its customers in "Good Hands®" as well as its employees, and has recently been listed on the Best Employers in Canada, Best Employers in the GTA, and Best Employers in Quebec lists. Allstate Canada is committed to making a positive difference in the communities in which it operates and has partnered with organizations such as Mothers Against Drunk Driving (MADD Canada), United Way and Junior Achievement. To learn more about Allstate Canada, visit www.allstate.ca. -30- For more information, please contact: Kevin Wilson Senior Communications Specialist T: 905.475.4527 email@example.com November 07, 2013 | Categories: Corporate

subset: commoncrawl


text:
Sunday, 25 August 2013 01:29
Are we digitally normal in Asia?
Singapore is the nation most motivated to go online by entertainment. Thailand is second only to the Chinese in their motivation for transactional use of the web, while Malaysia takes a relatively high score for self-expression use.
Monday, 26 August 2013 00:00
Download our free 2Q 2013 Thailand Mobile Market Information
We have put together some figures, tables, information and statistics about the Thai Mobile Market that you might find interesting. The PDF is available to download for free.
Wednesday, 26 June 2013 22:50
GSMA Report: Mobile Economy Asia Pacific 2013
GSMA has published a comprehensive assessment of the impact of the mobile industry on the Asia Pacific region.
Sunday, 23 June 2013 21:18
Laos: Lack of 3G bandwidth
Laos has seen one of the fastest growth of third generation (3G) coverage in the region, with mobile phone signal now covering almost the whole since the service was launched in 2008.


text:
If you look for a uniquely designed and well-made piece for yourself or important ones, then this scarf is it. You can frame the scarf and hang it on the wall when don't wear it. It has a good size as a piece of art and will become the focal point of your room right away.
Suggest professional dry clean.
The scarf is inspired by Patty Hudak' art work. It is made by using highest quality of silk. All the edges are hand rolled.
The Zivarly Swimming Silk Scarf is designed based on New York artist Patty Hudak's oil painting Swimming. It is made with highest quality silk and its edges are hand rolled. The scarf is like a magic palette, mixing glamorous color with Morandi colors in a tasteful way . Each time it can give you a different look, if you fold it in a different way. You will definitely stand out in the crowd with this scarf as your artistic and unique highlight.
• The scarf's size is like a real painting.
• You can iron it and frame it and hang it as a piece of art in your room when don't wear it. It will make a focal point of the room to generate attentions.
• Suggest professional dry clean.
AHAlife is committed to help you live a conscious and inspired life.
Many of the items you discover here are exclusive to AHAlife, which is what makes our community of designers and artisans so special.
If you find one of our products anywhere else for less than it's being sold on our site, we will match it.
Our dedicated Support Team is here to help. Reach out any time at:


text:
As you well know, if you read this blog, the saga of our endless search for a home continues. And that means I spend a lot of time reading the newspaper about the state of the housing market. And right now the Swedish central bank, the International Monetary Fund, and the EU central bank are all fighting with the Swedish government because, it the government thinks it is soooo stupid to pay back your damn mortgage.
At least that is what all of the finance experts in Sweden have to say. Would you be surprised to find that all of the finance experts are employed by the banks?
OK the theory is this: It is silly to pay off your mortgage, ever. Better to invest that money in something else. The bank will get its money back when the house is sold. You pay interest on the loan. Everyone is happy. Because, as we well know well, housing prices only go up.
Lately there has been a change in tune, and the government is 'encouraging' the banks to 'encourage' their customers to amortize 25% of their mortgages. That is correct. Over the life of the loan, you are expected to only pay back 25%. That means, if you actually made a full downpayment of 15%, you are only amortizing on 10% of the actual cost of your house (yes, this does mean that housing costs are crazily inflated to reflect this fact).
Most of the Swedish central bank employees are all like 'We shouldn't FORCE people to pay back their mortgages, because sometimes people fall on hard times and if we force them it would not be good for the economy'
Yes, the banks are saying it is silly to expect people to pay back loans on a monthly basis.
We went to one meeting with the bank that is starting to encourage 60 year amortization and was told 'don't worry, probably when you get to 50% we can talk about stopping amortization' and I was all 'you Swedes are crazy!' I mentioned a 30 year payment plan at our first mortgage meeting with one bank. Let's just say that subject won't come up again.
The good news: The good news is that due to the crazy structure, you can amortize at an accelerated rate without any penalty. At least that is what they say.
The bad news is: Seriously, no one is paying back their loans.
So is Sweden the only country that loans out hundreds of thousands of dollars and does not expect repayment until the house is sold? I have read that Finland has 30 year loans, and I know even crisis country Spain does as well.
Are there other regions where they think 'amortize smamortize?'
Because everyone seems to look at home equity like it is something that should be used long before you die, they keep giving these huge mortgages to people in their 60s, and I am left, once again, mind boggled and rather terrified by the whole thing.


text:
Zbigniew Brzezinski: Evil Spirit of 5 US Presidents – And Biggest Threat to World Peace
by Zen Gardner
There is a man who is more dangerous to mankind than any other living person today. His name is Zbigniew Brzezinski, a CFR-member , Arch-Trilateral Commissionist, Bilderberger. He has been the evil spirit behind 5 US presidents, including Obama – and he is obsessed with but one thought: The US is to dominate a communist one world state.
For that purpose, he sees Eurasia as his grand chessboard, where the battle is to be won. Like any chess player, he starts by occupying the centre of the chessboard, Central Asia.
He wants peace there, friendly arrangements, in particular with China, if possible, so that he can pursue the goal of his obsession, i.e. the purpose of the Trilateral Commission created by him and David Rockefeller: To create a world state by fusing a coming North American Union, at which he is working through the CSIS, the Union for the Mediterranean – and a Far East block which is now being created.
The Rest…HERE


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Grant Scicluna | Writer - Director
James has served time for drowning a little boy when he was a child, although the body was never found in the river. A visit from his victim's mother upon parole sends him on a quest to find the truth. With little time and danger at every turn, James risks his freedom and his life to uncover the trail of sins that might give closure to the grieving mother. Producer: Happening Films. 99min, 2015
Neon Skin
Two young men - one sighted, one blind - see the world and their bodies in different ways. They connect beyond the visual in the collision of taste, touch and sound. Neon Skin won the NFSA Orlando Award for Best Queer Short Film 2011. Producer: Happening Films. 5min, 2009.
Hurt's Rescue
On a remote farm in South Wales an unsettling transaction takes place to rescue a man held in captivity as a slave. UK/Australia production, HURT'S RESCUE is the fifth short film to be produced by the Iris Prize. Producer: Happening Films/The Festivalists. 15min, 2014.
Fast Lane
The consequences of his actions hit Ash head-on, forcing him to question the impact of his reckless decisions and his friendship with his best friend. Producer: Happening Films. 13min, 2007
The Wilding
Juvenile inmate Malcolm is torn between his chance for freedom and protecting the one he loves. Premiering at the Berlin Film Festival 2012, The Wilding has screened at over 100 festivals and won numerous awards including the Iris Prize. Producer: Happening Films. 15min, 2012.
For further information about these films, please click here to contact Happening FIlms


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This view of Vaughan Street, North Skelton dates from about 1906; it is from a used postcard bearing that date. The original village hall is today replaced by a more modern building, whilst "Smarts Stores" is now the location of 'Curly Tops' hairdressing salon. However I would not suggest trying to stand with a wheelbarrow in the middle of the street today; traffic is more prolific and moves at a faster pace that then.
Image courtesy of The Pem Holliday Collection and Derick Pearson.


