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Member News
LEGISLATIVE UPDATE (WEEK 9): In an effective power move led by Senate President Andy Biggs, the GOP Leadership team at the Arizona Legislature rammed a budget through that carried just enough votes to land on Governor Doug Ducey's desk today. The process began last Wednesday with the introduction of 13 identical budget bills in both chambers. Things moved relatively fast following that and after a lot of arm twisting by the Leadership and the Governor, the Legislature pulled a rare "all-nighter" last Friday and approved the austere $9.1 billion budget package. Governor Ducey has signed the budget bills.
Moderate Republican lawmakers tried to bargain for reduced cuts, and in the end only got some slight reductions along with a series of minor changes to policies in the budget proposal. The proposed $104 million cut to state universities, the largest sticking point for many lawmakers, was only reduced to $99 M. Likewise, the holdouts were unable to lessen the five (5) percent cut to provider rates under the AHCCCS (Medicaid) program, although that cut will not take effect until October 1st. Republican Rep. Heather Carter, along with most of the Democrat caucuses (led by Rep. Eric Meyer, MD, and Sen. Katie Hobbs) stood firmly and were among those who voted no on the health-related budget cuts. We made it clear to all that the effect of these cuts will put availability of physicians in jeopardy as payment for care may now be below costs. In numerous floor speeches, Republicans boasted about how the budget was fiscally responsible, balanced and set the state on a path to be fiscally balanced by FY18. However, this GOP-backed budget is a tenuous one and may be obliterated if the Legislature loses its appeal in the Cave Creek K-12 funding lawsuit.
SB 1290, an important measure sponsored by Sen. Kelli Ward of Lake Havasu to help protect physicians who perform independent medical exams (IMEs) in workers compensation cases, is heading to the Rules Committee, through the caucuses, and then to the floor. The bill is needed to protect physicians from unwarranted, harassing and potentially damaging licensing board complaints and to keep the workers comp system functioning at a high clinical level.
As previously reported, the SB 1258 (a follow-up bill to enacted SB 1149), to help relieve the AMB's licensing backlog, had been held up over concerns with an amendment added on the Senate floor to require that the AMB issue an RFI (request for information) to companies interested in doing the credentialing verification functions for the Board. The AMB is worried that this is a first step towards mandatory outsourcing of credentialing verification and has timing concerns, too. Fortunately, AMB appears to have worked things out with the bill's sponsor Sen. Ward, and an amendment will be offered to address the issues of concern to the AMB. In anticipation of that resolution the bill has been added to the Health Committee agenda for next week.
SB 1370, a bill reforming the controlled substance prescription monitoring program (CSPMP), easily cleared committees in the House and is scheduled to be heard on the floor. Still in the wings is a bill to extend peer review protections now enjoyed by hospitals to non-institutional settings that we think will remain viable and move next week.
SGR UPDATE: The current sustainable growth rate (SGR) temporary patch expires on March 31, and Congress must act by then to avoid a 21.2 percent reduction in Medicare payments to physicians. News outlets have been buzzing about a proposed deal circulating in Congress that includes a permanent repeal of the flawed SGR formula. The current proposal also addresses the Children's Health Insurance Program (CHIP) and with a total cost exceeding $200 billion, offers only a partial cost offset. Funding has stymied previous attempts at a permanent fix of SGR. There have also been speculations that any extension, temporary or permanent, could possibly be tied to another ICD-10 delay. Our congressional delegation is constantly being reminded a permanent fix is needed otherwise physicians will not be able to afford to see Medicare patients.
LEGISLATIVE UPDATE: It was another action-packed week at 1700 West Washington, as a package of state budget bills were introduced in unison by the Senate and House Republican Leadership, and they vowed to gather the needed "16 and 31" (the minimum number of yes votes needed to pass legislation in the Senate and House, respectively) to get the budget passed by this weekend. Governor Ducey signaled he welcomes this budget news and is ready to add his signature should the legislative process succeed. In general terms, this joint House/Senate GOP budget plan is more austere than the one the Governor offered two months back. It ups the cuts to the universities from Governor Ducey's $75 M to $104 M, it ends all state funding for Maricopa, Pima and Pinal community colleges, and makes a host of other cuts that are deeper that the Governor's proposal. Leadership argues that this greater austerity is needed to end years of structural imbalance and the reliance on accounting gimmicks to "balance" the budget each year.
On the health care front, there are changes too. Most notably and unfortunately, the cut to provider payments under AHCCCS are worse. Instead of the Governor plan's cut of three (3) percent, the legislative budget bills call for a five (5) percent cut. It is again left to the AHCCCS Director to decide how to mete out the cut. There is one small measure of good news, but a very modest one: instead of starting the cut in April (as called for by Gov. Ducey), the bills delay the cut until October 1, 2015. ArMA and PCMS is joining the chorus of voices expressing concern to lawmakers that this proposed five (5) percent cut will simply result in a significant number of physicians reluctantly deciding they can no longer afford to keep treating AHCCCS patients.
Another interesting piece of the health-related budget bill is a provision that tries to copycat states like Indiana, which recently received a waiver from CMS to allow cost-sharing mechanisms in the state's Medicaid program in return for agreeing to expand the program. The bill provision directs AHCCCS to seek approval from CMS for new cost-sharing mechanisms which differ slightly for the expansion population and the traditional Medicaid population.
So, will there be "16 and 31" for this tough budget package? It remains to be seen, as the Legislature works through this weekend to find out. At last report, there were a good number of Republican holdouts in both the House and Senate, so perhaps they will continue standing firm.
Turning to non-budget bills, in House Health this week we saw the quick passage of SB 1370, Sen. John Kavanagh's controlled substances prescription monitoring program (CSPMP) reform measure. SB 1370 passed unanimously, 7-0.
ArMA's advocacy team had dynamite physician testimony lined up to make a compelling case for our IME bill (SB 1290), a bill that Sen. Kelli Ward sponsored for us to help protect physicians who perform independent medical exams (IMEs) in workers comp cases from baseless, harassing complaints to the medical licensing boards. The bill was unanimously approved in the Senate, but due to late surfacing opposition from a few physicians, House Health Chair Rep. Heather Carter made a same-day decision to delay SB 1290 a week. Always fair and deliberate, Rep. Carter wanted a bit more time to study the bill and understand the arguments against it. We are confident she now understands the rationale behind the bill and sees that it helps solve a very real problem faced by the many highly-qualified physicians who perform IMEs. SB 1290 is now set for hearing on Tuesday afternoon, 3/10, and we will be ready for action then.
Likewise, Rep. Carter held at the request of the Arizona Medical Board (AMB) SB 1258, the follow-up bill to SB 1149, the bill that Governor Ducey signed as an emergency measure to help relieve the AMB's licensing backlog. The AMB has concerns with an amendment to SB 1258 that was added on the Senate floor, to require that they issue a RFI (request for information) to companies interested in doing the credentialing verification functions for the Board. There are concerns with this is a first step towards mandated outsourcing of the credentialing verification functions, and the AMB isn't ready to go in that direction, not yet anyway.
ACA UPDATE: Last week the U.S. Supreme Court heard arguments in the Affordable Care Act (ACA) challenge posed by King v. Burwell. This case challenges the legality of the Internal Revenue Service (IRS) rule allowing subsidies in states that opted to use the federal health insurance exchange rather than build their own. It is based on a close reading of the key phrase stating that subsidies will be available to Americans enrolled through "an exchange established by the state," and it has enormous implications. If SCOTUS rules in favor of the plaintiff, millions of Americans stand to lose their subsidies, and the health insurance industry anticipates upheaval. If SCOTUS did not include a delay in such a ruling, Republicans in Congress have even suggested that they might act to extend the subsidies to the end of 2015 in order to allow time for them to pass alternative legislation. The Obama Administration maintains that it does not have a contingency plan. Speculation abounds and the court appears split.
AMB APPOINTS NEW EXEC DIRECTOR: The Arizona Medical Board has appointed Patricia McSorley as executive director. Ms. McSorley has been employed by the Arizona Medical Board since 2005. For more than eight years, she managed the Investigations Department. On two occasions, she has been asked by the Board, and has served, as the Acting Interim Executive Director. Ms. McSorley holds a Juris Doctorate from Brooklyn Law School. Previously, she served as the Assistant Commissioner for the Bureau of Investigations and Trials with the New York City Fire Department. On February 26, the Board's Executive Director Committee appointed her as the Executive Director of the Arizona Medical Board and the Arizona Regulatory Board of Physician Assistants.
SCOTUS SETS TROUBLING PRECENDENT: In the case of North Carolina Board of Dental Examiners v. Federal Trade Commission, the U.S. Supreme Court ruled that the dental regulatory board illegally suppressed competition when it issued an edict against non-dentists offering teeth-whitening services. In effect, the ruling sets a precedent that state boards can be sued for antitrust. As it is common practice for regulatory boards to consist mostly of members of the profession, the case was of interest to physicians. The American Medical Association (AMA) had filed an amicus brief in support of North Carolina Board of Dental Examiners. There are serious concerns that this ruling could blur the line on determining whether certain medical procedures might be inappropriately undertaken by non-physicians, as dissent from the regulatory board of professionals can now be interpreted as an antitrust issue rather than a patient safety issue. The Arizona Medical Board has 12 members; it requires that four be non-physicians, one of which must be a licensed practical or professional nurse. The implications of this case for Arizona are both unclear and of concern.
LEGISLATIVE WEEK SIX: On Wednesday, Governor Doug Ducey wasted little time in putting his signature on SB 1149, only the second bill to reach him this session. It clears the physician licensing backlog at the Arizona Medical Board (AMB) which had affected many practices' ability to bring on new physician hires and stymied the license renewals of current AZ doctors. As amended, SB 1149 does three things: (1) rectifies the interpretation problems with the fingerprinting and criminal background check requirements added into law last session; (2) retroactively removes the requirement for fingerprinting of physicians at the time of license renewal (so this requirement will only apply to new license applicants); and, (3) requires the AMB to refund fees collected from physicians for background checks during their license renewals.
