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In the 1980s, health care payers in the public and private sectors have relied increasingly on utilization management to help control health care costs. As a result, the autonomy of health care providershospitals and professionalshas been curtailed as payers have applied predetermined criteria to judge the appropriateness of care. The medical community, in turn, has expressed concerns about the design of the clinical standards or algorithms governing utilization review decisions by health insurers, Blue Cross and Blue Shield plans, third-party administrators, and health maintenance organizations (HMOs). In particular, as payers seek to control costs more aggressively, physician organizations are seeking to review the criteria used for denial of services under second-opinion and prior authorization programs.1
At the same time, federal and state legislators, health policy analysts, and consumer groups are concerned about the impact of physician incentive plans on quality of care and accessibility to services in prepaid delivery systems. This concern was prompted, in part, by concerns about the quality of care delivered to Medicare beneficiaries enrolled in International Medical Centers Inc. (IMC), a for-profit HMO located in south Florida.2 The well-publicized IMC scandals raised a number of public policy issues, including enrollee understanding of benefit restrictions in HMOs,3 ineffective
*The authors are members of the accounting firm Coopers & Lybrand, San Francisco, Calif., and Washington, D.C.
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Appendix B Utilization Management and Quality Assurance in Health Maintenance Organizations: an Operational Assessment Joan B. Trauner and Sibyl Tilson*
In the 1980s, health care payers in the public and private sectors have relied increasingly on utilization management to help control health care costs. As a result, the autonomy of health care providershospitals and professionalshas been curtailed as payers have applied predetermined criteria to judge the appropriateness of care. The medical community, in turn, has expressed concerns about the design of the clinical standards or algorithms governing utilization review decisions by health insurers, Blue Cross and Blue Shield plans, third-party administrators, and health maintenance organizations (HMOs). In particular, as payers seek to control costs more aggressively, physician organizations are seeking to review the criteria used for denial of services under second-opinion and prior authorization programs.1
At the same time, federal and state legislators, health policy analysts, and consumer groups are concerned about the impact of physician incentive plans on quality of care and accessibility to services in prepaid delivery systems. This concern was prompted, in part, by concerns about the quality of care delivered to Medicare beneficiaries enrolled in International Medical Centers Inc. (IMC), a for-profit HMO located in south Florida.2 The well-publicized IMC scandals raised a number of public policy issues, including enrollee understanding of benefit restrictions in HMOs,3 ineffective
*The authors are members of the accounting firm Coopers & Lybrand, San Francisco, Calif., and Washington, D.C.
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quality assurance monitoring in HMOs (both internally by HMO staff and externally by regulatory agencies), and the impact of financial incentives on ordering of services and specialty referrals by HMO physicians.4 The intent of this paper is to describe the range of utilization management and quality assurance strategies that are used by HMOs and then to evaluate their actual implementation. The paper begins with a brief discussion of the methodology used in preparing this paper. The second section describes the organizational structure of existing HMOs, and the third discusses market, structural, and operational factors affecting HMO performance. The fourth section discusses the approaches to utilization management and quality assurance, and the fifth section evaluates the performance of utilization management and quality assurance programs in HMOs. In the sixth section, there is a review of existing research on physician risk incentives in HMOs, while the seventh section addresses some additional policy and research issues. The final section of this paper contains five condensed case histories.
Except for the discussions on the organizational structure of licensed HMOs, the term HMO is generically in this paper to cover all closed systems in which physicians are partly or fully capitated for delivery of care and where enrollees may receive services only from contracting providers.5 All state-licensed prepaid medical plans are included in this definition, regardless of whether they are federally qualified and offer a full range of benefits.
Methodology This paper reflects the authors' experience as health care consultants for an international accounting firm. During the past 3 years, we have had the opportunity to analyze the health benefits offered by numerous employers in both the public and private sectors and to help design their managed care programs. (By managed care, we refer to any program that channels patients to a specific set of health care providers.) During the same time, we and our associates have conducted operational reviews of over 20 HMOs, ranging from local to regional and multistate plans. In general, the HMO reviews have involved an analysis of financial, actuarial, enrollment, and utilization trends in the context of benefit design, premium pricing, marketing practices, claims processing procedures, contractual arrangements with providers, utilization review, and management reporting procedures.
This managed care and HMO consulting experience provides the background for this paper. To supplement our experience, we reviewed the health services research literature for HMO-related studies. In describing
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our personal experience, we do not purport to review a statistically representative sample of HMOs. In fact, because many of the plans that we studied are in transition, the paper may magnify some of the problems facing the HMO industry.6 The crucial advantage of an experiential analysis, however, is that it offers an internal view of HMO operations at all organizational levels that is not available through standard survey instruments or through a review of documents filed with regulatory agencies.7
In our HMO discussions, we do not refer to any plans by name, nor do we provide any information on exact plan size, geographic location, plan age, or precise sponsorship in order to preserve client confidentiality. The brief case histories for five plans that appear at the end of this paper do not include any plan identifiers, but do contain actual descriptions of the utilization management programs in place at the time that the operational reviews were conducted. We present these studies to show the range of operational problems that can undermine the structural design of utilization management and quality assurance programs.
Hmo Organizational Structure According to the current InterStudy classification of HMOs, there are four types: staff, group, network, and individual practice association (IPA) model plans.8 Staff model HMOs deliver health services through physicians who are under salary to the plan. Group model HMOs contract with one independent multispecialty group practice, whereas network model HMOs contract with two or more multispecialty groups. IPAs contract with physicians in private practice, either as individuals, through their group practices, or through separate physician associations.
Under the mandating process established by the HMO Act of 1973, an employer is required to offer only one group or staff model HMO and one IPA in a given service area. (The network classification did not exist under the original HMO Act.) In some geographic areas, HMOs have used a model designation that allows them to take advantage of the mandating process, rather than one that strictly corresponds to their underlying structure. For example, plans that contract almost exclusively with multispecialty groups have sought IPA designations to compete against long-established group or staff model plans. Therefore, any analysis of HMOs requires an assessment of the underlying contractual arrangement with physicians, rather than the plans own self-designation.9
More recently, ICF, Inc. has categorized HMOs as having two-tier or three-tier organizational structures.10 In the two-tier structure (Figure B-1), the HMO contracts directly with individual physicians; in the three-tier structure (Figure B-2), the HMO makes capitation or fee-for-service payments to the IPA or group, which, in turn, contracts with individual
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Figure B-1 Organizational structures within HMOs: two-tier structures.
Figure B-2 Organizational structures within HMOs: three-tier structures.
physicians. ICF originally included only staff model plans and direct contract IPAs in the two-tier classification. In Figure B-l, we have added two additional categories: HMOs owned by group practices and HMOs in which physicians contract directly with the HMO but are arbitrarily grouped into risk-sharing pools or ''pods.''
As described in the literature, a two-tier structure may facilitate contracting in areas where physicians are geographically dispersed (that is, suburban or rural areas) or where physicians have not developed their own
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IPAs. According to the literature, some HMOs elect to use a two-tier structure purposely to forestall physicians from creating IPAs, which, in turn, can function as bargaining units to provide physicians with higher fees.11
Lately, we have come across a new two-tier contractual arrangement involving those HMOs that contract directly with individual physicians and then create arbitrary physician risk pools, or pods. In these arrangements, the financial risk is shared with other providers with whom the physician may or may not have direct contact in daily practice.12 Depending upon the local market, pods may sometimes be organized by group practice or hospital affiliation; in other areas, physicians may be assigned to a pod solely on the basis of practice location.
In this paper, we use the two- and three-tier structure as the basis for much of our analysis. This approach allows us to focus on where responsibility for utilization management decisions actually rests. For example, in two-tier IPA arrangement's, most decision-making resides at the HMO level, whereas in three-tier arrangements those entities that contract with the HMO (for example, IPAs and multispecialty groups) may take over many of these responsibilities. In determining how plans are classified, we ignore the self-designated HMO plan type and instead examine the underlying contractual relationship that exists with participating physicians. In this way, we can describe more precisely utilization management activities in those plans that have contractual arrangements with varying types of provider entities (for example, plans that have group-, staff-, and hospital-based IPA arrangements).
Market, Structural, and Operational Factors Affecting Hmo Performance We believe that any review of HMO performance that focuses exclusively on structural measures will have serious limitations. The HMO market is in a state of flux. Not only are many plans reporting financial losses, but they are having to contend with employer demands regarding the provision of data and experience rating and with provider concerns about reimbursement rates and design of utilization review programs. In this section, we briefly describe the relationship of the health care marketplace to HMO structure and operations. The intent of the analysis is to show that plan performance, as measured by financial, utilization, and quality indicators, is a function of multiple variables, many of which are beyond the control of HMO management.
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The Health Care Marketplace An HMO both reacts to and helps shape the health care market in which it operates. For example, the regulatory environment establishes parameters for benefit design, premium pricing, and marketing practices. The employment market determines eligibility for health benefits, level of employer contributions, and design and pricing of indemnity benefits. Demographic and geographic factors, such as the size of Medicare and Medicaid populations, the location of local industry, and commuting patterns, affect product development and the boundaries of HMO service areas.
The use of a two- or three-tier contracting structure by an HMO is dependent upon existing alternatives to individual physician contracting, such as the presence of multispecialty group practices or hospital-sponsored IPAs, and the prior experience of local providers in working with other HMOs or managed care programs. Negotiation of reimbursement rates, capitation payments, and risk-sharing arrangements are dependent upon (1) hospital and physician supply, (2) the presence of competing HMOs and the design of their payment and risk arrangements, and (3) utilization and cost trends within the local market. In return, as an HMO becomes established, it will have an impact on the design and pricing of health benefits and health services in the local market, as well as on the structure of hospital and physician relationships (including the emergence of new IPAs, group practices, and joint ventures).