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I've often referred to myself as shark attack lucky rather than lottery lucky. I've been oh so close to a couple of $10,000+ wins in Draftkings or Fanduel just to be a player or two away. Players I even had in a lineup and swapped out. I've been a seat away from catching a live home-run ball. A seat away from a game used Udonis Haslem jersey he once threw into the crowd after an ejection. Right girl; wrong time. I could write a novel based on incidents of close calls and near misses where I wound up the unlucky one.
Don't get me wrong; I am blessed. I never confused the two. Blessings and luck are two totally separate things. You look around the world and see people and their struggles that they have no control over while the majority of us cry over a cracked phone screen. But I couldn't help but feel as if I was just unlucky, until 08/14/17 that is.
Me and my brother were on the way back down to South Florida from Pensacola. He was driving his truck and I was passenger along I-10. Not even an hour into the drive we both experienced the luckiest moments of our life.
We were in the left lane when a lady merged over without seeing us, nearly side swiping us. Hindsight, it would of been smartest for my brother to stay in his lane and let her graze us. We all probably would've left the incident with a couple scratches on the vehicles but that would more than likely be it. But who knows, by staying in our lane and allowing that to happen the event could've been catastrophic for everyone nearby.
I'm sure everyone who has been driving for sometime has been in an incident where they were almost side-swiped. Or maybe you were the one who didn't see the other vehicle in your blind spot and you nearly side-swiped someone. The point is, it happens and it's rather common. And most of the time you swerve, instinctively to avoid a car collision.
My brother swerved to the left and veered slightly off of the road to avoid the collision. The lady noticed and quickly got back in her lane. And for that moment everything seemed okay. He attempted to get back into his lane and it felt like we would get back to driving smoothly. However, the roads were a little wet and fate had other plans for our drive.
We began to hydroplane, rather quickly at that. As we got back into the highway it became apparent that we had lost control of the vehicle. Being a day and half removed from the incident some of it becomes a blur. The next thing I remember is being in the median drifting uncontrollably for what felt like an eternity.
It's hard to explain but from the time we first veered off road to the time in which we stopped the car it was maybe ten seconds tops. But as we hydroplaned across the median time slowed down. To us it felt like we were sliding for at least a minute. An eternity at that. All of our senses were heightened and aware. The best way I can explain it is that moment when a super hero first gets his powers and the world around him slows down.
We were driving at least seventy when we first veered off the road and began to descend in speed. But to us were moving in slow motion. Every turn felt extremely slow. As we began gliding in the median we almost flipped nearly four different times. And even though I saw everything in slow motion, it was as if my brain didn't have to time to fully react or complete a thought. With each and every turn of the wheel I could feel our wheels lift off.
How the vehicle did not flip is beyond me. But the next thing I notice is we began to drift into the other lane into oncoming traffic. How the road wasn't filled with traffic is another blessing. There was only one vehicle on the other side of the road; a semi truck. An eighteen wheeler. We drift into the lane and I can feel our wheels lift off again, within a split second of death and getting annihilated by this semi truck.
An in this moment as we drift off the median and into the gravel, time is at a complete stand still. B.o.B's "Lovelier Than You" plays so equolently in the background as we approach death. And all I can think is, "holy shit. We are gonna die. This is how it ends." And somehow as the adrenaline flows through my body and I see time freezing slower and slower, I'm at peace.
Death has always scared me. It's where all of my anxiety occurs. And somehow in this moment I felt so calm and tranquil. Just in disbelief that it would end this way.
My brother said the driver was able to swerve enough to where we just narrowly missed him. I didn't notice the driver swerve. But point being, we avoided contact. Within feet, and I mean maybe two or three of getting crushed. We swerved back into the median and very shortly after stopped the vehicle. I let out the biggest sigh of relief. My eyes welled with tears as I feel the purest form of elation that I have ever felt. We look at each other in total and utter disbelief. We made it.
Now death is unavoidable but on this day we defeated it. Here I am all my life thinking that I am shark attack lucky due to how many close calls I've had that didn't go my way. But a day and a half ago I had the best close call ever happen to me. We avoided death in that instance. And as I write this I still can't even stress how close we were. I am lucky. So amazingly lucky I still can't believe it. Who knows? I might still get bitten by a shark but…
I am certainly counting my blessings and not taking things for granted. I wrote this for me as a way to remember my near death experience but if you can use it to realize how valuable life truly is than by all means that works for me. Things get taken for granted all of the time and I'm not going to pretend like this incident won't change that for me. I know somedays I will still take things for granted but here's to hoping that happens less.
I am very spiritual. I don't necessarily believe in religion but I believe in God. A god. My God. And I pray everyday and communicate with God. As we stopped a witness came who happened to be a pastor. He watched the incident from a far and said he was praying the whole time. Take that for what it is. I'm not into pushing my spiritual beliefs upon you. I don't feel as if that's my job. However, if you take one thing away from this just remember how truly special and amazing life is and any day alive is a gift.
Sidenote: I broke down last week in Gainesville at mile marker 418. Six days later I nearly died on the date of 8/14. I haven't even thought of what that means and the coincidences. Just thought that it was wicked cool and I had to share it. Here's the picture I took after I broke down.


text:
Financial Seminar In Hong Kong
We came to Hong Kong twice before for a quick visit – right after our graduation in college and during our honeymoon.
This time, we came back here for business.
Well, almost 14 years have passed since we last set foot on this airport. We already forgotten the ins and outs of this place. Figuring out the fastest and cheapest way to get to our hotel was an arduous task.
Specially when the airport personnel we asked for direction seemed more lost than we are.
My Sweetie conducted thorough financial seminar at the Bayanihan in Kennedytown and at The Boys & Girls Club in Wanchai.
Our kababayans gained a lot of learning on how to grow their money through different methods of investment.
In addition to helping other people improve themselves personally and financially, we get to meet new friends as well.
Of course, gallivanting was part of the trip.
We brought Jme along because she was not yet weaned at that time.
She had a great time, indeed.
Even at 40,000 feet, she has no difficulty feeling comfy. She was a natural adventurer. Born to travel and fly just like her Mom.
We traveled to Hong Kong for the purpose of giving financial literacy seminar to our Kababayans in the hope that they would be able to learn how to save, invest and grow their hard-earned money so they can finally come home to their respective families for good.
This is our financial advocacy for a better Filipino Families, for a brighter Philippines.


text:
Home for the Holidays
Following the success of our first release in 2013, we are thrilled to offer our second CD, once again sung by our 300-voice CFCArts Community Choir! Home for the Holidays includes timeless Christmas classics, newer holiday songs and even a little gospel groove, all of which will thrill listeners of any age!
The CD is available as a physical CD and it will be available electronically very soon! Contact email@example.com with any questions.
Track List
- We Need A Little Christmas
- Home for the Holidays medley
- Sing Joy to the World
- Light A Candle
- Winter Medley
- Do You Hear What I Hear?
- A Big Band Christmas
- Celebrate the Wonder
- The Sounds of Christmas
- Jesus, Oh What A Wonderful Child
Purchasing Options
Digital Download
Now available on iTunes – get your copy today.
Physical CD
+ $3.00 Shipping
+ $3.00 Shipping


text: I was surprised at how well-done this book was in a number of ways. I won't go into it now, but Carie is a born-storyteller and quite good at using words to make new to us feelings that we've all had. She also paints an almost fairy tale world - in the right places - without laying it on too thick. I did prefer the first half or so to the end, as I didn't quite grasp what became a significant moral in the tale. I really don't know why everyone is so upset about 'titillation' in this Christian fiction novel. I feel people have used by far the wrong term there. This was an nod to sexuality that is born of love; surely that has a place in God's world and, therefore, in our representation of this world of God's. It happens; it needs to be acknowledged in the honorable of ways. Something I liked in this book is the suggestion that there is nothing sinful about sensuosity or sexuality, from the joy Serena took in paints and colors to the physical expression between Serena and Drake. I was really surprised that a novel with such a lovely, perfect fairy-tale-like name could prove itself so well. Kind of like the book that library-haunting readers always expect to find on a shelf but don't. Well, looks like I went and got into it, after all.


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Hi SMH Wedding Village!
I would just like to say a MASSIVE thank you for all your hard work during my wedding. Your flower, decor and cake service was outstanding. The flowers were absolutely beautiful- centre pieces really looked fresh and vibrant and the bouquets and buttonholes were stunning. The decor at all three venues was mesmerising- all my guests praised how amazing everything looked. Last but not least, the cake was soooo delicious!
The whole team at SMH Wedding Village went out of their way to ensure everything was set up on time, organised and jaw dropping! My day would not have been as wonderful without your services.
A year on- my husband and I are having a baby and we are using these services to help us with decorating the baby shower! The team are always helpful, friendly and welcoming- they give you an excellent tailored service that suits all your needs and budgets.
If this was a star review- I would give you 10/10! Looking forward to using your services again and AGAIN... best wishes, Kash xxx


text:
Welcome to Villa Dorada
A Beautiful Place to Call Home in Calexico, California
Welcome home to Villa Dorada, perfectly situated in the heart of Calexico, California! You'll be proud to call Villa Dorada your home. Our residents appreciate being in close proximity to a wide selection of shops, restaurants, and entertainment destinations. Come home to Villa Dorada today.
Stylish residences offering all the comforts of home await you at Villa Dorada. Our spacious floor plans are designed with your comfort and convenience in mind, offering amenities that are second to none! Choose from our selection of distinctive one, two and three bedroom floor plans that come well-appointed with your very own all electric kitchen, plush carpeting, covered parking, dishwasher, mini blinds, some paid utilities and much more! We've included everything you'd expect in an apartment home and more.
Take advantage of all the community amenities and services we offer here. Amenities include a business center, copy and fax services, high speed internet, a picnic area with barbecue and beautiful landscaping. Visit today and discover a new way of life!
- Access to Public Transportation
- Beautiful Landscaping
- Business Center
- Cable Available
- Children's Play Area
- Copy & Fax Services
- Covered Parking
- Disability Access
- Easy Access to Freeways
- Easy Access to Shopping
- High Speed Internet Access
- Laundry Facility
- On-Call Maintenance
- Picnic Area with Barbecue
- Public Parks Nearby
Community Amenities
- Air Conditioning
- All Electric Kitchen
- Cable Ready
- Carpeted Floors
- Central Air/Heating
- Covered Parking
- Disability Access
- Dishwasher
- Microwave
- Mini Blinds
- Refrigerator
- Some Paid Utilities
Apartment Features
Contact Us
Office Hours:
Mon-Fri: 8:00 AM-5:00 PM
Sat-Sun: Closed
Join Our Interest List
Thank you!
Thank you for your interest in our community. You will receive an e-mail confirmation shortly.
Floor Plans
** Prices subject to change and are based on new tenancy.