ArMA's legislation to stop spurious and burdensome licensing board complaints against physicians who perform independent medical exams (IMEs), SB 1290, garnered the full support of the AZ Senate yesterday, passing on third reading by a unanimous 29-0 vote.
Likewise, SB 1370, the bill sponsored by Sen. John Kavanagh to make compliance improvements to the state's controlled substance prescription monitoring program (CSPMP) came through Senate Committee of the Whole with ease. The bill now heads to third reading in the Senate, early next week.
CDC RECOGNIZES ARIZONA DESIGNATED EBOLA CENTER: This week, the Centers for Disease Control and Prevention (CDC) identified Maricopa Integrated Health System and University of Arizona Health Network as two of the 55 Ebola Treatment Centers in the United States. These two systems had already been designated Infectious Disease Treatment Centers of Excellence by the Governor's Council on Infectious Disease Preparedness and Response in fall of 2014. The Council was formed in response to concerns during the Ebola outbreak of 2014. CDC has posted a brand new list of all designated facilities and determined, because more than 80% of returning travelers from West Africa are within 200 miles from a designated treatment center, they will no longer be adding additional centers to their list. The plan and support from the Council allowed the Arizona facilities to be visited early by the CDC Rapid Ebola Preparedness Team and meet the requirements under a very short time period.
ARIZONA ADHS / VACCINE NEWS: ADHS Immunization Program Office released the latest edition of Arizona Vaccine News today. The publication provides an overview of vaccine news, new literature and resources. This edition covers topics in pertussis, measles and influenza, and recommendations for pneumococcal immunization of patients over 65 years of age, as well as CMS policy on Medicare payments. The edition also includes information on the efficacy of a new dengue vaccine.
CMS SHIFTING MEDICARE PAYMENT MODELS: The Department of Health and Human Services (HHS) has announced goals and timelines for Medicare related to quality and the use of alternative methods of healthcare delivery. By 2016, HHS intends that 30 percent of Medicare fee-for-service payments will tie to alternative payment models, such as Accountable Care Organizations (ACOs) and bundled payments, and 85 percent will be based on quality. These percentages will increase to 50% and 90%, respectively, by 2018. The HHS goals are intended to increase value and promote care coordination across the healthcare continuum by focusing on three areas:
- Payment incentives - rewarding value and care coordination, rather than volume and duplication of care
- Care delivery improvement and innovation - supporting providers to find ways to coordinate and integrate care with an emphasis on prevention and wellness
- Sharing information - creating more transparency on cost and the quality of health care; using electronic health information to inform care; and having the most recent scientific evidence available to help providers in clinical decision making.
HHS plans to work with state Medicaid agencies, private payers, providers, and others to expand alternative payment models into their programs. For additional information, visit the HHS website.
LEGISLATIVE WEEK FIVE: Licensing: Two very important AMB bills SB 1149 by Sen. Kelli Ward and HB 2521 by Rep. Heather Carter are being supported through fast tracking. These bills, which have been on converging paths in their respective legislative bodies, make critically needed quick-fixes to get the AMB back on the right track and relieve the licensing logjam, both for renewals and new licenses. As now amended, the bills do three things: (1) rectify the narrow interpretation problems with the fingerprinting and criminal background check requirements added last session; (2) retroactively remove the requirement for fingerprinting of physicians at the time of license renewal (so the requirement will only apply to new license applicants); and, (3) require the AMB to refund fees collected from physicians for fingerprinting during their license renewals. They both contain emergency enactment clauses, so if they receive 3/4 of the votes in both bodies of the Legislature, they will become effective as soon as the Governor signs them.
SB 1149 was rushed through the Senate this week, passing 28-0 (much more than a 3/4 vote). HB 2521 was for a short time held in House Rules, but late Thursday the House passed HB 2521 in COW and then (needing to send only one of the two bills to the Governor) swapped it with identical SB 1149, which it passed 58-0. In other words, the Legislature clearly heard our message on the need for these AMB "quick fixes" and everyone voted yes on this legislation! SB 1149 will now be transmitted to Governor Ducey, and we expect he will promptly sign this bill into law.
CSPMP: Another bill of importance to us is, SB 1370, which deals with checking the state's controlled substances prescription monitoring program (CSPMP). This bill, by Sen. John Kavanagh of Scottsdale, successfully came through Senate Health & Human Services on Wednesday, 7-0, and will be up in Rules on Monday. SB 1370 is one of two Senate bills on that topic this year (the other was Sen. Ward's SB 1031). ArMA advocate Steve Barclay worked effectively on both bills early in the session with other stakeholders to find an acceptable compromise with the two bill sponsors and remove some difficult language mandating the use of the CSPMP by physicians and other prescribers before writing prescriptions. Reporting by pharmacists when filling prescriptions for controlled substances is already mandatory. Sen. Ward ultimately agreed to give way to Sen. Kavanagh's SB 1370. So we now have a supportable bill by all concerned.
During the last weeks stakeholders helped modify SB 1370 into a bill that creates a more of a seamless, behind-the-scenes approach by the licensing boards to getting all prescribers holding DEA numbers registered with the monitoring program without further affirmative steps on the prescribers' part. The objective is to remove the obstacles to voluntary use of the program by all licensed prescribers, and then encourage (but not require) better use of the CSPMP. A pilot being run by the AZ Pharmacy Board to educate prescribers and give them useful feedback on their prescribing patterns should help with that part (so far the pilot is working well and it's to be rolled out in Maricopa and Pima Counties later this year). We appreciate the willingness of Senators Kavanagh and Ward to listen to ArMA's suggestions for improving compliance in a voluntary fashion -- if we can achieve a greater level of voluntary use of the CSPMP, we can avoid a future legislative mandate on physicians to do so.
Independent Medical Exam: The "IME" bill, SB 1290, has been successfully guided through the Senate Commerce Committee. This bill, to protect physicians from harassing licensing board complaints for merely performing an independent medical exam (IME) in a workers comp case, has been brought forward by ArMA and Copper Point Mutual Insurance, the state's largest comp carrier. Mr. Barclay provided the committee testimony - aided by very persuasive documentation from Carol Peairs, MD and Mike Powers, MD - and the bill passed handily on a 7-1 vote. It will now be considered in Rules.
Peer Review: An important measure to improve existing law protecting health care quality assurance (aka peer review) activities from disclosure (ARS Sections 36-2401 through 2403) was passed through House Health this week too, 5-0. This bill, which helps ensure that the sharing of the peer review data between entities won't waive the non-disclosure privilege, emerged via a "strike-everything" amendment to HB 2556 (a bill on a different topic). The sponsor of the striker amendment (and the underlying bill) is our new Vice Chair of Health, Rep. Gina Cobb, from Kingman, who is a practicing dentist.
MEASLES PROTOCAL: Measles is a highly contagious, acute viral illness which can cause severe health complications, including pneumonia, encephalitis, and death. It is transmitted by contact with an infected person through coughing and sneezing; infected people are contagious from four days before their rash starts through four days afterwards. After an infected person leaves a location, the virus remains viable for up to two hours on surfaces and in the air. Measles begins with fever (101 degrees F or higher), red, watery eyes, cough and coryza (runny nose). This is followed by a maculopapular rash (red, raised, and blotchy). The rash begins on the head at the hairline and moves down the trunk to the lower extremities. The rash may last for 5-6 days and turn brownish. Symptoms typically appear 7-12 days after exposure to measles but may take up to 21 days. A person with measles is considered to be contagious four (4) days before rash onset (generally one day prior to fever) through the fourth day after rash onset. Evidence of immunity for healthcare workers consists of two documented doses of MMR vaccine or positive serology or physician documented infection with measles. For those with one vaccine, they may receive a second and return to work. For those born prior to 1957, a single documented dose of vaccine or positive serology is sufficient unless we develop an outbreak in our community, in which case two doses of vaccine would be recommended for all ages.
All clinicians are strongly urged to:
- Ensure you are immune to measles. If a measles exposure occurs in a healthcare setting, healthcare workers without adequate evidence of immunity will be excluded from work for 21 days following the exposure or until the healthcare worker can provide evidence of immunity to measles.
- Review and ensure documented immunity to measles for ALL healthcare workers. This includes ancillary staff such as office staff, dietary, housekeeping, maintenance, vendors and volunteers - anyone who may share airspace in your facility with a patient. If such documentation does not exist, we recommend vaccination over serologic evaluation.
- Consider measles in your differential diagnosis for all patients with a consistent prodrome and exposure or ANY rash illness.
- Report all suspect cases to your infection control department and/or Pima County Health Department (http://webcms.pima.gov/cms/One.aspx?portalId=169&pageId=185804).
- Place surgical masks and signs at all healthcare entrances alerting anyone with cough, runny nose, red eyes, fever OR a rash illness to wear a mask BEFORE they enter the hospital/facility. These patients should tell the receptionist about their symptoms and be evaluated by a healthcare provider before they remove the mask. Ask visitors to postpone their visits to hospitalized patients until symptoms have resolved.
- Implement airborne isolation protocols for all patients with rash illness (i.e. possible measles) presenting for healthcare until an alternate firm diagnosis is made. If airborne isolation is not available, place the patient in a private room with the door closed and place a surgical mask on the patient.
ADHS has compiled extensive information for clinicians as well as the general public at www.azdhs.gov/measles/. ADHS has also updated its measles clinician fact sheet and it is available for download here.
