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Backgrounder #2679 on Health Care
April 12, 2012
April 12, 2012 | Backgrounder on Health Care
Abstract: One element of the Patient Protection and Affordable Care Act (PPACA) is the advancement of "comparative effectiveness research" (CER). Intended to compare available treatment options, CER can benefit patients if used for informational purposes only, but it could also be harmful in practice. The expansion of the Medicare bureaucracy under the PPACA will allow the use of CER for more government micromanagement of personal medical decision making—hurting patients, doctors, and the practice of medicine.
One of the most important goals of health care reform is to slow the runaway growth in health care spending. The United States spent 17.6 percent of its gross domestic product (GDP) on health care in 2009, projected to rise to almost 20 percent of GDP by 2020. Federal spending on Medicare, the federal health care program for the elderly and disabled, is of particular concern. Medicare's cost accounted for 3.7 percent of GDP in 2011 and is growing faster than any other area of federal spending due to increasing health care costs and the rising number of elderly eligible for the program. Another reason for the program's ballooning cost is its fee-for-service structure, which rewards providers for quantity of services and offers little incentive for patients to avoid doctors and other providers who offer poor value.
Meanwhile, the idea of advancing comparative effectiveness research (CER)—defined by the Institute of Medicine as "the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care"[1]—has gained traction. The Patient Protection and Affordable Care Act (PPACA) has created a quasi-governmental entity, the Patient-Centered Outcomes Research Institute (PCORI), to advance CER and its use by doctors, patients, and others.
Comparing available treatment options could certainly be beneficial by informing patients and physicians of the trade-offs of alternative options for treating a certain condition. But to improve quality of care, CER findings must be considered just one part of decision making.
CER must not edge out other crucial factors guiding medical decisions, including a physician's training and experience and a patient's values, preferences, goals, and lifestyle. In countries with nationalized health care, such as the United Kingdom, comparative and cost-effectiveness information is used to inform mandatory coverage and payment decisions, and this limits choice. The PPACA expands the Medicare bureaucracy and allows more government micromanagement of what should be personal medical decisions.
Being able to compare treatment options and pick the best, most cost-effective ones sounds ideal—in theory. Real-life applications of CER, however, can and often do take a different form.
The Patient-Centered Outcomes Research Institute. PCORI is established as a nonprofit organization funded by Medicare dollars and a new fee on private insurance. The institute is governed by key stakeholders in the health care system, appointed by the Government Accountability Office, and by the presidentially appointed directors of the National Institutes of Health and the Agency for Healthcare Research and Quality. PCORI is responsible for identifying national research priorities, establishing and executing a research agenda, and communicating research findings to interested parties.[2]
The first draft of PCORI's national priorities and research agenda did little to clarify how the information it produces will be used.[3] The draft includes few specifics beyond what was already established in the PPACA. PCORI's influence over how CER is actually used will be more or less limited to how it allocates its relatively small financial resources, but it will not be clear how it prioritizes funding for certain diseases and conditions until it actually begins to do so later in 2012. Obtaining cost information on different treatments will be one goal of the institute, the draft made clear.
While PCORI uses the term "patient-centered," its findings will not necessarily be used to promote patient-centered care. The institute was originally named the Comparative Effectiveness Research Institute, but the name was changed because of the controversy that this clear assertion of its intentions created.[4] The objectives of the institute remain largely the same, but according to PCORI's executive director, Joe V. Selby, the name change has inspired PCORI to become more patient-focused in its research.
According to the PCORI website, "Patients will play a major role in PCORI's work by telling PCORI what health care outcomes they value."[5] But it is imperative to differentiate between patient-centered research and patient-centered care—the former does not ensure the latter. Including input from patients and stakeholders in PCORI's research priorities and agenda could make findings more useful for doctors and patients, but the PPACA gives Medicare, in particular, the authority to use CER in ways that will limit patient choice and physician autonomy, making the opposite of patient-centered care more likely than not.
CER in the United Kingdom. CER use in the U.K. has been a far cry from what is implied by the rhetoric used to promote PCORI. Rather than focusing on the individual needs of patients, the United Kingdom's National Health Service (NHS) uses comparative and cost-effectiveness information to limit options as a budgetary tool.
The NHS offers health coverage to all British citizens and determines which treatments will be covered and paid for, and under which circumstances. Decisions are based on "recommendations" by the National Institute for Health and Clinical Excellence (NICE), whose stated purpose is to create clinical guidelines and standardize care using cost-effectiveness information, but the NHS is required to adhere to all of the recommendations made by NICE.
If a treatment is not covered, patients are able to go outside the NHS and receive it privately without regulatory or statutory obstacles—if they are able to afford this. (Because of Medicare's restrictions on private contracting, American seniors would not have this same option.)
Under the NHS, British patients have been refused effective treatments for several conditions because of cost.[6] After its initial assessment, NICE decided that fingolimod, a promising new medicine shown to reduce relapses and delay disease progression in multiple sclerosis (MS) patients, would not be covered. "Based on the available clinical evidence and economic analysis," NICE claimed, "our independent committee concluded that fingolimod would not be effective good use of NHS resources." But according to U.K. neurologist Eli Silber:
The computer models used to determine cost effectiveness don't take into account the significant amount of money that would be spent on patients at the end of life with severe disability, when there isn't much we can do. MS often affects young people, with families and work, and this decision denies them the opportunity to have the risk of disability reduced at a much earlier stage.[7]
After receiving criticism for its decision, NICE changed its guidelines to allow access to the treatment for a subgroup of British MS patients.[8] However, other decisions made by the rationing body may not receive the same level of attention.
By focusing on short-term savings, decisions that deny coverage can worsen the health of the population and increase long-term costs. Helen Evans, a nurse and health fellow at the London-based Adam Smith Institute, highlighted NICE's decision to provide Protelos, a drug that treats osteoporosis, to only a small number of patients as a last resort. She writes that "clinicians and osteoporosis support groups have pointed out that more than 70,000 hip fractures result in 13,000 premature deaths in the U.K. each year and that these otherwise avoidable episodes needlessly cost the NHS billions of pounds."[9]
Bringing CER to the United States. Proponents of the PPACA dismiss concerns that a U.K.-style system will arise under the health law, but the evolution of PCORI implies that the idea may not be so farfetched. Senators Max Baucus (D–MT) and Kent Conrad (D–ND) first introduced the Comparative Effectiveness Research Act in 2008 in order to create a new entity called the Health Care Comparative Effectiveness Research Institute, with the goal of advancing CER.[10] The proposal included almost no limitation on the use of CER within Medicare, and the Secretary of Health and Human Services, or the Secretary's designee, was included on the institute's board of governors, allowing the Department of Health and Human Services (HHS) ample opportunity to influence the direction of research.
In June 2009, Senators Baucus and Conrad offered a revised version of their earlier bill, changing the institute's name to today's Patient-Centered Outcomes Research Institute.[11] By the time the PPACA was signed into law, the original entity had been revised to include additional restrictions to make PCORI politically viable.
This idea of a CER board or institute was not unique. Before taking office, President Barack Obama chose former Democratic Senate Majority Leader Tom Daschle to serve as Secretary of HHS and director of the new White House Office of Health Reform and Jeanne Lambrew to serve as deputy director of the White House Office of Health Reform. In 2008, Daschle and Lambrew co-authored a proposal to overhaul the health care system, which included the creation of a Federal Health Board to use CER to make coverage decisions. The board would "define evidence-based health benefits and lower overall spending by determining which medicines, treatments, and procedures are most effective—and identifying those that do not justify their high price tags."[12]
Under their proposal, all federal health programs would have been required to adhere to the recommendations made by Daschle and Lambrew's Federal Health Board. Daschle and Lambrew even suggested linking the board's recommendations to the existing tax exclusion for health insurance, applying decisions to private coverage as well.[13] Ultimately, Daschle was not appointed as Secretary of HHS, but Jeanne Lambrew was chosen to serve as director of the HHS Office of Health Reform.
Others in the Obama Administration have been no less vocal about their support for the top-down use of CER. Peter Orszag, former director of the Office of Management and Budget, testified before the Senate Finance Committee: "To alter providers' behavior, it is probably necessary to combine comparative effectiveness research with aggressive promulgation of standards and changes in financial and other incentives."[14]