Hmo Structure HMO structure, in part, reflects plan sponsorship, consumer orientation date of entry into the market, and short- and long-term financial goals. The adoption of nonprofit or for-profit status may reflect the history of the sponsoring entity, the availability of capital, and the marketability of the program to investors or joint venture partners. Management's perspective on provider behavior, plus the existence of other HMOs in the local market, help to determine the operating model (staff, group, network, IPA, or hybrid), the approach to contracting (direct contract versus three-tier arrangement), and the extent of any risk-sharing arrangements.
Except in markets with a large oversupply of physicians and hospitals, there generally is some give and take in contract negotiations between an HMO and the provider community. While quality of care is always a concern in these negotiations, actual discussions usually end up focusing on economic considerations. As noted by Gnessin,13 there is an inherent conflict between the goals of any HMO's management and those of its participating physicians. Gnessin defines six goals for HMOs: (1) profit
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maximization; (2) capital appreciation; (3) enrollment growth; (4) shift of financial risk to third parties; (5) maximum utilization control with minimum malpractice exposure; and (6) control over all components of HMO operations, including the actual health care delivery system. For physicians, Gnessin defines five goals: (1) maximum autonomy in the practice of medicine; (2) minimal loss of existing patient base or patient volume; (3) expansion of patient base and volume; (4) minimal financial risk; and (5) increased income from new revenue sources (other than the direct provision of health services).
It is the tension between these two perspectives that establishes the setting for the negotiation and implementation of financial incentives. According to Gnessin's "fairness doctrine," at any given time either HMO management or HMO providers may be in a superior bargaining position. However, when the dominant party imposes its will unilaterally on the other, this strategy usually proves successful only in the short term; in the long term the imbalance in power will result in acrimony and disintegration of the relationship. In other words, a plan that transfers risk to providers without reimbursing them adequately or providing them with data to manage their practices runs the risk of losing physician participation in the long run. Conversely, a plan that accedes completely to physician demands and pays them market rates without changing practice patterns may price itself out of the marketplace or require the plan sponsors to absorb large operating losses.
Hmo Operations An HMO cannot transfer risk fairly to providers and deliver quality care in a cost-effective manner without (1) effective management information systems for tracking enrollment, premiums, and utilization and for providing usable and timely reports to management and participating providers; (2) efficient claims processing procedures to ensure prompt payment to providers and the accurate capture of procedural and diagnostic data; (3) accurate actuarial and underwriting procedures for reliable projection of utilization and delivery costs by provider class (hospital, primary care provider, specialist, and other ancillary providers); (4) representation of professional staff and/or a medical director at the HMO's upper management level; and (5) adequate professional staffing to support a utilization management and quality assurance program.
In Figures B-1 and B-2, we described two- and three-tier physician contracting arrangements, as first defined by ICF. There is considerable variation within these two- and three-tier arrangements, however, depending upon how much control any HMO wishes to retain for itself or to
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delegate to contracting providers. Broadly speaking, there are three issues that influence the HMO's decision-making process: (1) how physician groups and IPAs are organized in the local market in terms of the cost-effectiveness of their delivery networks, the design of their data systems, and their management capabilities; (2) how institutional and professional providers are reimbursed and whether the HMO wishes to retain control over the claims payment process; and (3) whether the HMOs believe that the physicians can discipline themselves effectively through the utilization review and peer review process.
As shown in Table B-1, which describes operational responsibilities, there are two control models for two-tier organizations and three control models for three-tier organizations. Responsibilities for utilization management and financial operations may rest almost entirely with the HMOs (Model 1), may be shared between the HMOs and providers (Model 2), or may be assumed largely by providers (Model 3). In two-tier arrangements, in which the physicians either are not independent contractors (for example, staff model, group-owned, or affiliated HMOs) or are fee-for-service providers contracting directly with the HMO, an arrangement like that in Model 3 is not feasible. Moreover, any sharing of services with providers is more limited in two-tier plans than it is in three-tier plans. Typically, sharing of services involves those utilization management and claims payment activities that revolve around the gatekeeper role of contracting primary care physicians (for example, preadmission authorizations and specialty referrals). In pod-type situations in which primary care physicians are capitated, the physicians may review claims from specialty providers before authorizing them for payment. In rare cases, when providers are individually capitated and have direct control over their own specialty funds, they may actually pay for specialty claims.
In three-tier organizations, HMOs are usually not responsible for physician selection and peer review, as these responsibilities rest with contracting IPAs or groups. In Model 1, the IPA or group may share limited utilization review functions with the HMO. For example, an IPA may receive utilization and financial reports from the HMO's claims system; the IPA, in turn, uses these reports as the basis for remedial action against errant providers. In Model 1, all physician payments and all risk incentives are calculated by the HMO.
In Model 2, the HMO creates a medical (physician) fund, which is then handled by the IPA or groups; this fund may represent a capitated payment or a budget allocation based upon anticipated fee-for-service charges. The IPA or group then processes and pays claims for services rendered by its member physicians, while the HMO continues to pay for hospital services and emergency and out-of-area claims. The IPA or group provides feedback on utilization patterns to contracting providers and provides encounter data
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TABLE B-1 Operational Responsibilities in Two- and Three-Tier Organizational Structures by Control Model
Two-Tier Organizations (with Pods)
Utilization review
Claims payment
Encounter data
Data analysis
Provider feedback
Peer review
Quality assurance
Three-Tier Organizations
Utilization review
Claims payment
Encounter data
Data analysis
Provider feedback
Peer review
Quality assurance
NOTE: MD indicates physician; Grp indicates group practice.
on medical services to the HMO itself. In Model 2, the HMO may also be responsible for utilization review for services covered by the medical fund (for example, specialty referrals and diagnostic testing). In Model 3, the HMO largely assumes the role of a broker; it markets benefits to employers, enrolls members, and pays claims for noncapitated services. Otherwise, the IPA or group is given complete responsibility for all utilization review and data analysis.
In the case studies, we have provided examples of one two-tier, Model 1 plan (Case 5), three three-tier, Model 1 plans (Case Studies 1, 3 and 4), and one three-tier, Model 3 plan (Case Study 2).
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Approaches to Utilization Management and Quality Assurance As previously noted, responsibility for specific aspects of an HMO's operations vary by control model. Understanding where the locus of control rests is particularly important when evaluating those cost-containment approaches that affect patient care decisions. For this analysis, we have divided utilization management into its underwriting benefits, delivery of health services, and quality assurance components.
Underwriting Benefits Almost always, benefit design and development of underwriting guidelines remain the responsibility of HMO management, not providers. (An exception occurs when providers require the use of copayments for office-based care to control unnecessary demand for services.) These functions can be described as follows.
Enrollment criteria are underwriting guidelines by industry or service class and by group size. Premium pricing and marketing practices also affect enrollment patterns and are included in this subcategory.
There has been a growing body of literature on enrollment patterns in HMOs to study the issue of selection bias. These analyses have been prompted, in part, by employer concerns that HMOs have attracted a disproportionate share of young and presumably healthy employees. In an analysis of 21 studies on self-selection, Wilensky and Rossiter concluded that most of the recent studies have shown HMOs to be enrolling a lower risk population. However, only rarely have any studies examined the impact of enrollee continuity on utilization rates.15
Benefit design relates to (1) the extent of coverage for specific services, drugs, and supplies; (2) any required copayments, coinsurance and/or deductibles; (3) level of services offered (for example, for mental health, the availability of individual or group therapy); (4) number of visits per condition; (5) out-of-pocket maximums; and (6) lifetime dollar benefits. Federally qualified HMOs have historically offered a more comprehensive set of benefits than have nonqualified prepaid plans or exclusive provider arrangements that are indemnity-based. With the recent growth of non-qualified plans and the move away from community rating and defined benefit packages to experience rating and negotiated benefits, there has been increased emphasis on benefit design as a cost-containment mechanism within HMOs.
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Delivery of Health Services The delivery component of utilization management involves seven subcategories, as follows.
Utilization review is usually administered under the auspices of a medical director and includes one or more of the following services; (1) preadmission review; (2) concurrent hospital review; (3) second surgical opinions; (4) specialty and/or out-of-network referral authorizations; (5) high-cost case management; (6) retrospective review of services; (7) bill audit; and (8) remedial action for providers suspected of fraud or noncompliance with utilization review or referral procedures.
Clinical protocols or guidelines are used for medical decision-making. Formal protocols exist in writing and define the exact procedures to be followed for specific clinical conditions. There are also informal guidelines that represent a consensus of the participating providers about delivery of care. Protocols and guidelines may define, for example, when it is clinically appropriate for a patient with a specific condition to undergo a surgical or diagnostic procedure; they may also define the types of services to be rendered to a patient with a given medical condition and the appropriate setting where these services should be provided. The development of formularies to control the dispensing of pharmaceuticals also falls into this category.
Patient flow procedures are used to control the scheduling and timing of patient services across the entire HMO physician network. Included in this category are the assignment of patients to "gatekeepers" for primary care services, guidelines for scheduling of visits by patient class (for example, acute-care patients, physical examinations, and follow-up visits), time allocated per appointment, access to specialists and tertiary providers, maintenance of telephone lines, office hours, and facility location. Development of staffing ratios for professional and administrative personnel represents another form of control over patient flow.
Physician selection involves an assessment of a physician's technical capabilities and practice style. In medical groups and staff model HMOs, the selection process begins at the initial time of hire and continues through a probationary period. In IPAs, the process is more limited and often focuses on establishing criteria for physician participation, such as a medical license in good standing, adequate malpractice coverage, local medical staff affiliation, and board certification or eligibility. For some community-based IPA HMOs, participation is on an "every willing provider" basis, with the intent of providing as widespread a geographic distribution of physicians as possible.
Data analysis involves a review of financial and utilization trends by practice site, by primary care or specialty service, by member class (for
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was provided to the group physicians or their support staffs. Thus, there was no consensus among the group physicians and the referral clerks as to which local providers were the most cost-efficient, in terms of future referrals.
