text:
Policies set by public and private purchasers, oversight bodies, and other health care leaders shape how health care is accessed, what services are delivered, and the manner in which they are delivered. Many of these policies already support the provision of some psychosocial health care. The decision by Medicare and leading purchasers in the private sector to pay for behavioral health assessments and interventions is a strong example of these policies, as is Medicare's recent decision to increase payment levels for patient evaluation and management services. However, other reimbursement policies have not kept pace with the evidence for the strong influence of psychological and social problems on health care and outcomes set forth in Chapter 2. Reimbursement approaches for care coordination for individuals with complex needs are not well articulated. Restrictions on which clinicians can be paid can make it difficult to access those with special expertise and present a barrier to the collocation of clinical oncology and mental health services—a situation that is problematic since collocation is an effective approach for increasing access to mental health services and coordination of those services with biomedical care. Moreover, the results of many studies finding that poor-quality health care is widespread show that reimbursement by itself does not ensure the provision of needed health care services. Reimbursement and other incentives need to be aligned with quality measurement and improvement activities, which currently are inadequate in addressing psychosocial health services.
To overcome these obstacles, the committee recommends that group purchasers of health care coverage, health plans, and quality oversight
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Public- and Private-Sector Policy Support
Policies set by public and priate purchasers, oersight bodies, and
other health care leaders shape how health care is accessed, what serices
are deliered, and the manner in which they are deliered. Many of these
policies already support the proision of some psychosocial health care.
The decision by Medicare and leading purchasers in the priate sector
to pay for behaioral health assessments and interentions is a strong
example of these policies, as is Medicare's recent decision to increase pay-
ment leels for patient ealuation and management serices. Howeer,
other reimbursement policies hae not kept pace with the eidence for
the strong influence of psychological and social problems on health care
and outcomes set forth in Chapter 2. Reimbursement approaches for care
coordination for indiiduals with complex needs are not well articulated.
Restrictions on which clinicians can be paid can make it difficult to access
those with special expertise and present a barrier to the collocation of clini-
cal oncology and mental health serices—a situation that is problematic
since collocation is an effectie approach for increasing access to mental
health serices and coordination of those serices with biomedical care.
Moreoer, the results of many studies finding that poor-quality health
care is widespread show that reimbursement by itself does not ensure
the proision of needed health care serices. Reimbursement and other
incenties need to be aligned with quality measurement and improement
actiities, which currently are inadequate in addressing psychosocial health
To oercome these obstacles, the committee recommends that group
purchasers of health care coerage, health plans, and quality oersight
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organizations take a number of actions to fully support the interentions
necessary to delier effectie psychosocial health serices. The National
Cancer Institute, the Agency for Healthcare Research and Quality, and
the Centers for Medicare & Medicaid Serices also should spearhead the
deelopment and use of performance measures to improe the deliery of
these serices.
Chapter 4 delineates the processes that all oncology providers need
to have in place to ensure that the psychosocial problems affecting their
patients' health care and outcomes are effectively addressed. These in-
clude processes that (1) support effective patient–provider communication;
(2) identify individuals with psychosocial health needs; (3) link patients
with service providers; (4) coordinate psychosocial and biomedical care;
(5) help patients manage their illness; and (6) follow up to ensure the ef-
fectiveness of services. The need for these processes is already recognized
by many group purchasers, insurers, and other policy makers, as reflected
in their policies (see Table 6-1 and the discussion that follows). Other poli-
cies, however, do not reflect existing evidence on the need for and methods
of delivering psychosocial health care.
Medicare policies are of particular interest for several reasons. Because
60 percent of new cancer cases occur among people aged 65 and older,
Medicare is the principal payer for cancer care (IOM, 1999). Moreover,
Medicare typically pays about 83 percent of what private insurers pay
(MEDPAC, 2007); therefore, to the extent that Medicare payment rates
allow for reimbursement of practice expenses related to the processes enu-
merated above, reimbursement by private payers should do so to a greater
extent. Medicare also is a leader in technology assessment and coverage
determinations; its decisions are often followed by private-sector insurers.
Finally, Medicare's policies on coverage determination and rate setting are
more visible to the public than those of the private sector, enabling their
study. This section reviews key Medicare reimbursement policies and their
effects on the provision of psychosocial health services to individuals with
cancer. The discussion encompasses both "traditional" Medicare payments
to physicians—payments made to individual health care clinicians on a fee-
for-service (FFS) basis after an individual patient has made an outpatient
visit or undergone a procedure—and Medicare's adance (prospective,
capitated) payments to managed care and other health plans for the delivery
of an array of inpatient and outpatient services that a Medicare beneficiary
may need over a specified period of time (the Medicare Advantage [MA]
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program).1 Policies of private insurers and of Medicaid, the State Children's
Health Insurance Program (SCHIP), and other government programs also
are discussed as data are available.
Policies Addressing Effective Patient–Provider Communication
As indicated in Table 6-1, a few large-scale policy initiatives are under
way to promote more effective patient–provider communication in general.2
The Cancer Survival Toolbox (available free of charge) teaches people living
with cancer how to obtain information, make decisions, solve problems,
and generally communicate more effectively with health care providers
(NCCS, 2007). The Questions Are the Answer Campaign (AHRQ, 2007b)
and Ask Me ™ initiative (Partnership for Clear Health Communication,
undated) also encourage all patients to ask questions of their providers.
Policy support for the provider side of the patient–provider partnership
is illustrated by the efforts of the Veterans Health Administration, whose
Employee Education System provides mandatory and optional classes on
such topics as clinician–patient communication to enhance health outcomes,
communication to affect behavior change, and disclosure of unanticipated
outcomes and medical errors. Other initiatives to improve patient–provider
communication by organizations such as Kaiser Permanente, Geisinger
Health System, the American Academy of Orthopedic Surgeons, Affinity
Health System, and Washington State University are chronicled by the In-
stitute for Healthcare Communication (2005), which has conducted more
than 9,000 workshops for more than 120,000 clinicians and health care
workers on improving communications between clinician and patient. Fur-
ther support is provided by the Agency for Healthcare Research and Qual-
ity's (AHRQ's) Consumer Assessment of Healthcare Providers and Systems
(CAHPS) Clinician and Group Survey Instruments. This ambulatory care
survey tool has separate versions for adult specialty care and adult and
child primary care, each containing multiple questions specifically asking
patients about how their physician communicated and shared decision mak-
ing with them (AHRQ, 2007a). In addition to these instruments' potential
use as performance measures, the American Board of Medical Specialties
(ABMS) is pursuing use of the specialty version to help determine physi-
cian competency in effective communication as part of its Maintenance
1 MA plans serve approximately 17 percent of Medicare beneficiaries (MEDPAC, 2007).
2 Many more initiatives are in place to improve provider communication with members of
cultural and ethnic minorities and other vulnerable populations.