Finally, President Obama appointed Donald Berwick, M.D., to serve as administrator of the Centers for Medicare and Medicaid Services (CMS). Much of Berwick's commentary praises the United Kingdom's NHS, about which Berwick claims, "I am romantic about the NHS; I love it."[15] His vision for health care reform depends on strong centralized power: "I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do."[16]
Berwick's comments about the role of government and elected officials are exactly what must be avoided as CER makes its way to the United States. Under the PPACA, CER will clearly not be used solely as a passive informational tool to guide decision making.
Do PPACA Limits on CER Use Carry Any Weight? The PPACA does limit PCORI's role and its use of research findings. The institute is forbidden from issuing coverage guidelines or making treatment recommendations and "shall not develop or employ a dollars-per-quality adjusted life year…as a threshold to establish what type of health care is cost effective or recommended."[17] But while the institute may not develop a dollars-per-quality measure of value, it is not explicitly restricted from supporting research on cost-effectiveness.
The PPACA also limits how PCORI findings can be used in administering Medicare, but it does not prevent CER findings from influencing this or other arms of the government in their decisions on coverage and payment. Sean Tunis, president of the Center for Medical Technology Policy, states that "the PPACA's statutory language does not prevent Medicare from considering CER studies generated by PCORI or other researchers for making coverage decisions, although it does impose some restrictions."[18]
The Secretary of HHS is prohibited from using CER to treat the lives of the elderly as being of less value than others and from using quality adjusted life-years or other similar measures "as a threshold to determine coverage, reimbursement, or incentive programs."[19] But beyond this, the limits are decidedly vague, leaving the future role of CER in Medicare open-ended. Meanwhile, other parts of the health law open the door for Medicare to use CER to micromanage the practice of medicine.
The PPACA threatens patient choice and physician autonomy for patients and providers who participate in Medicare. Reductions in provider payments and delivery system changes implicitly allow the program to ration care through so-called improvements in value and efficiency.
The PPACA allows government to micromanage the cost and utilization of medical goods and services in an attempt to eke out relatively small savings from a wildly insolvent program. This approach will not be sufficient to save Medicare, nor will it benefit patients. CER is a required tool in this failing exercise.
The Independent Payment Advisory Board. The new Independent Payment Advisory Board (IPAB), composed of 15 members appointed by the President and confirmed by the Senate, was created by the PPACA to enforce a per capita spending growth target in Medicare. If spending exceeds the set threshold, the board's recommendations will automatically go into effect unless Congress passes legislation that equally reduces growth in spending. Otherwise, IPAB's decisions will bypass congressional approval and require a two-thirds majority of Congress to override them.
IPAB is mostly limited to tinkering with provider payments to reduce cost growth and is restricted from explicitly rationing care (though no definition of "rationing" is supplied). But IPAB could still give other government authorities the ability to ration care using information like that produced by PCORI. American Enterprise Institute scholar and physician Scott Gottlieb warns, "Rather than making the tough clinical judgments themselves, the IPAB would grant CMS authority to rely on judgment of the agency's largely thin clinical staff about the relative benefits of competing treatments."[20]
According to Gottlieb, IPAB could give the Centers for Medicare and Medicaid Services the authority to consolidate drugs, medical devices, and other services under one payment code and then pay for the "least costly alternative" among comparable approaches.
Medicare Hospital Value-Based Purchasing. Another way that Medicare could end up rationing care is by adjusting provider reimbursement under the new value-based purchasing program (VBP). Value-based purchasing was included in the PPACA as acknowledgment that Medicare has long struggled to reward certain providers and punish others based on value of care.
In other areas of the economy, where the purchaser of a good or service and its user are generally one and the same, consumers achieve these goals. Supporters of the PPACA, however, ignore this fact by trying to replace the role of the consumer with more central planning. As Ethics and Public Policy Center fellow James Capretta states, "Efforts to control costs from the top-down have always devolved into price setting and across-the-board payment-rate reductions, which is detrimental to the quality of American medicine."[21]
Despite claims by PPACA supporters that improvements in quality and efficiency in the PPACA will reverse Medicare's growing financial predicament, the Congressional Budget Office finds that "demonstrations that paid bonuses to providers on the basis of their quality scores, estimated savings, or both, produced little or no savings."[22] Nevertheless, the PPACA requires Medicare to measure providers' performance and alter their payments based on a scoring system in its new value-based purchasing program.
Beginning in 2013, hospitals will face financial incentives to comply with federal quality measures. The Secretary of HHS is responsible for determining the performance standards and methodology used to calculate hospital performance scores, which will reflect achievement and improvement, and, beginning in 2014, include efficiency measures, such as Medicare spending per beneficiary. The law also calls for extension of VBP into other areas of care.
Hospital payments will reflect performance on the scored measures, but the performance payment is not a true bonus, since its funding is made available by first cutting base payments across the board by 1 percent ($850 million) in the first year, gradually increasing to 2 percent by 2017. Hospitals will be scored on both their achievement relative to other hospitals and their improvement, and payment will reflect the higher score of the two. Penalizing some in order to reward others is like grading on a curve, which makes it impossible for every student in class to get an "A."
The 13 measures chosen to "grade" hospitals in the program's first year were selected from those used currently under the Medicare Hospital Quality Reporting Program for five prevalent conditions, and the Secretary of HHS has broad discretion to add or remove measures. Though the first year includes only a handful of quality measures, it is clear that more will be added in the future.[23]
In its first year, the VBP program may seem fairly benign, but it is unlikely to remain so. Even IPAB could use the program to exercise its role as arbiter of cost-containing changes in Medicare. One of the few mechanisms available to the IPAB is to reduce provider reimbursements. One way that IPAB could do this and simultaneously claim to advance its other goal to "protect and improve Medicare beneficiaries' access to necessary and evidence-based items and services" (a directive that gives the board just as much authority to limit care as it does to protect it) would be to drastically reduce base hospital payments and make an increasing portion of provider reimbursement contingent on performance scores and adherence to VBP program quality measures.
As CER and other evidence is used to inform the quality measures and increase their size and scope, IPAB could effectively make the measures mandatory for providers. Even if the VBP program as created in the statute is left unchanged, it could still harm patient care.
CER is already seen as a viable basis for health care quality measures, and the door is open for its use in the VBP program. According to HHS, "When hospitals follow these types of proven best practices, patients receive higher quality care and see better outcomes."[24] But the evidence indicates otherwise. Measuring and rewarding quality according to measures of processes or outcomes can have negative consequences for patients and physicians alike. VBP could encourage physician behavior that does not put the patient first, meanwhile treating providers in ways that are unfair, inequitable, and unlikely to truly reflect better-value, high-quality care.
A Strategy Doomed from the Start. Evidence from government demonstration programs shows that value-based purchasing is an ineffective strategy to improve outcomes. Even so, the authors of the PPACA allowed it to become law, affecting almost every hospital in the country.
Legislation in 2001 and 2003 gave CMS the authority to collaborate with Premier, a nationwide organization of not-for-profit hospitals, to perform the Premier Hospital Quality Incentive Demonstration (PHQID). The demonstration program offered 278 participating hospitals incentive payments to improve their performance based on 34 quality measures, 27 of which measured process and seven of which measured outcomes.
CMS reported early on that the program led hospitals to improve their performance scores by 17.2 percentage points within the first three years. Other studies reached similar conclusions.[25] But the focus of these studies was on process measures, not actual outcomes, which do not tell the whole story. Rodney Hayward, M.D., warns that "experience with performance measurement…has generally shown that 'what you measure improves,' but unfortunately, we often settle for measuring that which is simple and easy to gauge and then sit back and celebrate the improvements in our 'measures.'"[26]
Other studies assessed whether the quality of outcomes improved under the demonstration and came to different conclusions. One study analyzed the demonstration's short-term effects on mortality and cost reduction, following a previous analysis that showed that the demonstration had no impact on mortality for patients suffering from acute myocardial infarction.[27] The results showed that the demonstration did not significantly reduce mortality or cost. While mortality did decrease for the measured conditions, similar reductions occurred at hospitals that did not participate, and reductions were also observed for conditions that were not measured. The study concluded that "by not reducing mortality or cost growth, the PHQID has made little impact on the value of inpatient care purchased by Medicare."[28]