text:
It's actually happened -- after bringing BlackBerry from pager to the top of the smartphone world only to see the iPhone and Android all but demolish their share, RIM today announced founders and co-CEOs Mike Lazaridis and Jim Balsillie would be stepping down, and current operations head Thorsten Heins would be taking over as the new, unified CEO.
And one of his first official acts was to call our own Kevin Michaluk, founder of CrackBerry.com and #1 BlackBerry fanboy.
It's hard to express just how big of a change this is for RIM. Let's put it this way. Since launching CrackBerry.com in 2007 I have been wanting to get an interview with RIM's CEOs. It has never happened. With Thorsten, it happened in literally minutes, and it wasn't even me who asked for it to happen, but rather it was the CEO wanting to do it. I have nothing but the utmost respect for Mike and Jim and all they have done for BlackBerry over the years, but it's clear that for BlackBerry to thrive again RIM needed a shake up, and I think Thorsten is going to do an amazing job leading the way.
With their marketshare continuing to slide, lackluster PlayBook sales, and QNX/BlackBerry 10 superphones still months away, it's clear RIM needed to do something to reassure investors and enthusiasts alike. Here's wishing Heins every success. Strong BlackBerry competition is good for everyone. Bring it on.
Source: CrackBerry.com


text:
Things You will want
Natural laser hint
Preparing Your Burning up Laser Pointer
Place a sheet regarding newspaper on a work area. Contain the green laser beam hint at the back stop, using your left-hand. Support the pliers within your right-hand.
Hold the particular oral cavity with the pliers throughout the front end of the eco-friendly lazer pointer. Pose the actual pliers to discover top finish in the green laser beam tip from your tailgate end. Take leading conclusion off with your pliers.
Hold your teeth around the side from the lazer set up, currently herniated from the back end of the natural lazer pointer. Move your lazer construction by helping cover their your pliers. Position the laser beam assemblage for the newspapers with all the enterprise aboard going through way up.
Place the particular flat-edged jeweler's screw driver to the screw about the signal aboard. Turn the particular attach 1 / 4 change clockwise to improve your concentration of the particular laserlight diode.
Heat up the actual soldering flat iron pertaining to a few minutes. Contact the end from the soldering straightener to the computer nick over the attach. Eliminate the suggestion of the soldering metal soon after 15 seconds has passed, to be able to conquer your computer chips power to limit the intensity of the actual laser beam diode.
Solder the conductive flag to 1 of these two contacts on the bottom of the lazer set up. Permit the solder neat to get a instant. Solder the other conductive pin to the other make contact with at the base with the laser beam set up. Permit the solder awesome to get a moment.
Unscrew the reflector from the front-end of the flashlight. Force the actual plastic-type material contact lens within the reflector rid of interior of your reflector. Dispose of the plastic material contact lens. Place the reflector on the newspaper.
Eliminate the retaining band from your nose in the light. Position the maintaining wedding ring for the magazine.
Secure the particular oral cavity of the pliers on an fringe of the incandescent lamp assembly, that is today stuffed through the front end of the flashlight. Move your incandescent light assemblage from the front-end from the light.
Unscrew the incandescent light, Dispose of it correctly. Place the incandescent lamp construction on the newspaper.
Piecing together Your Using up Laser beam
Solder no more one of many conductive pin on the middle gap inside the incandescent bulb construction. Permit the solder cool for a instant.
Solder the end of the other conductive green towards the speak to circling the outlet inside the incandescent light bulb construction. Permit the solder great to get a instant.
Put in your incandescent lamp construction into the front-end of the torch. Place the keeping ring about the nose from the torch.
Attach the reflector again on top of the front in the flash light. Implement silicone substance around the inside the reflector to hold the particular incandescent light bulb assembly set up. Let the rubber paste dry out for an hours.
Goal the actual using lazer you earn at the newspapers from your handful of inches aside.
Push the "On" switch on the light. Click your "On" button once again to turn over burning laserlight once the newspaper sets out to smolder. Cover the particular used up pit within the newspapers while using damp fabric to stop your paper via smoldering.
Tips & Warnings
Possess fresh electric batteries available since the laser light will empty your flashlights battery packs rapidly.
Utilizing your burning laserlight within a open public position could get that taken away from the law enforcement.
Never ever aim a laser beam in a individual for the reason that light can damage the retina of the sight.
Adult guidance is completely required, in case you are underage, since the soldering iron is employed to create the actual laser beam.


text:
I tried to take a photo along the way by my sweaty hands failed me. But I did see The Google Streetview Car. So I figure I would just used Google Streetview to show you what I woulda taken a photo of.
HOLY FUCKING SHIT Google Maps spells it one way and the sign in the store spells it another way. The point I was trying to make was that when a sign say U.N. PIECE CLEANERS it only goes further to make it more impossibleer for a guy like me to know how to spell these kinds of words. Maybe I will send Google a correction. Me correcting Google's spelling. What has the world come to?
View Larger Map
Update 9-19 Got this in an email from Google "Thank you for taking time to notify us about an issue with Un Peace Cleaners. We will use your feedback to investigate, verify the correct information and publish any necessary changes.
Thanks for your help,
The Google Maps team"
Yea, I ran almost 23 miles, crossed 6 bridges, through 4 boroughs, countless parks and the only photos I would have take was of a laundry shop. Oh, and I was only annoyed at the billion camera crews blocking my way as I passed the United Nations because we still we still have relative world peace. Yes, for now the wold is still in one piece.


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It's not unheard of for a mid-life crisis to end in the purchase of an ostentatiously expensive automobile like a Ferrari. The car is only half the equation, though. To really splurge, you have to get the matching luxury watch as well. Does your car have a matching watch? I didn't think so.
The Hublot MP-05 LaFerrari is designed to be the timepiece counterpart to the car of the same name. The LaFerrari itself was announced in March with a hybrid V12 engine pumping out nearly 1000 horsepower. The car will set you back $1.3 million, if you can even get one of the 499 limited edition units. The MP-05 watch? That will be even harder to get — Hublot is only making 50 of them. The price for adorning your wrist with a LaFerrari watch is expected to be about $300,000… or more than many new Ferrari models.
The LaFerrari watch is a precision piece of engineering almost as complicated as the car. It was designed by Hublot engineers along side the car. The sapphire crystal facade is sculpted to imitate the lines of the automobile, and the casing is constructed from tough PVD titanium. The movement is powered by 637 individual components — a record for Hublot. Another record, the MP-05 has a 50-day power reserve. No other hand-wound Tourbillon wristwatch has come close.
The watch is wound with a special power drill that spins up a series of 11 barrels arranged down the center of the "face." As the barrels wind down, a cylindrical indicator on the left face counts down the days. The overall design has more than a passing resemblance to a Ferrari engine.
Let's not forget that a watch is supposed to be used for telling time. The MP-05 displays the time on a cylinder off to the right that spins around under the crystal covering.These anodized black aluminum dials are inlaid with SuperLuminova markings, a common nontoxic photoluminescent pigment.
This is a beautiful watch, and an amazing piece of engineering.That $300,000 price is still only an estimate — it could be even more. Hublot is going after a very specific audience, though. People that could buy a $1.3 million car might not mind the price of their matching luxury watch being bumped up at the last minute. With only 50 being made, I'm sure they'll all sell.