THE LEGISLATURE WEEK FOUR: We are very pleased to report SB 1040, a dangerous bill to allow chiropractors to seek an advance certification as part of their licenses to be allowed to prescribe four drugs: two NSAIDs (ibuprofen and naproxyn) and two muscle relaxants (cyclobenzaprine and methocarbomol), has been stopped! The bill was sponsored by Senator Nancy Barto, who as Chair of Senate Health was in a powerful position in terms of pushing her bill through that very committee.
Tucson's Ray Woosley, MD PhD, wowed the committee with his heartfelt, impactful testimony on the dangers of allowing untrained, unqualified providers to prescribe these potentially dangerous drugs. Dr. Woosley, as many of you know, is the founding President and Chairman of the Board for CredibleMeds Worldwide, a non-profit organization dedicated to safe use of medications. He is the quintessential expert on clinical pharmacology.
This is a very gratifying considering the bill posed a threat to the integrity of the sunrise process required of scope of practice expansions, and most importantly, to patient health and safety. We'll stay on guard and be ready should the bill resurface in Health or another legislative committee.
IMEs: Working in tandem with Copper Point Mutual (the former State Comp Fund), ArMA has a helpful bill teed up to address an annoying problem: the filing of licensing board complaints against doctors for the sole reason that they perform "IMEs" (independent medical exams) on injured claimants in workers comp cases. The complaints are being filed by claimants for harassment and intimidation purposes, to cause a chilling effect on doctors so they won't do more IMEs. SB 1290, sponsored by our friend (and doctor) Sen. Kelli Ward, will help fix this problem. The bill comes up for its first committee hearing on Monday afternoon.
AHCCCS CUTS: A fact sheet packet about the impact of proposed AHCCCS provider reimbursement cuts has been created and will be shared with our legislators. The packet includes an overview of the findings from the AHCCCS provider survey ArMA conducted several weeks ago. The packet can be viewed here.
THE LEGISLATURE WEEK THREE: The week at the Capitol began with a large meeting of stakeholders from both the health professions and their regulatory bodies, plus Senators Kavanagh and Ward, to discuss the proposed improvements to and streamlining of the prescription drug monitoring program (PDMP). At first the regulatory boards seemed reluctant to agree. They didn't like the bill draft that essentially told them to "work things out" to make for a more seamless process of registering licensees automatically for the PDMP and not making them jump through added hoops to access it and renew their registrations. But then Sen. Kavanagh and Sen. Ward walked in, and let's just say the mood changed a lot...so, we now have a game plan moving forward that, once implemented, should help clear the barriers to voluntary compliance by all types of DEA-license-holding prescribers with the PDMP. Bear in mind, though, that the Legislature will be watching how we all do, and if there isn't continued increase in terms of checking the PDMP before prescribing class II drugs, then we may face a mandate to use the PDMP in a few years.
On Tuesday, the House Health Committee heard brief testimony from the Arizona Medical Board (AMB) and then quickly approved the House version of the AMB "quick fix" bill, HB 2521, by a 6-0 vote. The bill, and its mirror image bill in the Senate (SB 1149), does two critical things: fixes the physician background check snag with the FBI, and retroactively gets rid of the fingerprinting requirement for renewals (in other words, it will apply only to new applicants). The bills also contain emergency enactment clauses, so they can take effect faster (if they both secure a 3/4 vote).
House Health Chair Heather Carter said HB 2521 was one of the most important bills her committee would consider this session. The next afternoon, the Senate Health Committee unanimously approved the counterpart bill, SB 1149. The sponsor of SB 1149, Sen. Kelli Ward, announced that she intends to offer an amendment on the Senate floor to require the AMB to issue refunds to licensees who paid fees for fingerprinting that will not be necessary with the passage of these bills. While the bills both have to be considered in Rules and then go to the full House or Senate.
Last week ArMA's advocate Steve Barclay and our allies at the Arizona Osteopathic Medical Association (AOMA) and Arizona Chapter of the American Academy of Pediatrics (AzAAP) were asked to meet with Senator Nancy Barto and representatives of the Arizona Association of Chiropractic (AAC) to discuss the Senator's bill for the AAC, SB 1040. This bill would give prescribing privileges to chiropractors -- after yet-to-be-defined added educational and rotational prerequisites -- for four drugs: ibuprofen, naproxen, methocarbomol, and cyclobenzaphrine. Even more troubling, however, is that SB 1040 was never approved through the "sunrise" process by the legislative Committee of Reference (COR). Their application for these prescribing privileges was rejected in 2013 by the COR (on a 4-3 vote against), and last fall the AAC elected not to apply again through the sunrise process. Instead, they are trying to do an end-run on the sunrise process and avoid having their drug prescribing proposal rejected again by the COR.
Unfortunately, Sen. Barto believes that the AAC has met the spirit of the sunrise process (if not the letter). She's pushing their bill forward over our objections and those of AOMA and AzAAP, and we will have to try to stop her bill in Senate Health next week. Steve and his colleagues will be putting on a full court press to do that, arguing both against the end-run around the sunrise process and the lack of valid science to support allowing even limited prescribing privileges to chiropractors.
MEASLES IN ARIZONA: There are currently SEVEN confirmed cases of measles in Arizona, with >1,000 exposures in the community and at four healthcare facilities in Maricopa, Pinal, and Gila counties. Pima County has NO confirmed cases. Recommendations for providers:
- Isolate patients presenting with a febrile rash illness and evaluate for measles
- Immunocompromised patients may not have rash or present with atypical rash
- IMMEDIATELY consult with your local health department for suspected measles cases
- Collect NP (Dacron) swabs & urine for PCR and serum for IgM serology on suspected cases
- Ensure patients and staff are up to date on MMR vaccine and other vaccinations.
HHS SHIFTS REIMBURSEMENTS FROM VOLUME TO VALUE: HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments. To make these goals scalable beyond Medicare, Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network. Through the Learning and Action Network, HHS will work with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models into their programs. HHS will intensify its work with states and private payers to support adoption of alternative payments models through their own aligned work, sometimes even exceeding the goals set for Medicare. The Network will hold its first meeting in March 2015, and more details will be announced in the near future.
ACA UPDATE: This week, the federal government filed its brief responding to the challengers in the King v. Burwell lawsuit, which claims the Affordable Care Act (ACA) language does not allow for subsidies to be available to people in states on the federal exchange. The brief argues that the "text, structure, design, and history" of the law indicates its intent to make subsidies available regardless of who sets up the exchanges; in addition, the brief argues that the challengers' reading of the law transforms the subsidy structure into a "threat" and therefore disrespects "state sovereignty."
This tax season marks the first time families will be asked to answer basic questions regarding their health insurance on their tax returns. Most consumers just need to check a box to indicate they have coverage, but those with Marketplace coverage will receive a new form in the mail, Form 1095-A, that they will use to reconcile their upfront financial assistance. In the coming weeks, tools and resources will be made available for those tax filers who have health coverage through the Marketplaces, those seeking an exemption, and those looking for information about the fee for those who could afford to purchase health coverage but chose not to.
ADHS HEALTH ADVISORY: The Arizona Department of Health Services reports that 40 patients have had adverse events associated with Wallcur's simulated IV saline solution, Practi-0.9% sodium chloride solution and it is associated with various adverse events, hospitalization and 1 death in Florida, Georgia, Idaho, Louisiana, North Carolina, New York, and Colorado. No deaths or adverse events have been reported in Arizona at this time. These products are not sterile and should not be injected in humans or animals. Clinicians and office staff are encouraged to take steps to ensure IV solution simulation products are removed from office inventory to eliminate the possible injection of Wallcur simulated products into patients. If you suspect that any Wallcur training IV products have been administered to patients please contact FDA's MedWatch program online or at 1-800-332-1088. FDA recommendations and guidance can be located here. If you have any questions or concerns you may contact Arizona Department of Health Services HAI Program at 602-376-3676 or firstname.lastname@example.com.
IRS, TAX RETURN SCAM UPDATE: In 2014, a number of physicians nationwide found themselves victims of a tax-filing scam. ArMA worked with the FBI, IRS and Secret Service to locate and assist any ArMA members impacted by the scam. In order to allow those who were affected by the scam to file electronically in the future, all reported victims will be provided with a special individual pin number that will allow you to again file electronically. The IRS has updated us that all those reporting a scam have received a PIN so that they can file electronically. If you have not yet received your PIN, contact your local IRS office.
SEVERAL SCOPE OF PRACTICE EXPANSIONS DEFEATED: The Arizona Medical Association announced last week that two scope of practice expansion Sunrise applications had been withdrawn by their sponsors. The Sunrise Process is unique to Arizona and was lobbied into place by ArMA many years ago in order to minimize the lack of scientific presentations that were occurring at the legislature over medical scope of practice expansion requests as well as requests for new licensure. Non-physician groups were finding legislative sponsors to introduce licensure or scope expansion bills, and hearings were taking place where little or no scientific justification was presented as to the rationale or qualifications of the group seeking these changes. The Sunrise Process established a requirement that any group seeking certification or an expansion in its scope needed to notify the legislature of their request prior to the session convening, and a bi-cameral group, Sunrise Committee of Reference (COR), was established to hear testimony as to the need for the expansion or certification, and qualifications of the group seeking the changes. The COR then issues a report indicating support or lack thereof for the application. The findings report and recommendation of the COR is very influential as to whether or not the group goes forward with its legislative request and the ultimate legislative outcome.