Medical Director and Utilization Management Support Staff Both of the medical directors devoted approximately 50 percent of their time to their clinical practices and appeared to have taken on the management role with some reluctance. Neither had worked with their medical staffs to develop referral protocols or had undertaken any educational efforts to make them aware of referral costs by specialty. Moreover, both medical directors were extremely fearful about undertaking any program that would antagonize local physicians; thus, they did not encourage any claims review that would result in fee cutbacks by eliminating billing abuses or by using a fee schedule. Rather, the intent of the medical directors was twofold: to initiate preferred provider contracting with the specialists identified as being the most cost efficient and to internalize the high-volume specialties as quickly as possible to control the dollar outflow. However, the plan's ability to recruit specialty staff was dependent, in part, on its ability to expand its existing facilities and/or develop new clinical sites.
Case Study 3: Carrier-Sponsored Hmo Background In the mid-1980s, a carrier took over an existing IPA model HMO operation that had a number of start-up sites. The computer system that was in place was inadequate to handle the variations in benefit packages across sites, as well as the different payment mechanisms used to reimburse hospitals and physicians. Because of the losses sustained at most of the HMO sites and the costs associated with upgrading the HMO software and developing new products (that is, triple option or a point-of-service HMO), the carrier decided to evaluate the future of each HMO site. The following description relates to one of the sites with fewer than 25,000 enrollees.
Control Type Three-tier, with control resting with the HMO (Model 1).
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Financial Incentives Participating primary care providers received a monthly age- and sex-adjusted capitation payment for a CPT-coded list of services; this payment was subject to a 20 percent withhold (that could be increased to 30 percent, under specific conditions). Primary care physicians retained the right to self-refer for services not covered under the capitation agreement. The individual PCPs were then grouped into pods or arbitrary physician incentive pools with a minimum of at least 1,000 members; the withholds of all PCPs in each pod were then combined. For each pod, there was a separate referral services budget to cover the costs for specialty, hospital, and ancillary services; this payment was based upon the number of members in the pod, adjusted for their age and sex mix.
Specialists were paid out of the referral services budget, according to the 70th percentile of usual and customary rates, subject to a withhold. Hospitals were paid according to diagnosis-related groups (DRGs) or discounted charges, but not per diems. During the calendar year, if there were deficits in the referral services fund, the overrun was to be made up first through withholds in the specialist pool and then through withholds in the primary care pool, and finally, any remaining deficits were the responsibility of the carrier. Individual stop-loss coverage from the carrier protected the PCP from responsibility for charges in excess of $7,000 per calendar year.
Despite the ability of the HMO to penalize physicians for poor performance, there was a strong fear by plan management of antagonizing primary care doctors and losing their participation in the plan. Thus, for calendar years 1986 and 1987, a corporate decision was made to return 75 percent of the physician withholds at each of the HMO sites, regardless of the extent of deficits in the referral services funds.
Design of Mis System The hardware and software were inadequate to support membership size, leading to a backlog of claims in excess of 20 days for the HMO site as of December 31, 1987. Moreover, at any given time, the number of unentered claims and their dollar value were unknown. Once a claim was entered into the system, there were minimal edits to allow processors to detect inappropriate or unnecessary services or unusual billing practices by referral physicians.
From a statistical perspective, the information that came off the claims system was suspect. For example, if a PCP submitted a bill that included both capitated services and specialty care (for a self-referral), two encounter numbers had to be generated; if supplies, reimbursable on a cost basis, were also included in the billing, a third encounter form was generated. Thus,
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the reports on cost per PCP encounter were unreliable. Another example related to classification of claims by location of service. All claims had to be grouped into one of three categories: inpatient, outpatient, or other. As a result, nursing home expenses could not be easily separated out from hospital expenses, while home health care expenses, for example, could not easily be separated from those for physical and occupational therapy. As reported by the executive director at the local site, the system was designed strictly to allocate costs to the pods and to calculate withholds.
Utilization Management There were no data by pod on patient demographics and no analysis of utilization patterns within pods to determine where or why deficits were occurring. In effect, there was no way to evaluate the performance of individual PCPs, except in terms of expenditures for self-referrals and outside referrals. Yet, the physicians in the pod were supposed to be self-disciplining. Their contract, however, did not specify the mechanics of any review process, nor did it define how a poorly performing physician could be removed from a pod.
Medical Director and Utilization Management Support Staff At the local level there was a part-time medical director who largely handled physician and hospital contracting. Utilization review was handled by three nurses who functioned as patient care coordinators. They received all incoming calls for the authorization of hospital admissions, and depending upon the case and available time, they were responsible for conducting on-site concurrent review. The three nurses were also supposed to authorize referrals for some 20 high-cost diagnostic tests and procedures, such as use of magnetic resonance imagers and lithotripters. However, a number of PCPs regularly ignored this requirement, knowing that the plan had no intent of closely monitoring their behavior. In fact, other than the initial credentialing process, there was no quality assurance program in place.
Case Study 4: Carrier-Sponsored Hmo Background A carrier established an IPA model HMO which then contracted with a series of open panel IPAs. Each IPA was responsible for delivering care in one or two counties of the state. The HMO provided all marketing, administrative, enrollment, accounting, financial, claims processing, and
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MIS services for the IPAs. Under its contract, it was also responsible for supplying the IPAs with necessary data and reports to enable the IPAs to perform peer review, to operate a quality assurance program, and to determine the status of withhold accounts.
Problems arose when one of the IPAs discovered that it was operating at a deficit and requested an increase in its monthly capitation rate. The physicians in this IPA were convinced that the deficits were attributable to three problems: (1) the HMO's use of outmoded actuarial information, leading to an underestimation of outpatient costs and a miscalculation of the capitation payment to the IPA; (2) the miscoding or misclassification of claims data, preventing a meaningful comparison between capitated payments and actual claims costs; and (3) the failure of the HMO to provide the IPA with detailed financial and utilization reports on a timely basis. This case study examines the experience of this one IPA.
Control Type Three-tier, with control resting with the HMO (Model 1).
Financial Incentives The HMO allocated to the IPA capitation on a per-member, per-month basis (not adjusted by age or sex), with the HMO processing all hospital and professional claims. Claims from participating IPA physicians were to be paid by the HMO according to the lesser of billed charges or a maximum fee schedule. This schedule was approximately 10 percent higher than the sponsoring carrier's schedule for its standard business. Twenty percent of all physician's fees were to be withheld and placed in a risk account.
The IPA required enrolled members to sign up with a primary care physician, but did not actively support a gatekeeper system. Patients could self-refer to participating specialists. Authorizations for hospital admissions could be requested by primary care physicians or treating specialists. Moreover, there were no built-in financial incentives for performing the gatekeeper function. For example, the IPA did not allocate any percentage of funds in the withhold to primary care physicians, but distributed the funds on a pro-rata basis across the entire IPA membership.
Design of Mis System Only management reports, not claims processing procedures, were reviewed. By April 30 of each year, an annual financial accounting was due, showing all capitation payments to the IPA for covered services and all billed and paid services adjusted for incurred but not reported claims;
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from this accounting, the HMO would determine whether any or all of the physician withhold would be available to the IPA for distribution to participating physicians.
The reports received from the HMO in April 1986 indicated that the IPA did not have an operational deficit, and, therefore, the 1985 withhold was returned and the amount of the withhold was decreased from 20 to 10 percent. IPA leadership continued to believe that the IPA was operating profitably until the end of the year, when the HMO reported a substantial deficit in the IPA account, requiring an increase in the withhold.
Apparently, during the year the HMO had experienced a buildup in unpaid claims, resulting in a miscalculation of the incurred but not reported claim and a restatement of the IPA's financial position. At the same time, the IPA was not receiving adequate information from the HMO to develop any estimates of its own performance. For example, while the HMO provided monthly totals on admissions per 1,000 members and the average length of stay per discharge, there was no financial information on average cost per patient-day or per discharge, by type of service, or by diagnosis. Detailed information on cost per patient visit and average cost per procedure was not provided to the IPA prior to the announcement of the IPA's operational deficit.
The capitation shortfall was attributed in part to the fact that the HMO was predicating utilization rates on statistics presented by outside actuarial consultants; however, the data classification system in place at the HMO did not correspond to that used by the outside consultants. For example, laboratory and x-ray costs were allocated differently in the two systems, resulting in an underestimation of the cost of outpatient services in the capitation payment.
Utilization Management and Support Staff For all hospital admissions, the admitting physician was to call the utilization review department at the HMO for preauthorization. The appropriateness of the admission and the site (inpatient versus outpatient) was not questioned initially by the staff, but rather was reviewed retrospectively. Nurses at the HMO were responsible for conducting concurrent utilization review by phone and/or handling on-site reviews. An additional team of one physician and two nurses handled all psychiatric admissions.
For outpatient services, the claims were screened by processors at the HMO by using a series of routine edits to detect duplicate billings, noncovered services, medically outmoded services, and services covered by total charges. Otherwise, there were no screens to review the frequency of services or upgrading of procedure codes. Individual claims were not subject to special review unless physicians contested not getting paid for all
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services rendered. There were no reports issued on a regular basis (that is, monthly or quarterly) listing physicians who routinely billed for more services per visit or had higher costs per visit than the IPA averageor the average across all participating IPAs. There was no separate tracking of ancillary services with respect to volume and dollar amounts, by referring or treating physician.
Approximately every 6 months, on an "as-needed basis," there was a joint meeting of IPA leadership and the HMO medical director and review staff to resolve outstanding problems. Actions of that committee typically included a determination of which physicians were utilizing nonparticipating providers and/or failing to notify the HMO of inpatient admissions. The IPA was then authorized to levy a $100 fine against noncomplying physicians; over a 2-year period, approximately 12 fines were issued. Otherwise, the combined HMO-IPA review team, which theoretically was responsible for quality assurance activities, did not undertake any analysis of member grievances, incident reports, admissions by diagnosis, or mortality rates.