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Time for an update! Most of you know I had a follow-up appointment at my Functional Medicine provider's office in Knoxville yesterday. Although she didn't have all of the test results yet, she told me to come in since I have been feeling so bad. I am not a doctor so I am just relaying the information about my own situation to you in the best way that I understand it. I'm a complicated mess!! If you don't want to read all the science-y stuff, that's fine, but I am finding it completely fascinating, and this is what I wanted. Someone to tell me the specific root cause of my issues and how to fix them. Disclaimer: Please do not take any of my musings as advice. Speak to your own healthcare provider about your own issues.
I am happy/not happy to report more diagnoses. Yay! (I can't decide if that's sarcasm or sincerity. In some ways, it's very validating to know that I am NOT crazy and there is REAL EVIDENCE that I am seriously ill. HALLELUJAH!!)
First of all, I definitely have Hypothyroidism. However, I did not have any thyroid antibodies, which just means that it is NOT an autoimmune thyroid disease. That was fairly surprising but she said that since it is not autoimmune, there is a chance I will not have to take the meds for the rest of my life. That's pretty great.
Secondly, my adrenal stress is at a phase 2 (of 3), so not completely shot but getting there. She explained that unless you take care of your adrenals too, a thyroid med is not going to do a whole lot of good. So, she put me on a calming thyroid supplement (my panicked self says, thank goodness!), along with a bio-identical thyroid med, which just means it's natural and non-synthetic. Also, at least according to this article, popular synthetic thyroid meds usually only contain the thyroid hormone T4, while bio-identical thyroid meds usually contain T1, T2, T3 and T4. Since I stopped taking my other thyroid supplements, and the med hasn't kicked in yet, I'm having some very severe panic attacks. Would love you all to be praying me through until this stuff starts working or I lose my mind! If you want to read more about hypothyroidism and anxiety, you can click here and here. Yes, it is more likely for HYPERthyroidism to cause anxiety than HYPOthyroidism, but since I personally know at least two people besides myself who suffer from hypothyroid-related panic attacks, and I have read countless testimonies from others, it is not as uncommon as we think. Leave it to me to get anxiety and actually lose weight with hypothyroidism. But my own provider has a hypothyroid and lost weight with it so, while uncommon, that is not unheard-of either. I encourage you to read Emily Kopek, PA-C's Journey into Functional Medicine. She is my new provider and has a fascinating story.
Third, my SIBO (Small Intestine Bacterial Overgrowth) test was surprisingly negative, meaning I do not have a bacterial overgrowth in my guts. However, I do definitely have some malabsorption issues, which I knew all along, but now it is finally confirmed.
Fourth, I am severely anemic and she couldn't believe no one has ever told me that. It hasn't been too long ago that a doctor told me my iron was too high. I am unsure how it dropped that much that quickly. She did more labs yesterday so she can figure out exactly what to give me to treat the anemia.
Lastly for now, my Homocysteine level is the highest she has ever seen, as in, double the highest it should be. Yay, me! I'm extra-special! Homocysteine? What the heck is that? LifeExtention has a huge amount of useful information on homocysteine if you are interested. From what I understand, a high homocysteine level means that I am not getting enough B vitamins and Folate, which help to get rid of excess homocysteine. This could be due to my malabsorption issues, or a genetic issue I will discuss below. I'm super-happy to read that a reduction of homocysteine often leads to a reduction of migraines and brain fog. I haven't wanted to admit it but lately I've been having more serious brain fog than just the feeling of cotton balls or fog in my head. I've actually been starting to forget where I am going when I'm driving somewhere. Not just the direction I need to turn, but actually where I intended to go when I got in the car! Yikes! A high homocysteine level is also likely the reason I have such trouble detoxifying anything out of my body, and contributes to my extremely high inflammation levels. I never know if the next thing I put into my mouth is going to cause a serious struggle for my body to detox. I can smell someone's perfume or dryer sheets and be sick for a week. I have to make Jason go get our washing soda to make laundry detergent because I cannot go near that aisle in the grocery store. I can be stuck in traffic and smell exhaust and become ill. I LIVE IN CONSTANT FEAR.
So, how did my homocysteine level get so high? The answer is potentially a combination of malabsorption and a genetic mutation that she thinks I very likely have called MTHFR. Did I just cuss you out? Nope, it's a real thing. MTHFR produces an enzyme that helps your body use B9, so if I'm not getting enough B9, my body can't clear out the excess homocysteine. How's that for a domino effect? Shew, my head is spinning with all this info! If you're still with me, you are my amazing health warriors!
I had suspected that I have the MTHFR mutation in the past, but wasn't sure exactly how you get a doctor to look into it without having multiple miscarriages (the mutation makes you highly susceptible for miscarriages). Now, I am completely fascinated to learn that it could explain so many things from my past that have always seemed so odd to me. Random example – I have always felt sick drinking any amount of alcohol, which is why I've hardly drank anything in my life. (That, and the fact that the taste is horrendous! I shall never understand you alcohol-drinkers, but excuse my rabbit trail). People with MTHFR often have extra trouble detoxifying alcohol. It's a pretty big blessing that I've always gotten sick with just one drink of alcohol, because the nightmare of the last few years probably would have made alcohol look pretty enticing! MTHFR can also be a major cause of my anxiety as well. Double-whammy! I learned a lot of this information from Wellness Mama, and this site also has a video about MTHFR and Thyroid Disorders that I'm looking forward to watching when my head stops spinning a bit. INFORMATION OVERLOAD!
The enzyme produced by MTHFR is also needed to produce glutathione, which, according to this article, is The Mother Of All Antioxidants. This is a big reason for the difficulty detoxifying. Therefore, a huge part of my treatment will be boosting my poor body's lack of this precious antioxidant.
In short, I very likely have the MTHFR gene mutation, which causes a decreased ability to detoxify the body and absorb certain nutrients. Therefore, I will be receiving IV infusions of Glutathione, which is a high-powered antioxidant that will act as 'fly paper', collecting free radicals and other toxins to help detoxify my body. I have my first infusion on Tuesday and I am super-nervous but super-excited! It scares me because they infuse Zofran first due to reported nausea in most patients and I'm nauseous all the time anyway. Also, I do not do well with needles and the infusion takes an hour and a half. They will give me a half-dose on Tuesday to see how I do, wait a week, and then do a full dose. Then, I will likely have the infusions quarterly along with a possible infusions of Vitamins B and C.
What I am assuming from the above information is that, when I have these high-powered antioxidant treatments, my body will be able to start detoxifying the bad stuff again. My poor guts will finally be able to start to heal, along with the proper diet. Maybe one day, just maybe, I will not have to live in so much fear. While I will probably always get sick with certain things, I may not have to feel like I am dying anymore. I will finally be as close to FREE as possible. That is the hope I am taking from all of this, and I am so excited!
Once my other test comes back, we will start working on my diet. I told her I've changed my diet so many times, I honestly have no idea how to eat anymore. Thankfully, her goal is to get me feeling better enough to add as much food back in as possible except gluten. I will never knowingly put another shred of gluten into my body. With an autoimmune disease and a severe intolerance, it is just too risky.
Well, that was a whole bunch of complicated stuff that only some of you may have wanted to know! But, it definitely helped me understand it better by researching and writing it all down. Throughout this journey, I have learned that I HAVE TO BE THE EXPERT IN MY OWN BODY. NO ONE ELSE WILL DO IT FOR ME!!! So, that is my tidbit of advice to you today. Study, learn, and DO NOT GIVE UP!!
I will leave you with a passage I came across today that gave me some encouragement.
"In repentance and rest is your salvation, in quietness and trust is your strength... Although the Lord gives you the bread of adversity and the water of affliction, your teachers will be hidden no more; with your own eyes you will see them. Whether you turn to the right or to the left, your ears will hear a voice behind you, saying, 'This is the way; walk in it.'" - Isaiah 30:15,20-21(NIV)
What I took from this is TRUST. God's got this. He's using the right people at the right time to teach me the right way. I covet your prayers that this is truly the final answer, but HIS will be done.
Thank you, my loves! Now, let's all go take a brain-break! Here's a pretty picture to get you started!