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TABLE 6-1 Examples of Policy Support for Interventions to Deliver
Psychosocial Health Care
Interventions (from
Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP
Support for Effective
Communication (excluding
initiatives providing
information on services
only and those focused
solely on cross-cultural
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Other Government
Private Insurance Programs Other Private Sector
• Some health plans and Support is provided by: Support is provided by:
providers make patient– • Agency for Healthcare • Accreditation Council
provider communication Research and Quality's for Graduate Medical
a priority throughout (AHRQ) Questions Are Education (ACGME)
their organization. the Answer campaign Outcome Project
See examples at • AHRQ's Consumer competencies on residents'
Institute for Healthcare Assessment of interpersonal and
Communication: http:// Healthcare Providers communication skills
www.healthcarecomm. and Systems (CAHPS) • American Board of Medical
org/index.php Clinician and Group Specialties' Maintenance of
Survey questions on Certification initiative
effective provider • Cancer Survival Toolbox
communication and • Joint Commission Speak
shared decision making Up™ initiatives
• Veterans Health • Partnership for Clear Health
Administration's Communication's Ask Me
mandatory and optional ™ Initiative
courses on effective
communication for all
employees and National
Symposium on Clinician-
Patient Communication
• National Cancer
Institute's (NCI):
–Research Symposium
on Consumer–Provider
Communication in
–Synthesis of literature
on physicians'
behaviors in cancer
care and generally
report Patient-Centered
Communication in
Cancer Care puts
forth a comprehensive
research agenda
(Epstein and Street,
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TABLE 6-1 Continued
Interventions (from
Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP
Identification of • Medicare law generally Coverage and reimbursement
Psychosocial Needs proscribes fee-for-service vary by state, but generally:
(FFS) reimbursement • Some screening covered
for "screening," but for children under age
screening still occurs 21 through the Medicaid
in FFS and Medicare Early Periodic Screening,
Advantage plans in Diagnosis, and Treatment
several ways (EPSDT) benefit
• Medicare FFS also • Coverage of Health
provides full coverage and Behavior Current
for health and behavior Procedural Terminology
assessment (CPT) codes varies by state
Care Planning; Linking of • Some reimbursement • Medicaid payments are
Patients with Psychosocial is provided as part generally low, but states'
Services; Coordination of FFS payments for Primary Care Case
of Psychosocial and medical Evaluation and Management (PCCM)
Biomedical Care; Management (E/M) programs offer some
Follow-up services, and payments financial support, as do
for some E/M services state Medicaid agency
increased in 2007 contracts with managed
• Medicare Advantage care plans; as of 2005,
plans' more flexible 25 states offered PCCM
reimbursement also services with some limits
allows for these services • Most states also
• Multiple demonstration offer "targeted case
projects are ongoing management" to certain
to test models of care beneficiaries to enable
coordination access to and coordination
of necessary medical, social,
and educational care and
other service needs (CMS,
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Other Government
Private Insurance Programs Other Private Sector
• Coverage of mental Other government Voluntary organizations offer
health screening varies programs reimburse or mental health screenings
by health plan provide services to identify
• Coverage for health and psychosocial needs, e.g.,
behavior assessment • Department of Veterans
CPT codes is provided Affairs Medical Centers
by many insurers annually screen all
patients for depression
and alcohol misuse
prompted by patients'
computerized medical
• Older Americans Act
programs also perform
needs assessments
• Some support is Support is provided by Support is provided by
provided through nurse Maternal and Child Health American Cancer Society's
support systems for Programs for Children Patient Navigator program
patients established by with Special Health Care
some private insurers Needs
• Some support also
provided through the
E/M billing codes
reimbursed by private
• Managed care
plans' more flexible
reimbursement also
facilitates these services
(see, e.g., AHIP, 2007)
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TABLE 6-1 Continued
Interventions (from
Figure 4-1 in Chapter 4) Medicare Medicaid/SCHIP
Support for Illness • Full coverage is provided • Patient and family
Self-Management for Health and Behavior instruction/education in
Intervention CPT codes managing illness is provided
• Patient and family for in E/M codes, but
instruction/education Medicaid payment rates are
in managing illness is lower than those of private
provided for in E/M insurance and Medicare,
codes which may be a disincentive
• Multiple care to provide these services
are teaching illness
management practices
of Certification initiative.3 A CAHPS specialty version could be used in
oncology practices as a way to systematically measure and help improve
patient–provider communication.
Despite the above initiatives to help patients and providers commu-
nicate more effectively, the limited number and scope of such initiatives
constrains improvement in this area. The new CAHPS Clinician and Group
Survey instruments can provide a vehicle to help educate both patients
and providers and facilitate clinicians' adoption of new communication
behaviors, but mechanisms need to be in place to collect the data from
patients and relay them back to providers in ways that will improve com-
munication. These mechanisms (discussed later in this chapter) are not yet
in place. In addition, although ineffective patient–provider communication
is not typically identified as resulting from a failure to reimburse for effec-
tive communication, financial incentives to see greater numbers of patients
(and thereby limit providers' time with each patient) are sometimes cited as
3 The ABMS Member Boards helped develop the three versions of the survey—one for adult
primary care, one for proceduralists/surgeons, and one for pediatricians. The impetus for these
efforts was the need for instruments to measure patient care experiences and physician–patient
communication as an aspect of physician competence in the ABMS Maintenance of Compe-
tence Program. Personal communication, Stephen Miller, MD, President, ABMS, March 23,
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Other Government
Private Insurance Programs Other Private Sector
• Some coverage is • Administration on Aging • Large number of programs
provided for Health and grant program to states offered in the voluntary
Behavior Intervention and local communities, sector (see Chapter 3)
CPT codes • Employer programs and
Empowering Older
• Managed care policies such as Employee
People to Take More
plans' more flexible Assistance Programs
Control of Their Health
reimbursement also and leave policies, e.g.,
through Eidence-
facilitates these services availability of extended
Based Preention,
(see, e.g., AHIP, 2007) requires use of illness leave of absence, flex
• Patient and family self-management time work hours, and
instruction/education unscheduled leave
in managing illness is
provided for in E/M
• Some telephonic case
management or nurse
support systems offered
by some private insurers
offer support
a barrier to addressing psychosocial issues (Astin et al., 2006). Reimburse-
ment policies could be structured in ways that would reward providers with
the best performance in communicating with patients.
Policies Addressing the Identification of Psychosocial Needs
As discussed in Chapter 4, two general means are used to identify pa-
tients' psychosocial needs reliably: screening for problems, followed by an
assessment, or bypassing screening and conducting a more comprehensive
assessment by itself. Given the brevity of several reliable and valid screen-
ing instruments (as discussed in Chapter 4) and the fact that many of these
instruments can be self-administered by the patient (often in the waiting
room prior to contact with the physician, also as discussed in Chapter 4),
the resources required to administer such instruments may not be substan-
tial, although following up on numerous, complex needs thus identified
may be, as discussed below.
Although FFS Medicare generally does not pay explicitly and sepa-
rately for screening services (except when coverage for a specific screening
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procedure is explicitly added to the Medicare statute by congressional ac-
tion), this may not be a major barrier to the performance of psychosocial
screening by itself. First, the exemplar organizations described in Chapter
5 (and others identified by the committee but not discussed in this report)
all perform screening and more in-depth assessment under a variety of sce-
narios. These practices provide some evidence of the feasibility of screening
under current policies. Second, MA private plans are not restricted to offer-
ing services explicitly allowed under Medicare's FFS statutory provisions.
MA plans (especially health maintenance organization [HMO]–type plans,
as opposed to preferred provider organizations [PPOs] and private FFS
plans) often offer benefits beyond those in FFS Medicare, such as routine
health exams, some care coordination, and eyeglasses. Managed care plans
in the private sector also often offer additional services. For example, in
2005 Aetna began an initiative offering financial incentives to primary care
physicians to identify and care for certain health plan enrollees with depres-
sion. Primary care physicians who serve Aetna enrollees are trained in the
use of the Patient Health Questionnaire-9 (PHQ-9) depression screening
tool, are supplied with care management resources designed to support
patients and primary care providers, and have access to mental health
specialists for collaborative consultation (Moran, 2006). For every patient
identified though screening as positive for symptoms of depression, Aetna
pays the physician $15.00.4
Moreover, brief screening for some conditions takes place and is reim-
bursed as part of Medicare's FFS payment for office visits. For example,
when a nurse takes a patient's blood pressure at each routine visit, this is
essentially screening for hypertension. Similarly, if a primary care provider
incorporates depression screening or screening for alcohol misuse into a
visit for evaluation or management of physical symptoms or an already
documented medical condition, these screening services are included in
Medicare's payment for Evaluation and Management (E/M) services—one
of the most commonly delivered health services. Such screening is explic-
itly identified as a component of E/M services in the Current Procedural
Terminology (CPT) codes5 reimbursed by all payers (public and private)
(Beebe et al., 2006).
4 Personal communication, Hyong Un, MD, National Medical Director for Behavioral
Health, Aetna, March 29, 2007.
5 CPT, maintained by the American Medical Association, is a listing of medical services and
procedures (and an accompanying numerical code for each) used by physicians and certain
other clinicians (e.g., physician assistants, nurse practitioners, and nurse midwives) to report
the services and procedures they perform as part of their claims to insurers for reimbursement.
CPT codes are designated by the federal government as the national standard for coding such
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Assessment of Psychosocial Needs
Assessing and following up on psychosocial problems takes more time
than screening; as a result, payment becomes more of an issue. In 2002,
new Health and Behavior Assessment and Intervention (H/B) codes were
incorporated into the CPT coding set generally used by all ambulatory
health care providers when submitting a claim for reimbursement.6 At the
time, these codes were described as a "paradigm shift" (Foxhall, 2000)
because they allowed direct billing—by nonphysicians such as clinical psy-
chologists—for psychosocial services for general medical illnesses such as
diabetes or heart disease as opposed to mental illnesses. The new codes
were intended to allow behavioral health specialists to address psychologi-
cal, behavioral, emotional, cognitive, and social problems interfering with
patients' ability to manage their physical illnesses. Prior to the new codes,
the only way to deliver such services was to submit a bill for a mental health
intervention, which required a diagnosis of mental illness.