Medical Director and Utilization Management Support Staff There was a nominal flow of information down to the IPA from the medical director and his support staff at the HMO. As a result, physicians participating in the IPA continued to practice under fee-for-service incentives. The medical director of the IPA, along with the leadership of the IPA, had never supported an active utilization management program. For example, using annual information produced by the HMO on the distribution of office visits by specialty, the medical director had never sought to review the practice patterns of individual physicians identified as being in the top 25 percent by cost per visit. He had not worked with IPA leadership to develop protocols to curb unnecessary ordering of ancillary services and diagnostic testing or to foster the use of outpatient surgery. Rather, the focus of the IPA's managementand the medical directorhad been directed to renegotiation of the capitation payment to eliminate the IPAs operational deficit.
Case Study 5: Physician-Sponsored Ipa Background A physician-owned IPA model HMO with under 25,000 members and a panel of more than 1,000 physicians had consistently reported operating losses since its founding in the mid-1980s. In 1987, it was reported to be out of compliance with the capital reserve requirements of the state's insurance department. Accordingly, the IPA sought to determine how best to obtain
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an immediate infusion of funds. Two primary sources had previously been identified: additional contributions from participating physicians or a loan from one or more local hospitals. However, the analysis revealed that the physicians were quickly becoming disenchanted with the plan and were unlikely to contribute additional monies, while the hospitals were not anxious to loan money unless the operational expenses of the plan could be brought under control.
Control Type Two-tier, with control resting with the HMO (Model 1).
Financial Incentives The physician shareholders in the plan each originally contributed between $600 and $1,750 to finance the plan's start-up. The HMO has operated on a discounted fee-for-service basis, with reimbursement predicated upon the 85th percentile of the customary and reasonable rates used by carriers operating in the local market. After the first full year's experience, these rates were reviewed and adjusted downward to control operating costs. In addition, the plan retained 20 percent of paid charges as a withhold; this withhold was not returned after the initial year of operation, but was returned after the second year as a good faith effort on the part of the IPA leadership.
There were no other incentives in this plan other than the discounted fees and the withhold. Participating physicians who were interviewed felt that the withhold had no impact on utilization patterns in terms of frequency of office visits, ordering of ancillary services, or use of referrals. In fact, with the discounted fee arrangement, some primary care physicians noted that it was more cost-efficient to refer difficult or time-consuming patients to a specialist in order to maintain the patient flow within their own offices.
Because of the failure of the withhold to control utilization, plan management is now considering a preestablished budget by practice type or specialty; under this approach, a percentage of the premium will be designated to cover specific services (for example, family practice, obstetrical care, surgery, and allergy), with a reserve fund created from the premium allocation. Payback of this withhold would be based upon the combined experience of the specialties covered under each withhold.
Design of Mis System The claims processing section was originally under the jurisdiction of the chief financial officer, who had no previous experience with a claims
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operation. As a result, the operation was poorly managed find understaffed, resulting in low morale, high employee turnover, and periodic claims lags. As for the claims system, the existing hardware was adequate to support the membership size, but the software lacked the necessary edits to detect unusual physician billing practices as well as a flexible report writer to produce reports according to management specifications.
Utilization Management The primary care physician functioned as a gatekeeper and in that capacity was responsible for completing referral forms for all specialty, ancillary, and hospital services. Once an authorization was entered into the system, all claims were automatically paid without review, except for emergency room visits, mental health services, physical therapy, speech and occupational therapy, out-of-area claims, and out-of-plan referrals.
Because the IPA was originally established by the leaders of several local medical societies and/or hospital boards and because these individuals collectively represented the medical establishment in their communities, there was a reluctance on the part of the nurse reviewers to challenge participating physicians regarding their practice patterns. This problem was further compounded by the fact that there were few or no data with which to document consistent patterns of overutilization of services or unnecessary admissions.
The plan had two medical directors; one was largely responsible for utilization review and the other was responsible for physician relations and for recruiting primary care physicians for outlying areas. To date, the approach to utilization management has been through gentle persuasion, rather than tightly written protocols. However, the failure of the plan to bring utilization rates down (for example, to lower hospital utilization under 375 days per 1,000 members for the under age 65 population) has resulted in a decision to implement a more stringent review process.
Ipa Management The same chief executive officer has remained in place since the plan was founded. However, within the first year of its operations, the plan lost its original chief financial officer, its director of management information systems, its director of claims, its nursing supervisor (who was responsible for quality assurance), and several other key administrative staff. There continues to be a high degree of tension between the physician leadership of the IPA and its lay management. One area of major conflict has been over underwriting practices. Plan management had established a policy of not accepting groups with fewer than 25 employees because of potential high
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utilization. However, the IPA board of directors overruled management and decreed that participating physician offices and families were eligible for HMO membership. The offering was also extended to members of the local medical societies. Despite evidence to show that the physician offices had been high utilizers, the IPA physicians continued to overrule plan management.
Notes and References 1. Page, Leigh, ''New Era in Utilization Review,'' American Medical News, Vol. 1, December 9, 1988, pp. 48-49. (See also Scheier, Ronni, "Medicine by the Book," American Medical News, January 6, 1989, pp. 1, 20).
2. U.S. General Accounting Office, Medicare Issues Raised by Florida Health Maintenance Organization Demonstrations, Report to Congress, GAO/HRD-86-97, Washington, DC, July 1986.
3. U.S. Congress, House, Maintaining Medicare's HMOs: Problems, Protections, and Prospects, Hearing before the Select Committee on Aging, 100th Congress, First Session, Washington, DC, June 11, 1987.
4. U.S. General Accounting Office, Medicare: Physician Incentive Payments by Hospitals Could Lead to Abuse, Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, U.S. House of Representatives, GAO/HRD-86-103, Washington, DC, July 1986.
5. Trauner, Joan B., "The HMO Identity Crisis." Best's Review 87, April 1987, pp. 60-70.
6. The Group Health Association of America's 1988 analysis of HMO industry performance, using 1986 survey data, showed that 39.2 percent of 181 plans submitting financial data had a profit or surplus. Of the HMOs that we reviewed, 25 percent were profitable in 1986. See Group Health Association of America, Inc., HMO Industry Profile: Financial Performance, Vol. 3, Washington, DC, September 1988.
7. In a study of physician incentives in HMOs, ICF researchers noted that they were unable to check the consistency or accuracy of information supplied by the plans. They also noted that information on file at the federal Office of Prepaid Health Care (OPHC) was not always reliable; in some cases, financial incentive arrangements contained in applications for federal qualification had never become operational, and in other cases, design of incentives had changed without being reported to OPHC. ICF, Inc., Final Report: Study of Incentive Arrangements Offered by HMOs and CMPs to Physicians, Submitted to the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, Washington, DC, May 18, 1988, p. II21.
8. InterStudy, The InterStudy Edge, Excelsior, MN, Spring 1988, p. 54.
9. For a different approach, when traditional community- or foundation-based IPAs are contrasted with newer group-based IPAs, see Welch, W. P., "The New Structure of Individual Practice Associations, Journal of Health Politics Policy and Law, Vol. 12, Winter 1987, pp. 723-739.
10. ICF, Inc., Final Report, p. IV-6 (see note 7 above).
11. Gnessin, Alan M., "Physician Incentive Payment Systems and Risk Sharing Alternatives," in Group Health Association of America, Inc., Physician Incentive Programs: Defining the Risk, Washington, DC, October 28-30, 1987.
12. For a description of an HMO in which individual physician incentives are used within pods, see the statement by Jerome Beloff, Corporate Medical Director, Av-Med Health
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Plan of Florida before the Physician Payment Review Commission, Washington, DC, July 15, 1988.
13. Gnessin, Alan M., "Physician Incentive Payment Systems and Risk Sharing Alternatives," 1987 (see note 11 above).
14. Wilensky, Gall R., and Rossiter, Louis E, "Patient Self-Selection in HMOs," Health Affairs, Vol. 5, Spring 1986, pp. 66-80. For a more recent study showing the impact of dependents' claims on health plan selection see Lairson, David R., and Herd, J. Alan, "The Role of Health Practices, Health Status, and Prior Health Care Claims in HMO Selection Bias," Inquiry, Vol. 24, Fall 1987, pp. 276-284.
15. Neipp, Joachim, and Zeckhauser, Richard, "Persistence in the Choice of Health Plans," Advances in Health Economics and Health Services Research, Vol. 6, 1985, pp. 47-72.
16. Borok, Gerald M., "Appropriate Utilization of Resources Program," Quality Assurance and Utilization Review, Vol. 2, May 1987, pp. 57-61.
17. Donabedian, Avedis, "Explorations in Quality Assessment and Monitoring," The Definition of Quality and Approaches to Its Assessment, Vol. I, Ann Arbor, MI: Health Administration Press, 1980.
18. Mosser, Gordon, "Quality Assurance in HMOs," Presentation to Management and Physician Orientation Program, Group Health Association of America, Inc., New Orleans, December 9-11, 1987.
19. For a discussion of 15 ways in which out-of-plan use may occur, see Mott, Peter D., "Hospital Utilization by Health Maintenance Organizations: Separating Apples from Oranges," Medical Care, Vol. 24, May 1986, pp. 398-406.
20. For a discussion of the process used by the Rand Corporation to impute mental health visits and expenditures at one large HMO (Group Health Cooperative of Puget Sound), see Wells, Kenneth, Manning, Willard Jr., and Benjamin, Bernadette, "Comparison of Use of Outpatient Mental Health Services in an HMO and Fee-for-Service Plans: Sensitivity to Definition of a Visit," Medical Care, Vol. 25, September 1987, pp. 894-903.
21. Joint Commission on Accreditation of Health Care Organizations, Report of the Findings of the Joint Commission's Quality Assurance Evaluation and Medical Records Audits of Health Maintenance Organizations in Ohio under the Medical Assistance Program, Submitted to the Bureau of Alternative Delivery Systems, Ohio Department of Human Services, December 1987.