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Claudia Carrillo
CLAUDIA CARRILLO, RGN, Lic.Ac., DipBioregM, DipHTox, DipHMesoT, MBRCP
Claudia Carrillo is a Biomedical Practitioner providing a range of complementary therapies and techniques, aimed at restoring good health and wellbeing. More about bioregulatory medicine...
She is also the owner and manager of the Natural Health & Beauty Clinic is a registered nurse with 20 years experiences in various fields. Her interest in natural healing practices led her to study acupuncture at the British Academy of Western Medical Acupuncture (BAWMA) in Liverpool during her college degree in Complementary Therapies at UCLAN. With her continued desire for further knowledge she completed Diplomas in 2009 in Homotoxicology at the International Academy for Homotoxicology & Integrated Medicine (IAH) and Bioregulatory Medicine in 2011 at the Biomedic Centre in London.
Claudia qualified in advanced aesthetic procedures with the IVHB institute in Nottingham. Combining elements of conventional and aesthetic medicine with complex homeopathy and nutrition and other complementary therapies is known as Anti-aging Bioregulatory Medicine. This enables the experienced practitioner to take a holistic approach to identify and deal with underlying causes of illnesses while making the client feel and look younger and healthier. This approach does not intend to interfere or replace existing conventional medical treatment, but rather to integrate with it.
Brief History
Born in 1973 in a town called Erfurt situated within the former East part of Germany, I received my school education with a very different view of the world then most people of my age. My professional education took place within two different health and governmental systems which enhanced my ability to look at my surrounded environment critically and objectively.
After five years of working in Cardiology and Internal Medicine Intensive Care, it was time for travelling and gaining professional experiences in various nursing fields in different countries around the globe. I have been fortunate to work for the NHS in the West Midlands, did agency nursing and care home nursing in Northern Ireland and also been nursing for intensive care requiring patients as well as patients in need of general medicine nursing care in Belize, Central America.
After participating as a volunteer for environmental improvement projects in Belize, I have been offered to become a faculty member of St. Luke's University, School of Medicine, Belize. I had the responsibility to develop a community medicine program for international students on one side and to assist the development of primary care provision and prevention programs within the south east of the country Belize. My work load included for example; HIV testing and counseling, pesticide testing for banana and citrus fruit farmers and the development of a health education program for the primary school curriculum along side being a team member of a very busy primary care centre with emergency night cover.
On return to Europe, I had decided to take my professional development further to be able to reach out to patients and deliver the best possible nursing care and a natural approach to health service provision to the highest quality achievable. Therefore, I found the possibility of becoming a practitioner of Complementary Medicine very attractive. Having worked within the allopathic way of medicine, promoted preventative medicine in a developing country and my steadily growing interest and belief manifestation towards complementary medicine made the decision very easy.
Over the past 6 years I studied Aromatherapy, Remedial Massage, Baby & Pregnancy Massage, Homotoxicology, Reiki, Hopi Ear Candling, Bioregulatory Medicine and Aesthetic Procedures. My professional background has been proven to be very useful and led me to undertake a Western Acupuncture training course with the B.A.W.M.A. I have registered my own business providing high quality nursing care which includes all therapies already learned and able to practice as well as running the newly opened clinic where clients can receive high quality treatments in a friendly and warm atmosphere since September 2009.
I am building a concrete holistic approach of treating medical/care problems with the great assistance of my steady growing knowledge and experiences.
Yours, Claudia


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Being on the Dean's List can have it's privileges and you'll see what we mean in this hot new bareback threeway from Corbin Fisher starring Hunter, Marc, and Zeb! As the scene begins, Hunter is making out with recent Dean's List addition Marc. Zeb (also a new Dean's List addition) walks in on them and decides to join the fray. They don't even discuss it, because apparently when you're on the Dean's List you can fuck whoever you want! This is actually one of the hottest Corbin Fisher threeways that we've seen in quite a while, mainly because all three of the guys are equally into each other. After some threeway cock sucking, Hunter Fucks Marc. Then Zeb fucks Marc. Then Marc fucks Hunter. Then Zeb fucks Hunter. Then Marc fucks Zeb. Then
Are you confused yet? If so, don't worry about it. It's a lot like a game of musical chairs, but with bareback cocks instead of chairs. In the end, Marc fucks Zeb until he pulls out and cums all over his chest. Then Hunter uses Marc's cum as lube and fucks Zeb until he's ready to cum into Marc's mouth. Hunter then fucks Zeb and cums, followed by Zeb. This video may leave you feeling a bit disoriented, but in a good way.
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Gay IM Live (Live Web Cams)
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You Love Jack