Of note, when the American Psychological Association put forth its
proposal for the adoption of these codes, the following pediatric oncology
case study was used as one example of the range of interventions the codes
were intended to capture:
A 5-year-old boy undergoing treatment for acute lymphoblastic leuke-
mia is referred for assessment of pain and severe behavioral distress and
combativeness associated with repeated lumbar punctures and intrathecal
chemotherapy administration. Previously unsuccessful approaches had
included pharmacologic treatment of anxiety (Ativan), conscious seda-
tion using Versed, and finally, chlorohydrate, which only exacerbated the
child's distress as a result of partial sedation. General anesthesia was ruled
out because the child's asthma increased respiratory risk to unacceptable
Intervention: The patient was assessed using standard questionnaires (e.g.,
the Information-Seeking scale, Pediatric Pain Questionnaire, Coping Strat-
egies Inventory), which, in view of the child's age, were administered in a
structured format. The medical staff and child's parents were also inter-
viewed. On the day of a scheduled medical procedure, the child completed
a self-report distress questionnaire. Behavioral observations were also
made during the procedure using the CAMPIS-R, a structured observation
scale that quantifies child, parent, and medical staff behavior.7
As defined in the 2007 CPT coding manual (Beebe et al., 2006:410–411),
6 Reimbursement generally does not take place without a code to describe accurately the
service delivered.
7 Personal communication, Diane Pedulla, JD, American Psychological Association, January
5, 2007.
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TABLE 6- Continued
Number and Description of Adopted/
Number of Endorsed Performance Measures
Performance Measures Addressing Psychosocial Health Care in
Initiative Adopted/Endorsed Community Settings
2006 National 211 measures, • Cancer-specific measures do not address
Health Care Quality including 15 addressing psychosocial health services
Report effectiveness of cancer • 8 address effectiveness of mental health
care and substance abuse care
• 15 address timeliness of care
• 24 address patient–provider
communication across conditions
National Quality • 6 measures for • No psychosocial measures among the
Forum breast cancer; 4 for breast and colorectal cancer measures
colorectal cancer
(NQF, 2007a)
• 9 measures • Symptom management and end-of-life
of symptom measures predominantly (8 or 9 of 9)
management and address hospice, death, and last 30 days
end-of-life care for of life
patients with cancer
• 112 ambulatory • Ambulatory measures for mental health
care measures address major depressive disorders, new
endorsed as of July episodes of depression, attention-deficit
2007 for treatment hyperactivity disorder, bipolar disorder,
of 9 noncancer alcohol and other drug treatment
conditions (e.g., • Other ambulatory care measures
asthma, diabetes), address tobacco cessation, physical
plus emergency care, activity, and cancer screening
geriatrics, medication • Patient experience of care measures
management, patient include CAHPS survey of adult
experience with specialty care and survey for children
care, screening, with chronic conditions
and preventive care
(NQF, 2007b)
pilot testing the measures, ensuring calculation and submission of the
measures, auditing to ensure their accuracy, analyzing and displaying mea-
surement results in a format suitable for the intended audiences, and main-
taining the measures' accuracy and reliability over time (IOM, 2006a).
Structures and processes for performing many of these functions already
exist within the health care system. However, marshaling these resources,
especially with respect to ensuring the calculation and submission of the
measures, will require leadership.
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Leadership is a critical factor in the success of any major change ini-
tiative or quality improvement effort (Burns, 1978; Bodenheimer et al.,
2004; National Institute of Standards and Technology, 2007). Fortunately,
a number of organizations that already play a leadership role in oncology
have the ability to influence quality through their certifying activities, fi-
nancial support, and ability to inform consumers in the marketplace. Such
organizations, working together, could constitute a critical mass of leader-
ship creating substantial incentives for oncology providers to improve the
delivery of psychosocial health care for patients with cancer and their fami-
lies by supporting the development of a small, strategic set of performance
measures addressing psychosocial health care and then incorporating these
measures into their organizational policies and practices.
As the nation's leader in cancer care, NCI has a number of venues
through which performance measures could be used to improve psycho-
social health care. NCI's 61 designated cancer centers and comprehensive
cancer centers together constitute the "centerpiece of the nation's effort to
reduce morbidity and mortality from cancer" (NCI, 2004:2) and are "char-
acterized by strong organizational capabilities, institutional commitment,
and trans-disciplinary, cancer-focused science; experienced scientific and
administrative leadership, and state-of-the-art cancer research and patient
care facilities [emphasis added]" (NCI, undated-a). NCI could encourage
these facilities to set the benchmark for performance in meeting standards
for psychosocial health care incorporated in the performance measures, and
to measure and report their performance in providing such care.
NCI's Outcomes Research Branch also coordinates and sponsors re-
search aimed at improving cancer outcomes; reducing health disparities;
and reducing the cancer burden on patients, families, and society. In doing
so, it coordinates and funds research and applications designed to assess,
monitor, and improve the quality of cancer care, and translates research
findings into products and strategies for use by public and private policy
makers who provide, pay for, regulate, and set standards for cancer care
(NCI, undated-b). Incorporating the development and application of per-
formance measures of psychosocial health care into this agenda also could
help advance the use of such measures.
Leading private-sector funders of cancer research and demonstrations,
such as the American Cancer Society, Lance Armstrong Foundation, and
Susan G. Komen for the Cure Foundation, also could incentivize the calcu-
lation and public reporting of performance measures of psychosocial health
care by including questions about how organizations deliver such care in
their requests for proposals, making awards based on applicants' perfor-
mance in these areas, and requiring the calculation and reporting of the
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measures as a condition of their financial support. For example, the Lance
Armstrong Foundation could require participants in its LIVESTRONG
Survivorship Center of Excellence Network (Lance Armstrong Foundation,
2007) to calculate and submit the measures to a performance measures
repository as part of membership in the network.
Organizations supporting patients with cancer and their families as
consumers in the marketplace could also use performance measures to
create strong incentives for improved performance in psychosocial health
care. Approved performance measures constitute de facto standards of per-
formance. Publicizing the measures (even before there are any measurement
results) can help educate consumers about what services to expect and ask
about when they begin their cancer care. Publicizing the measures can also
filter up to employers (and other group purchasers), who want the best pos-
sible care for their employees facing treatment, and thereby to the insurers
with whom they contract to provide coverage for health care.
An Infrastructure to Support Performance Measurement
As discussed above, successful performance measurement requires more
than the creation of measures and an entity that will require their calcula-
tion. Structures and processes are needed to transform the concepts to be
measured into sets of technical specifications, pilot test the measures, audit
a sample of measures to ensure their accuracy, analyze and display mea-
surement results, and maintain the accuracy of measurement specifications
over time. Structures and processes for performing many of these functions
already exist within the health care system. The National Quality Forum,
for example, working in collaboration with many of its members, has devel-
oped or endorsed technical specifications for many measures across a wide
variety of conditions. Accrediting bodies such as the Joint Commission and
the National Committee for Quality Assurance (NCQA) serve as reposito-
ries of submitted data and convert the data to formats useful to consumers
and others. Consolidating a combination of organizations and resources
to carry out the various performance measurement–related activities will
require planning, collaboration, and perhaps financial support. This, too,
will require leadership across many sectors of cancer care.
The committee concludes that, although the policies and practices of
many organizations support the delivery of several components of psy-
chosocial health care, such is not always the case. Available mechanisms
to compensate providers for assessments and interventions to help pa-
tients manage their illness are not fully utilized by all insurers. While FFS
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reimbursement codes take into consideration the basic need to coordinate
care, FFS reimbursement does not well support processes for care coordi-
nation that require additional resources. Although capitated payments to
managed care plans allow better for the provision of linking services, care
coordination, follow-up, and illness self-management support, these ex-
amples are still considered noteworthy, rather than "usual and customary"
practice. Lack of health insurance, high cost sharing for patients, and health
plan policies that hinder collocated services and access to certain providers
also can keep patients from receiving needed services. Solutions exist that
are feasible for group purchasers of health care coverage and health plans
to implement.
Recommendation: Support from payers. Group purchasers of health
care coverage and health plans should fully support the evidence-
based interventions necessary to deliver effective psychosocial health
• Group purchasers should include provisions in their contracts
and agreements with health plans that ensure coverage and reim-
bursement of mechanisms for identifying the psychosocial needs
of cancer patients, linking patients with appropriate providers
who can meet those needs, and coordinating psychosocial ser-
vices with patients' biomedical care.
• Group purchasers should review cost-sharing provisions that
affect mental health services and revise those that impede cancer
patients' access to such services.
• Group purchasers and health plans should ensure that their cov-
erage policies do not impede cancer patients' access to providers
with expertise in the treatment of mental health conditions in
individuals undergoing complex medical regimens such as those
used to treat cancer. Health plans whose networks lack this
expertise should reimburse for mental health services provided
by out-of-network practitioners with this expertise who meet
the plan's quality and other standards (at rates paid to similar
providers within the plan's network).
• Group purchasers and health plans should include incentives
for the effective delivery of psychosocial care in payment reform
programs—such as pay-for-performance and pay-for-reporting
initiatives—in which they participate.