Recently the Arizona Naturopathic Medical Association notified the legislature they were withdrawing their request to be authorized to prescribe Schedule II drugs. ArMA, PCMS, MCMS and others have been intense in our opposition, and we had provided legislators with medical, scientific facts from a renowned physician expert explaining the danger this presented to patients. It became clear our opposition was convincing and we had the votes to stop it. The naturopaths opted to withdraw the application rather than sustain a significant loss. A thank you goes out to Ray Woosley, MD, PhD, University of Arizona faculty and pharmacology expert, who provided irrefutable information on the danger this presented. Also of significance was the withdrawal of the Arizona Pharmacy Association's application to allow pharmacists to immunize children ages 6-17 without a physician's prescription. ArMA, the Arizona Chapter of the American Academy of Pediatrics (AzAAP), and the Arizona Academy of Family Physicians (AzAFP) collaborated to oppose this request which would have shattered a key element of physician oversight with young children. The pharmacists, who we should point out are generally supportive of our issues, realized the validity of our concerns and decided to withdraw their request. In all, this is a very good ending to actions we feel would have compromised patient care, in some cases to a dangerous degree. Both are clear, working examples of how critical it is for medicine to advocate for patient safety, during the legislative session and throughout the year.
NEW MEDICARE PAY CUTS SCHEDULED IN 2015: Physicians have until December 31 to decide whether they will be participating or nonparticipating physicians in the Medicare program next year. In addition to the annual threat of a steep payment cut as a result of the sustainable growth rate (SGR) formula, another factor for physicians to consider in making the decision this time around is that 2015 will be the first year that the Centers for Medicare & Medicaid Services (CMS) will impose penalties under the value-based modifier (VBM) program. According to CMS, 1,010 groups of 100 or more eligible professionals will see payment adjustments from the VBM in 2015. More than 300 of these groups will face Medicare payment cuts of 1 percent, while a few others will see cuts of 0.5 percent. Only 16 groups will receive bonuses of an amount yet unknown. Other penalties that will be applied in 2015 based on 2013 performance-including those tied to quality reporting, meaningful use and ePrescribing-will decrease the limiting charge amounts that nonparticipating physicians can bill to patients for unassigned claims. The VBM penalties and bonuses, however, will not apply to unassigned claims so that means practices facing a VBM penalty next year could avoid the penalty by choosing the nonparticipating physician status option. As described in the AMA guide to Medicare participation options, the Medicare payment schedule for nonparticipating physicians is set 5 percent below the participating physician payment schedule. At the same time, nonparticipating physicians can bill patients for 15 percent above that lower payment schedule amount. While participating physicians agree to accept assignment for all Medicare claims, nonparticipating physicians can decide whether to accept assignment on a claim-by-claim basis. This year, 96.6 percent of physicians are participating. Physicians who want to become nonparticipating in 2015 must send a letter to their Medicare contractor postmarked before January 1 to terminate their participation agreement for the coming year. (Source: AMA Advocacy Update, 12/04/2014)
ADHS RELEASES OPIOID PRESCRIBING GUIDLEINES: The Division of Public Health Services at the Arizona Department of Health Services has released the final version of the state's Opioid Prescribing Guidelines. They are the result of input and expertise of practitioners from across the state representing professional associations, health plans, academic institutions, federal health care providers and others.
The objective of the guidelines is to balance the appropriate treatment of pain with approaches to more safely prescribe opioids and complements other statewide "best practice" guidelines for Emergency Department Controlled Substance Prescribing and Dispensing Controlled Substances.
An important next step to encourage use of the Arizona Opioid Prescribing Guidelines is training that will help prescribers implement Arizona's guidelines. The University of Arizona is in the process of putting together free, online training that is expected to be available in January. We will notify you when the training is available.
TEN (10) MEDICARE PAYMENT REVISIONS IMPORTANT TO YOU: Without a doubt you haven't read through the nearly 1,200 pages that makes up the 2015 Medicare Physician Fee Schedule final rule released Oct. 31 and published Thursday in the Federal Register. Here are the 10 top payment policy changes discussed in this humongous document that you need to know about.
- The sustainable growth rate (SGR) formula calls for a 21.2 percent cut to physician payments, effective April 1.
- Continuing medical education (CME) will not be reported under the Physician Payments Sunshine Act.
- Proposed penalties under the value-based payment modifier (VBM) will be scaled back.
- The Physician Quality Reporting System (PQRS) becomes a penalty-only program next year.
- The Physician Compare website will continue to expand-but not as much as planned.
- Chronic care management services will be supported by a monthly payment.
- Four services now are eligible for telehealth payment.
- Surgical global periods will change from 10- and 90-day periods to 0-day periods.
- There are 350 CPT codes identified as new, revised or potentially misvalued-318 of these changes were based on physician input.
The timeline for submitting new codes and revaluations of services will shift. The deadline for receiving all code and value recommendations for the following year's payment policies will be February to allow more time for public comment.
You can read more about these and other components of next year's Medicare payment policies by viewing the complete AMA Wire post.
FLU ALERT: The Arizona Department of Health Services and the Pima County Health Department have confirmed the first influenza case in Arizona for the 2014-2015 influenza season. A child with no recent travel was diagnosed with influenza A (H3) by PCR at the Arizona State Public Health Laboratory.
We strongly recommend vaccinating your patients and staff against influenza throughout the flu season. All eligible individuals aged 6 months or older should be vaccinated.
Please remind your patients the best way to prevent flu and other respiratory diseases, include:
- Get vaccinated against the flu,
- Wash hands often,
- Avoid touching your face with unwashed hands,
- Cover your cough and sneezes,
- Clean and disinfect surfaces frequently,
- Avoid close contact with sick people, and
- Stay at home if you are sick
For questions regarding the 2014-2015 flu vaccine, you can call your local health agency or the Arizona Immunization Program Office at (602) 364-3630.
For a list of influenza vaccine clinics please go to www.StopTheSpreadAZ.org. This year's national influenza vaccine recommendations are available at www.cdc.gov/flu/protect/vaccine/index.htm or www.cdc.gov/vaccines/hcp/acip-recs/index.html.
For more information about flu, please contact your local health department or the Arizona Department of Health Services or log on to www.azdhs.gov/flu/ or www.cdc.gov/flu/.
CDC OFFERS UP NEW ALGORITHM FOR MANAGEMENT OF POTENTIAL EBOLA PATIENTS: Dr. Francisco Garcia, director and chief medical officer for the Pima County Health Department, has asked that we post the attached algorithm for our membership. This is the protocol being followed by the health department for first responders, hospitals and clinics. To review go to: http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf
CDC ISSUES REVISED INTERIM U.S. GUIDANCE FOR MONITORING AND MOVEMENT OF PERSONS WITH POTENTIAL EBOLA VIRUS EXPOSURE (Issued October 28, 2014):
The Centers for Disease Control and Prevention (CDC) issued revised Interim U.S. Guidance for Monitoring and Movement of Persons with Ebola Virus Exposure. This guidance provides new information public health authorities and other partners can use to determine appropriate public health actions based on Ebola exposure risk factors and clinical presentation. It also includes criteria for monitoring exposed people and for when movement restrictions may be needed.
In determining the right approach, we have put the health and safety of Americans first and foremost, and our deliberations have been informed by our most knowledgeable and experienced public health and homeland security professionals. As with everything we have done to respond to the threat of Ebola both at home and abroad, we have been guided by the best science available.
Coordinated public health actions are essential to stop and reverse the spread of Ebola virus. CDC announced last week that public health authorities will begin active post-arrival monitoring of travelers whose travel originates in Liberia, Sierra Leone, or Guinea and arrive at one of the five airports in the United States doing enhanced screening. The revised interim guidance released today is intended to guide state and local health officials with decisions about managing the movement of individuals being monitored, including travelers from the countries with widespread transmission and others who may have been exposed in the United States.
Active post-arrival monitoring means that travelers without febrile illness or symptoms consistent with Ebola will be contacted daily by state and local health departments for 21 days from the date of their departure from Liberia, Sierra Leone, or Guinea. Six states (New York, Pennsylvania, Maryland, Virginia, New Jersey, and Georgia), where approximately 70% of incoming travelers are headed, will start active monitoring today, with the remainder of the states starting in the days following.
This guidance also outlines appropriate public health actions for those individuals classified as "some risk." These include health care workers who are providing direct care to Ebola patients in West Africa or others, such as observers, who enter an Ebola treatment area where Ebola patients are being cared for. Additional precautions, such as direct active monitoring, are recommended for those classified as "some risk." In addition, the guidance recommends public health authorities determine on an individualized case-by-case basis whether additional restrictions, such as controlled movement, workplace exclusions, or restrictions on other activities, are appropriate. This daily health consultation will give additional confidence to the community that a returning health care worker is asymptomatic and therefore not contagious.
Returning health care workers should be treated with dignity and respect. They, along with our civilian and military personnel in the region, are working tirelessly on the frontlines against Ebola, and their success is what ultimately will enable us to eliminate the threat of additional domestic Ebola cases. We must not prevent or unduly discourage them from undertaking this indispensable and selfless work.
Guidance for returning health care workers from West Africa should be distinguished from health care workers providing care for Ebola patients in the United States. There are important differences between providing care or performing public health tasks in Africa versus in a U.S. hospital. A U.S. hospital provides a more controlled setting than a field hospital in West Africa. A U.S. healthcare worker would be able to anticipate most procedures that would put them at risk of exposure and wear additional personal protective equipment as recommended. In some places in Africa, the same may not be true and workers may not have the ability to prepare for potential exposures.
This guidance is interim guidance and could be updated or changed as new information becomes available.
CDC ANNOUNCES ACTIVE POST-ARRIVAL MONITORING FOR TRAVELERS FROM IMPACTED COUNTRIES: The Centers for Disease Control and Prevention (CDC) announced that public health authorities will begin active post-arrival monitoring of travelers whose travel originates in Liberia, Sierra Leone, or Guinea. These travelers are now arriving to the United States at one of five airports where entry screening is being conducted by Customs and Border Protection and CDC. Active post-arrival monitoring means that travelers without febrile illness or symptoms consistent with Ebola will be followed up daily by state and local health departments for 21 days from the date of their departure from West Africa. Six states (New York, Pennsylvania, Maryland, Virginia, New Jersey, and Georgia), where approximately 70% of incoming travelers are headed, have already taken steps to plan and implement active post-arrival monitoring which will begin on Monday, October 27. Active post-arrival monitoring will begin in the remaining states in the days following. CDC is providing assistance with active post-arrival monitoring to state and local health departments, including information on travelers arriving in their states, and upon request, technical support, consultation and funding.