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August 23, 2016
Mr. Andy Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1628-P
P.O. Box 8010
Baltimore, Maryland 21244-8010
Re: CMS-1651-P—CMS Proposed Updates to Policies and Payment Rates for ESRD PPS, QIP, Coverage and Payment for Acute Kidney Injury, DMEPOS Competitive Bidding Program and Fee Schedule, and Comprehensive ESRD Care Model
Dear Acting Administrator Slavitt:
On behalf of Home Dialyzors United (HDU), we are pleased to offer comments on the proposals to update the Calendar Year (CY) 2017 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) and the ESRD Quality Incentive Program (QIP), which was published in the June 30 Federal Register, vol. 81, no. 126, pages 42802-42880.
HDU, a 501(c)(3) non-profit organization, is the only dialysis patient group dedicated to promoting home dialysis. Our mission is to inspire, inform, and advocate for an extraordinary quality of life for the home dialyzor community. We know from personal experience that, with the right dialysis treatment, many patients with ESRD (and their families and care partners) can lead a normal life, enjoying family and friends, and pursuing employment, education, volunteer, and leisure activities.
We also know that studies have repeatedly shown that patients who dialyze at home have better treatment outcomes.[1] See Appendix A – Improving Patient Access to Home Dialysis (HDU, May 2016).
We also recognize that there is no one-size-fits-all mode of dialysis, and are strongly committed to ensuring that patients are fully informed as to their treatment options and how each option fits their treatment and life goals. However, we believe that a significant number of the nearly 90% of dialysis patients still receiving traditional in-center treatments three to four hours a day, three times a week, could benefit from switching to home dialysis modalities. Traditional in-center treatment itself can be disabling, stressing the heart and other vital organs and may contribute to premature death. In too many cases, patients who would like to continue working, must undergo their in-center treatments during working hours. Even if they are able to find work that accommodates their treatment schedule, many are too exhausted from their dialysis session to work. In short, too many patients are still living to dialyze, rather than dialyzing to live.
It is fortuitous that the comment period for the proposed rule for the ESRD PPS and QIP coincides with the 2016 Olympics, because for patients and caregivers dealing with ESRD (or preferably chronic kidney failure) often requires an Olympian effort. On August 15, thousands of individual athletes from around the world converged on Rio de Janeiro to go for the Gold. They differ in the sports they pursue, the skills they bring, and the hurdles they have overcome to get to Rio.
What they have in common is that they are educated about the requirements of their events, engaged in preparing for their events, and empowered to pursue their goals through access to the best coaches, training, and equipment available.
For many kidney patients, going for the Gold in treatment means getting a transplant, and there are currently about 115,000 people waiting for this opportunity. For others, going for the Gold means having access to a treatment mode that will have the least adverse impact on their on their overall health and enjoyment of life. For all, however, the keys to winning the Gold are: (a) education about their illness and treatment options; (b) engagement as full partners with their doctors and dialysis providers in every aspect of their care; and (c) being empowered to pursue their treatment and life goals through access to the best care. See Appendix B – ESRD Treatment and Patient-Centered Care (HDU, Aug. 2016).
For a lucky few, dealing with ESRD proves to be a sprint from kidney failure to transplant, but most patients with ESRD are, or will become, long-distance hurdlers. The two biggest hurdles have been and continue to be:
- Lack of accurate, meaningful information about all of their treatment options. The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 requires that patients be educated about all treatment modalities. However, many dialysis facilities still fail to provide complete, unbiased information to their patients. For patients who could potentially benefit from home hemodialysis (HHD), including nocturnal HHD, this problem is particularly acute. Unfortunately the problem may be exacerbated by the release in the past year of the Arbor Research Collaborative for Health's (Arbor) decision tool for dialysis patients, http://choosingdialysis.org/. Funded by a grant from the Patient-Centered Outcomes Research Institute, the tool only provides information about traditional in-center and home peritoneal dialysis (PD). Efforts by HDU and others to work with Arbor to expand the scope of the tool to include HHD were unsuccessful. HDU notes that a much more comprehensive and easy to use tool, "My Dialysis, My Choice," developed by the Medical Education Institute, is available online at mydialysischoice.org.
- Lack of access to centers offering all dialysis modalities. Although there are dialysis centers throughout the United States, very few offer all modalities, and whether a patient has access to a particular modality is largely dependent on where the patient lives. In fact, only 24 percent of dialysis centers are certified to provide home hemodialysis training, and even fewer are actively engaged in training.
On November 18, 2013, CMS published it Quality Strategy for 2013 – Beyond ("Quality Strategy"). The Quality Strategy, which was required by the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), establishes a number of goals for improving the quality of health care and reducing costs. These include the following, which have a direct bearing on how patients diagnosed with ESRD receive their dialysis treatments:
- Making care safer by reducing harm caused in the delivery of care.
- Strengthening person and family engagement as partners in care, keeping patient and family preferences central in decision processes and implementation.
- Promoting effective communication and coordination of care, in part by increasing patient self-management of health issues.
- Promoting effective prevention and treatment of chronic disease, to reduce the rates of mortality for leading causes of death.
HDU strongly encourages CMS to develop a policy that "Dialysis follows the patient," across all inpatient and residential settings receiving Medicare or Medicaid payments. While we recognize that such a policy is beyond the scope of the proposed rule, HDU believes this policy is critical to fulfilling all four goals in the Quality Strategy.
Under current practice, when a patient on dialysis is admitted to a hospital, skilled nursing facility, or other inpatient or residential setting, the facility determines what kind of dialysis the patient will receive and on what schedule.
For patients who have been dialyzing at home successfully, a change in their dialysis treatments can have significant adverse effects on their recovery and overall health. For adult patients who wish to continue the type of treatment and schedule they have followed at home, being required to adhere to a fixed, one-size-fits-all regimen in the inpatient or residential setting can undermine the relationships between the patients and their care teams. For pediatric patients, many of whom receive PD at home, administered by a parent or familiar caregiver, the change in routine can exacerbate the trauma of hospitalization.
HDU notes that CMS has published a proposed rule, Reform Requirements for Long-Term Care Facilities, CMS-3260-P, which would require these facilities to offer dialysis services "in accordance with professional standards of practice and the residents' choices." 80 Federal Register 42167, 42199 (July 16, 2015). HDU strongly urges CMS to finalize this language as soon as possible, and to adopt similar language in the Conditions of Participation or Conditions of Coverage for other facilities.
- Proposed Payment for Excess Treatments
Under current regulations, CMS limits payment for HD to three treatments a week, unless the Medicare Administrative Contractor (MAC) determines in individual circumstances that additional treatments are medically necessary. The MACs pay for medically necessary excess treatments at the full ESRD rate. The proposed rule observes that dialysis facilities are increasingly offering HD treatments more frequently than three times per week without demonstrating the medical necessity of the more frequent treatments, and that there is variation among the MACs as to whether to pay for these additional treatments. CMS is now proposing to pay for excess treatments that lack medical necessity justification, based on a rate equivalent to the weekly payment for standard treatments.
HDU strongly believes that in light of the significant medical benefits to patients of more frequent dialysis, CMS should not distinguish between excess treatments that are deemed "medically necessary" and those that are not.
Studies consistently find that patients who undergo traditional dialysis have worse clinical outcomes than those who have slower, more frequent, and gentler treatment regimens. The decision about the frequency of dialysis should be left to the patient and the patient's treating physician, in light of the patient's total circumstances and fully informed treatment choices.
- Add-on Payment for Home Dialysis Training
Because HDU has raised repeatedly raised concerns about the adequacy of the training add-on payment, we are very pleased that CMS is proposing to increase the add-on payment for home and self-dialysis training the current $50.16 to $95.57. In discussing the proposal to increase the home dialysis training add-on payment, the proposed rule acknowledges that currently available data are inadequate to determine actual training costs, and that the proposed payment increase is intended to serve as a proxy until more data are available. As stated on page 42815 of the proposed rule:
Based on our analysis of ESRD facility claims and cost reports… , we are pursuing changes which we believe will enable us to use the data to set the home dialysis training add-on payment adjustment in the future. Although we have already begun the process to implement changes to the cost report and claims, it will take several years for the changes to be implemented and yield data we could use as the basis for a change in the home training add-on payment adjustment. However, each year since implementation of the ESRD PPS in 2011, we have received public comments about the inadequacy of the home dialysis training add-on payment adjustment. In addition, we are committed to ensuring that all beneficiaries who are appropriate candidates for home dialysis have access to these treatment options, which generally improve beneficiaries' quality of life. For these reasons, we looked for a reasonable proxy for the home training add-on so that we could provide additional payments to support home dialysis in the interim until we are able to make changes to the home dialysis training add-on based on claim and cost report data.
HDU applauds CMS's commitment to improving the data collected on claims and cost reports, and looks forward to working with CMS in this process. However, we believe that the proposed proxy amount is still inadequate to cover the true costs to facilities for HHD training for the reasons set out below.
Group Training Sessions for Home Dialysis:
CMS says on page 42813 of the proposed rule, second column:
Home HD patients also acknowledged that the training they received took place in a group setting, indicating perhaps that the amount of hands-on RN training time gradually decreased over the course of training, so that by the end of training, the patient was able to perform home dialysis independently.
In fact, the ESRD Conditions of Coverage appear to contemplate that training, whether for PD or HHD, will involve one nurse training one patient (and a care partner) at a time, and that the nurse will be present, observing and available to assist, throughout the duration of a treatment that includes training. The language of the ESRD Conditions for Coverage specify the requirements for home dialysis training as follows:
- 494.100 Condition: Care at home.
- Standard: Training. The interdisciplinary team must oversee training of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis (as defined in §494.10) and when the home dialysis caregiver or home dialysis modality changes. The training must—
(1) Be provided by a dialysis facility that is approved to provide home dialysis services;
(2) Be conducted by a registered nurse who meets the requirements of §494.140(b)(2); and
(3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas:
(i) The nature and management of ESRD.
(ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician's prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient's plan of care.
(iii) How to detect, report, and manage potential dialysis complications, including water treatment problems.
(iv) Availability of support resources and how to access and use resources.
(v) How to self-monitor health status and record and report health status information.
(vi) How to handle medical and non-medical emergencies.
(vii) Infection control precautions.
(viii) Proper waste storage and disposal procedures. [Emphasis added.]
Although patients often receive pre-dialysis education in group settings, we know of no one who has been trained to perform HHD in a group setting in recent years. If CMS has received comments to the contrary, such instances should be extremely rare in light of the Conditions of Participation and should not affect the calculation of the costs of HHD training.