In the above recommendation, "group purchasers" include purchasers
in the public sector (e.g., Medicare and Medicaid), as well as group pur-
chasers in the private sector (e.g., employer purchasers). In recommending
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that group purchasers include in their contracts and agreements with health
plans provisions to ensure the coverage and reimbursement of mechanisms
to identify psychosocial needs, link patients to psychosocial health services,
and coordinate these services with biomedical care, the committee is not
necessarily calling for these interventions to be reimbursed separately by
group purchasers and health plans. Rather, these parties should assess the
extent to which these processes are explicitly addressed in their agreements
with each other and with health care providers, make these expectations
explicit if they are not already so, and assess the adequacy of their payment
rates for these processes. Purchasers and health plans may find, for ex-
ample, that these interventions are currently provided for in their capitated
payments or included to some extent in FFS reimbursements. In contrast,
mechanisms may need to be developed for reimbursing higher-than-average
levels of care coordination. The predictive modeling techniques now being
used by some health plans can help identify when special reimbursement of
or arrangements for care coordination may be called for.
With respect to reimbursement of out-of-network providers when nec-
essary, mental health care providers "with expertise in the treatment of
mental health conditions in individuals undergoing complex medical regi-
mens such as those used to treat cancer" include mental health care provid-
ers who possess this expertise through formal education (such as specialists
in psychosomatic medicine), as well as mental health care providers who
have gained expertise though their clinical experiences, such as mental
health clinicians collocated with and part of an interdisciplinary oncology
The recommended approach of guaranteeing access to such expertise
through the use of out-of-network providers is consistent with similar
recommendations of other health care quality initiatives (Shalala, 2000),
including the President's Advisory Commission on Consumer Protection
and Quality in the Health Care Industry (1998), whose patient Bill of
Rights states: "All health plan networks should provide access to sufficient
numbers and types of providers to assure that all covered services will be
accessible without unreasonable delay. . . . If a health plan has an insuffi-
cient number or type of providers to provide a covered benefit with the ap-
propriate degree of specialization, the plan should ensure that the consumer
obtains the benefit outside the network at no greater cost than if the benefit
were obtained from participating providers. Plans also should establish and
maintain adequate arrangements to ensure reasonable proximity of provid-
ers to the business or personal residence of their members" (p. A-31).
Further, ensuring access to such providers means more than just allow-
ing them to receive reimbursement; a health care provider possessing this
expertise must be accessible to the cancer patient. If, for example, an indi-
vidual with such expertise is collocated with the patient's other oncology
OCR for page 241
providers, this individual should be allowed to receive reimbursement pro-
vided that (as specified in the recommendation above) he or she meets the
plan's quality and other standards. The provider should also accept reim-
bursement at rates paid to similar providers within the plan's network.
In recognition that full implementation of the above recommendation
will not by itself ensure the provision of appropriate psychosocial health
services, the committee also makes the following recommendation.
Recommendation: Quality oversight. The National Cancer Institute,
CMS, and AHRQ should fund research focused on the development
of performance measures for psychosocial cancer care. Organizations
setting standards for cancer care (e.g., National Comprehensive Can-
cer Network, American Society of Clinical Oncology, American Col-
lege of Surgeons' Commission on Cancer, Oncology Nursing Society,
American Psychosocial Oncology Society) and other standards-setting
organizations (e.g., National Quality Forum, National Committee for
Quality Assurance, URAC, Joint Commission) should
• Create oversight mechanisms that can be used to measure and
report on the quality of ambulatory oncology care (including
psychosocial health care).
• Incorporate requirements for identifying and responding to psy-
chosocial health care needs into their protocols, policies, and
• Develop and use performance measures for psychosocial health
care in their quality oversight activities.
The research to be funded will need to transform concepts to be mea-
sured into technical specifications, pilot test the measures, audit a sample
of measures to ensure their accuracy, analyze and display measurement
results, and address how the accuracy and reliability of the measures will
be maintained over time. The committee expects that these activities will
make use of already established mechanisms and organizations that cur-
rently perform these functions, but that some funding may be needed to
support certain other activities, such as the initial development of the mea-
sure specifications.
The committee also believes that a small number of measures (five or
fewer) should be targeted for development, and that these could consist
of structural as well as process and outcome-of-care measures. Structural
measures are typically addressed in accreditation processes and could be
used to deal with such areas of concern as whether a health plan or clini-
cal practice requires or uses a validated instrument or approach to identify
systematically all cancer patients with psychosocial needs. Patient report
OCR for page 241
instruments, such as AHRQ's CAHPS Clinician and Group Survey ques-
tions, could also be used to obtain information from patients about the
extent to which they were linked to needed psychosocial services and re-
ceived education and training in managing their illness. Thus, the expert
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text:
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subset: commoncrawl


text:
Vegetarian and Vegan
> Food suggestions for vegan 12 month old
My lil guy is really into finger foods lately and I'm stumped as to what to give him. I delayed giving him solids until 7 months, and he's still bf'n a lot. He usually just has breakfast, lunch and dinner, like we do. Things he's had before are: bananas,raisins,carrots, peas, fake cheerios (made from oats), oatmeal, brown rice, and then many flavors of organic baby food. Come meal time it takes forever to think of something to give him. Any suggestions? He's slowly being introduced to grains (spelt and whole wheat), I give him frozen bagels or bread to chew/teethe on. He hasn't been introduced to soy or mock meats yet, I want to hold off a lil longer on that as well. He's had homemade cashew milk and seemed to love it (he drank like 1/4 cup in a matter of minutes!). He drinks about 1/4-1 cup of diluted juice on days when I get around to giving him his sippy cup (75%water, 25% juice, it's very diluted).
Thanks in advance!
I have the same issues with Aria
Try some nutbutter on the bannas
I will take soem bread and smear it with hummus or nutbutter for her
VEggie barley soup. She loves it. I just put some veggies and veg broth in the crock pot with pearled barley and let it cook
what about cooked sweet potatoes?
She loves diced dried apricots.
another fun thing is those organic teething biscuits from healthy times. vegan and yummy, she goes nuts for them.
beans beans and beans.
I give them to her plain. She loves to pick them up. black and kidney are her favs.
thse are just some ideas
(ohh I mix her rice with a lil mild salsa too, she loves it)
how about those baby foods used as a sauce for things like pasta or the fruit ones are good in oatmeal.
Just some ideas...
Erin Pavlina
Vegan also. Trying to remember what we did.
Black beans with barbecue sauce.
Baked potato cut into cubes with non-dairy dressing (Creamy Garlic from Follow Your Heart, best)
Hummus and pita
Avocado and pita
sweet potatoes
Broccoli and butternut squash steamed together with some soy sauce and a dash of ginger.
Miso soup with seaweed flecks. (good minerals)
Any and every fruit.
That's all I can think of at the moment.
broccoli pieces - he loves the texture!
we have a newfound fascination with blueberries. who knew they were so great?
bebe luna
I think yams (or sweet potatoes) are great! You can cut them up into wedges and bake them (home fries) or bake them whole (sweeter)...
Baked apples with raisins
Roasted vegis sprinkled with tamari
Rice cakes (with almond butter or apple butter)
coconut date rolls
Baked plantain or sliced panfried plantain
steamed carrot "sticks"
oat or rice flour pancakes and apple butter or other fruit
most of the above +
quinoa w/ almond or soy milk and fruit
we buy organic dry cereals, one is millet + rice, then let them soak in some kind of vegan milk til soft enough to eat but still solid enough to pick up
oatmeal with - milk and fruit, or sometimes i use this great local jam made with only fruit + honey
or else molasses
tahini or nut butter with molasses on different breads - have you got manna breads where you are? they're soft sprouted cake-like unleavened, different kinds of grains, organic and without anything but the grain!
steamed broccoli
anything with tomato on it
cashew butter sauce on spelt penne or rotini
beans+rice, any kind but especially black refried beans with corn, tomato, cumin
baked vegetables
we also love tofu baked with tamari and all kinds of different flavours
smoothies with things thrown in
blended soups like apple-squash-ginger, tomato+other veg
i know it is sometimes hard to think of anything
i write it down if we liked it, that helps next time, and i keep some little distractors on hand like rice cakes, raisins, oranges, so she has s omething to eat while i cook.
really fast: frozen organic peas, blueberries, etc.!
good luck
Saffron's 11 months old & is vegan. This is further complicated by her having excema which the naturopath said was yeast related so no more dried fruits. She loves dried figs & dried prunes as finger foods. To top all this she only has 2 top & 2 bottom teeth so we're only doing fruits & veges. My only cheat on this is tahini.