Active post-arrival monitoring is an approach in which state and local health officials maintain daily contact with all travelers from the three affected countries for the entire 21 days following their last possible date of exposure to Ebola virus. Twenty-one days is the longest time it can take from the time a person is infected with Ebola until that person has symptoms of Ebola.
Specifically, state and local authorities will require travelers to report the following information daily: their temperature and the presence or absence of other Ebola symptoms such as headache, joint and muscle aches, weakness, diarrhea, vomiting, stomach pain, lack of appetite, or abnormal bleeding; and their intent to travel in-state or out-of-state. In the event a traveler does not report in, state or local public health officials will take immediate steps to locate the individual to ensure that active monitoring continues on a daily basis.
In addition, travelers will receive a CARE (Check And Report Ebola) kit at the airport that contains a tracking log and pictorial description of symptoms, a thermometer, guidance for how to monitor with thermometer, a wallet card on who to contact if they have symptoms and that they can present to a health care provider, and a health advisory infographic on monitoring health for three weeks.
Active monitoring establishes daily contact between public health officials and travelers from the affected region. In the event a traveler begins to show symptoms, public health officials will implement an isolation and evaluation plan following appropriate protocols to limit exposure, and direct the individual to a local hospital that has been trained to receive potential Ebola patients.
Post arrival monitoring is an added safeguard that complements the existing exit screening protocols, which require all outbound passengers from the affected West African countries to be screened for fever, Ebola symptoms, and contact with Ebola and enhanced screening protocols at the five U.S. airports that will now receive all travelers from the affected countries. All three of these nations have asked for, and continue to receive, CDC assistance implementing exit screening.
All the latest information on Ebola is here: http://www.cdc.gov/vhf/ebola/
ADHS URGES HEALTHCARE FACILITIES DEVELOP AN EBOLA PREPARATION AND RESPONSE PLAN: Ebola has arrived in the United States. It is imperative that every practitioner, infection preventionist, clinic and health department is prepared to identify, isolate and manage suspected and confirmed cases of Ebola.
To assist with outpatient clinic preparation, the Arizona Department of Health Services has created an Ebola Outpatient Clinic Toolkit. This toolkit provides concise checklists, planning templates, screening guidelines and posters for clinics to use in building a practical and feasible Ebola Preparation and Response Plan.
The Arizona Department of Health Services strongly urges every healthcare facility to develop an Ebola Preparation and Response Plan. The key to Ebola control in Arizona relies on the training and response of each and every facility.
To begin, the following actions can be performed immediately.
- Appoint 1-2 individuals to be responsible for receiving and distributing Arizona Ebola communications
- Complete the Outpatient Clinic Checklist for Ebola Preparedness to assess readiness.
- Implement a facility specific screening protocol for Ebola virus.
- Schedule a tabletop exercise or drill for the management of an Ebola patient.
As the situation is continually evolving, Arizona's Ebola toolkits and website will be updated frequently. Interim questions should be directed to local health departments or to the Office of Infectious Disease Services at the Arizona Department of Health Services at (602) 364-3676.
AZ COURTS DO NOT SEE TREATING PHYSICIANS AS EXPERTS: ArMA, PCMS and MCMS all have been involved in numerous defenses of attempts by plaintiffs' personal injury attorneys to dismantle our legislative tort success. We report on this periodically as we have had numerous important successes, including a decision at the State Supreme Court keeping in place our qualifications of expert witness statute. Most recently, we petitioned to reverse a court rule that has more practical financial implications. In summary, the Court of Appeals ruled in Sanchez v. Gama that treating physicians are not considered experts and thus are only entitled to $12.00 per day for providing a deposition or testifying at trial, plus $.20 per mile for travel, one way. Accordingly, if a doctor receives a subpoena for a deposition or to testify at trial and is the treating physician in the suit, under the Court of Appeals' decision, they are not entitled to compensation for time out of the office. However, if the doctor has been retained as an expert witness in the suit, pursuant to Rule 26(b)(4)(C) of the Arizona Rules of Civil Procedure, the party noticing the deposition must pay the doctor "a reasonable fee." Because the Arizona Supreme Court denied the rule change petition to provide compensation for treating physicians, and because the Arizona Supreme Court denied the Petition for Review of the Sanchez decision, the Arizona Court of Appeals' decision in Sanchez still governs this issue. This is unfortunate news for those called into the Arizona court system as treating physicians.
HYDROCODONE RECLASSIFICATION: If you prescribe hydrocodone combination products, prescribing these medications to the patients who need them to alleviate pain just became more complicated. A new rule from the Drug Enforcement Administration (DEA) taking effect Oct. 6 reclassifies hydrocodone combination products as Schedule II controlled substances, prohibiting refills and establishing other restrictions that will require major changes to prescribing practices. Here are six key points you need to know so you can take appropriate action over the next few weeks:
1. Refills aren't allowed for prescriptions that are written beginning Oct. 6. Be prepared to issue new hard-copy or electronic prescriptions for patients. Note that eScripts can only be used if state law permits and the prescriber is certified to ePrescribe Schedule II substances. Pharmacies also must be certified to accept eScripts for controlled substances.
2. Prescriptions issued before Oct. 6 won't necessarily qualify for refills; plan to issue new ones. Although the DEA rule allows refills of prescriptions issued before Oct. 6 until April 8, 2015, other factors could prevent patients from getting those refills. Several states have published notices that they will treat hydrocodone combination product prescriptions issued before Oct. 6 in the same way they will handle prescriptions issued after the rule's implementation date. In addition, any state laws that are more stringent than the DEA rule will govern refills. Meanwhile, some pharmacy quality and safety processes may not allow refills for prescriptions issued before Oct. 6, and some health insurers will not pay for those refills.
3. Prescriptions can't be called in or faxed. Make sure to plan ahead for any patients who may need refills. The new rule prohibits pharmacies from filling prescriptions delivered over the phone or via fax, so you'll need to issue written scripts. The only exception to this rule is emergency treatment, which would allow physicians to call in a limited quantity of the medication to cover the emergency period only. Pharmacies are required to report prescribers to the DEA if they make such a request and do not give the pharmacy a written prescription within seven days.
4. Allied health professionals might not be able to write prescriptions for these drugs going forward. Check your state's restrictions around Schedule II substances to confirm whether any non-physician members of your team who have prescriptive authority will be able to continue issuing prescriptions for hydrocodone combination products. You may need to modify your collaborative practice agreements accordingly.
5. Multiple prescriptions may be issued at one time under certain circumstances. The new rule does allow a patient to receive prescriptions that would total a 90-day supply, if the prescriber has determined it is appropriate to see the patient only once every 90 days. Each prescription must include written instructions that specify the earliest date it may be filled. In addition to sound medical judgment and established medical standards, make sure to base your practice's policy on issuing multiple prescriptions on relevant federal and state laws.
6. Patients should be notified of the new requirements and processes. Make sure your patients understand that their new prescriptions will not be refilled and are aware of the procedures they will need to follow going forward.
We have warned the DEA about the potential unintended consequences of reclassifying hydrocodone combination products since the agency made the proposal early last year. Eliminating phoned-in prescriptions and refills could make it difficult for some patients to get the pain relief they need, especially patients in nursing homes and those with persistent pain and disabilities. The rule is published in the Federal Register.
ADHS HEALTH NOTICE / ENTEROVIRUS D68 ASSOCIATED WITH SEVERE RESPIRATORY ILLNESS IN CHILDREN: In late August, the Centers for Disease Control and Prevention (CDC) was notified by two states of an increase in children hospitalized with severe respiratory illness. Enterovirus D68 (EV-D68) was identified in many of these patients. There are now several other states reporting increases in admissions for severe respiratory illness. It is possible that these are also associated with EV-D68. EV-D68 appears to spread via close contact (e.g., saliva, sputum, feces) with infected individuals. Currently, there is no vaccine to prevent EV-D68 and no specific antiviral treatment recommended. However, patients can help protect themselves and others from respiratory illnesses by:
- avoiding close contact with people who are sick;
- avoiding touching eyes, nose, and mouth with unwashed hands;
- washing hands often with soap and water, especially after changing diapers;
- cleaning/disinfecting frequently touched surfaces, such as toys and doorknobs, especially if someone is sick;
- ensuring vaccinations, including the influenza vaccine, are up to date.
Clinicians should be aware of EV-D68 as one of many causes of viral respiratory disease and should report clusters of unexplained respiratory illness to the Pima County Health Department. Please refer to this MMWR for more detailed information.
FSMB RELEASES MODEL LEGISLATION FOR CREATING MULTISTATE COMPACT SYSTEM: In a move to facilitate the growth of telemedicine and speed increased healthcare access to residents in rural areas, the Federation of State Medical Boards has released model legislation that could be used to create a multistate agreement, or "compact" system, under which physicians who are licensed in one state can use a streamlined process to be quickly licensed in another. The Wyoming State Board of Medicine spearheaded the effort; Executive Director Kevin Bohnenblust said states like his are accustomed to interstate compacts. The model legislation calls for at least seven states to participate in the compact and with participating states to have representatives on a governing commission. Once enough states have joined the effort, participating states would share credential and disciplinary information on physicians licensed by their states with other states so they could quickly issue their own licenses without collecting the usual load of paperwork normally required. Read more at Modern Healthcare.