CBO analysis later concluded that the Premier demonstration "had no effect on Medicare spending" and only "slightly improved quality of care based on the measures adopted for those demonstrations."[29] A study published in The New England Journal of Medicine assessing the long-term effects of the six-year program at its conclusion echoed these results. According to the authors, they "found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest."[30] The PPACA's value-based purchasing program, which begins in 2012, falls directly under this category.
In addition to the growing evidence that VBP will be ineffective, several other studies highlight the harmful consequences that can arise from these kinds of pay-for-performance programs. Researchers in the United Kingdom examined the impact of pay-for-performance in the U.K. and in California on primary-care physicians and concluded that adverse effects included "encouraging physicians to avoid sicker patients, exacerbating disparities, and neglecting types of care for which quality is not measured."[31]
Misaligned Incentives Threaten Quality of Care. Quality measures do not always translate into what is best for an individual patient, in which case practicing medicine "to the test" can harm patients. Harvard School of Medicine's Jerome Groopman, M.D., writes, "Over the past decade, federal 'choice architects'—i.e., doctors and other experts acting for the government and making use of research on comparative effectiveness—have repeatedly identified 'best practices,' only to have them shown to be ineffective or even deleterious."[32]
In 2007, the Journal of the American Medical Association published the findings of a study which showed that none of the measures commonly used to quantify performance for treating heart failure was strongly associated with better mortality rates.[33] A 2010 University of Michigan study came to a similar conclusion when comparing surgery outcomes at 2,189 hospitals for their adherence to process measures reported by Hospital Compare, a website used to publicly report hospital compliance with measures under the Medicare Hospital Quality Reporting Program.[34] The authors "found little evidence of a consistent relationship between hospital compliance with processes of care and operative mortality rate." Furthermore, they claim, "Currently available information on the Hospital Compare website will not help patients identify hospitals with better outcomes for high-risk surgery."[35]Again, a rigid model with the wrong focus may be at fault.
Since such performance measures have fallen short time and again, Medicare's value-based purchasing program is most likely, at best, to lead to arbitrary reimbursement levels for hospitals at inequitable rates with no resulting benefit. Worse is the possibility of encouraging medical professionals to act in ways that are unnecessary or even harmful to a patient in order to comply with the measures. Groopman cites several examples:
Medicare specified that it was a "best practice" to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this "best practice" was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).[36]
In addition to potentially encouraging physicians to do the wrong thing, quality measures with financial strings attached can punish doctors for doing the right thing. Related to the VBP, the PPACA will also financially penalize hospitals with high readmission rates for certain medical conditions beginning in 2012.[37] Again, however, this model could fail to achieve its intended goal of improving quality.
A study by Cleveland Clinic researchers showed that high provider readmission rates might not necessarily indicate lower quality care: While the Cleveland Clinic had a higher-than-average readmission rate for heart failure, its average 30-day mortality rate for the same condition was lower than average.[38] The researchers concluded that "if a hospital has a lower mortality rate, then a greater proportion of its discharged patients are eligible for readmission. As such, to some extent, a higher readmission rate may be a consequence of successful care."[39] One of the researchers, Dr. Eiran Z. Gorodeski, further warns that "the message to patients and the general public is that they should be wary of seemingly simple measures of quality of care."[40]
Several health care systems already use electronic health records and evidence-based quality measures to standardize care, but the crucial difference is that physicians are usually able to document and defend their reasoning for deviating from best practices. One study assessed the frequency with which quality measures were ignored for appropriate exceptions and found that, of 650 exceptions reported during a seven-month period, 93.6 percent were medically appropriate.[41]
Under Medicare's VBP program, physicians will not have the opportunity to justify deviations from established standards. Instead, they will have to choose between compliance for payment and what they consider to be most appropriate for the patient.
Cherry-Picking Endangers the Doctor–Patient Relationship. Another significant issue in a system that pays providers based on quality measures is that providers are not single-handedly responsible for health outcomes. Individuals, their behavior, and several other factors can significantly affect health outcomes. Rewarding or punishing providers based on factors beyond their control is unfair and threatens patient-centered care by altering the way physicians interact with patients and encouraging them to "cherry-pick" patients and treatments that will enhance their performance score.
The University of Manchester study showed that this occurred in the pay-for-performance programs in California and the United Kingdom.[42] The researchers reported that physicians "expressed resentment about patients who refused to comply with their advice" and that "interviews contained reports of seriously dysfunctional or coercive behavior" by doctors when patients were noncompliant. In extreme cases, doctors threatened to un-enroll patients, accused them of hurting their ratings, or lied about the consequences for failing to comply with their orders. Physicians even reported disregarding informed-consent procedures to meet screening targets for certain diseases.
Another study reinforces the fact that patients, not just the care they receive, can drastically change performance ratings.[43] Primary-care physicians who ranked highest according to widely used measures generally attended to older patients with more complex illnesses. Compared to the lowest-ranked physicians, those physicians also treated fewer minority patients, non-English speakers, and patients covered by Medicaid or what the authors categorize as underinsured. When the researchers adjusted the ranking system to account for these factors, 36 percent of primary-care physicians were reclassified.
Pay-for-performance programs could encourage providers to cherry-pick procedures as well, focusing on the measured services to the neglect of others:
[R]ather than creating a culture of quality, [pay for performance] could lead to distortions in reporting or misplaced quality improvement efforts driven primarily by bonus payments. Such developments could lead to the unintended consequence of hospitals narrowly focusing their interventions at the expense of broadly improving care.[44]
Even the PPACA's strategy to punish hospitals for high readmission rates is misguided, since it focuses incentives on hospitals even though they are not solely responsible for a patient's care following a discharge. Reducing readmissions rates is widely considered to be a goal for health care reform, and success requires improving care coordination following a hospital stay. Evidence shows that private plans in Medicare Advantage are already doing a better job on several measures of quality, including reducing readmissions by increasing other types of care after an inpatient episode.[45]
The Inevitable Bias of Quality Measures. Only patients can truly and effectively define value in the health care system, and any attempt to do so by the federal government is certain to reflect an Administration's political priorities and influence from special interests. As some health policy experts point out, "Although the quality measures are evidence-based and supported by clinical science, collapsing the measures into composite scores and specifying bonus and penalty formulas require policy choices for which there is no scientific foundation."[46]
The practice of medicine inherently requires some level of subjectivity and judgment. Because it is an imprecise science, it would be impossible, even for the most expert of central planners, to remove all gray areas from medicine. Thus, patients and their physicians are best positioned to make the most reasonable decisions.
In 2009, the United States Preventive Services Task Force (USPSTF) changed its rating of mammography for women between the ages of 40 and 49 to "not recommended," intending to signal that women in this age bracket should determine with their doctors whether they should receive routine screening.[47] If such a recommendation were made a requirement, this intent would be ignored. Physicians Kerianne Quanstrum and Rodney Hayward explain that:
[S]cientific evidence can only help us describe the continuum of benefit versus harm. The assessment of whether the benefit is great enough to warrant the risk of harm…is necessarily a value judgment. When either side in the mammography wars claims that the evidence suggests that women should or should not undergo routine mammography starting at the age of 40 years, they are deceiving themselves and the public about what the evidence can tell us. They are really just making different value judgments about where to set the threshold.[48]
It would be impossible to remove all judgment calls from the practice of medicine. The next best option is to allow the providers closest to each case and the patients affected to make the decisions in order to keep others' priorities—political, budgetary, or otherwise—from shaping their outcome.