22. Conversation with Jo Ellen Ross, Chief Executive Office, California Medical Review Inc., San Francisco, January 17, 1989.
23. U.S. General Accounting Office, Medicare: Physician Incentive Payments, Washington, DC, July 1986.
24. Mathematica Policy Research, Inc., National Medicare Competition Evaluation, Final Analysis Report: The Structure of Quality Assurance Programs in HMOs and CMPs Enrolling Medicare Beneficiaries, Washington, DC, February 1987.
25. Gold, Marsha and Reeves, Ingrid, "Preliminary Results of the GHAA-BC/BS Survey of Physician Incentives in Health Maintenance Organizations (HMOs)," Group Health Association of America, Inc., Research Briefs, Vol. 1, November 1987, pp. 1-15.
26. Findings from the BC/BS survey have been used to augment the GHAA survey, with duplications removed. For the BC/BS results, see Blue Cross and Blue Shield Association, "A Survey of Physician Financial Payment Arrangements in Blue Cross and Blue Shield Plan HMOs," Chicago, January 1987.
27. Hillman, Alan, "Sounding Board: Toward Full Disclosure of Referral Restrictions and Financial Incentives by Prepaid Health Plans," New England Journal of Medicine, Vol. 317, December 31, 1987, pp. 1743-1748.
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28. ICF, Inc., Final Report (see note 7 above).
29. Memorandum from Lewin/ICF, Inc. and Group Health Association of America to Chris Bladen, Division of Health Financing Policy, U.S. Department of Health and Human Services, Washington, DC, June 24, 1988.
30. For a review of early research studies on utilization rates in HMO and fee-for-service settings and across HMOs, see Luft, Harold S., Health Maintenance Organizations: Dimensions of HMO Performance, New York: Wiley, 1981.
31. See, for example, Yelin, Edward H., Henke, Curtis J., Kramer, Jane S., Nevitt, Michael C., Shearn, Martin, and Epstein, Wallace V., "A Comparison of the Treatment of Rheumatoid Arthritis in Health Maintenance Organizations and Fee-for-Service Practices," New England Journal of Medicine, Vol. 312, April 11, 1985, pp. 962-967. Also see Quick, Jonathan D., Greenlick, Merwyn R., and Roghmann, Klaus J., "Prenatal Care and Pregnancy Outcome in an HMO and General Population: A Multivariate Cohort Analysis," American Journal of Public Health, Vol. 71, April 1981, pp. 381-390.
32. For a study that assumed that the differential use of diagnostic testing was due to its increased profitability to fee-for-service providers, see Epstein, Arnold M., Begg, Colin B., and McNeil, Barbara J., "The Use of Ambulatory Testing in Prepaid and Fee-for-Service Group Practices: Relation to Perceived Profitability," New England Journal of Medicine, Vol. 314, April 24, 1986, pp. 1089-1094.
33. Scovern, Henry, "Hired Help: A Physician's Experiences in a For-Profit Staff-Model HMO," New England Journal of Medicine, Vol. 319, September 22, 1988, pp. 787-790.
34. For an example of a discussion on referral patterns, see Piland, Neil E, White, Robert E., and Smith, Howard L., "Physician Referral Patterns: Implications for Group Practice," GHAA Journal, Vol. 7, Winter 1986, pp. 4-12. For an example of a discussion on provider feedback, see Berwick, Donald M., and Coltin, Kathryn L., "Feedback Reduces Test Use in a Health Maintenance Organization," Journal of the American Medical Association, Vol. 255, March 21, 1986, pp. 1450-1454. See also Braham, Robert L, and Ruchlin, Hirsch S., "Physician Practice Profiles: A Case Study of the Use of Audit and Feedback in an Ambulatory Care Group Practice,'' Health Care Management Review, Vol. 12, 1987, pp. 11-16.


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You never know, your query may have been answered already.
Welcome to Kitchen Queries, where the nigella.com team will answer your cooking or food related questions. We'd love you to submit some of your recipe problems, dilemmas or queries for us to get our teeth into!
Submit your queryPlease note, we are only able to answer questions selected for publication and aren't able to enter into personal correspondence.
Hi there, I'm looking to find a recipe that Nigella features in one of her tv shows for biscuits. During the programme she showed us her amazing cookie cutter collection, then went on to make simple biscuits using an array of shapes which her children and their friends then decorated with coloured icing. I have my neice and nephew coming to stay for Easter and thought it would be a fun couple of hours one afternoon with them, and give me the chance to use my new "easter bunny" cutter?! I wonder if you'd be able to point me in the right direction for his great biscuit recipe?? Much appreciated Sue
Posted by snaught. Answered on 25th Mar 2011 at 12.00
Read The AnswerHi, I'll be attempting to make Nigella's Devils Food Cake and I have some questions: - Our only good quality dark chocolate available here in Dubai is either Marks and Spencer 72% Organic Dark Chocolate or Lindt 70% Dark Chocolate. All of them are in Bar form and not in Buttons or Chips. Can i use them in the Chocolate Frosting for the Devils Food Cake? What brand of Cocoa powder does Nigella usually use for cakes? Unfortunately, the only brand of cocoa powder available here is Hersheys and I was wondering if that's good enough. Thank you so much for answering these, Brandon.
Posted by brand.seph. Answered on 24th Mar 2011 at 12.00
Read The AnswerI've made these oaten rolls (from p87 of KITCHEN) twice. The first time I cut the recipe in half and used agave syrup not honey since I didn't have any honey. They looked exactly like the picture but tasted strongly of baking soda, so I figured I made a mistake when halving the recipe...oops The second time, today, I made the recipe exactly as written. they looked nothing like the picture, or the first batch - they were wet, not shape-able and tasted only OK. Much less oat-y. What might I have done wrong this time?
Posted by frolis. Answered on 23rd Mar 2011 at 12.00
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- Leadership
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Some MA hospitals back price curbs
Support is building among some Massachusetts hospitals for temporary government limits on healthcare prices, a...
West Penn Hospital would have closed without Highmark deal
Without its acquisition by Highmark Inc., West Penn Allegheny Health System would have been forced to shutter West...
In CO, a tale of two hospitals
Aspen Valley Hospital will give its employees an average pay increase of 2.4% this month, while the Vail Valley...
$1.5B DMC deal close set for Friday
On Friday, the Detroit Medical Center should be part of the Vanguard Health Systems, capping months of work and a...
With healthcare, is bigger always better?
Carilion Clinic owns the two hospitals in Roanoke, VA, and six others in the region, employs 550 doctors and...
Hospital merger prompts lawsuit
A lawsuit filed Wednesday charges that the recent merger between tax-supported Bert Fish Medical Center and privately...
Lawsuit: HMA paid doctors to refer patients to specific hospitals
The former executive of
a.inline_topic:hover {
background-color: #EAEAEA;
}Physicians Regional Medical Center at...
Caritas sale opponents write to pope
A group of Catholics opposed to the sale of Caritas Christi Health Care to the private equity firm Cerberus Capital...
Florida Hospital prepares to ax United Healthcare if talks fail
The Florida Hospital system and United Healthcare are embroiled in a contract standoff. If the two companies cannot...
LifePoint's CEO steers for measured growth
LifePoint Hospitals and its CEO/President Bill Carpenter oversee 48 acute care facilities and 21,000 employees over 17...
The Complete Guide to Women's Health Service Line Marketing
Women are the family healthcare gatekeeper attract them to your women's service line and you will attract their family...


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Video: The Mason Lane Farm
This video from McGraw-Hill Construction is a close look at the Mason Lane Farm, a LEED-Gold Farm Storage and Service Center in Goshen, Kentucky. Narrated by architect Roberto De Leon of De Leon & Primmer Architecture Workshop, the video gives insight into the strategies associated with passive, economic and simple construction systems. De Leon discusses orienting the buildings on the site, assessing appropriate materials and providing comfortable conditions for the workers on the farm.
For a more detailed look at the Mason Lane Farm by following this link: Mason Lane Farm / De Leon & Primmer Architecture Workshop.
Casa Talia / Vivian Haddad and Marco Giunta
Architect: Vivian Haddad and Marco Giunta
Location: Via Exaudinos, 1/9, 97015 Modica, Italy
Styling: Arianna Lelli Mami
Photographs: Andrea Ferrari
Museum of Energy / Arquitecturia
Architects: Arquitecturia
Location: Tarragona, Spain
Collaborators: M. Agudo, I. Sola, A. Horta, J. Farres, A. Serrats
Contractor: TCSA
Project Year: 2010
Photographs: Pedro Pegenaute
FAU College of Computer Science and Engineering Building / Leo A Daly
Leo A Daly architects has recently completed Flordia Atlantic University's College of Computer Science and Engineering Building. The new building holds the numerous different labs of the Computer Science and Engineering Programs within a building that leads the way for Florida's academic buildings in technology and sustainability.
Architect: Leo A Daly
Location: Boca Raton, Florida, United States
Project Team: William A. Hanser, AIA, Robert Thomas, AIA, Ron Wiendl, Stella Perico
Consultants: Affiliated Engineers SE, Inc., OMN&J, Inc., James Santiago, Miller Legg, Green Building Services
Project Area: 96,000 square feet
Project Year: 2011
Photographs: Island Studios Photography – Stuart Gobey
The Green Building to Host U.S. Green Building Council LEED Platinum Plaque Ceremony & Exhibit Reception
In honor of its LEED Platinum certification earlier this year by the U.S.Green Building Council (USGBC), The Green Building of Louisville, KY will host an official plaque ceremony and exhibition reception for the public on Friday, September 2, 2011.
Details after the break.