Payment Incentives for Peritoneal Dialysis v. Home Hemodialysis:
As CMS recognized, it takes longer and costs more to train a patient to do HHD than to do PD. Nonetheless, the add-on payment adjustment is the same per treatment. According to the proposed rule (page 42813, second column), CMS made this decision to "incentivize the use of PD when medically appropriate." It should be noted that dialysis facilities often train patients to perform PD in the first 120 days of dialysis, and, therefore, their centers receive the new patient payment adjustment in lieu of other add-on payments. Patients who choose HHD, on the other hand, have usually been on either in-center or doing PD, and therefore, the only incentive for the center to offer home dialysis training is the add-on payment.
HDU urges CMS to set payment rates for home dialysis training based on the actual costs of the training for each mode of home dialysis, rather than using the payment rates to create incentives favoring one modality over another.
Assumptions Underlying Calculation of the Home Training Add-on Payment Rate
The proposed rule states on page 42813:
It has never been our intention that the training add-on payment adjustment would reimburse a facility for all of its costs associated with home dialysis training treatments. Rather, for each home dialysis training treatment, Medicare pays the ESRD PPS base rate, all applicable case-mix and facility-level adjustments, and outlier payments plus a training add-on payment of $50.16 [for 2016] to account for RN time devoted to training. The home dialysis training add-on payment provides ESRD facilities with payment in addition to the ESRD PPS payment amount.. Therefore, the ESRD PPS payment amount plus the $50.16 training add-on payment should be considered the Medicare payment for each home dialysis training treatment and not the home dialysis training add-on payment alone.
We believe that the training add-on payment should reflect the full costs to the facility of providing home dialysis training. Moreover, we disagree with CMS's policy to pay the same rate for both PD and HHD training, since this may create a payment incentive to choose one modality over another. Nonetheless, accepting CMS's rationale for considering payment for home dialysis training as including the facility's adjusted base rate plus the training add-on payment, we believe the methodology for calculating this contains several errors that, if corrected, would create a more accurate proxy.
First of all, the 67 percent/33 percent weighting used in the calculation, appears to assume that all PD training treatments receive the dialysis add on payments, when, in fact, most are paid under the new patient adjustment. If we assume, for illustration purposes, that 57 percent of PD training is paid under the new patient adjustment, and only 10 percent is paid with the training add-on payment, the calculation changes as follows:
.10 x 2 hours for PD = 0.2 hours + .90 x 4 hours for HHD = 3.6 hours
Weighted total hours 3.8 hours x 35.93 = $136.53, an increase of $86.37 over the current payment rate
Second, CMS has based its calculation on the current hourly rate for a registered nurse of $35.93, using Bureau of Labor Statistics data for 2015, adjusted for inflation to 2017 dollars. However, the hourly cost of an employee to an employer is higher than the wage rate, and includes such items as fringe benefits, employer taxes, etc.
HDU strongly urges CMS to recalculate the proxy to take into account (1) only those PD training sessions that actually receive the training add-on payment rather than those that are paid under the new patient adjustment, and (2) the fully loaded costs to the employer for an hour of registered nursing time.
III. QIP – Application to Home Dialysis Patients
When Congress mandated the creation of the ESRD PPS and QIP, it intended to achieve the twin goals of lowering costs and improving quality of treatment. HDU continues to urge CMS to include more measures that are important to patients in the QIP – that is, to raise the standard for ESRD care from adequate dialysis to optimal dialysis, based on the patient's treatment and life goals.
Although HDU cautions that as the number of measures in the QIP increases, the impact of any one measure is diluted, HDU supports the pain assessment and depression screening reporting measures as steps toward patient-centered measures. However, we strongly emphasize that these measures need to be further developed to ensure that the facility assesses the psychosocial and quality of life issues that may contribute to the patient's depression or pain. In addition, we believe the measure should ensure that appropriate follow-up steps are taken to help relieve pain and depression. Because HHD has been shown to improve patient scores in these areas, it is critical that follow-up include assessing the patient's interest in HHD and assisting the patient with the transition to HHD if that is the patient's wish.
However, HDU continues to be concerned that using the CAHPS® In-Center Hemodialysis Survey as the basis for a measure for patient satisfaction ignores the experiences of home dialysis patients. Patients who are dialyzing at home still see a nephrologist and still interact with the center at least once a month. Therefore, most of the questions in the In-Center Hemodialysis Survey – such as those about the patient's experience with the nephrologist and with dialysis center staff — are equally applicable to home dialyzors.
While surveys like the CAHPS® In-Center Hemodialysis Survey are designed to measure the patient's satisfaction with the quality of treatment, we continue to believe that CMS should adopt a measure that addresses the larger question of the patient's goals for treatment, and assesses how well the dialysis care supports the achievement of those goals. There have been numerous articles discussing the types of measures that would foster better, patient-centered care. These measures would give greater weight to the patient experience and engagement, to clinical care coordination, to the assessment and alleviation of symptoms of ESRD, and to helping patients with poor prognoses choose the care that best meets their needs. For a more thorough discussion, see Moss and Davison, How the ESRD Quality Incentive Program Could Potentially Improve Quality of Life for Patients on Dialysis, www.cjasn.org, Vol. 10, pp. 888-893, May 2015.
Finally, HDU again strongly urges CMS to restore a measure establishing a minimal standard for anemia management. In the first QIP, centers were measured on how well they kept a patient's hemoglobin within specified ranges. In subsequent years, the QIP looked only at whether a patient was being over-treated, but not whether he or she is being under-treated. We are particularly concerned that in the month between visits to the center, a patient's anemia can progress from an acceptable level under the QIP, to a level that is disabling. The QIP should ensure that patients dialyzing at home are given appropriate anemia treatment.
We continue to believe that patients and care partners must have the opportunity to be engaged in the process of developing ESRD regulations, including establishing new quality measures that are truly meaningful to their quality of life, if the ESRD PPS and QIP are to achieve the twin goals of reducing costs and improving care.
We suggest that this engagement begin early in the rulemaking cycle to help shape the proposed rule, rather than waiting to submit comments after formal proposals have been published in the Federal Register. We believe that a less formal interaction, similar to what occurs at Kidney Health Initiative (KHI) meetings would prove fruitful for all sides. The KHI is a successful public-private partnership that encourages and facilitates patient and care partner involvement in exploring what kinds of kidney research would make the greatest difference for kidney patients. At KHI meetings, we have seen patients, government officials, and representatives of industry engaging in lively, candid, and mutually enlightening conversations. We were especially pleased, incidentally, to see that CMS representatives were present and active participants in the most recent KHI meeting, and hope they will continue to attend.
We appreciate the opportunity to comment on the ESRD and QIP proposed rules. We believe that making it possible for more patients to dialyze at home, either using PD or HHD, promotes patient engagement and offers a better quality of life. We also believe that although there may be a cost to increasing the HHD payment rate, it will be more than offset by better care, including reducing the need for physician, hospital, and other health care services, and allowing patients to thrive with fewer medications. Finally, we believe that with access to better kidney care, many more patients would choose to continue working and would be able to do so.
We look forward to working closely with CMS in the future to develop payment rates and quality incentives that will improve the ESRD patient's experience of care while on dialysis.
Denise Eilers, BSN, RN, President (Former Care Partner)
Nieltje Gedney, Vice President (Home Dialyzor)
Pat Colongione, Treasurer (Former Care Partner)
Vanessa Evans, Secretary (Home Dialyzor)
Ellen Griffith Cohen, J.D., (HDU Advisory Board, Living Donor Transplant Recipient)
APPENDIX A – Improving Patient Access to Home Dialysis (HDU, May 2016)
APPENDIX B – ESRD Treatment and Patient-Centered Care (HDU, Aug. 2016)
Numerous studies have shown that patients with End-Stage Renal Disease (ESRD) who dialyze at home, using either peritoneal dialysis (PD) or home hemodialysis (HHD) have a much better quality of life and excellent treatment outcomes, including increased survival rates and fewer hospitalizations. For most patients with ESRD, dialysis is the primary option when renal replacement therapy (RRT) is needed, and the overwhelming majority of these patients undergo dialysis in outpatient dialysis centers. Few of these centers offer home dialysis, and of those that do, most only offer PD. In fact, only 2 percent of dialyzors in the U.S. currently use HHD.
Home Dialyzors United (HDU) is working to improve access to home dialysis for all patients who wish to use this method of RRT, to promote unbiased education about all modality choices (as required by statute), and to ensure that efforts to promote the quality of dialysis treatment focus on improving the patient's experience of care, treatment outcomes, and ability to lead a normal life.
Benefits of Home Dialysis
Home dialysis puts individuals with ESRD (and their families or care partners) in control of their treatment decisions. Home dialyzors are engaged in actively managing their disease rather than passively receiving medical services. Home dialyzors have flexibility in determining when and how to dialyze, more freedom to spend with family and friends, and more energy to pursue their interests, whether those include working, attending school, volunteering, or engaging in recreational activities and travel.
From a purely physiological standpoint, home dialysis is clearly superior. The great majority of individuals with ESRD receive in-center treatments, three times a week for between three and four hours per treatment, or approximately nine to 12 hours per week. By contrast, and with the recent approval of nocturnal dialysis, it is now possible to dialyze for longer periods at a slower, gentler pace, more closely approximating natural kidney function. Frequent, slower home dialysis is also less stressful on the patient's heart, lowering the risk of premature death, and increasing the likelihood of survival to transplant, if that is the patient's treatment goal. In addition, home dialyzors require fewer medications and fewer hospital services. Finally, although there are upfront costs to training a patient to dialyze at home, once the patient has been trained, the costs per treatment are lower.
Barriers to Increasing Use of Home Dialysis
Lack of Information about Home Therapies
Although the Social Security Act specifies that Congress intends for any patient who is a suitable candidate for home dialysis to be so treated, and Medicare requires centers to educate patients about all treatment options, too many patients are unaware that they can dialyze at home. Efforts to improve patient awareness of treatment choices too often ignore HHD as a treatment option. According to the most recent information:
- Only 12% of patients report being educated about HHD.
- Only 24% of centers are certified to offer home hemodialysis (and not all centers that are certified to offer HHD actually do so.). This means that access to HHD may depend on such arbitrary factors as where the patient lives.
- As a result, fewer than 2% of patients with ESRD are currently doing HHD, although many nephrologists believe that a much higher percentage of patients would be good candidates for HHD and, according to surveys of nephrologists, most would choose home dialysis for themselves or family members.
Inadequate Reimbursement for Home Training:
Although CMS has increased the payment to centers to train patients for home dialysis to $50.16 from the original $33.44 per training session, the payment amount is still not adequate to pay for the typical 4-5 hours per day, 3-4 week training typically needed for HHD, and thus, provides a disincentive for centers to offer HHD. Moreover, CMS has stated that a portion of home dialysis training costs was taken out of the bundled payment to create a separate payment for home dialysis training, HDU does not understand why any payment for home dialysis training should be included in the bundle and received by facilities that do not offer this training. In the short run, the payment for HHD training should be increased; in the long run, we would be happy to work with CMS on other potential training and payment models.