What she eats is :
avocados, steamed brocolli & karengo. Karengo is a new zealand seaweed similar to dulse. I mash it all up reserving some of the brocolli florets for her to chew on as well.
asparagus spears
hummus - I sprout the chickpeas & either cook them or puree them raw depending on how I feel.
guacamole - avocado, garlic, lemon, brocolli sprouts.
lentil sprouts & pieces of red capsicum.
She was quite into pumpkins but the organic ones are out of season here at the moment.
any type of leafy green - cooked or raw.
any sprout as a finger food.
There's heaps of stuff. I you want, I'll post some recipes out of my vegan baby book later coz Im a bit knackered now & am off to bed.
A few of my kids all time favorites were tofu that was soaked in juice and cubed for finger food. Also cheerios type cereal and frozen peas they enjoyed trying to put the peas in the cheerios hole and popping them in there mouth ...good luck!


text:
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Adoptable pets: Aug. 8, 2010 Previous Next This adorable dachshund mix is 5 and very happy. Zaxby weighs nine pounds and would love a family to snuggle with. Adopt this dog by calling 287-2549 or going to www.caninecastaways.org. Canine Castaways is a foster-based group and all of the dogs are spayed/neutered, up to date on shots and microchipped. An adoption application, home visit and adoption fee apply to all dogs available for adoption. Lombardi is not only handsome but ready to entertain you. He loves to play and is ready for his forever home. Adopt him for $70. Adoption fee includes de-worming, flea testing, neutering or spaying, vaccinations and a microchip. Visit the kittens and cats for adoption from 10 a.m. to 4 p.m. Saturdays and Sundays at Naples PetSmart, 2235 Pine Ridge Road, Naples or by appointment at 290-6274. www.volunteerservicesforanimals.com. Be the prince to Cinderella and adopt this wonderful dog. This lady-in-waiting is a 5-year-old boxer who is good looking and well behaved. She will obey your commands and be a perfect companion. Call Brooke's Legacy Animal Rescue at 434-7480, brookeslegacyanimalrescue.com. Kevin adores people and enjoys being with other cats. He is a handsome one-year-old cat that is available for adoption for $55. Visit all the pets at the Humane Society Naples, 370 Airport-Pulling Road N., Naples from 11 a.m. to 7 p.m. Tuesday and Thursday and 11 a.m. to 5 p.m. Wednesday, Friday, Saturday and Sunday. 643-1555; www.HSNaples.org. Poppy and Nettle are 10-month-old sisters who want to be part of your loving home. They are not only playful but very sweet and loving. Adopt them both for $70. For the Love of Cats is a no-kill rescue and shelter on Marco Island. See all the cats and kittens available for adoption from 10 a.m. to 2 p.m. Saturdays and 11 a.m. to 3 p.m. Sundays at Petsmart, 2235 Pine Ridge Road, Naples or call 642-8674 for an appointment. You can also go online at www.floridacatrescue.com. Cody is a sociable Siberian husky who loves to be with people. He walks well on his leash and enjoys car rides. This active boy wants to be part of a loving family. South Florida Siberian Husky Rescue Inc. is a non-profit 501 c3 volunteer organization. Adoption fees vary based on the age of the dog. Call (954) 540-7373 or go to www.sibrescue.com to see the available dogs. Show Caption Hide Caption


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Luke fon Fabre
this wiki
Luke fon Fabre | |
Information | |
Game | Tales of the Abyss |
Hometown | Baticul |
Age | 17 (beginning of the story) 20 (end of the story) |
Weight | 150 lbs / 68 kg |
Height | 5'7" / 171 cm |
Race | Human |
Weapon | Sword |
Japanese Voice Actor | Chihiro Suzuki |
English Voice Actor | Yuri Lowenthal[1] |
Luke fon Fabre, known in Japan as Luke fone Fabre (ルーク・フォン・ファブレ Ruuku fon Fabure?), is the main protagonist in Tales of the Abyss. In the Ancient Ispanian language, his name means Light of the Sacred Flame (聖なる焔の光 Seinaru Homura no Hikari?). He is the son of Duke Crimson Herzog fon Fabre and Duchess Susanne fon Fabre, and by extension, the nephew of King Ingobert VI.
Seven years prior to the events of the story, Luke is reportedly kidnapped by the Malkuth Empire, an experience so traumatic as to cause him to lose all memory of events and people encountered before this event. Since his return to Kimlasca, he has been confined in the Fabre manor in Baticul, by orders of his uncle, King Ingobert VI, having only the company of his parents, Natalia Luzu Kimlasca-Lanvaldear, the servants, his teacher Van Grants, and his best friend Guy Cecil. Because of this, Luke has attempted to escape many times from the manor, but to no avail. His methods of escaping have included hiding inside a bag left in a wagon that came to deliver goods to the kitchen's manor, climbing the fence, and disguising himself as a "White Knight". Since this event, Luke has periodically experienced painful headaches, similar to migraines but apparently less severe and with no perceptible cause, hearing voices each time they occur. Luke's family believe them to be linked to the kidnapping.
Spirited Away
One day in the middle of sword practice, Tear Grants enters the Fabre manor using a fonic hymn to lull its occupants to sleep, and attempts to assassinate Van. Luke intervenes, causing an isofon-induced hyperressonance which transports the two away into the Tataroo Valley, which lies within the territory of the Malkuth Empire. Thus begins Luke's adventure into the world he has never had knowledge about with Tear as his guide. As he makes his way across Malkuth, Luke begins to develop a better understanding of the world outside his manor, despite still behaving like a spoiled child until much later in the story. Shortly after their arrival in the farming village of Engeve, Luke and Tear encounter Malkuth Colonel Jade Curtiss and Fon Master Guardian Anise Tatlin of Daath.
It is later revealed that the two are escorting Fon Master Ion of the Order of Lorelei to the Kimlascan Capital, Baticul, in the hope of persuading the king of Kimlasca not to go to war with Malkuth. Luke agrees to aid Jade and Ion in obtaining an audience with his uncle, King Ingobert VI of Kimlasca-Lanvaldear, after being captured by Malkuth forces and taken aboard the Tartarus following an investigation of food theft by the cheagles under threat of being eaten by ligers. They are later joined by Guy after the Tartarus is attacked and commandeered by the six God-Generals of the Order of Lorelei, who appears miraculously on time to save Luke, Jade and Tear from Legretta and Arietta. When Largo is supposedly killed by Jade, Luke is astonished to see how Jade simply murders him. He is placed on guard when he unwilling kills an enemy soldier. Luke is shocked that he killed someone, and after some convincing conversations with Tear, he once again picks up his sword. When the party, now accompanied by Guy, runs into more soldiers, Luke cannot bring himself to draw his sword. Tear jumps in the way as the soldier prepares to strike the killing blow. Fortunately, Tear is not hurt badly, but Luke places it upon himself to not be as fearful of killing because of her injury.
After the return to Baticul, Luke discovers that Van has been arrested and possibly faces execution. However, Van is freed, and after a meeting with him Luke sees the promise of becoming a hero as stated in Lorelei's score. Luke is tricked by his very own master into destroying Akzeriuth, the mining town to which he and his party had been sent to provide assistance following an earthquake that released the miasma from below the surface. As a result of Van's deception, the Sephiroth supporting the mining town was destroyed and the entire city fell into the Qliphoth, the world beneath the Outer Lands. The Qliphoth is known only to the upper echelons of the Order of Lorelei, is shrouded in the deadly miasma, and spreads beneath the Outer Lands as an expanse of liquified crust beneath an eerie, violet sky. After the catastrophe with the destruction of Akzeriuth at Luke's hands, he starts to lose the trust and support of the whole party. They turn from him when he needs their support most. His selfish and arrogant attitude had proven to be too much for the group. They chose to abandon his side to deal with the situation that he refused to acknowledge his share of the blame of, ultimately leading him to tears. The only one who would stay by his side was Mieu.
Desire to Change
After his close encounter with God-General Asch, Luke enters in a depression shock after finding out that he is merely a replica of Asch, and that Asch is the original Luke kidnapped by Van in order to overturn Yulia Jue's Score. He is unable to overcome this on his own. As he saw through Asch's eyes the way that Guy still considered him a friend, and Tear's council about what exactly to do to make up for his mistake, Luke cuts his hair with Tear's knife to throw away his old self and try to change into a better person. From this point on, Luke's resolve seems solid, since he now wants to save the world, even if that does not make up for his actions at Akzeriuth. A little later in the game, Luke finds his own way to save the world by controlling the Sephiroth Passage Rings with his hyperressonance. If done correctly, this could allow him to steadily lower the Outer Lands into the Qliphoth before they fall.