Lawmakers should continue to support Medicare reform that rewards value and does not reduce quality of care, but while several private health systems have begun to use financial incentives to encourage adherence to quality measures, the federal government is simply incapable of replicating the private sector's success. When innovations prove unsuccessful in the private sector, they are simply discontinued, while governments need to issue new regulations or pass new laws. Also, in the private sector, Physicians who go against best practices, as defined by CER or other evidence, for the unique case of a specific patient can often explain their reasoning in order to avoid penalties. And physicians and patients alike have the option of going elsewhere if dissatisfied.
CER can either serve as a complement to the creation and introduction of new treatments or as a strong deterrent. Which becomes the reality will, again, depend on how the research findings are applied to the practice of medicine. Using CER to guide provider payment or make coverage decisions would have repercussions extending far beyond the bedside. Since focusing on existing treatments for which data is available stacks the deck against new ones, this reactionary approach would discourage further medical innovation.
The United States "is both a major producer and consumer of health care which means that both demand for and supply of medical technology is very high. Investment in new medical technologies is very high as [are] their levels of availability and rate of diffusion."[49] The U.S. is the largest producer of medical technology in the world due to this unique demand for health care advancements and a welcoming environment where the public sector invests in research and private-sector talent leads to the development of new technology.[50]
However, experts warn that the nation's gradual move toward policies of top-down cost containment in health care spending could jeopardize the country's ability to produce new treatments and make them available to patients.[51] Cleveland Clinic chief executive Toby Cosgrove states that "if we only pay for one of those, we begin to limit what people are willing to do in terms of developing new products."[52] Research shows that CER could reduce investment in research and development of medical technology by $10 billion—approximately 10 percent to 12 percent—each year.[53]
The impact of CER on "personalized medicine," which includes the identification and use of a disease's genetic origins to indicate the correct treatment or medication dosage is especially worrisome. Advances in this area already affect patients with lung, colon, or breast cancer and hold great potential for other areas of medicine. According to a Lewin Group study:
[T]he absence of [personalized medicine] considerations in CER could be suboptimal for patient interests, particularly to the extent that CER findings are used to support gatekeeping or other authoritative functions, such as product labeling, clinical practice guidelines, coverage policies, and quality measures and criteria.[54]
Personalized medicine could replace the widely used "trial-and-error" treatment paradigm, improve health outcomes, and reduce health care spending. Currently, most physicians choose a treatment that is most likely to be effective and then try another if the first is not successful. This is costly and clearly not ideal for the patient. However, the problem might not be that the first treatment was ineffective, but that it was not effective for all patients. CER might discourage the option that is effective less often when what is really needed is information revealing for which patients it is effective and how to identify them.
If employed correctly, CER does not have to pose a threat to innovation. It could, in fact, complement personalized medicine by illuminating areas in which differing responses emerge due to genetic differences.
Researchers Robert Epstein and J. Russell Teagarden highlight an example in which CER compared two statin treatments used to lower cholesterol in high-risk cardiovascular patients. The findings supported the conclusions that the stronger dose of statins lowered the risk of adverse outcomes. But that was not the entire story. Later genetic analysis revealed that the stronger treatment held no added benefit unless a patient carried a particular gene variant.[55] While CER on its own might have concluded that the higher dose was better, more in-depth research revealed that this was not the case.
Regrettably, the PPACA puts CER use on the wrong path. Allowing unelected officials to determine how and to whom resources are allocated rather than empowering doctors and patients to make decisions is the wrong approach. Though the PPACA may not immediately result in overt rationing of care, its changes in Medicare open the door to top-down use of CER and interference with the care seniors receive.
As Medicare spending rises, PCORI and the research it produces will increasingly be considered a viable resource to micromanage the practice of medicine, and the PPACA creates the machinery to make this happen. For these reasons, the step forward should be to repeal the law and start over.
The alternative is not to discourage the development of CER, since research findings can positively influence treatment decisions. Instead, after fully repealing the PPACA, Congress should focus on transforming the failing Medicare program to avoid bureaucratic intrusion into patient care, for which CER is a tool, not the source. Transitioning seniors' health benefits to a premium support system like that included in The Heritage Foundation's Saving the American Dream budget reform proposal would not only make the program solvent, but also prevent further central planning and its unwanted consequences.[56]
Reform should build on the proven success of the Federal Employees Health Benefits Program, which provides health coverage to the nation's 8 million federal workers, retirees, and their families, and Medicare Part D, which provides seniors with a voluntary prescription drug benefit.[57] In both programs, enrollees receive a contribution to apply for the private plan of their choice and can shop around for a more affordable option if costs increase or they become otherwise dissatisfied. Moreover, evidence suggests that Medicare Advantage, which offers traditional Medicare benefits to seniors through a menu of private plans, is providing its beneficiaries with a higher quality of care than traditional Medicare.
As patients and consumers, Americans support the idea of using more information to reveal the comparative benefits of their treatment alternatives. They do not, however, favor allowing the government to use such information to limit their options.[58]
Increased attention to comparative studies of medical interventions can have a positive impact on the practice of medicine, but it must be limited to assisting doctors and patients to determine the right course of action. If treated as a budgetary constraint, CER will cease to be purely informational and will have widespread negative effects. The PPACA creates the infrastructure to propel the U.S. health care system, and Medicare in particular, in this flawed direction.
There is no debate over the fact that health care resources are limited and that Congress must act to reduce runaway health care spending, but Congress must do so without using CER to allow the government to micromanage the practice of medicine. Using research findings to strengthen bureaucracy is a losing combination that will erode quality of care for Americans.
—Kathryn Nix is a Policy Analyst in the Center for Health Policy Studies at The Heritage Foundation.
Show references in this report
[1]Institute of Medicine, "Initial National Priorities for Comparative Effectiveness Research," Report Brief, June 2009, p. 1, at http://www.hrsonline.org/Policy/LegislationTakeAction/upload/CER-report-brief-6-22-09.pdf (accessed February 27, 2012).
[2]Patient Protection and Affordable Care Act, Public Law 111-148, § 6301.
[3]Kathryn Nix, "Inside the Patient-Centered Outcomes Research Institute: No Promise of Protection from Government Rationing," Heritage Foundation WebMemo No. 3474, January 26, 2012, at http://www.heritage.org/research/reports/2012/01/patient-centered-outcomes-research-institutes-health-care-priorities.
[4]CER entered the national spotlight when the American Recovery and Reinvestment Act of 2009 (also known as the stimulus bill) granted $1.1 billion to the Agency for Healthcare Research and Quality, the National Institutes of Health, and the Department of Health and Human Services to fund CER. The law also created the Federal Coordinating Council for Comparative Effectiveness Research to coordinate research and funding, which was replaced by PCORI under the PPACA.
[5]PCORI, "About Us," 2012, at http://www.pcori.org/about/ (accessed February 27, 2012).
[6]Helen Evans, "Comparative Effectiveness in Health Care Reform: Lessons from Abroad," Heritage Foundation Backgrounder No. 2239, February 4, 2009, at http://www.heritage.org/research/reports/2009/02/comparative-effectiveness-in-health-care-reform-lessons-from-abroad, and Gurjeet Guram and Robert E. Moffit, "The Concept of a Federal Health Board: Learning from Britain's Experience," Heritage Foundation WebMemo No. 2154, December 4, 2008, at http://www.heritage.org/Research/Reports/2008/12/The-Concept-of-a-Federal-Health-Board-Learning-from-Britains-Experience.
[7]Jenny Hope, "Breakthrough MS Pill Rejected as Too Expensive by NHS Watchdog (but You Can Get It in U.S. and Germany)," MailOnline.com, August 5, 2011, at http://www.dailymail.co.uk/health/article-2022767/Miracle-MS-pill-rejected-expensive-NHS-watchdog-available-U-S-Germany.html (accessed February 27, 2012), and news release, "MS Drug Should Not Be Prescribed on NHS, Says Draft Guidance," National Health Services, August 4, 2011, at http://www.nice.org.uk/newsroom/pressreleases/MSDrugDraftGuidance.jsp?zbrandid=4337&zidType=CH&zid=7637383&zsubscriberId=1024035413&zbdom=http://npc.informz.net (accessed February 27, 2012).
[8]National Institute for Health and Clinical Excellence, "Final Appraisal Determination: Fingolimod for the Treatment of Highly Active Relapsing-Remitting Multiple Sclerosis," March 2012, at http://www.nice.org.uk/nicemedia/live/12170/58500/58500.pdf (accessed April 4, 2012).
[9]Evans, "Comparative Effectiveness in Health Care Reform: Lessons from Abroad."
[10]Comparative Effectiveness Research Act of 2008 (S. 3408), at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_bills&docid=f:s3408is.txt.pdf (accessed February 27, 2012).
[11]Patient-Centered Outcomes Research Act of 2009 (S. 1213), at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:s1213is.txt.pdf (accessed February 28, 2012).