DEA TO ALLOW RETURN OF UNUSED PRESCRIPTIONS TO PHARMACIES AND HOSPITALS: The abuse of prescription medications has been termed a "public health crisis." In an effort to address the nation's growing prescription drug abuse problem, the U.S. Drug Enforcement Administration (DEA) announced this week that it will allow hospitals, clinics and pharmacies to collect unused prescription drugs. Effective next month, the DEA's new regulation will also provide residents at long-term health facilities with the option of turning in unused prescription drugs on-site. Under the new regulation, patients and their relatives will also be allowed to mail unused prescription drugs to an authorized collector using packages to be made available at pharmacies and other locations, like libraries and senior centers. Read more here. Further information on drug disposal as well as the final published rule is available at the DEA website.
HEALTHCARE DATA BREACHES INCREASING: The recent theft of 4.5 million medical records by hackers highlights one undeniable truth about healthcare data: it's valuable, and people want it. Identity thieves can sell patient information to be used for obtaining free medical care or to file bogus insurance claims. Since federal reporting requirements kicked in, the U.S.
Department of Health and Human Services' (HHS) database of major breach reports (those affecting 500 people or more) has tracked 944 incidents affecting personal information from about 30.1 million people. A majority of those records are tied to theft (17.4 million people), followed by data loss (7.2 million people), hacking (3.6 million), and unauthorized access accounts (1.9 million people). There are also many more incidents of smaller-scale breaches. In 2012, HHS received 21,194 reports of smaller breaches affecting 165,135 people, according to the department's most recent report to Congress. Healthcare data has seemingly become increasingly targeted, accounting for 43% of major data breaches reported in 2013, according to the Identity Theft Resource Center. That's the first time the healthcare sector topped the group's annual list, and it's on the same pace for 2014. Read more here: https://www.magnetmail.net/actions/email_web_version.cfm?recipient_id=1450658731&message_id=5994069&user_id=PIAA&group_id=1210335&jobid=21166378
AHCCCS CLARIFIES NEW REQUIREMENT FOR SAM COVERAGE: Physicians have asked AHCCCS to offer clarification of their new requirement regarding insurance coverage for Sexual Abuse and Molestation (SAM). According officials, SAM is discretionary.
MICA-insureds can find a newsbrief that notes, subject to the terms of the policy, MICA's medical professional liability insurance policy provides for defense of an insured when faced with these kinds of claims. For non-MICA policy holders, check with your carrier about coverage but don't be pressured into purchasing coverage that you already have, or may not need.
ADHS RELEASES INFECTIOUS DISEASES MANAUAL: The Arizona Department of Health Services recently released "An Introduction to Arizona's Infectious Diseases" manual. To view the new guide click here: http://www.scribd.com/doc/236048552/Arizona-Dept-of-Health-Physician-Manual?secret_password=J281p3z1rxz2HUEL24tS
IOM REPORT STIRS GME FUNDING CONTROVERSY: The federal government, mostly via the Medicare program, currently provides more than $11 billion per year in payments to support graduate medical education (GME), the training of doctors who have graduated medical school. Most of these funds go to the hospitals that sponsor interns and residents. States, through the Medicaid program, contribute nearly another $4 billion annually. But there is little data on how those funds are spent and how well they contribute to the preparation of a medical workforce needed for the 21st century. This week saw the release of a report from an expert panel by the Institutes of Medicine (IOM) that recommended a complete overhaul of the way government pays for the training of physicians. The five major recommendations the committee made were:
- Medicare should maintain its GME support but should be replaced in phases by a new payment system.
- A GME policy council should be created in the Office of the Secretary of Health and Human Services, as well as a GME Center within the Centers for Medicare and Medicaid Services.
- The single Medicare GME fund should be divided into two parts: an Operational Fund to support residency training positions that are currently approved and a Transformation Fund to develop and test new GME programs.
- Medicare should make a single payment to GME programs based on a national, geographically adjusted, per-resident amount.
- Medicaid funding for GME should remain at the discretion of individual states.
The Association of American Medical Colleges issued sharp criticism of the report, stating that the recommendations threaten the viability of excellent training programs. The panel did not recommend lifting the current cap on residency slots currently supported by Medicare which were established with the 1997 Balanced Budget Act.
PHYSICIANS SHIFTING TO EMPLOYMENT RATHER THAN PRIVATE PRACTICE: Jackson Healthcare this week released the findings of a survey on physician practice environment, workload and patient access. A total of 1,527 physicians across the nation completed the survey this spring. When comparing previous survey results, this year's findings noted that the percentage of hospital-employed primary care physicians doubled from 10 percent in 2012 to 20 percent in 2014. The number of primary care physicians with an ownership stake in a single-specialty practice decreased from 12 percent in 2012 to 7 percent in 2014. When responding to why they chose employment, overall, the lifestyle that employment offers is the underlying factor driving physician preference. The number of physicians taking call in 2012 (77 percent) dropped to 57 percent in 2014. Eighty-five percent of physician practices reported accepting new Medicare patients. Sixty percent reported accepting new Medicaid patients. Survey details here: http://www.jacksonhealthcare.com/media-room/articles/physician-trends/physician-data-on-practice-environment-workload-and-patient-access.aspx
PHYSICIANS CHALLENGED BY ACA PLANS: A new study released by the Medical Group Management Association (MGMA) surveyed 728 practices representing 40,000 physicians in 46 states during April 2014. Almost 80% of the medical groups reported their practice is participating with new health insurance products sold on the ACA exchanges, and over 90% of these practices have already seen patients with this coverage. These practices report that verification processes were more difficult and lengthy than with commercial plans. Nearly 60% of respondents indicated that it is more difficult to verify patient eligibility, obtain cost-sharing or network information, or get information about the plan's provider network, in order to facilitate referrals. For practices not participating with ACA insurance exchange product, 48.1% cited concerns about assuming financial liability during a 90-day grace period for ACA exchange enrollees. For practices that chose to participate with ACA insurance exchange products, 57.6% cited remaining competitive in the local market as the reason for doing so. Almost half of respondents reported they have been unable to provide covered services to exchange patients because their practice is out of the patient's network. About 36.6% of respondents indicated that average payment rates for ACA exchange insurers were equal to payment rates from traditional commercial and traditional Medicare contracts; 32% indicated that average payment rates were somewhat lower. The American Medical Association (AMA) has created a physician practice resource page for grace period information. Resources include model language and sample letter forms for notifying patients.
WEBSITE OFFERS ACCESS TO CLINICAL TRIALS: Participating in vital health-related research to help improve or saves lives has gotten easier, thanks to a new website that features the clinical trials at the Arizona Health Sciences Center. The new Clinical Research Studies website facilitates access to research studies at the University of Arizona for the general public and for researchers recruiting people to their studies. The UA Clinical Research Studies website is searchable by health topic and makes access to information about the studies easy to find. The studies are listed by disease area and in laymen's terms for ease of navigation and understanding, and more in-depth medical information also is included for both UA and community health-care providers. Currently, there are over 100 UA studies focusing on a variety of diseases. The studies are led by nationally renowned researchers who are working to identify new cancer therapies, treatments for heart disease, asthma and lung disease, depression, Alzheimer's disease, Parkinson's disease, diabetes, and to find innovative uses for technology in health care.
ICD-10 CODING: The requirement to use the ICD-10 coding system has been extended to Oct. 1, 2015, however if your practice hasn't developed an implementation plan these resource sites can assist.
Online ICD-10 Guide: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html
Introduction to ICD-10: http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
Basics for Small and Rural Practices: http://www.cms.gov/Medicare/Coding/ICD10/Medicare-Fee-for-Service-Provider-Resources.html
AMA's What You Need to Know for the Upcoming Transition to ICD-10: http://www.azmed.org/ckfinder/userfiles/files/icd-10-transition.pdf
AMA's Your 12-Step Transition Plan for ICD-10: http://www.azmed.org/ckfinder/userfiles/files/AMA_icd-10-action-plan-12-step-transition.pdf
PCMS / FAVORITE STAFFING SERVICE: If you need staffing, contact Favorite our affiliate medical staffing service. Favorite provides a full range of services including direct hire, contract, temp- to-perm, permanent placement and "just –in-time" per diem. Special rates are given to member physicians. Call Amy Erbe at 319-5766. She is anxious to assist.
WALK-WITH-A-DOC: The Society is teaming with the Arizona Chapter of the American College of Physicians (ACP) to host and provide physician leaders for the monthly Walk-With-A-Doc outings. Walkers sign in at the ramada east of Swan Bridge on the south bank.PCMS physicians are encouraged to urge patients to participate in the program. Each walk begins with a brief discussion on a health topic and includes a one- or two-mile walk on level ground. Please contact Dennis Carey at 795-7985 or firstname.lastname@example.com with questions. There is one more walk scheduled for 2013. It's on December 14. In 2014 walks will be held on January 11, February 8, March 8, April 12, September 13, October 11, November 8 and December 13. They begin at 8 a.m.


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Trust me when I say that I'm no Kim Kardashian (or rather, I'm no Mario Dedivanovic – her makeup artist), but I don't hate the contouring trend circulating lately. I have a few cream contour products, but for a quick, everyday high-cheekbone, I tend to reach for powder!
The Kevyn Aucoin Sculpting Powder in Medium ($44) was my first foray into the contouring world, and I'll tell you what; it was a good one! This taupe powder leans grey, which is great for my olive skin. It is extremely pigmented, so it takes some getting used to in order to get the right amount, but it is a spectacular powder. TheBalm's Bahama Mama Bronzer is a great alternative for the Kevyn Aucoin at a slightly more friendly price point ($20, and you can often find it on sale at Hautelook, etc.). It is slightly less pigmented, so it allows a little more room for mistakes, and it doubles as a very flattering matte eyeshadow.
The Anastasia Contour Kit is an animal all of its own. It has sold out like crazy all over the states, probably because of its versatility! I have the "light to medium" version, and it contains 6 shades, ranging from a shimmery highlighter to a deep bronzer. I really enjoy using the two matte highlighting colors on the top left, but in general, this palette runs a little too orange for me. That being said, the formula is unreal, and it is basically fool proof! I would highly recommend this nearly anyone.