Meaning of Birth
One month after the Outer Lands were lowered, Luke has returned to his manor in the city of Baticul. This time though, he has decided to keep in contact with his friends. After a while, Luke and his friends reunite and start travelling the world once again. As they do, it becomes clear that the world was not fully saved by their actions. Miasma starts to pour back into the Outer Lands, and replicas wander the streets with nowhere to go but the mysterious Tower of Rem. Eventually, Luke discovers a way to save the world that would involve the loss of ten thousand lives and one Seventh Fonist. The replicas, willing to die if it will put an end to their pain, offer themselves up as a sacrifice as well as Luke. He believes that he has no reason to exist and thinks that by living, he is denying Asch the life he was meant to be living. His friends try and persuade him that he is wrong, but Luke makes up his mind. He and the replicas travel to the top of the Tower of Rem and Luke starts to cast an amplified hyperressonance to absorb the world's miasma. During this time, Luke realizes that he does not want to die. His efforts to remove the miasma are not enough, and Asch is forced to step in and help again. Both him and Luke are caught up in the energy field and when it disappears, they are both still alive. Both the miasma and the replicas are gone, however.
Slow Death
Even with the miasma gone, the fate of the world still hangs in the balance. Van Grants has replicated the destroyed city of Hod, now renamed Eldrant, and will use it to destroy the world and build a new age of replicas. Luke and the others decide that they have to stop this from happening, and that they have to do it fast. At the Tower of Rem, Luke finds Asch attempting to use the replicas to erase the world's miasma, but Luke refuses to let this happen and argues with Asch for the sword. Luke tells Asch, that he should be the one to die since he is a replica. Asch leaves after failing in this attempt and Luke and his party head to Daath. At Daath, he reveals his choice that he will sacrifice his life and allow Asch to live. At the tower, Luke and Asch fight again on who will use the Key of Lorelei, but Luke manages to take Asch's place when Jade manages to hold on to Asch. While attempting this, a large object emerges from Luke's chest. Asch reveals that it is the Jewel of Lorelei that they had been searching for, and that Luke must have sealed into himself during the fight with Van. Luke uses the sword along with jewel to clear the miasma. Luke and rest of the party are surprised to see Luke living, but Luke notices that his hand is becoming transparent. The party goes back to Belkend to speak with the doctor; the doctor explains that Luke's Seventh Fonons are separating, and at some point he will die.
Desire to Live
As Luke makes his way to Eldrant to stop Van, he realizes that his remaining time after finally discovering the meaning of life is too short. Tear tries to persuade him that he is going to live and keep on living, even with the Seventh Fonons inside of him slowly fading away. He eventually reaches Eldrant but finds himself falling through a trap door into a large, sealed off chamber. Asch is down there too, and he has discovered a way to escape. Unfortunately, it requires one person to stay behind and hold the door open using hyperressonance. Luke volunteers to stay, saying that Asch would be able to defeat Van easier, being the original. Asch cannot stand Luke putting himself down though, and he cannot allow Luke to decide who is stronger on his own. He challenges his replica to fight. The winner will be declared stronger and will be allowed to go forward and defeat Van. Luke emerges from the fight victorious and Asch hold the door open for him. Afterwards though, Asch is killed by Oracle Knight replicas. As he breathes his last breath, he gives Luke what remains of his power, allowing Luke to perform Second Order hyperressonance. After defeating Van, Luke frees Lorelei and saves the world. But after catching Asch's dead body, both of them are engulfed in a blinding light as Asch's finger twitches.
One year after the battle on Eldrant, three years after the start of his initial journey, Luke is presumed to be dead, either killed in the destruction of Eldrant or worn down by separating Seventh Fonons. However, on the night of his coming of age ceremony, his twentieth birthday, Luke mysteriously reappears in Tataroo Valley. But the Luke seen is slightly different than the one who defeated Van. Notable changes include longer hair, with a hair tone between Asch's dark ends and Luke's light ends, a completely different outfit, a slightly different voice from both Luke and Asch, and the Key of Lorelei positioned in the same way Luke always had his sword. When Tear asks why he was here, he replies that there was a nice view of Hod, and he tells her that he made a promise to someone. Tear begins to cry as she rushes over to him, joined by his other friends who were nearby except Jade, who merely smiles.
Fighting Style
Luke continues the tradition of being a slower-hitting, more powerful swordsman who chooses to focus on more damaging techniques with less emphasis on combos. As such, he has techniques such as Raging Blast and Guardian Field, both of which do not chain well in combos. Luke has many elemental attacks which can create incomplete FOF Circles, adding a unique amount of elemental versatility that enables him to form his own FOF Changes when needed. Through a series of sidequest events involving the Albert-style textbooks, Luke can learn additional techniques like Sonic Thrust, Demon Fist, and Slag Assault.
Tear Grants - At first, Luke and Tear are off to a horrible start. Tear thinks Luke is a spoiled brat, while Luke regards Tear as bossy and cold. The only thing Luke knows about Tear is that her self-admitted ignorance of his having the power of the Seventh Fonon has caused them both to be transported across the lands. He treats Tear, and everyone else, terribly, constantly complaining and talking down to her. Tear puts up with it only because of his status and the feeling of responsibility she has for placing him in this situation. Still, she is quick to criticize him, and he comes to think of her as a pretty face with a bad attitude.
The most notable change in their relationship is after Akzeriuth is destroyed, and the party leaves Luke behind in Yulia City with Tear, who did not want to return to the surface. Awakening, Luke sees Tear in the garden behind her house. He approaches her with plans to save St. Binah, but she does not believe in him. Though Luke speaks of understanding and change, he can tell Tear does not believe him. Using one of her daggers, he cuts off his hair to symbolize his cutting himself off from his old way of being. Tear is still unconvinced, but Luke believes his actions will prove his words true. He asks Tear to watch him, make sure he stays on the right path. Tear agrees to do so. As time goes on, Luke's determination begins to affect Tear, and slowly she begins to trust him.
As the story progresses, it becomes obvious that Luke thinks the world of Tear. However, he is not very good at showing his feelings, and screws up whenever he tries to do so. It does not help that he is dense to a fault and all hints thrown his way by other people about Tear's feelings towards him misses him completely. The two constantly deny their growing feelings for each other, much to the amusement of their fellow party members. Along with their growing feelings for each other, the both of them also begin to have increasing concerns about one another. When activating the Sephiroth, Tear begins to become increasingly exhausted with each Sephiroth they trigger. When they discover that the miasma is being absorbed into her body causing her exhaustion, Luke insists on staying by her side recognizing that while he wants her to stop, there is no other way around the situation. Even when they finish using the Sephiroth, Luke is still concerned about the miasma in her body.
Later in the story, the roles are reversed when Tear becomes extremely worried on Luke's behalf as he tries to find his worth in the world. Because of this, he is now prone to making irrational decisions if he thinks it will give his life meaning forcing Tear to look after him more closely. This reaches its peak when Luke is faced with sacrificing himself to eliminate the miasma at the Tower of Rem. She states that even if Luke were to die to eliminate the miasma and be called a hero, she would hate him but also says that she will leave that choice up to him as he did with her when they were activating the Sephiroth.
When she realizes he is going through with it, she immediately tries to run to him to stop him, her eyes about to burst crying, only to be held back by Guy. She is relieved to find him alive after the whole ordeal but becomes concerned for him again once she finds out about Luke's declining fonons. Unlike the situation with Tear where she is able to suppress and eventually eliminate the miasma from killing her, there is no way around Luke's ailment and he will ultimately die. While talking to him about it gives Luke someone to talk to about his ailment, she feels completely useless while Luke slowly dies.
The night before the group's final battle, Luke attempts to tell Tear something important, but, in the end, is too nervous to say it. Should the player read Luke's diary, it is implied that Luke had wanted to tell Tear of his true feelings for her, but backed out in the end since he believed that announcing his feelings would cause her pain as he was unsure if he would survive past the final battle due to the continuous deterioration of his fonons. After the final battle with Van, as everyone says their parting words to Luke, Tear tells him tearfully to come home after everything is over, which Luke promises he will.
Other Appearances
Tales of the World: Radiant Mythology
Luke appears along with Tear in Tales of the World: Radiant Mythology as a playable character. He is classed as a Swordsman with the "Duke's Son" title. It is implied that Luke and Tear reached Terresia though a hyperresonance reaction, much like what spirited them away to Malkuth in the beginning of Tales of the Abyss. They also leave through another hyperresonance reaction. The sword Luke uses throughout the entire game is the average "Cutlass".