[12]Tom Daschle, Critical: What We Can Do About the Health-Care Crisis (New York: Thomas Dunne Books, February 2008), p. 136.
[13]Ibid., p. 179.
[14]Peter R. Orszag, "Opportunities to Increase Efficiency in Health Care," testimony before Health Reform Summit of the Committee on Finance, U.S. Senate, June 16, 2008, at http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/93xx/doc9384/06-16-healthsummit.pdf (accessed February 28, 2012).
[15]Donald M. Berwick, "A Transatlantic Review of the NHS at 60," Physicians for a National Health Program, July 1, 2008, at http://www.pnhp.org/news/2010/may/a-transatlantic-review-of-the-nhs-at-60 (accessed February 28, 2012).
[17]Patient Protection and Affordable Care Act, § 6301.
[18]Sean R. Tunis, Robert A. Berenson, Steve E. Phurrough, and Penny E. Mohr, "Improving the Quality and Efficiency of the Medicare Program Through Coverage Policy," Urban Institute and Robert Wood Johnson Foundation, August 2011, at http://www.rwjf.org/files/research/72761summarymedicarecoveragequickstrike20110816.pdf (accessed February 28, 2012).
[19]Patient Protection and Affordable Care Act.
[20]Scott Gottlieb, "IPAB: The Controversial Consequences for Medicare and Seniors," statement before the Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives, July 13, 2011, at http://republicans.energycommerce.house.gov/Media/file/Hearings/Health/071311/Gottlieb.pdf (accessed February 28, 2012).
[21]James C. Capretta, "Why the Obama Health Plan is Not Entitlement Reform," Galen Institute, July 2010, p. 17, at http://www.thenewatlantis.com/docLib/20100804_CaprettaHealthPlan.pdf (accessed February 28, 2012).
[22]Congressional Budget Office, "Lessons from Medicare's Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment," January 18, 2012, at http://www.cbo.gov/doc.cfm?index=12663 (accessed February 28, 2012).
[23]News release, "Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs," HealthCare.gov, April 29, 2011, at http://www.healthcare.gov/news/factsheets/2011/04/valuebasedpurchasing04292011a.html (accessed April 4, 2012).
[24]News release, "Administration Implements New Health Reform Provision to Improve Care Quality, Lower Costs," U.S. Department of Health and Human Services, April 29, 2011, at http://www.hhs.gov/news/press/2011pres/04/20110429a.html (accessed February 28, 2012).
[25]"Premier Hospital Quality Incentive Demonstration: Rewarding Superior Quality Care," Centers for Medicare and Medicaid Services Fact Sheet, July 2009, at http://www.qualitycoalition.net/Data/Sites/2/media/position-statement/hqid-fact-sheet.pdf (accessed February 28, 2012), and Peter K. Lindenauer et al., "Public Reporting and Pay for Performance in Hospital Quality Improvement," The New England Journal of Medicine, February 2007, at http://www.nejm.org/doi/full/10.1056/NEJMsa064964#t=articleMethods (accessed February 28, 2012).
[26]Rodney A. Hayward, "Performance Measurement in Search of a Path," The New England Journal of Medicine, March 2007, p. 951, at http://www.nejm.org/doi/full/10.1056/NEJMe068285 (accessed February 12, 2012).
[27]Andrew M. Ryan, James F. Burgess, Christopher P. Tompkins, and Stanley S. Wallack, "The Relationship Between Medicare's Process of Care Quality Measures and Mortality," Inquiry, Vol. 46, No. 3 (September 2009), pp. 274–290, at http://www.inquiryjournalonline.org/doi/abs/10.5034/inquiryjrnl_46.03.274 (accessed February 28, 2012).
[29]Congressional Budget Office, "Lessons from Medicare's Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment."
[30]Ashish K. Jha, Karen E. Joynt, E. John Orav, and Arnold M. Epstein, "The Long-Term Effect of Premier Pay for Performance on Patient Outcomes," The New England Journal of Medicine, March 28, 2012, at http://www.nejm.org/doi/full/10.1056/NEJMsa1112351#t=article (accessed April 4, 2012).
[31]Ruth McDonald and Martin Roland, "Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences," Annals of Family Medicine, Vol. 7, No. 2 (March 2009), pp. 121–127, at http://www.annfammed.org/cgi/reprint/7/2/121 (accessed February 28, 2012).
[32]Jerome Groopman, "Health Care: Who Knows 'Best'?" The New York Review of Books, February 11, 2010, at http://www.nybooks.com/articles/archives/2010/feb/11/health-care-who-knows-best/ (accessed February 28, 2012).
[33]Gregg C. Fonarow et al., "Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure," Journal of the American Medical Association, Vol. 297, No. 1 (January 2007), at http://jama.ama-assn.org/cgi/reprint/297/1/61 (accessed February 28, 2012).
[34]Lauren H. Nicholas, Nicholas H. Osborne, John D. Birkmeyer, and Justin B. Dimick, "Hospital Process Compliance and Surgical Outcomes in Medicare Beneficiaries," Archives of Surgery, Vol. 145, No. 10 (2010), pp. 999–1004, at http://archsurg.ama-assn.org/cgi/content/short/145/10/999 (accessed February 28, 2012).
[35]Thomas M. Burton, "Medicare Faulted on Surgery Evaluation," The Wall Street Journal, October 18, 2010, at http://online.wsj.com/article/SB10001424052702303496104575560522424599924.html (accessed February 28, 2012).
[36]Groopman, "Health Care: Who Knows 'Best'?"
[37]Patient Protection and Affordable Care Act.
[38]Karen Pallarito, "High Readmission Rates May Not Mean Worse Hospital Care," Bloomberg Businessweek, July 14, 2010, at http://www.businessweek.com/lifestyle/content/healthday/641139.html (accessed February 28, 2012).
[39]Eiran Z. Gorodeski, Randall C. Starling, and Eugene H. Blackstone, "Are All Readmissions Bad Readmissions?" The New England Journal of Medicine, Vol. 363, No. 3 (July 15, 2010), at http://www.nejm.org/doi/full/10.1056/NEJMc1001882 (accessed February 28, 2012).
[40]Pallarito, "High Readmission Rates May Not Mean Worse Hospital Care."
[41]Stephen D. Persell, Nancy C. Dolan, Elisha M. Friesema, Jason A. Thompson, Darren Kaiser, and David W. Baker, "Frequency of Inappropriate Medical Exceptions to Quality Measures," Annals of Internal Medicine, Vol. 152, No. 4 (February 2010), pp. 225–231, at http://www.annals.org/content/152/4/225.abstract (accessed February 28, 2012).
[42]McDonald and Roland, "Pay for Performance in Primary Care in England and California."
[43]Clemens S. Hong, Steven J. Atlas, Yuchiao Chang, S. V. Subramanian, Jeffrey M. Ashburner, Michael J. Barry, and Richard W. Grant, "Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings," Journal of the American Medical Association, Vol. 304, No. 10 (2010), pp. 1107–1113, at http://jama.ama-assn.org/content/304/10/1107.abstract (accessed February 28, 2012).
[44]Charles N. Kahn III, Thomas Ault, Howard Isenstein, Lisa Potetz, and Susan Van Gelder, "Snapshot of Hospital Quality Reporting and Pay-For-Performance Under Medicare," Health Affairs, Vol. 25, No.1 (2006), pp. 148–162, at http://content.healthaffairs.org/cgi/reprint/25/1/148 (accessed February 28, 2012).
[45]Kathryn Nix, "How Competition Improves Quality: The Case of Medicare Advantage," Heritage Foundation Center for Policy Innovation Research Summary No. 2, January 11, 2012, at http://www.heritage.org/research/reports/2012/01/how-competition-improves-quality-the-case-of-medicare-advantage.
[46]Kahn et al., "Snapshot of Hospital Quality Reporting and Pay-For-Performance Under Medicare," p. 160.
[47]The Senate later agreed to prohibit the use of this specific recommendation from the USPSTF in its determination of required "free" preventive services under the Affordable Care Act. See David M. Herszenhorn, "Senate Blocks Use of New Mammogram Guidelines," The New York Times, December 3, 2009, at http://prescriptions.blogs.nytimes.com/2009/12/03/gop-amendments-aim-at-new-cancer-guidelines (accessed April 4, 2012).
[48]Kerianne H. Quanstrum and Rodney A. Hayward, "Lessons from the Mammography Wars," The New England Journal of Medicine, Vol. 363 (September 9, 2010), p. 1077, at http://healthpolicyandreform.nejm.org/?p=12525 (accessed February 28, 2012).
[49]Meir P. Pugatch and Helen Davison, "A Healthy Market: Health Technology Assessment in Context," Stockholm Network Paper on Health Technology Assessment No. 2, July 2007, p. 13, at http://www.stockholm-network.org/downloads/publications/Health_Technology_Assessment_in_Context.pdf (accessed February 28, 2012).
[50]Battelle Technology Partnership Practice, "Gone Tomorrow? A Call to Promote Medical Innovation, Create Jobs, and Find Cures in America," June 10, 2010, at http://www.americanmedicalinnovation.org/sites/default/files/Gone_Tomorrow.pdf (accessed February 28, 2012).
[51]Pugatch and Davison, "A Healthy Market," p. 14.
[52]Diana Suchetka, "Cleveland Clinic CEO Toby Cosgrove Talks About Health-Care Reform and More at City Club," Cleveland.com, August 19, 2010, at http://www.cleveland.com/healthfit/index.ssf/2010/08/cleveland_clinic_ceo_toby_cosg.html (accessed February 28, 2012).
[53]Benjamin Zycher, "Comparative Effectiveness Reviews: Quantitative Analysis of Research and Development Investment Effects," Pacific Research Institute, July 15, 2011, at http://www.pacificresearch.org/docLib/20110715_Zycher_CER_F.pdf (accesses February 28, 2012).
[54]Clifford Goodman, "Comparative Effectiveness Research and Personalized Medicine: From Contradiction to Synergy," The Lewin Group, October 2009, p. 22, at http://www.lewin.com/publications/publication/386/ (accessed February 28, 2012).
[55]Robert Epstein and J. Russell Teagarden, "Comparative Effectiveness and Personalized Medicine: Evolving Together or Apart?" Health Affairs, Vol. 29, No. 10 (October 2010), at http://content.healthaffairs.org/cgi/content/abstract/29/10/1783 (accessed February 28, 2012).
[56]Stuart M. Butler, Alison Acosta Fraser, and William W. Beach, eds., Saving the American Dream: The Heritage Plan to Fix the Debt, Cut Spending, and Restore Prosperity, The Heritage Foundation, 2011, at http://savingthedream.org.
[57]Walton Francis, "The FEHBP as a Model for Medicare Reform: Separating Fact from Fiction," Heritage Foundation Backgrounder No. 1674, August 7, 2003, at http://www.heritage.org/research/reports/2003/08/the-fehbp-as-a-model-for-medicare-reform-separating-fact-from-fiction, and Kathryn Nix, "A Recipe for Reform: Success of Consumer-Driven Principles in Medicare Programs," Heritage Foundation WebMemo No. 3340, August 10, 2011, at http://www.heritage.org/Research/Reports/2011/08/Consumer-Driven-Medicare-Reform-Models-for-Success.
[58]Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor Dowling, "The Public Wants Information, Not Board Mandates, from Comparative Effectiveness Research," Health Affairs, Vol. 29, No. 10 (October 2010), pp. 1874–1875, at http://content.healthaffairs.org/cgi/content/abstract/29/10/1872 (accessed February 28, 2012).