Do y'all contour for daytime makeup?

subset: commoncrawl


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465-bed Kentucky Medical Center seeking Neurologist
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Ashland , KY
General Neurology practice opportunity in the Lakeland area of western Kentucky
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Madisonville, KY
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Owensboro, KY
While practicing Neurology, enjoy the southern hospitality of Western Kentucky
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Paducah, KY
Neurology Opportunity in Louisville, KY
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Louisville, KY
Great Neurology opportunity in Mayo Clinic Care Network affiliated Hospital
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Hot Topics
Trending news, culture and entertainment for the Seattle area.
Trend talk: Why 'New York Times' stories go viral
A week into writing this blog, one thing's become clear: understanding what trends and why is not as easy as checking the daily buzz on Google, Twitter and Yahoo. Cracking the common conversation is an art. A science, even. And we've got a lot of work to do. [Read More]
Twitter's tops for travel with Hillary Clinton
And so continues Twitter's seemingly unstoppable rise to global domination. From The Associated Press: [Read More]
'Miss me yet?' asks billboard George W. Bush
Heard about the "Miss Me Yet" billboard featuring a waving George W. Bush? [Read More]
What Conan's 'Tonight Show' studio looks like now (sniffle)
The last time Conan O'Brien hosted "The Tonight Show," the late-night host told audience members they should steal everything they could from the short-lived set. [Read More]
Got 60 seconds? This color test might surprise you
We want so bad to figure out what CEOs are thinking, we'll even give them color tests. [Read More]
Dockers free pants: We're all cattle after all
It's easy to say consumers are cattle, but not so easy to prove. [Read More]
Whoa. Was that a Google ad?
They're rare, but they do exist. Here's the Google ad that sent a hush over Super Bowl parties, right before the collective "Awwww." "Someone said 'Hell has indeed frozen over,'" joked Google CEO Eric Schmidt on Twitter. What do you think: Should Bing be … [Read More]
'Who? The Who?' And other thoughts on the Super Bowl halftime show
They're not exactly the hip, happening band of the decade, but legendary rock band The Who brought the hits to Super Bowl 44. [Read More]


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Play Video
Squirrel stealing butter
Our pet squirrel trying to steal butter from the fridge !!
Our pet squirrel trying to steal butter from the fridge !!
That is the last time that squirrel tries to steal some bird feed.
If you ever wanted a first person experience of being a squirrel, here ya g...
A rascally squirrel steals an otters' cell phone and threatens to make a lo...
Squirrles stealing bird seed
cool squirrel
Our squirrel playing in some snow.
Trying to bury her stash in her pumpkin
playing in her new cage(converted closet in bedroom.
bryan and carlos see a squirrel
Squirrels are awesome.
picked up a squirrel
Steal Away performed by Philip Ashley. The song was originally a spiritua...
It is a small video clip, where the advertising against a piracy is not bad...
My friend stealing flagstones infront of a local bar


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These are used as vertical summer flower arrangements
They bloom all the time, especially in summer heat. The pictures were taken in South China.
This post was edited by jujujojo on Sun, Jul 13, 14 at 16:38
Wow, those are some happy Pelargonium.
Around here I have trouble finding those classic, really trailing cultivars.
Instead they offer a kind of cushion type which grow more compact, no matter how much fertilizer you give them... I noticed that the long ones come in two colors, this bright red and simple pink. The modern cultivars show a wider range of color, like burgundy, dark red or white, some even with double flowers.
Where dis you take this pic, j?
Have a nice weekend, bye, Lin
Lin, I have admired trailing geraniums in pink and red when I travel in Switzerland. To me this is one of the signature flowers of Switzerland. I've copied the look on our contemporary balcony - but it's always hard to find the properly trailing geraniums, and I imagined it would be easy to find them in Switzerland because of how common they are. In any case, I love that look!
Posted by linaria 7 Switzerland (My Page) on Sun, Jul 13, 14 at 1:09
The pictures were taken in South China.


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CHURUBUSCO — Churubusco dropped to third in the latest Class A Indiana High School Wrestling Coaches Association Poll.
The Eagles fell from their first place pre-season ranking to third behind first place Adams Central and second place Fremont High School. Adams Central polled 78 points, Fremont 65 and 'Busco was third with 50 points.
The Eagles led Bremen, which was fourth with 42 points and South Adams rounded out the top five with 41 points.
Churubusco next takes the mats Saturday Dec. 20 when they travel to Carroll for the Carroll Super Duals.
Michael Conochan's Pro Football Recap- Week 15
Thursday Night Football 12/11/14
Arizona (11-3) 12 @
St. Louis (6-8) 6
COLUMBIA CITY — The Indian Springs Middle School Eagles 7th grade boys' basketball team finished a three-game week with two wins. The first win came Wednesday night against cross-county rival Whitko, 69-23, and second on Thursday against New Haven, 52-36.
Against Whitko, the Eagles jumped out to 27-3 lead after the first quarter and a 39-9 lead at the half. Every member of Eagles turned in quality minutes in the win, with all 10 players scoring at least two points. The Eagles were led in scoring by Max Bedwell with 32 and Seth Schaeper with 17 points.
The Columbia City Elks Lodge #1417 held its annual Hoop Shoot contest at Indian Springs Middle School. Local winners from the three-county school systems were in attendance, with the winners of this contest advancing to the District contest, which will be held Jan. 18, 2015 at ISMS. First place winners: from left, Olivia Shearer (12-13 girls), Jillian Whaley (10-11 girls), Jensyn Longenbaugh (8-9 girls), Brady Hartman (8-9 boys), Brock Uher (10-11 boys) and Mason Baker.
FORT WAYNE — The Columbia City Eagle wrestling team traveled to Homestead for the final Northeast Hoosier Conference (NHC) Triple Dual meet. The annual meet matches Columbia City, New Haven, Homestead and Carroll against each other. The Eagles forged a 2-1 record, downing host Homestead and New Haven before falling to reigning Sectional Champion Carroll.
CHURUBUSCO — An injury-depleted Churubusco wrestling team played host to new Northeast Corner Conference foe Garrett Thursday night. The visiting Railroaders broke a 21-21 tie, taking five of the remaining six bouts to down the Eagles 48-24
With bouts starting at 152 pounds, the visitors jumped on top 6-0 by way of a third-period pin by Garrett's Sam Lawrence over Busco's Dean Gaerte. The Eagles evened the score 6-6, when senior Lyle McParlan pinned Garrett's Alax Egly with five seconds left on the clock in their 160-pound match-up.
ANGOLA — Trine defeated Heidelberg, 68-61, in non-conference women's basketball action Wednesday evening in a home contest to extend their winning-streak to six games.
The win gives the Thunder six-consecutive victories for the first-time since the 2011-12 team opened the season on a six-game run.
WINONA LAKE — Grace College men's basketball team may have led nearly the entire game against Indiana Tech on Tuesday, but the outcome wasn't settled until the final seconds.
The Lancers (10-3) held on late for a 70-67 home victory over the Warriors (5-7) Tuesday night at the Manahan Orthopaedic Capital Center.
SOUTH WHITLEY — The Whitko boys basketball team dug a nine-point hole Tuesday Night before a fourth quarter rally fell just short allowing the visiting Central Noble Cougars to escape with a 58-55 win.
Central Noble outscored the Wildcats 16-11 in the first quarter and 11-8 in the second to take a 27-19 lead at halftime.
CHURUBUSCO — In a battle of Eagles, the visiting Columbia City Eagles used a strong first quarter and good free throw shooting down the stretch to down the Churubusco Eagles 59-51 in Tuesday night's battle of Whitley County rivals.
Columbia City raced out to a 16-5 lead at the end of the first quarter, led by six free throws from 6-feet 7-inch junior Brachen Hazen and three-point baskets from Justin Bachelder and Cooper Parish.


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Nyack News
Nyack's Earl Miller Guest Speaker at Suffern UMC
Earl Miller, executive director of community relations at Nyack College, will be the Martin Luther King Day guest speaker at Suffern United Methodist Church located at 18 Parkside Drive in Suffern on Sunday, January 19 at 3:00 p.m.
A native of Atlanta, GA, Miller grew up with the children of Rev. Martin Luther King, Jr.; Rev. Ralph Abernathy; and the Honorable Andrew Young. He is committed to connecting today's youth to the significance and legacy of the Civil Rights Movement in America.
He is also an ordained minister with extensive urban and international ministerial experience. Rev. Miller is a four-time NYC marathon runner and an avid golfer. The Nyack alumnus holds an undergraduate degree in religious studies and a master's degree in organizational leadership. He is currently completing graduate studies in marriage and family counseling at Nyack's Alliance Graduate School of Counseling.
He and his wife Jonette are the parents of a college student, 21-year-old Isaiah.
Recent Posts
- APRIL 10: Nyack College Rockland Chorale Spring Concert
- Service With a Smile #NyackCityServe
- Pianist Johnny Walsh In Concert on Nyack Rockland Campus
- Music Students Minister at Morristown's Market Street Mission
- Nyack College Student Research Conference Rockland Campus
- ATS Colloquium On State and Religion: The Case of Israel
- Live from New York...Nyack's School of Music at Avery Fisher Hall, Lincoln Center!
- Nyack Says Thank You to Community Sponsors
- Nyack...We're Here to Serve!
- Broken To Minister CD Launch Event at NYC Campus
- 15-City Promo Tour for Nyack NYC Campus Music Prof Damien Sneed
- Becker Professional Education Presentation
- FEBRUARY 23-24: Pianist Marcelo Liano in Concert at Nyack Rockland
- Colloquium Series Features Dr. Kale Yu on "Earth in Mind"
- Denise Lewis Patrick, Award-Winning Author and Nyack Adjunct, Presents Connected Souls
- Browse Blog Archive>>
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Free This Blogger!