Tales of the World: Radiant Mythology 2
Short-haired Luke and most of the Abyss characters appear as playable characters. Luke is first seen when the Protagonist and the guild on the Van Eltia see his ship is attacked out on sea. He along with Tear, Guy, and Jade flee into a nearby cave and stay in there until the manage to recover from the attack. After the player gets the story mission to go save him and along with the others. Deep inside the cave where they are located Luke is injured badly and Guy is trying to wait for Tear to show up to heal him. After defeating Guy, Luke is prepared to fight to the player also, but Jade and Tear stop this from happening and explains to Luke that the player is not their enemy. After Tear heals Luke, he heads to ship with the others to report to Chat and he is available to called out into the players party after. Unlike the original Tales of the Abyss and other spin-off games, Asch and Luke are portrayed as twins instead of Luke being Asch's replica or clone. During the course of the game Luke tries to get along with Asch, but he just ignores him. The sword Luke uses throughout the entire game is the "Fonic Sword".
Tales of VS.
He appears as a playable character along with most of the Abyss characters. In the game's timeline and plot, he is the prince of the Kingdom of Niddhog. He has a very haughty attitude due to him being brought up as a spoiled prince who has never faced any hardships or problems. He was forced to join the Yggdrasill Battle which is part of a rite for the Imperial succession of the kingdom of Nidhogg. As in Tales of the Abyss, Luke is a replica of Asch and was raised as the real Luke. When he finds out the truth, he decides to change, then cuts his hair. Although, the long-haired Luke can still be played by pressing the Start button while choosing Luke in the character selection screen.
Tales of the World: Radiant Mythology 3
In Tales of the World: Radiant Mythology 3, Luke takes part in the game with his long-haired appearance. He is the eldest son of Duke fon Fabre and the first successor to the throne of the kingdom of Lima. Asch is designated as his twin brother, younger than Luke and second in line to ascend to the throne. They both escape to the Van Eltia under the escort of their shared swordsmanship instructor Van, while the riot brews within their country, caused by a Descender-worshiping cult known as the Disciples of the Dawn. They reunite unwillingly with Natalia, Tear, and Jade, joining them to work for the guild in exchange for staying on the ship. Luke's personality follows that of the first half of the original game's story. He shows strong immaturity through his obstinate and wayward mannerisms, frustrated by boredom, extremely emotional, and bossy towards his guild colleagues. He showed a great lack of aristocratic manners. Asch refers him as trash, and the brothers always quarrel against each other. Eventually, Van arranges a test for both of them to prove who is more suitable to be the throne successor, leading to an outcome of failure for both of them compared to Van's expectations.
Tales of the Heroes: Twin Brave
In Tales of the Heroes: Twin Brave, Luke appears in Guy's serious scenario as his partner. He remains as the son of Duke Fabre, and he takes up his long-haired appearance at first. On hearing a voice in his head telling him that he will become a hero to save the world using the Eternal Sword, Luke leaves the manor and activates the sword in spite of Guy's efforts to stop him. But it turns out that he has been deceived by the owner of the voice, Elrane, resulting in the death of thousands of people. Unable to accept the gravity of what he has done, Luke flees and is absent for two chapters.
When Guy finally finds him, he is on the verge of an emotional breakdown, and he even wants to commit suicide. Guy stops him by saying that death is nothing but an escape from responsibilities, and he assures Luke that he will accompany him as always in his upcoming life to pay for the crime he has committed. Luke recovers himself and destroys the Eternal Sword together with Guy. At the end of the story Luke cuts his hair to show his determination. His short-haired appearance can be seen in a picture after the story is cleared. Luke is also the protagonist of a comical scenario with Guy assisting him. He is again the long-haired spoiled son of Duke Fabre in this story who causes chaos with other Tales characters. In the end, however, he somehow saves the world from Schwartz by talking her out of revenge on human with unintended words. When Luke appears as a boss in other stories in the game, it is most often because he is the one that has caused troubles.
- Following the typical hereditary order of succession in existing monarchies in the real world, Luke is currently third in line to inherit the throne of the kingdom of Kimlasca-Lanvaldear. He is preceded by the second in line, Luke's mother Suzanne, who is the sister of the reigning king, and further preceded by the royal heir and Luke's cousin, Natalia. This disregards all complications related to replication and genetic lineage. If Luke and Natalia's intended plan of marriage had progressed, Luke would not bypass the order of succession to become the next king, instead becoming the prince consort, while Natalia retains her position as queen regnant.
- In Tales of Vesperia, in Nordopolica, the sign behind the talking gladiator lists and mentions a small description of Luke and the other playable Abyss characters. On Laulyse Island, a monster named "Gentlereplica" appears when it is raining. While it is a variation of the typical "Gentleman", it wears a mask of Luke, granting it the ability to parody Luke's fighting style, including the arte Raging Blast. This enemy also appears in the Majestic rank of the coliseum, alongside similarly styled parody creatures that represent Tear and Mieu. Also, in the PlayStation 3 port of the game, Flynn Scifo can dress as Luke by equipping the "Seinaru Homura no Hikari" title, which people could acquire through the pre-order bonus, or through the "Lorelei no Kenshi" title, which can be bought through the PlayStation Network.
- An outfit based on Luke's appearance is available to Genis Sage in the PlayStation 3 port of Tales of Symphonia and as a DLC costume for Dezel in Tales of Zestiria.[2]
- ↑ RPG Site - Yuri Lowenthal Interview RPG Site: Gaming Articles, Reviews, Media and Information (2009) Retrieved on 2009-12-19.
- ↑ "Loads of New Tales of Zestiria Screenshots Part 2..." / Abyssal Chronicles (2014-12-26) Retrieved on 2015-01-13.
Luke fon Fabre | Tear Grants | Jade Curtiss | Anise Tatlin | Guy Cecil | Natalia L.K. Lanvaldear | Asch
Ion | Mieu | Ingobert VI | Peony Upala Malkuth IX | Teodoro Grants | Yulia Jue | Lorelei
Noelle | Ginji | Spinoza | Belkend Class I | Sheridan Class M | Aslan Frings | Jozette Cecille
Nephry Osborne | Crimson Herzog fon Fabre | Susanne fon Fabre | Noir | York | Urushi
Florian | Ion (original) | Francis Daath | Freyr Albert | Walter Sigmund | Cantabile | Marcel Oslo


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With ESPN's Michael Smith as the MC, members of the media, press, VIPs, NBA players from the present and past, are gathering now at a undisclosed location in New York City for the unveiling of Air Jordan XX9. Draped in larger-than-life images of basketball greats and with an ambiance of a shrine to the game, Larry Miller, President of Jordan Brand, took to the stage from a brief introduction. In his monologue to the gathered guests, he also hinted an official release set in September 2014 to welcome new NBA season. With the mic now in designer Tinker Hatfield's hand, Smith welcomed His Airness Michael Jordan to the stage along with a first look at the upcoming Air Jordan XX9… Since the event is taking place right now, stay tuned for more developments to come soon.
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Co-Founders / Dan Hwang / Yu-Ming Wu
Editors / Dave Chung / John Kim
Contributors / Greg Vernick / Jesse Carr / Patrick Mallory
© 2003-2014 Freshness Creative Corp., All Right Reserved


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Please Note: The date of the question indicates the date it is assigned, and not the due date. Answers to the questions are due a week after they are assigned. The current question is highlighted. Please play attention to these dates, as they relate to the material currently being covered in class.
Date | Due Date |
Question |
9/04 | 9/09 | No question. |
9/09 | 9/16 | Do you think that artists have special gifts that other, "ordinary" people do not, or do you think they acquire their skills through practice and effort? Please explain why. |
9/16 | 9/23 | How would you define good and bad art? |
9/23 | 9/30 | Have you ever had a strong emotional reaction, good or bad, to a work of art? |
9/30 | 10/07 | Can a work of art be ugly and still be art? |
10/07 | 10/14 | Does art in public places have to appeal to everyone? |
10/14 | 10/21 | Have you ever been offended by a work of art? Please explain. If not, please explain what might offend you. |
10/21 | 10/28 | Should members of your community be able to restrict which images you can and cannot see? |
10/28 | 11/04 | Has controversy ever influenced which movies you would or would not attend? Please explain. |
11/04 | 11/11 | Can movie violence make the audience indifferent to real violence? Can it make an audience member more violent? |
11/11 | 11/18 | Can television, with its fast pace and immediacy, make people less appreciative of the other performing and visual arts, such as painting sculpture etc? |
11/18 | 11/25 | Should you pay taxes to support struggling artists? In other words, is it important or valuable that the arts be supported by public funding? |
11/25 | 12/02 | Would you got see a film, or a play, or an art exhibit or buy a book and read it simply because one of your favorite artists/authors/actors was involved in it, without knowing anything else about the project. (So, we are talking about the pull/influence of the artist alone). |
12/02 | 12/09 | Do we (humans) need the arts? Why or why not? |
Remember, on the week you present your Group Project, you are NOT required to do the Weekly Assignment.