Lack of Access in Rural Areas to Home Dialysis Modalities
Rural areas are traditionally underserved, and, according to the Medicare Payment Advisory Commission's most recent report, the number of rural centers is decreasing. Recent advances in telemedicine will help this underserved population. In the 2016 Physician Fee Schedule final rule, CMS created 12 new codes for physicians to use to bill for telemedicine visits to home dialysis patients. HDU commends this action. However, despite comments urging CMS to allow nephrologists to bill the new Chronic Care Management Codes for coordinating services to ESRD patients, the final rule continues to exclude nephrologists from billing these codes, leaving dialysis patients who have multiple chronic conditions to coordinate their own care. The lack of care coordination for patients with multiple chronic conditions has been a major issue for a lot of dialyzors, including home dialyzors.
The GAO Report:
The Government Accountability Office (GAO) Report, Medicare Payment Refinements Could Promote Increased Use of Home Dialysis, GAO-16-125, released in October 2015, acknowledges that home hemodialysis offers patients a better quality of life and improvements in physical and mental health. The report identifies specific statutory provisions and regulatory decisions in the physician payment policies under Medicare's Physician Fee Schedule, and facility payment policies under the End-Stage Renal Disease Prospective Payment System, that create incentives to use in-center rather than home dialysis modalities.
HDU was pleased to be the only patient organization invited to offer comment and review the draft document. The GAO recommendations include increasing the accuracy of cost report data, especially for home hemodialysis. The report also acknowledges the shortcomings of the Kidney Disease Education Benefit. HDU encourages support for education far earlier in the disease and appropriate reimbursement for both early education providers and for home dialysis training
The Food and Drug Administration's Partner Requirement:
The FDA clearances for dialysis machines to be used in the home require that the patient have a care partner who can assist in emergencies. This requirement prevents people who live alone (or whose care partner is temporarily absent) from doing HHD, and may place an undue burden on the family unit. HDU believes that a dialyzor should be able to choose to perform HHD with or without a care partner, as their training and comfort level dictates. The center should discuss with the patient the risks of dialyzing alone, assess the dialyzor's ability to perform his or her own treatments without assistance, and discuss alternate safety precautions available to the patient if the patient chooses to forego having a care partner.
Patient Centric Quality Measures:
HDU is also concerned about the quality measures used to evaluate care given to chronic kidney failure patients, and to adjust payments to individual dialysis centers. While biochemical data are important in the clinical management of ESRD, they have little relevance to promoting the quality of life for patients and their families. HDU believes that the goal of treatment for ESRD, like the goal of treatment for other medical conditions, should be to provide optimal care, not just adequate dialysis. A recent study by Urquhart-Secord et al in the AJKD cited the following: Patient priorities for outcomes emphasize quality of life over outcomes that are frequently reported in hemodialysis trials: biochemical markers, mortality, and adverse events. In view of this mismatch, researchers should consider interventions that are likely to improve patients' overall well-being and measure and report patient-important outcomes.
Home Dialyzors United (HDU), a 501(c)(3) non-profit organization, is the only dialysis patient group dedicated to home dialysis. We believe that patients with end-stage renal disease (ESRD) and their families and care partners can lead a normal life, enjoying family and friends and pursuing employment, education, volunteer, and leisure activities. We further believe that Congress, the Centers for Medicare & Medicaid Services (CMS), which pays the largest share of the costs of dialysis treatment, and the Food and Drug Administration (FDA), which regulates devices used in dialysis, all have a role to play in eliminating the barriers that prevent more individuals with ESRD from getting optimal care.
Individuals diagnosed with ESRD have a range of treatment choices from conservative care without dialysis, to one of several dialysis modalities, to transplant. However, even when transplant is the goal, most patients spend many years on dialysis. There are currently 115,000 patients on the kidney waiting list, and, while the incidence of ESRD is growing, the supply of usable kidneys is declining.
When dialysis is the choice, either pending a transplant or long-term, there are, in theory, a number of treatment modalities, including:
- Traditional in-center (i.e., 3 days a week, 3-4 hours a day) hemodialysis (HD)
- Nocturnal in-center HD
- Continuous ambulatory peritoneal dialysis (CAPD)
- Continuous cycler-assisted peritoneal dialysis (CCPD)
- Short daily home HD (HHD)
- Nocturnal HHD
The Medicare law expressly favors home dialysis and transplantation as treatment options for individuals with ESRD. Specifically, the statute states:
(6) It is the intent of the Congress that the maximum practical number of patients who are medically, socially, and psychologically suitable candidates for home dialysis or transplantation should be so treated. The Secretary shall consult with appropriate professional and network organizations and consider available evidence relating to developments in research, treatment methods, and technology for home dialysis and transplantation. SSA Section 1881(c)(1)(A)(i)(6)
However, dialysis centers incur different costs for each modality, while Medicare payment rates are based on a single traditional in-center HD treatment. Payment for PD, which is performed daily, is paid at the HD equivalent amount. As a result, many dialysis centers (and the nephrologists who have financial interests in them), do not offer all treatment modalities. Those that offer several modalities often steer patients to their lower-cost (and higher profit) modalities.
In fact, only 24 percent of dialysis centers are certified to provide HHD training, and the data show that even fewer are actively engaged in training. Whether a patient has access to a particular modality is largely dependent on where the patient lives. The impact of location on access is illustrated in the table below, based on information from Medicare's Dialysis Compare.
|Bethesda, MD
|< 10 miles
|< 25 miles
|< 50 miles
|Kearneysville, WV
|< 10 miles
|< 25 miles
|< 50 miles
|Davenport, IA
|< 10 miles
|< 25 miles
|< 50 miles
The Medicare law and Medicare's Conditions for Coverage for dialysis centers require centers to provide patients with information about all dialysis modalities, including those that the center does not offer:
- 494.70 Condition: Patients' rights.
The dialysis facility must inform patients (or their representatives) of their rights (including their privacy rights) and responsibilities when they begin their treatment and must protect and provide for the exercise of those rights.
(a) Standard: Patients' rights. The patient has the right to –
(1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD;
(2) Receive all information in a way that he or she can understand;
…(5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research;
….(7) Be informed about all treatment modalities and settings, including but not limited to, transplantation, home dialysis modalities (home hemodialysis, intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, continuous cycling peritoneal dialysis), and in-facility hemodialysis. The patient has the right to receive resource information for dialysis modalities not offered by the facility, including information about alternative scheduling options for working patients;
However, in a survey of HDU members, a significant number of respondents said that their centers:
- Did not tell them of all treatment options (39%).
- Did not take into account their interests and goals (such as returning to work, pursuing education, and resuming normal daily activities) (38%).
- Did not give them information about where they could get home dialysis training, when the patient's center did not offer this (41%).
- Did not make a plan for home dialysis training when that was the patient's expressed choice (28%)
- Did not present modality options to them in a way that was unbiased and addressed their personal needs (59%).
For patients, choosing the right dialysis modality for them in light of all of their circumstances and values can be complicated. There are a number of decision aids. For example, the Medical Education Institute, a private nonprofit organization, has developed a decision aid, available at www.mydialysischoice.org that encompasses all dialysis modalities and evaluates them in light of their impact on a wide range of activities and interests – working, travel, pet ownership, dietary restrictions, medications, costs, etc. This decision aid allows patients to choose a modality that will most closely align with their values and priorities.
One of the common misconceptions about individuals with ESRD is that their disease is so disabling that they cannot continue working at their current employment, and must either find alternate employment that is less demanding or stop working entirely and rely on disability benefits.
Although it is true that individuals with ESRD may have disabilities, it does not follow that they are actually disabled. Unfortunately, it is too often the treatment modality that is disabling. First of all, it is difficult to work during normal business hours if the individual has to go to in-center treatment three times a week. And often the traditional treatment is sufficiently intense that the post-treatment recovery may take hours. In fact, the Social Security Administration recognizes ESRD requiring frequent dialysis as a possible qualifying condition for Social Security Disability Insurance (SSDI).
In addition, there are a number of complications that are associated with hemodialysis and that may impede the person's ability to work. Some of these are short-term, occurring in connection with a dialysis treatment. These include:
- Low blood pressure (hypotension), which may be accompanied by shortness of breath, abdominal cramps, muscle cramps, nausea or vomiting.
- Muscle cramps.
- Physical exhaustion, preventing a return to normal activities for hours after treatment.
Others are chronic, and may result in the need for costly medical services that are paid by Medicare outside the ESRD PPS. These include:
- Heart failure or pulmonary edema, including high blood pressure (hypertension).
- Severe itching.
- Sleep problems.
- Mineral and bone disorder.
For individuals receiving traditional in-center dialysis, these complications are managed through restrictions on diet and fluid intake, and medication. For individuals on home dialysis, which is slower and gentler, and can be done more frequently, many of the complications are avoided, and therefore, there is no need for the dietary and fluid restrictions or additional medications. Importantly, because individuals using home hemodialysis have great flexibility in scheduling treatments, they are more likely to engage in social interaction with family and friends, avoiding the isolation that can cause or contribute to depression.
One of the major justifications that Congress gave for creating the Medicare ESRD program was make it possible for individuals with ESRD to be able to work and to ensure that they are supported in their efforts to do so. Specifically, the statute says:
(6) It is the intent of the Congress that . . . the maximum practical number of patients who are suitable candidates for vocational rehabilitation services be given access to such services and encouraged to return to gainful employment. SSA Section 1881(c)(1)(A)(i)(6)
Despite the statutory language, two-thirds of the patients in the HDU survey responded that their center did not offer them rehabilitation services to help them maintain, return to, or achieve their desired life activities. Even when a center offered rehabilitation services, it rarely made referrals for the patient or assisted the patient in getting access to these services, nor did it assess whether the patient's needs for rehabilitation had been met.
HDU firmly believes that adopting an ESRD treatment model that focuses on patient-centered care would lead to an increase in patients using home dialysis modalities, especially HHD. As research has repeatedly shown, these modalities offer patients better treatment outcomes with fewer complications, and a better quality of life. In addition, patients who need dialysis often would prefer to work (and pay taxes) than to rely on disability payments. HDU also believes that investing in patient-centered ESRD treatment would have net economic benefits for the larger economy. These would include lower health care spending for physicians, hospitals, and other items and services required to treat the complications of dialysis, as well as lower disability and other social safety net payments, that would more than offset any increase in the costs of the ESRD PPS program.
[1] http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/home-hemodialysis/Pages/home-hemodialysis.aspx