Bing Thom and the Surrey City Centre Library: How architects are using Facebook and Twitter for public design
Facing an abbreviated schedule for the information-gathering phase of the Surrey City Centre Libary, Bing Thom Architects (BTA) turned to social media for real-time public input. The result was spectacular!
in November 2009 Bing Thom, winner of the 2011 RAIC gold medal, was commissioned to build a $36M, 80,000 square foot library in the Vancouver suburb. Funds for the library project, from Canada's Federal Infrastructure program, mandated that the money be used by strict deadline or be lost. But with little time for standard due dilligence , BTA launched a library website, Facebook page, YouTube presence, Twitter account, and RSS feed, inviting public comment. The sites were populated with images of the project and invited users to publish their own images and text regarding their ideas for the future library in an online "ideasbook."
The respondent group was more diverse than the crowd that usually shows up for public forums. The largest percentage of the library's 487 Facebook fans, for example, are under 25. The second largest are women, age 35-44.
Check out FASTCO Design's coverage of Bing Thom's use of social media in the design of the Surrey City Centre Library.
If it seems too good to be true, it probably is
Everyone knows the old adage and has most likely been stung by its inevitable truth. What happens, eventually, is that the other shoe unfortunately falls; the truth rears its ugly head and leaves us with egg on our face.
Well, it is no different in the world of architecture, construction, and real estate. Being deceived is a product of wanting something for less than its real value. Oftentimes we fall into the deception trap to close an unwanted gap between our budget and what we want actually costs. Budget and cost either match or they don't! Expecting to get something for nothing, while human nature, is foolish. Either today or somewhere down the line, the truth will come out or it may be very hard to accept.
Five years ago, when the real estate and construction boom was out of control, there was always a shortage of really competent help because everyone was so busy. Prices became artificially high. People who were less and less qualified entered the workforce and were being hired regardless of the obvious. Let's use Brooks as an example. I remember Brooks say, "He's only a plumber. I'm not him paying $32,000…it's only plumbing." So instead of paying the licensed/insured/bonded plumbing company what they deserved, he had his general contractor friend (first mistake) hire some under qualified guy in order to "save" about 30%. "That's gonna pay for my Viking stove," he boasted at the time.
Taking a second look at MoMA's Rising Currents Exhibit, Zone 0 by ARO and dlandstudio
In the wake of Hurricane Irene it only seemed appropriate to take a second look at Rising Current, an exhibit that was featured at the MoMA just last year. To give you a refresher, the exhibit was a cohesive showcase of five projects tackling the lingering truth that within a few years, the waterfront of the New York harbor will drastically change.
Team Zero, comprised of ARO and dlandstudio, specifically took a look at the lower Manhattan landscape, proposing to develop a new soft and hard infrastructure solution paved with a mesh of cast concrete and engineered soil and salt tolerant plants. This would create greenways that act as absorptive sponges for rainwater. The porous green streets address daily tidal flows and storm surges with 3 interrelated high performance systems (network of parks, wetlands and tidal salt marshes). These systems stop sewage overflow, block higher sea levels and mitigate storm surge.
Rising Current provided an emphasis on how to re-think the city, relevant before, and even more pressing now after the flooding from the hurricane. Let's hope that the ideas for solutions that were generated from the exhibit can now be considered for implementation. More about Rising Currents and Team Zero's solution following the break.
Urban Topos / HOLODECK architects
Architect: HOLODECK architects
Location: Turnergasse 24, 1150 Vienna, Austria
Project Team: Arch. Marlies Breuss, Arch. Michael Ogertschnig, DI Carolin Saile, DI Christian Rottensteiner, Nana Schilling
Structural Engineer: DI Bernhard Ruczka Building Physics: DI Röhrer
Consultants: Ing. Riebenbauer, Oberwart Site Management: Arch. Reicheln
Building Firm: Habau GmbH Project Year: 2011
Photographs: Hertha Hurnaus
The Pros and Cons of Cargo Container Architecture
With the green premise growing in popularity across the globe, more and more people are turning to cargo container structures for green alternatives. There are countless numbers of empty, unused shipping containers around the world just sitting on shipping docks taking up space. The reason for this is that it's too expensive for a country to ship empty containers back to their origin. In most cases, it's just cheaper to buy new containers from Asia. The result is an extremely high surplus of empty shipping containers that are just waiting to become a home, office, apartment, school, dormitory, studio, emergency shelter, and everything else. More information after the break.
Chapel at Rio Roca Ranch / Maurice Jennings + Walter Jennings Architects
Architect of Record: Maurice Jennings + Walter Jennings Architects
Project Location: Palo Pinto County, Texas, USA
Project Team: Maurice Jennings, Walter Jennings, Lori Yazwinski Santa-Rita, David Pullium
Consultants: HP Engineering (MEP), Myers-Beatty Engineering (Structural)
Project Area: 1,080 square feet
Project Year: 2010
Photographs: Walter Jennings
Busan Opera House Proposal / Nabito Arquitectura
The new Busan Opera House, designed by Nabito Arquitectura, will put the city on the international map, allowing it to become part of the network of world renowned opera houses. As another node in the network, the I-Opera, the title of their project, will not only be integrated on an international level, but it will also serve as a landmark on the local level. It will be present in the collective memory of the people of Busan and also be a part of their daily life experience. More images and architects' description after the break.
Win a copy of Blueprints of the Star Wars Galaxy
Last week we presented you the book Blueprints of the Star Wars Galaxy, an amazing compilation of over 200 highly detailed architectural drawings created for all six films of the Star Wars Saga.
The book will be limited to only 5,000 prints in english, and thanks to ArchDaily and Epic Ink Books you can win a copy!
To win this 35-pound book (priced at $500) all you need to do is follow these simple instructions:
Mark Magazine #33
We recently received the newest edition of Mark Magazine. Number 33 offers in depth looks of several projects ArchDaily has previously featured such as: Sunset Chapel by BNKR Arquitectura, iGuzzini Illuminazione Spain Headquarters by MiAS Arquitectes, Villa Geldrop by Hofman Dujardin Architects, the 3D Athletics Track by Subarquitectura, Helicopter Building by Stephane Maupin & Nicolas Hugon, House in Nasu by Kazunori Fujimoto Architect & Associates, House in Sunami by Kazunori Fujimoto, Merida Factory Youth Movement by Selgas Cano, Metropol Parasol by J. Mayer H. Architects, Inside House & Outside House by Takeshi Hosaka Architects, Atelier Tenjinyama by Ikimono Architects, and The Termite Pavilion by Rupert Soar. If you enjoyed these features you'll want to pick up this copy of Mark. There are several more project featured and an interview with structural engineer Niccolo Baldassin who has worked with Frank Gehry, Tom Mayne, and Renzo Piano.
Summer Retreat / RRA
Architect: Reiulf Ramstad Arkitekter (RRA)
Location: Fuglevik, Norway
Project Area: 130 sqm
Project Year: 2011
Photographs: Courtesy of Reiulf Ramstad Arkitekter
URBANbuild / Tulane University
Check out a preview we spotted on PublicInterestDesign of Tulane University's School of Architecture URBANbuild program, a total collaborative effort of "individuals, organizations, and businesses committed to revitalizing New Orleans' rich cultural and architectural heritage." Working with Professor Byron Mouton, Make It Right and Neighborhood Housing Services of New Orleans, students have designed and built several LEED-certified homes such as URBANbuild 04 featured in the clip. This particular residence is situated in Central City of New Orleans and completely breaks with the traditional "shotgun homes" that line the streets. The young homeowner, Tami, appreciates the students' talents and abilities to go beyond what the neighborhood, and even the city, is comfortable with to create a new urban identity. Challenged by Mouton to introduce new ideas, the students have created a beautiful residence that they can certainly be proud of and one that Tami loves View her story and a bit of the project's journey in the video.
University of Arizona Poetry Center / Line and Space
Architect: Line and Space, LLC
Location: Tucson, Arizona
Project Year: 2008
Project Area: 18,000SqFt
Contractor: Diversified Design and Construction
Structural Engineer: Turner Structural Engineering
Civil Engineer: Presidio Engineering
MEP Engineer: Kelly, Wright, and Associates
Electrical Engineer: R.A. Alcala & Associates
Landscape Architect: Design Collaborations
Photography: Robert Reck, Henry Tom, Jared Logue
Vienna Design Week 2011
The Vienna Design Week, now in its fifth year, is Austria's most important international design festival. From 30 September – 9 October 2011, it will bring some of the best designers of our time to the Austrian capital while simultaneously fostering talents of tomorrow. The festival is diverse in content – comprising the areas of product design, industrial design, and furniture design.
With exhibitions, venue-specific installations, theme specials, talks, and of course plenty of opportunities to party and network, Vienna Design Week is an attraction not only for the international design scene. It most explicitly aims to appeal to a wide public audience in Vienna, including international guests: in cooperation with many partners – museums, institutions and companies – the whole city becomes a platform and a showcase for design. The Vienna Design Week does not have the character of a trade fair, but instead offers a variety of venues and approaches specific to Vienna. More information on the event after the break.


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Pennsylvania and New York Businesses
Business Partners
Here are a few business partners we rely on and can heartily recommend. If you can suggest others you trust, please let us know.
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Property Prep & Detail Co.
Schultz Furniture Superstore, John V. Schultz CompanyFrank "Frankie" IacovettaSchultz Furniture Superstore, John V. Schultz CompanyJohn V. Schultz CompanyEriePA 16509 US
Phone: 814-868-7125 x182 -
Macko Builders
Caesar Lombardozzi General Contractors Inc.Caesar LombardozziCaesar Lombardozzi General Contractors Inc.www.lombardozzibuilders.com/EriePA US
Phone: 1-814-836-0056 -
Jason Elwell Roofing & ConstructionJason ElwellJason Elwell Roofing & ConstructionJason Elwell Roofing & ConstructionEriePA US
Phone: 814.866.1661 -
Jackson Plumbing Inc.
Lighthouse Heating & CoolingMichael SprickmanLighthouse Heating & CoolingEriePA US
Phone: (814) 454-2110 -
Finer Things Wood Design
Finer Things is a culmination of 35 years of Frank's love of the design and build process which began with those balsa wood models in his childhood. If you are considering adding new furniture or cabinetry to your home, please contact Frank.