Syllabus | Course Outline | Weekly Question | Lecture Outlines | Grading | Group Projects |
Midterm Project | Revised Course Outline | Midterm Exam Study Guide | Final Exam Study Guide | Group Presentation Schedule |


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In a 42 U.S.C. section 1983 action claiming that the Mississippi Secretary of State wrongfully failed to place plaintiff on the presidential ballot, dismissal of the action is vacated and the case is remanded with instructions to consider whether to abstain from deciding the case based on the uncertain questions of Mississippi law it involved.
Read Moore v. Hosemann, No. 09-60424
Appellate Information
Filed December 18, 2009
Opinion by Judge Smith


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An inspiration brought the Fellowship of Isis (FOI) into being at Clonegal Castle, County Wexford, Ireland, in 1976. The FOI is open to both men and women who wish to explore the mysteries through its unique liturgy. Write directly to the Fellowship of Isis at Clonegal Castle, County Wexford, Ireland, or access the Iseum of the Nine Muses at www.webnik.com.
What do Pagans have in common with Henry David Thoreau? The Unitarian Universalist Association established a Pagan branch in 1985. The Covenant of Unitarian Universalist Pagans, Inc. (CUUPS), 8190A Beechmont Avenue #335, Cincinnati, Ohio 45255-3154, will provide the address of the CUUPS chapter closest to you (there are over 60 chapters nationwide). Their Web site is www.cuups.org.
Books for those who want to know more about the Pagan Way:
RavenWolf, Silver, To
Ride a Silver Broomstick: New Generation Witchcraft (Llewellyn, 1993). This popular introduction to Wicca includes special acknowledgment of many who worked to make it a viable spiritual path.
Buy this book
Kondratiev, Alexei, The Apple Branch: A Path to Celtic Ritual, (Collins Press, 1998).
The Celtic contribution to the neo-Pagan movement, discussed in a scholarly manner, makes this book worth seeking.
Buy this book
Cott, Jonathan, Isis and Osiris, Doubleday, 1994. Ancient Egypt's great love story discussed from different viewpoints, including interviews with Egyptologists, the
founders of the Fellowship of Isis, and others.
Buy this book
One of nine articles in our Mind/ Body/ Spirit Supplement.


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DATE: Will be calculated from "Release Start Date" field.
Social media has exploded around the web and Ford has been a significant participant in the last year or two. Click here to visit the @Ford Social Media Hub - Ford Motor Company's resource for all personnel who have an interest in learning more about the social web.
The Nerdist Channel's newest show, Nerdy Jobs, gives viewers an inside look at some of the world's most geek-centric and technologically advanced jobs.
Recently, host Matt Bennett got behind the wheel with Ford's R&D team. He paid a visit to Ford World Headquarters to check out some of our "nerdy jobs" on site - used virtual reality and tested the dangers of texting and driving with our simulator technology.
Click here, to check out this episode of Nerdy Jobs for yourself.
Click here to continue reading this blog post.


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July 5, 2012, 09:58 PM | #1 |
Join Date: February 14, 2009
Posts: 17
Which color ACOG reticle?
What are the advantages / disadvantages of the red, green, and amber reticles? I'm trying to decide which one to get. Which is best for daylight use? I imagine they're all similar for low light use.
Thanks! |
July 7, 2012, 12:43 AM | #2 |
Senior Member
Join Date: September 12, 2010
Location: Boise, ID
Posts: 447
I can't speak for amber, but red works fine, even at night. I have a switchable red/green optic, and green leaves me with a dead-center blind spot (mild, but very noticeable) on any of 7 brightness settings, during the day. I can't imagine what it would do at night...
http://www.workwithcolor.com/color-luminance-2233.htm (ignore the words and look at the pretty pictures, they're all that are needed here) Links above shows a basic representation of perceived brightness of different colors... http://hyperphysics.phy-astr.gsu.edu...dcone.html#c3b The above link explains (lightly) why blue is a bad choice... Add the two up, and red is a fairly standout choice for a reticle, barring extenuating circumstances making amber a better choice. Blue and Purple would effect vision less, due to lower perceived brightness, but blue light is typically blurry(er) for most people, and purple contains blue. |
July 7, 2012, 02:17 AM | #3 |
Join Date: February 14, 2009
Posts: 17
Thanks a lot. That's interesting and helps me narrow it down.
July 7, 2012, 07:08 PM | #4 |
Senior Member
Join Date: July 17, 2011
Location: NJ
Posts: 583
I'd go with red.
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This website and its contentsare a service ofthe City of Manchester, NH
The Parks, Recreation & Cemetery Department offers a number of Youth Programs, some offered directly by the department, including Fun In The Sun, Saturday Junior Basketball, and the Hershey Track Meet, and various Youth Sports Programs run by volunteers.
The Fun In The Sun program is a summer day camp for Manchester residents ages 6 - 12.
Program Locations: JFK Memorial Coliseum, Livingston Park (Dorr's Pond House), Piscataquog River Park
Program Start Date: 2015 Dates TBD
Program Hours: Monday - Friday 9:00 AM to 3:30 PM
Program End Date: 2015 TBD
For more information, please call Brenda Dwyer at (603) 665-6817
SaturdayBasketball shoot around is available to boys and girls who reside in Manchester. The program runs on Saturdays at Beech Street School from December to March. There is no charge for this program and applications can be picked up at the school on Saturdays only while the program is running.
Starts: Saturday December 6, 2014. This is NOT a basketball league with teams and standings it is simply a program that allows certain age groups an hour and a half in the gym to shoot around or play pick up games. The age breakdown is as follows:
For more information contact Brenda at (603) 665-6817
The Hershey track meet is for kids age 9-14 years old as of December 31st of the current year. There is no residency requirement providing that your town does not offer a meet.
Tryouts for the 2015 meet TBA at Livingston Track. Registration is at 5:30 PM, with the actual meet beginning at 6:00 PM.
Please be aware, our regional meet has moved to Lebanon, NH and will be held TBD. Again this year, other than athletes anyone coming to watch the event both regional and state will be charged $1.00.
For further information contact Brenda at the Parks and Recreation Department at (603) 665-6817
The Summer Fun Runs will run every Thursday beginning June 26, 2014 and run every Thursday in July at the Gatsas Athletic Complex in Livingston Park. Registration begins at 5:15 PM, with events beginning at 6:00 PM.
50 (2 - 6 yr olds)
For more information contact:
Brenda at Parks and Recreation at (603) 665-6817 email email@example.com
Kelly at (603) 548-6802 email firstname.lastname@example.com
Volunteers run the following youth sports program in the City:
Registration is usually done the season before the sport actually takes place. Please call the Parks, Recreation & Cemetery Department at (603) 624-6565 for contact names and numbers.


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Take a Part Airplane Set
The Take A Part Airplane Set from Battat challenges children to flex their spatial reasoning and fine motor skills! It features a 21-piece plastic airplane for kids to assemble and disassemble with the included power screwdriver with 3 different, plastic, drill bits. Imaginations will soar with this airplane set, an awesome construction and pretend play toy! Requires 2 "AA" batteries, not included. Plane measures 9.75"x9.75"x6.25".
From Battat |
Item # 68024 TS
- Price:
- $29.95
- Customer Reviews:
- Currently 0/5 Stars.
- Recommended Age:
- 3 years and up
- Usually Ships:
- within 24 hours
- 25-piece set: 21 airplane parts, 3 drill bits, and power screwdriver
- Kids can take apart and put together airplane
- Requires 2 "AA" batteries, not included
- Plane measures 9.75"x9.75"x6.25"
- WARNING: CHOKING HAZARD - Small parts. Not for children under 3 yrs.


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Vans Contest Results
Posted by Rob, Tuesday, July 31, 2007 2:27 PM
Ice, air conditioning, cold beer, greenbacks... Schaefer and I (along with Dirty Bird) are back in US and A. Very nice. Here are the results from the Vans WSR07 Contest this past weekend in Rotterdam: Street Semi-Finals, Street Finals, and Vert. Coverage from that is coming up later.
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3242 U.S. 70 Lonoke, AR 72086
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A former private club now opened to the public; hosts rehearsal dinners, weddings and receptions, showers, birthday parties, family reunions, etc. Five private bedrooms, two bunk rooms, five bathrooms, two living rooms/social areas, commercial kitchen; shuffleboard, regulation pool table, SLS theater-style sound system; multiple covered patios; 70" flat screen television. Lodge sleeps up to 20. Great room can hold up to 150 people. Shuttle and limousine services, wine tasting, and food services can be arranged. Day trip packages to nearby hunting farms or shooting ranges available. Catering and hunting guide services available.