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Bass Pro Shops Storage Boxes
Keep your lures protected and well organized with one of Bass Pro Shops®' Tackle Storage Boxes. With a variety of designs available, you'll have no problem finding the right tackle storage system for your favorite soft-plastics, crankbaits and terminal tackle.
- See-thru polypropylene
- Adjustable dividers
- Lifetime hinges
- Worm-proof
- Allows you to categorize tackle fast
Outdoor Answers
Get help about this item from fellow customers.
Ask your questions. Share your answers.
what is the best way to store soft pasticsin these or leave theme in the original package?
Is it air tight?
Can I remove all dividers?
i would recommend doing so because honestly I don't know how to getg new dividers
but bass pro employees are always helpful
How many compartments and/or dividers do the different types come with? I mainly want to know about the 360 and 370 models.
what soft bags will the 370-3 storage boxes fit in?
424-340-00, 427-119-00, 421-207-00, 426-782-00, 426-024-00
how many come in a package??
For the two or three $$, you are getting one lure.
Need Help? 7 days a week: 7am to 10pm CT or call 1.800.227.7776 anytime

subset: commoncrawl


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Donald Trump becomes 45th President of the United States
Law contains many flaws
The state's rapid-fire passage of a gun law is over, but it left controversy in its wake.
Some of the provisions are sensible, but others are questionable or wrongheaded.
New rules requiring safe storage of guns, reporting stolen weapons within 24 hours and more severe penalties for people who shoot at first responders fall in the sensible category. Common sense says you don't leave guns lying around, and life in prison without parole seems right for shooters who try to kill responders. Theoretically, extra money to schools for metal detectors, surveillance cameras and security doors sounds good if schools are able to maintain them.
We also see merit in the law's requirement that background checks be done for private gun sales except to immediate relatives, and for ammunition sales.
Then there are the questionable parts of the bill.
It requires a state registry of pistol-permit holders and assault-weapons owners and five-year recertifications to ensure the owners still can legally own the weapons. Fulton County Sheriff Thomas Lorey pointed out this is an expensive administrative burden for local law enforcement, but a potentially new revenue source for the state.
Also questionable is the quasi-law-enforcement role placed on therapists, doctors, nurses and social workers who are required to report a client they believe could hurt themselves or others. Some experts worry this could discourage some patients from getting help and cause some mental health providers to ignore the law.
The limitation of weapons magazines to seven rounds – three rounds below the federal limit – seems like nonsense. What makes seven the magic number?
Tucked away in this legislation is another serious concern: It allows local authorities to withhold the identities of registered gun owners, infringing on the public's right to know.
The state's hurriedly assembled gun-control law clearly is flawed.


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My son has wanted to get his room re-painted in Cavs colors as a b-day gift this year. After "The Backstabbing" I asked if he still wanted that done and his response was "I don't care about LeBron, I just love the Cavs!"
What he doesn't know yet is that there's an authograhed Carr jersey sitting in my closet that will be getting framed and pu in his room as well.


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Monster Saturday got all the press, but this is one of the more compelling slates I have seen in the last few years. How are you splitting your time?
I will be watching:
scUM vs. Indiana. I like Indiana in the upset. Neither team has a defense, but the game is in Bloominton and Indiana has hate on their side as they feel like they got jobbed last year. Indiana 45 scUM 38.
OU vs UT: UT is not very good this year. OU wins a snoozer 31-14.
Fl vs. AL: I like the Gayturds in an upset. I watched an interview with Urban Meyer yesterday and he is portraying a quiet sense of confidence. He had the, "cat that ate the bird" look on his face. I think the Gators turned a corner last week, and I like them to win this one 27-24.
Stanford vs. Oregon: I like the sexy cardinals in an upset. THey are just a more complete team. Oregon doesn't play defense and I don't think their offense is quite as good as the national media has portrayed. I think they have feasted on some pretty weak teams. That said, I love their RBs James, and Barner.
I like Miami over Clemson. I just haven't seen anything on Clemson that makes me think that they can match UM's talent. Of course, if Jacory throws 17 picks... well, that invalidates all my assumptions. 'Canes 34-10.
Navy USAF is an interesting battle. Both teams play the same way, I just think AF does it better and I really think they are probably a top 25 team this year. AF 34-10.
Wiscy runs over MSU: 24-13. Better players on both sides of the ball, John Clay and Tolzien go for big games.
Iowa over PSU in a game that is closer than most think, 20-17. I think Iowa's D-line has been a little overrated to this point in the season, but I think they do well enough today to force the "not quite ready for prime time" freshman QB at PSU into some dumb mistakes. That said, this year's PSU teams is one of those teams that screws me up. Every time you think PSU is down, they come out of nowhere and win 11 games and you wonder how the hell they do it. So, I would only watch this game for entertainment, not to improve my cash flow.
OSU vs. Illinois. I like OSU minus 18, I just don't see anyone putting up enough points in the big ten to keep the OSU offense from covering. Bucks 42-10. It will be more of the same, suffocating defense, bad running (from OSU running backs), great running (from TP), a very efficient passing game TP goes 22-30 with 297, 3TDs (one more on the ground), 75 yards on the ground. I will give BS 6 carries for 10 yards; Boom Herron 20 carries for 90 yards. Jordan Hall gets a couple of carries for 20 yards and 3 receptions for 30.
The D-Line will come up huge today. THis will be the "break out game" as I think Illinois will get bold and try to throw the ball downfield leading to more sacks and action forced by that line. This will be the first team to try to hold the ball long enough to throw down the field, and they will pay.