Mary Huffman's Cakes
The Lawrence Park Dinor
948 Silk City diner manufactured in Patterson, NJ. This place takes you back in time from the minute you walk through the front door. Homemade soups made fresh daily, lunch specials, great atmosphere providing great service with a smile!! Please stop in and join us for either breakfast or lunch!
J. Francis & Co.
J. Francis & Co., is located in Erie, Pennsylvania in Village West Plaza. We are a locally owned retail business, established in 1999, offering distinctive home decor, fragrance and gifts, interior design consulting services and premium gift packaging. There's nothing else like it!
Just Right Home InspectionsJohn HallJust Right Home InspectionsJust Right Home Inspections3017 Oakley Dr.Erie16506 US
Phone: 814.450.7512If you are looking for first-class service in home inspections, you have come to the right place! My goal is to be friendly and approachable, while conducting a thorough and complete inspection of your current or prospective home.
Presque Isle Designs, LLC
Presque Isle Designs creates and manages all of our marketing and branding materials.


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Here's a lesson in how you should never respond to someone on LinkedIn.
You may have suffered through a tough job interview, but you've probably never made any of these huge mistakes. Check out some of the most unbelievable interview mishaps here.
Whether you're interviewing for a job or negotiating a contract, these are five mistakes that can turn off the face on the other side of the table.
The life of a meeting professional is filled with time outside of the office. Treks to the airport, cross-country or continent flights, sitting around the terminal – it's endless and you need to stay on top of projects. Here's a few helpful tips to get you through your next trip.
Your travels don't stop deadlines so use your Google, iCal, Outlook (or all) to your advantage. Have something you need to review? Put it in the calendar. Need to send out an email at a certain time? Put it in the calendar. Need a report run? Put…you get it.
Communication is key for any team, department or organization to be successful. Let your team know when you're available, what you expect from them while you're gone and, most importantly, what kind of gift you're bringing back for them.
Wi-Fi is a beautiful invention, not only can you stream Netflix or watch hilarious cat videos… (go ahead click it, we'll wait) on your flight but you can get work done too! Use this time to your advantage, stuck 30,000 feet in the air and free from distractions (except the person who keeps making you get up so they can use the restroom) so make the most of it. These truly are amazing times.
This one may seem a little skewed since how can you get anything done if you're busy catching Z's but don't underestimate what a good night's sleep can do for you. You'll wake up refreshed and ready to tackle everything on your...
You've got your reminders set up, your team is ready for your absence and you're well rested. Writing out a to-do list will help you prioritize your busy day and physically writing things down help you remember. Plus the sweet satisfaction of drawing a line through that completed task is (almost) better than chocolate cake.
Have others? Share them in the comments below.
Please log in to post comments.
Audience engagement just got a whole lot easier. Poll Everywhere took a big leap forward by announcing the launch of a new polling app directly integrated into PowerPoint.
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General Forums >> Ask A Nurse >> How o you know an interview went well
How o you know an interview went well
9 posts back to top |
Posted over 2 years ago Hello, I am a new LPN grad and just went on my first interview to a LTC facility. It was a very strange interview. Lets start off by saying that from the time the DON first emailed me to tell me he would like to interview with me, he forgot to tell me the address to the facility, which I thought was odd. I had to wind up asking him for the address. Then when I finally met with him, he hardly asked any question about me, nor did he introduce me to other staff member, never got a tour of the facility, then he just cut the interview short and said well if theres nothing else...so before he was about to end the interview I remembered to ask what shifts were available. I dont understand how you dont even ask what shift you are looking to fill. But at the very end he asked me for three references. I thought it was a completely weird interview. I wanted to see your take on it . If any one has opionions or advice I would greatly appreciate it. Thanks PS: Dont want to forget to mention he kept getting interupted in the interview by phones calls and knocks on the door |
9 posts back to top |
| Posted over 2 years ago Is there anyone out there that has advice?? |
28667 posts back to top |
| Posted over 2 years ago This sure sounds a little fuzzy, I think I would look else where.. Best of luck, Teresa |


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walkman - 7:42 am on May 3, 2005 (gmt 0)
I wonder if they still do :). what do you guys think, was this manual, algo because of so many inbound links or just a minor G burp and they'll be back in a week? If it was a penalty: In their case they can never remove all the inbound links, but if they could, would they be back?
"Side with the big guy was the motive for those


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Don Goldmann, vice president of Word & Brown University at the Word & Brown General Agency, has been elected vice president of the National Association of Health Underwriters (NAHU). For the past two years, Goldmann has served as secretary on NAHU's board of trustees; he is also a past president of the California Association of Health Underwriters. Goldmann's election was announced at NAHU's 83rd Annual Convention and Exhibition in Atlanta. Also at that meeting Goldmann received the organization's Distinguished Service Award honoring his "significant contributions to volunteer service at the local, state and national level." In presenting the award NAHU said that Goldman's efforts "have greatly improved the health insurance industry through an extraordinary commitment of time, talents and professional experience," according to a report at the Fort Mill Times.
California Broker 2013 Directory
Insurance Industry Links


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Definition of Section, longitudinal
Section, longitudinal: A section that is cut along the long axis of a structure. Longitudinal section is the opposite of cross-section.
Source: MedTerms™ Medical Dictionaryhttp://www.medterms.com/script/main/art.asp?articlekey=5437
Last Editorial Review: 3/30/2012
Drug Medical Dictionary of Terms by Letter
Medical Dictionary Term:
Women's Health
Find out what women really need.


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Looking for something else?
The Rutland330 North Promenade, Blackpool, FY1 2JG (Show map)
Score from 56 reviews
Great clean family hotel. Very friendly owners who could not do enough to help. Plentiful breakfast. even gave us a late check-out at no extra cost. We will be returning when the weather is better. Thanks for a great family break
I was staying with two colleagues for an Exhibition at the Hilton, so the Hotel location was ideal for us. Immediately on arrival there is a warm welcome from Kay . The rooms were modern and clean and the breakfast was excellent. we will definately be staying at the Rutland next year.
Our stay was great better than we expected
Bar and location
Location was very good,staff very helpful and nice and friendly..Room a bit small but clean and cosy also nice and warm. Breakfast choice was excellent and service very good. Would recommend to my friends and family.
Very clean hotel and friendly staff who .were willing to help with everything, very good breakfast. We would recommend to anybody!
everything else was ok
Comfortable warm and friendly atmosphere had all the facilities we needed as a family for the week
Newmarket, Suffolk
The Hotel was lovely and clean, we had a family room and it was spacious and comfortable, the owners were friendly and welcoming and happy to help. The girls who worked in the mornings were lovely, always smiling and chatty and really good with the kids. Would recommend a stay at this hotel.
staff where very nice
nantyglo gwent
This family-run seafront hotel has a free Wi-Fi connection and superb views of the Irish Sea from the bar, restaurant and many of its recently refurbished rooms. With 3-star European Travel Commission accredited status, The Rutland has a relaxing well-stocked bar and restaurant, with special diets always catered for upon request. Children and pets are welcome, with a family-friendly bar area overlooking the sea and world-famous Illuminations. Relax with a cappuccino or a game of pool. The Rutland is well positioned for town centre shops, theatre shows, the Winter Gardens, several golf courses, Blackpool Tower and the highly popular Blackpool beach. Hotel Rooms: 19 Why use Booking.com?Why use Booking.com?Low ratesNo booking fees • Save money! • Best Price Guaranteed 433,187 properties worldwide
Including 116,364 holiday rentals Unbiased reviews26,050,000 reviews from real guests We speak your languageWebsite and customer service in English (UK) and 41 other languages Booking is safeWhen you book with us your details are protected by a secure connection. ActivitiesGames room Food & DrinkRestaurant, Bar InternetFree! WiFi is available in public areas and is free of charge. ParkingFree! Free public parking is possible on site (reservation is not needed). ServicesPacked lunches GeneralNon-smoking rooms, Family rooms, Non-smoking throughout Check-in15:00 - 22:30 hours Check-out08:00 - 10:00 hours Cancellation/
Craig-y-DonSituated on Blackpool's Promenade, Craig-y-Don offers free Wi-Fi, live entertainment and wonderful views over the Irish Sea. Central Pier is just a 5-minute walk away.
Score from 59 reviews
- 9/10
Barton HotelThis family-run hotel is metres from Blackpool Pleasure Beach and the Sandcastle Water Park. It has free parking, a bar with pool table and en suite rooms with a Freeview TV.Most recent booking for this hotel was yesterday at 19:56
Score from 265 reviews
- 8.9/10
Tiffany's HotelTiffany's is well-placed on Blackpool's North Promenade, 5 minutes' walk from Blackpool Tower and the North Pier.Most recent booking for this hotel was today at 13:31
Score from 197 reviews
- 7.4/10
Windsor HotelLocated just a few minutes from the Pleasure Beach, Windsor Hotel has been graded 3 AA Diamonds and offers excellent standards of accommodation.
Score from 124 reviews
- 8.6/10


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Super fast shipping, item exactly as described. Will purchase from this company again. ... read more
Cumberland Ceramic Table Lamp In A Turquoise Glaze And Silver Leaf Finish. The Shade Is A Light Gray Faux Silk With A Cream Liner
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*Free shipping on all Legrand orders. Free shipping on non-Legrand orders over $49. No sales tax except on orders to Missouri
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Find a Conversation
Wed, 07-25-2012 - 3:53pm |
Hi everyone I am due in February. My due date is a little confusing right now due to an early US I had because of a constant pain I was (and still) having. My LMP puts my date at Feb 8, but the US measuring had me later than that so right now I'm due anywhere between Feb. 8 and Feb. 16th. So we are not telling a soul until my fist apt which is in august so we can clarify the baby is growing and I have an official due date. I have finally gotten used to the idea of being pregnant, but hating how I am feeling. I have constant Nausea that starts at about 1100 and lasts the entire day, and the exhaustion that hits at 2 pm is crippling some days. I work full time so it is extremely hard when I can hardly keep my eyes open all afternoon. Can"t wait for the 1st trimester to be over so I can enjoy being pregnant. This is my 3rd pregnancy, we have a girl who is 5 and a boy who is 3. Looking forward to getting to know everyone through these next months
Wed, 07-25-2012 - 5:02pm |
Hi! and Welcome! Sorry about the pain you are having and hope it can get figured out. Sounds like since you are pretty sick (like me) baby is growing ok. I'm on #3 also! Hope to see you around the boards!