Raif Badawi was sentenced to 10 years in prison and 1,000 public lashes for setting up a website. Tell Saudi officials: end this injustice!
Take Action Now
March 25, 2015
On 31 March a court in Kirsanov, Tambov Region, will consider Yevgeniy Vitishko's request for parole. He is a prisoner of conscience and should be released immediately and unconditionally.
March 24, 2015
Two Bangladeshi men have been sentenced to death in Bahrain for murder. They have the right to appeal the sentence.
March 24, 2015
Two of the five women activists who are in detention in China have been transferred to hospital with serious health problems. These are thought to have been aggravated by their continued detention,...
March 23, 2015
The whereabouts of 42 of the disappeared students remains unknown. The investigation has made some progress but it is mired with flaws. The Mexican authorities have accepted repeated calls from rel...


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|Additional Features
|Variable Browning
|Built in Warming Rack
|Cancel Button
|18.2H x 25.9W x 15.9D cm
|Model Number
|Number of Slices
|2 Slices
|Product Type
|Removable Crumb Tray
Delivered from £2.95
by Thursday 09 April
by Thursday 09 April
|Standard: 3-5 days
|Next day
|Named day
|Named day and time
|More delivery info
Returns for UKIf for any reason you are not satisfied with your George Clothing or George Home product, simply return it within 100 days with proof of purchase for an exchange or refund. George branded products only. Excludes watches, jewellery, hair accessories, part assembled flat pack furniture and mattresses. The 100 Day Guarantee only applies to George branded products. Please refer to our terms and conditions for details of our returns and refund process for non-George branded products. Your statutory rights are not affected. UK Mainland stores only. Excludes franchises.
Rated 4.4 out of 5 by 5 reviewers.
Rated 5 out of 5 by Bluevalentine Stylish and efficient! Easy, fast and so easy to use. Love the variable width function, easy controls and looks so modern and stylish. 24 May 2012
Rated 4 out of 5 by cooliomum nice looking toaster Bought this as a replacement and to be honest its a very good value for money little toaster. Does what it says on the tin. Bugbear is that (like all other toasters these days) you need to turn the toast as the bread is too long. apart from that, I'm happy with my purchase. 03 October 2014
Rated 4 out of 5 by supermuminuk Sturdy and good value A sturdy toaster at a reasonable price. My only criticism is that it doesn't really take a normal large loaf slice. The top section sticks out and doesn't get toasted. Best for square slices. 20 December 2014
Rated 4 out of 5 by Primula Toaster Toaster works well but it's not wide enough for Kingsmill / Hovis it's the bread that we use 24 September 2014
Rated 5 out of 5 by Janjo1940 Best one yet Love it, it was cheap does what it should so yes please with it 20 April 2014
1-5 of 5


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Up for sale in the Houston showroom is one gorgeous street rod the 1941 Willys Coupe. The Willys Americar for sale was a line... More
Willys Jeep CJ2A 1947. Older restoration, but still looks good. Drives and performs correctly. All steel Body. New Military Firestone tires 16x 6.00. New... More
1940 Willys All Steel Frame and all body parts original to this car. Rebuilt 1957 392 Hemi Muncie 4 speed transmission 57 Olds posse rearend... More
1949 Willys Jeepster For Sale or Trade. Owned by same classic car enthusiast for over 35 years. Was bought in Arizona and then brought... More
Stk. 1899 1942 Willys Jeep Military MB-PGW The Jeep legend began in November 1940, in the early days of World War II, just a year... More
Here is a Custom 1949 Willys Jeepster that is equipped with a 132ci engine a 12 volt system and a 3 speed manual transmission.... More
This 1946 Jeep Willys CJ-2A 4x4 Convertible features a 4-Cylinder cyl Gasoline engine. It is equipped with a 3 Speed Manual transmission. The vehicle... More


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need suggestions for this old floor
carol0512July 12, 2012
1886 random width pine floor. paint spills, plain old age, neglect, residue from rubber backed rugs, etc. wall to wall not option, need suggestions - floor is both living room and dining room 15 feet wide by 26 length. thanks
On second look I see the random width boards. Nice floor. Waterlox is an option for you and it will give you good color. The lightest result can be achieved with a commercial quality two-part waterborne (non-yellowing) wood floor polyurethane.
I agree with the bruising comment. Whether you sand or had scrape, expect some of this bruising damage to remain visible. Doesn't necessarily make the floor look bad...it's just the nature of the beast.


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credit suisse group ag-reg
(CSGN:SIX Swiss Ex)
Executive Profile*
Riccardo Gullotti
Former Member of Advisory Board, Credit Suisse Group AG
|Total Calculated Compensation
|This person is connected to 0 board members in 1 different organizations across 2 different industries.
Mr. Riccardo Gullotti serves as Attorney-at-Law and Owner of Gullotti and Partner Management and Consulting Services, Berne, Switzerland. Mr. Gullotti served as Deputy Chairman at Swiss International Air Lines AG. He serves as Member of Advisory Board of SAirGroup AG. Mr. Gullotti served as Member of Advisory Board of Credit Suisse Group.
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Paradeplatz 8Phone: 41 44 212 16 16
Zurich, Zurich 8070
Fax: 41 44 332 55 55
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First I would like to thank LarryG for your response to my previous post. Since I have been paying attention to the hot water heater I have been noticing a very slight gas odor from the area around the pilot. I have to put my nose right up to it to smell it and can't smell the gas just by standing by the hot water heater. Is this a normal thing with gas water heaters or should I have someone out to check it out? I also notice that the gas odor is a little stronger when I turn up the thermostat and the burners come on and this odor dissipates quickly. FYI, I was able to detect a slight gas odor from our previous hot water heater as well. Thanks.
For peace of mind you can call the gas company and they will check for leaks free of charge. Better safe than sorry right?
Thank you again LarryG. I have the gas company coming out this afternoon to make sure there are no leaks. I have read different things about the odor I am smelling and some say this is normal for some gas hot water heaters and others say that you shouldn't smell any gas smell.
Just an update on what the gas company found. There is a small leak under the pilot button control and this is where I was smelling the gas odor. We were told it wasn't an immediate safety issue and is common in hot water heaters. We are replacing our hot water heater this week since it is 10 years old. Thanks again LarryG.
Another hot water heater problem
fumes and hot water heater
Gas hot water heater will not light
Gas hot water heater noise
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Senior Member
Whenever I try to patch it says "The Launcher has Experienced an Error"
and then I restarted it 7 times, and it wouldn't work still, I had this once before, but I restarted and it fixed, but this time it won't get fixed, any ideas to fix it?
Try this out http://www.leagueoflegends.com/board...d.php?t=618719
© 2015 Riot Games, Inc. All rights reserved. Riot Games, League of Legends and PvP.net are trademarks, services marks, or registered trademarks of Riot Games, Inc.


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The Anton-Bauer EgripZ Handheld DSLR Support is an ergonomic grip that helps make DSLRs easier to handle when shooting video, combining less back and shoulder ache with more stable images. Wide, flexible handles allow one hand to firmly support the camera while the other is free to manipulate the shutter and other controls. The handles can also be twisted in opposite directions or to one side for use as a shoulder or chest mount. Designed for use on any DSLR utilizing a 1/4"-20 tripod mount, the EgripZ brings a simple, affordable level of comfort and smoothness to handheld shooting.
Note: Unlike camcorders, DSLRs do not contain a guide pin socket, so the guide pin on this model has been removed to allow proper mounting.


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Latest Men's Health Shows
Utah Has the Lowest Vaccination Rate of This Cancer-Reducing VaccineFeb 19, 2015
If you knew a simple vaccine could protect your children from cancer, would you give it to them? The HPV vaccine does just that, but many Utahns miss opportunities to vaccinate their children. Why? Dr. Kirtly Parker Jones and Dr. Deanna Kepka discusses the many benefits of the HPV vaccine, as well a ... Read More
Do Domestic Abusers Want to Stop Abusing?Jan 13, 2015
One in every four women will be a victim of domestic violence in her lifetime. Do the abusers want to stop hurting their partners? Social worker Wendy James talks about the cycle of guilt often felt by abusers and why they stick to their abusive patterns. She discusses options for couples who want t ... Read More
Are There Better Male Contraceptive Options?Apr 10, 2014
About 50 percent of American pregnancies are unplanned. What are we doing wrong? Dr. Kirtly Jones says it may not be all the fault of women. Dr. Jones talks about the recent research and developments of male contraceptive options and discuss whether or not - and how much - they play into unplanned p ... Read More
Can't Get Pregnant? What to Do Part 1Mar 27, 2014
How long should a couple try to conceive before seeking help from a specialist? Dr. Kirtly Jones talks about what you should do when you've made the decision to have a baby, but for some reason or another can't seem to conceive. ... Read More
Can't Get Pregnant? What to Do Part 2Mar 27, 2014
You've been trying for over a year to conceive a child but it's just not happening. Dr. Kirtly Jones talks about the next steps to take and what specialists are available. ... Read More
Should You Get a PSA Test for Prostate Cancer?Mar 18, 2014
Over 200,000 men in the United States will be diagnosed with prostate cancer this year. Of that, 35,000 will die. The prostate-specific antigen (PSA) test can help identify cancer in its early stages, when treatment is most effective - but it's not for every men. Dr. Tom Miller and Dr. Blake Hamil ... Read More
ER or Not: Kicked in the "Love Zone"Feb 13, 2014
It's probably happened to every guy at least once - getting kicked or hit in the crotch. Sure it hurts when it happens, but does it really damage things? Is there ever a time where it merits a trip to the emergency room? You might be surprised at the answer. Find out from Dr. Troy Madsen on this e ... Read More