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A man was shot and killed at a Franklinton motel early yesterday morning, the second shooting there in the past year.
Columbus police were called to the Travelodge at 1551 W. Broad St. at 6:27 a.m. When officers arrived, they found a man dead inside room 510.
The woman who called police was not on the scene at the time of the shooting, homicide detective Melissa Carlson said. It appears someone called the woman, and then she called police.
The room was rented in a woman's name at 1:40 p.m. on Friday.
Police are trying to identify a suspect, who they described as a black male with dark skin. He was seen leaving the motel with a white, red-haired woman in a blue car.
Detectives have identified the victim as David Duff, 23.
Anyone with information on the shooting should call the homicide squad at 614-645-4730.
The man's death is the city's 17th homicide, and the second shooting in a year at the motel. On March 23 last year, a man was left a quadriplegic in a drug deal that became violent.
Peter A. Hunter, 40, and Derrick E. Wade, 44, went to the motel that day to sell drugs to a couple staying there. Wade shot Danny Lowe III, now 25, during a struggle. Lowe is incapacitated, his girlfriend, Jessica Devore, told the court in February. She and their 4-year-old son were unhurt during the incident.
Wade, 44, pleaded guilty to attempted murder and aggravated robbery in January. He is scheduled to be sentenced on Thursday.
Hunter was sentenced to 27 1/2 years in prison on Feb. 3 for armed robbery. Charges of attempted murder, felonious assault and kidnapping were dismissed after a jury deadlocked.


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Friday, November 2, 2012
Mission Theater
Mortified Portland! 5th Anniversary shows!
6 p.m. doors; 8 p.m. show
21 and over
$12 per person
Mortified Portland! 5th Anniversary shows!
Launched in Los Angeles in 2002, Mortified describes itself as a "comic excavation" of the past, inviting all to mine shoeboxes, closets – wherever lost secrets are stored – for documents of their youth, much like founder Dave Nadelberg did in the late 1990s when he found an old love letter he'd neglected to give its intended. "I started reading it to friends," he recalled. "I'm not a performer in any way, but I found that I was getting a big, cathartic rush by sharing it, even with strangers. Then they started telling me they had writings of their own."
There seems to be no shortage of shoeboxes and packed attics. Mortified has grown from its L.A. roots to eight U.S. cities (and Sweden) and blossomed from a stage show into a grassroots phenomenon, thanks to curious press, word-of-mouth, and an endless fascination with adolescent folly. The Web site, getmortified.com, boasts blogs, video and other embarrassing artifacts in addition to informational content.


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Yesterday, President Barack Obama and First Lady Michelle Obama welcomed world leaders to the United Nations General Assembly during a reception at the Metropolitan Museum in New York. The President and First Lady posed for photos with the leaders, which you may view here.
Barbara in California writes:
Fantastic pictures! Thank you for sharing! What a wonderful President and First Lady. I am very proud to be an American.
B.E. in Pakistan writes:
thay looks good there:)
Mark in California writes:
A splendid blog -- and a superb window on American foreign policy for Americans and others as well. The sheer size of the menu of international concerns confronting the USA and its global partners is both daunting and inspiring. We simply must advance for the good of all. Bravo and smooth sailing.


text:
You are leaving this Nike website and going to a site operated by a third party.
You will be redirected in 5 seconds.
Nike corporate employees shatter limits daily at company headquarters and offices around the world.
Nike currently has the following openings in Moscow. Moscow jobs vary from time to time based on our current openings. Please check back often for new Moscow job openings to find a career that is right for you. Thank you for considering a career in Moscow at Nike.
Get fully immersed in our culture of curiosity and innovation. Start a corporate internship at Nike.
Take a behind the scenes look at how Nike employees shaped product and experiences for the biggest football tournament in the world.
As part of the world's leading sports brand enjoy great benefits that fit, varied by position and location.
Employees in six continents and 53-plus countries make up one global Nike team.


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I'm a bit behind on this story, but as was reported by numerous media outlets over the past few months, a new trend has begun at some American churches. ATM machines, dubbed "Automatic Tithing Machines," are appearing at some Protestant churches in the South. The machines are administered by the for-profit business SecureGive, run by Pastor Marty Baker and his wife, who integrated the machines at their Stevens Creek Community Church in 2005.
Proponents point to the transition to a digital age and the convenience of electronic transactions. Stevens Creek Community attendee Josh Marshall said of using the machines, "I paid for gas today with a card, and got lunch with one. This is really no different."
Amy Forrest said this, "If you give cash, you think about it. And if you swipe a credit card, you don't. It makes it easier to type that 4-0."
These attitudes may not be truly representative, but they at the very least illustrate the potential for the convenience offered by these machines to turn faithful giving into something that is unreflective, automatic, mundane, and worldly. That's certainly not the kind of giving that God wants.
Baker says of his concept, "It's truly like an ATM for Jesus." (more…)


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Topic: Missing time in page rendering
When I bring a specific page on my application, I notice it takes quite awhile to load. I went into my log and the complete response for that given action took 542570ms but if I add up the DB queries in the log it adds up to roughly 60ms. I was wondering if there was a way to setup my log files or some other way to show me where all that extra time is getting used.


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Dec. 22, 2011
Delaware State University now has a revised Mission Statement that is more current and reflective of the University's purpose, according to Dr. Harry L. Williams, president.
"While the current mission defined DSU's identity and important role in the community, it was time to examine it in light of the University's new vision, its core values and its expanding portfolio of academic and research programs," said Dr. Williams.
The revised mission, approved at the December 20, 2011, special Board of Trustees meeting, is as follows:
Delaware State University is a public, comprehensive, 1890 land-grant institution that offers access and opportunity to diverse populations from Delaware, the nation, and the world. Building on its heritage as a historically black college, the University purposefully integrates the highest standards of excellence in teaching, research, and service in its baccalaureate, master's and doctoral programs. Its commitment to advance science, technology, liberal arts, and the professions produces capable and productive leaders who contribute to the sustainability and economic development of the global community.
Provost Alton Thompson chaired the revision process that incorporated methods for feedback. Several comment periods yielded suggestions from trustees, faculty, staff, students and alumni. A revision writing team, appointed by the president to assist the provost, consisted of Carolyn Curry, Victor Gomia, Jessica Horton, Kamillah Lewis, Dyremple Marsh, Noureddine Melikechi, Marlene Saunders and Charlie Wilson. The team incorporated the suggestions that resulted in the final mission for approval.