Thu, 07-26-2012 - 9:09am |
Congratulations on expecting your third child and welcome to the February 2013 Expecting Club! I hope that you find friendship and support here during your pregnancy journey. Wishing you a very happy and healthy nine months!
Sun, 07-29-2012 - 11:05pm |


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How the sons of Eazy-E and Dr. Dre plan to write the next chapter of NWA's legacy in . . . Lake Forest?!
By: Brian McManusIf you listen closely to Ke$ha's songs (and is there any other way to listen to Ke$ha? ), you already know quite a bit about her. She wakes up in the morning feeling like P. Diddy. She uses a bottle of Jack to brush her teeth (which sounds dangerous). Etc. Etc. So on. So forth. ANYW ... More >>
Norman Doray June 24, 2012 Yost TheaterSee also: *Rusko and Andy C - Hollywood Palladium - 6/1/12 *Armin Van Buuren - Sutra - 5/28/12 *Bingo Players - Yost Theater - 5/22/12 This past Saturday, the Yost Theater in downtown Santa Ana hosted DJ Norman Doray, a fiery French selector who hit the dec ... More >>
Watch out for 3hree Things (usually) every Tuesday, where Riley Breckenridge, drummer of Orange County's favorite local alt-rock band Thrice, gives his take on life in Southern California as an OC native.My obsession with the NBA Slam Dunk Contest started in 1985, and thrived for almost a ... More >>
The Detroit rapper lives the dream on his debut album
[Mental Notes] Plus: Introducing the softer side of Rob Zombie, and NYC inmate says he shot Tupac
Two men were arrested in England this week for trying to abduct the soul singer Joss Stone. Making the case stranger, the suspects reportedly had in their possession a Samurai sword and written plans to kill Stone and dump her into a river. Call us a bunch of softies, but we're perplexed that an ... More >>
The death of R&B legend Teena Marie continues to shock fans and fellow musicians around the world. Many stars have shared their memories and thoughts on this sad event. Celebrities including Mary J. Blige, Alicia Keys, Lenny Kravitz, along with news reporters and millions of fans, have paid t ... More >>
[Trendzilla] Find some of America's finest pair of denims at his La Habra store
'I'm Still Here' takes on the Hollywood machine. We think
I interviewed Soulja Boy (who I'll just go ahead and call by his real name DeAndre Way) recently, and it was pretty wild. The Atlanta-based, teen millionaire rapper wore his colossal, eponymous pendant--which he says contains a hundred Gs of diamonds--and bragged about how all the big names in hi ... More >>
●We'll dispense with the usual rundown of all things eye-rollingly wretched in the Reggie this week—our way of being nice, what with the new round of departures at OC's largest-circ fishwrap just announced. So we won't even get into that intellectually-challenging poll where the Reggie a ... More >>
Puffy AmiYumi Go Butch (Walker), Rock Harder, Stay Cute
Jay-Z's American Gangster Proves He Ain't All That—and Never Was
The (White) Rapper Flow: Loose Logic's Rhymes and Production Are On (Dana) Point
Ex-Dantalians Chariot guitarist comes to Orange County
Take the Kanye West aptitude test
Ugly Ducklings Politics Are Even Uglier
Ikey Owens and the sonic politics of race
Flub and bluster in Made
Is Cornel West the most hopeful man in America?
Ugly Duckling's Amazing Journey
Quick answers to questions we needed to ask OC's finest roots musicians!
Black Guys Imitating White Guys Imitating Black Guys: The strange end of the hip-hop revolution


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OK, thanks Terry and to all those who responded.
Type: Posts; User: rpdwyer; Keyword(s):
OK, thanks Terry and to all those who responded.
OK, so plywood glued and screwed to each joist... not a problem. However, as per my previous post, my concern is the finished position of the horizontal pipe in it's new location. It will likely be...
Gary, thanks.
Great idea. Glue and screw 2x2's. I've seen plywood used as well, glued and screw before the holes are punched to add extra support. Not sure which would be stronger, but I'm not...
Thanks Terry.
OK, so if I start my penetration on the first joist right at the 2" mark (from the bottom of the joist)... when I punch through my fourth joist next to the new toilet location, with...
Hello all.
Just joined this forum looking for some advice.
I have a master bath that was rough plumbed 10 years ago. We are only starting to convert it to a finished master bath (until now,...


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Share your Cajun tales and be part of library project
Published: Monday, September 11, 2006 at 11:00 a.m.
Last Modified: Monday, September 11, 2006 at 11:11 a.m.
THIBODAUX -- The Lafourche Parish Public Library is looking for help from the public to tell the story of Golden Meadow and south Lafourche.
The library, in cooperation with the town of Golden Meadow, plans to open an interactive historical center at the Golden Meadow branch focusing on the culture and history of the town and surrounding region.
"Its a dying culture," said library Director Beverly Arabie. "As the older generation dies off, the culture goes with them."
The primary purpose of the center will be to research, collect and display books and papers, pictures and photographs and other items that reflect the social, cultural, educational and economic history of Lafourche Parish and the Golden Meadow and south Lafourche areas in particular, Arabie said.
She said the library is hoping people will donate some of their own pictures, along with other artifacts such as furniture. Pictures can be donated or loaned and scanned.
Some displays will be permanent, some temporary; changing exhibits might focus on local American Indians or Mardi Gras, Arabie said.
The center features a patio styled to look like the front of a Cajun house, where organizers plan to videotape interviews with local people to preserve their stories of the past and present for future generations.
"They can talk and tell stories," Arabie said. "Its getting to where a lot of that history is getting lost."
An opening date for the center has not been set; rather, organizers simply plan to open when they think its ready. The library system and the town of Golden Meadow will share the cost, although the exact split has not yet been determined.
Arabie said the steering committee in charge of the new center is headed by local women Peggy Duet, Evelyn Anselmi and library board member Lorraine Bouzigard.
She said the three women are active in preserving the local history and culture; they were part of the team that got Golden Meadow Middle School declared a historical landmark.
For information about the Golden Meadow Library Historical Center, call 475-5660 or visit the library at 1403 N. Bayou Drive.
More information about the library system is available at www.lafourche.org.
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Brother Vs. Brother: Photo Highlights From Episode 4
See the amazing results of the first Brother Vs. Brother two-part challenge.
(45 photos)It's girls against guys and twin versus twin with the finish line in sight. Which contestant will win the $50,000 prize, and which brother will be crowned the first victor? Read on to find out.
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See the amazing results of the first Brother Vs. Brother two-part challenge.
(45 photos)How much value can you add to a house in 48 hours? Drew and Jonathan challenged their teams to find out in the Brother Vs....
(37 photos)Check out this recap from the series premiere of Brother Vs. Brother as HGTV's Jonathan and Drew Scott lead two teams of...
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Veils and YouTube trigger Canadian security investigation over passenger identification
Score one for social media: some guy popped a video of two fully veiled women boarding a plane on YouTube, and now the Canadian authorities are investigating. The video is said to show passengers hopping onto an Air Canada flight to London from Montreal on July 11, 2010. The beef isn't so much the veils as ensuring "that airline personnel are verifying the identity of all of passengers before they board a flight," according to the AFP.
In the video, shot by a British traveler, the women were not required to show their faces before boarding, which Canadian Minister of Transportation John Baird called "deeply disturbing" in a statement released Sunday. He added that it "poses a serious threat to the security of the air travelling public."
Filed under: North America, Canada, Airlines, Airports
Reader Comments (Page 1 of 1)
Vcitoria Aug 3rd 2010 4:42PM
If they were already checked at a security checkpoint, does it matter if they get on the right plane? That's more of an airline logistics issue than a security threat. Identity is irrelevant once someone has made it into the secure area, they're assumed to be weapon free and boarding a plane to their int'l destination. If they get on a wrong plane, like say a flight that would've cost way more than their original itinerary, the airline is out some money, but no one on the plane is in danger. On US domestic flights we never checked ID, just took their boarding pass and specifically announced that they wouldn't need their IDs at the gate. They were all security cleared, it's their problem if they go to Tulsa, OK instead of Spokane, WA...and believe me, it happened quite often with the correct boarding pass in had and all ;)
Former Gate Agent and Veiled Muslim.


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It's easy to get bored with green smoothies making them day after day. We always have our eyes peeled for new ways to mix them up and make them interesting and seasonal. With the idea of holiday foods already in full swing, we couldn't resist sharing this pie-inspired smoothie recipe from Krysten at The Daily Kale.
With protein, healthy fats and fiber from the almond butter and chia seeds, antioxidants from the berries and plenty of leafy greens, this smoothie packs a one-two punch – adding a great kick of nutrition to your morning and sending pie-cravings out the window!
Homemade Blueberry Pie Smoothie
1/2 cup blueberries
1 tbsp fresh ground almond butter
2 big leaves of kale
1 banana
1 tbsp chia seeds
handful of spinach
pinch of cinnamon
almond milk/water to desired consistency
Blend all ingredients thoroughly til smooth and enjoy a sweet and spiced way to get your greens on!
Do you make green smoothies you think are exceptional? We want your recipes! Send your green smoothie recipes to email@example.com and your smoothie could be featured on The Chalkboard next!