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Alaska Professional Communicators Abstract Q&A and Hints
The following information was supplied by Alaska Professional Communicators:
Abstract Q&A and Hints
What Is an abstract?
An abstract is a brief statement of the essential, or most important, thoughts about your project. It should summarize, very clearly and simply, the main points of your experiment. (Please DO NOT submit abstracts for collections, models, displays, or demonstrations; AKProCom judges abstracts for experiments only.)
Why is an abstract important?
Although it is the last part of your project that you do, it may be the FIRST thing that the judges and visitors read when they come to look at your project. Together with your display, it tells them what your project is about.
You want to get the judges' attention and hold their interest, so they will take the extra time to read your report, study your work more closely, and ask you questions about your project. You may have worked on your experiment for weeks or even months, but other people have only a few minutes to see what you did.
What should be included in your abstract?
After finishing research and experimentation, you are required to write a (maximum) 250-word, one-page abstract. An abstract should include:
Only minimal reference to previous work may be included.
What should NOT be included in your abstract?
An abstract should not include:
How long should your abstract be?
Your abstract should be between 100 to 250 words. We encourage you to use a computer and printer to prepare your abstract; however, neat hand printing in blue or black ink on white paper is acceptable.
What can submitting an abstract do for you?
Alaska Professional Communicators gives cash awards and certificates for the best abstract and the best project display. You could win an award.
Alaska Professional Communicators Judging Hints (useful for students and judges)
Alaska Professional Communicators Contests
Hint: The Intel International Science and Engineering Fair (ISEF) also provides some excellent information about abstracts and display boards. See the links called "Master the Abstract Writing Process" and "Creating an Effective Project Display" (PowerPoint presentations) at the ISEF site: http://www.societyforscience.org/Page.aspx?pid=282 Find these links about halfway down that page under the "Resources for Students & Teachers" heading.


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SugarCRM Wins InfoWorld Bossie Award for Fourth Consecutive Year
Sugar Named Best Open Source Application for Sales Force Automation and Customer Support Services
CUPERTINO, Calif.—September 16, 2011—SugarCRM, the world's fastest-growing Customer Relationship Management (CRM) company, today announced that the company has claimed the top spot in the InfoWorld Bossie Awards program for best open source CRM software for the fourth year in a row. The company was recognized for its ability to provide outstanding Sales Force Automation and customer support services.
Companies around the world rely on technology to enable and enhance their business operations and deliver on their business strategies. Each year, The InfoWorld Bossie Awards recognize the best business-oriented open source software products in a variety of categories.
"In every software category worth mentioning, you'll find a competitive open source solution," said Doug Dineley, Executive Editor/Test Center, InfoWorld. "And in some cases, open source is the only solution. Our 2011 Bossie Award winners represent the best that open source has to offer in application development, desktop productivity, mobile computing, and the data center."
"Our mission is to empower organizations to gain and retain customers, clients and constituents, and this recognition from InfoWorld is a proof point that shows we are successfully executing upon that mission," said Nick Halsey, chief marketing officer and executive vice president of corporate development for SugarCRM. "With Sugar, our community has the opportunity to create a customized solution that meets real-world needs, and in turn, provides an optimized customer experience."
In addition to the InfoWorld Bossie Award, SugarCRM has claimed several other awards this year. A full list of 2011 award wins is as follows:
- Winner – Open Source CRM category, CRM magazine
- Leader – Midmarket Suite CRM category, CRM magazine
- Leader – Small-Business Suite CRM category, CRM magazine
- One to Watch – Sales Force Automation category, CRM magazine
- Winner – OnDemand Top 100, AlwaysOn
- Finalist – Demonstration of Business Value through Social Business, Lotus Awards
- Finalist – CTO Award, Lotus Awards
For a complete list of this year's InfoWorld Bossie Award winners visit InfoWorld.com.
Also, feel free to fan SugarCRM on Facebook, follow the company on Twitter and subscribe to the company's YouTube channel.
Tweet this:
@sugarcrm wins @infoworld Bossie Award for best open source CRM for the fourth consecutive year http://bit.ly/mZCpms #OSS
About InfoWorld Media Group
InfoWorld Media Group helps IT Decision Makers choose the right technology, within the context of a cohesive strategy for business impact at their organizations. InfoWorld identifies and promotes emerging technology segments that add unique value for the organizations that implement them, as well as the vendors that provide those solutions. Using an integrated communications approach including online, events, research, and a continued investment in an independent Test Center, InfoWorld analysts and editors provide hands-on analysis and evaluation, as well as expert commentary on issues surrounding emerging technologies and products. Visit InfoWorld at http://www.infoworld.com.
About International Data Group
International Data Group (IDG) is the world's leading technology media, events, and research company. IDG's online network includes more than 450 web sites spanning business technology, consumer technology, digital entertainment and video games worldwide. IDG also publishes more than 300 magazines and newspapers in 85 countries. IDG's media brands include CIO, CSO, Computerworld, GamePro, InfoWorld, Macworld, Network World, and PC World. IDG's lead-generation service, IDG Connect, matches technology companies with an audience of engaged, high-quality IT professionals, influencers, and decision makers. IDG is a leading producer of more than 750 technology-related events including Macworld Conference & Expo, LinuxWorld Conference & Expo, Entertainment for All Expo (E for All), DEMO, Storage Networking World, and IDC Directions. IDC, a subsidiary of IDG, is the premier global provider of market intelligence, advisory services, and events. Over 900 IDC analysts in more than 90 countries provide global, regional, and local expertise on technology and industry opportunities and trends.
Additional information about IDG, a privately held company, is available at http://www.idg.com.
About SugarCRM
SugarCRM makes CRM simple. As the world's fastest growing customer relationship management (CRM) company, SugarCRM applications have been downloaded more than ten million times and currently serve over 850,000 end users in 80 languages. Over 7,000 customers have chosen SugarCRM's On-Site and Cloud Computing services over proprietary alternatives. SugarCRM has been recognized for its customer success and product innovation by CRM Magazine, InfoWorld, Customer Interaction Solutions and Intelligent Enterprise.
For more information, call (408) 454-6900 or 1 87 SUGARCRM toll-free in the US, email firstname.lastname@example.com, or visit http://www.sugarcrm.com.
Media Contact:
Elena Annuzzi


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I'm Karen and this is My diary.
I've just decided that anyone who does the Donation thing during December will get a copy of my Christmas card as an extra seasonal thank you.
Which doesn't mean at some point I won't post it here as well so I can shower Christmas greetings on everyone who follows my adventures, so it's not
special, but...
What was my point again?
Oh yes, Christmas Card!
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Debates of June 9th, 2003
House of Commons Hansard #114 of the 37th Parliament, 2nd Session. (The original version is on Parliament's site.) The word of the day was parties.
- Free Trade Agreements
- Canada Elections Act
- Jeux d'été du Québec
- World Indoor Lacrosse Championships
- Date Rape Drugs
- Court Challenges Program
- Prime Minister's Award for Teaching Excellence
- Amateur Sport
- Canada Customs and Revenue Agency
- Aung San Suu Kyi
- Dairy Month
- Portuguese Canadians
- Nature-Action Québec
- Montreal Holocaust Memorial Museum
- Montreal Holocaust Memorial Centre Museum
- The Economy
- Citizenship and Immigration
- Jonquière Taxation Data Centre
- Prime Minister of Canada
- Agriculture
- Health
- Political Party Financing
- Government Contracts
- Federal-Provincial Relations
- Agriculture
- Health
- Agriculture
- Government Contracts
- Agriculture
- Immigration Board
- Health
- The Environment
- Government Contracts
- Immigration and Refugee Board
- Foreign Affairs
- Pharmaceutical Industry
- National Defence
- Softwood Lumber
- Government Contracts
- Health
- Immigration and Refugee Board
- Société Radio-Canada
- Agriculture
- International Trade
- Aboriginal Affairs
- Public Works and Government Services
- Presence in Gallery
- Ways and Means
- Points of Order
- Petitions
- Questions on the Order Paper
- Canada Elections Act
Portuguese Canadians
Statements By Members
2:05 p.m.
Canadian Alliance
John Reynolds West Vancouver—Sunshine Coast, BC
Mr. Speaker, on May 13, 1953 the first officially recognized Portuguese immigrants arrived in Halifax on pier 21. This means that 2003 marks the 50th anniversary of official immigration from Portugal to Canada. I rise today to offer congratulations to the approximately 360,000 Canadians of Portuguese origin on Portugal's national day and to commemorate this historic occasion.
Portuguese Canadians have sewn a beautiful thread through the multicultural tapestry of Canadian society. Whether it is listening to the music of famous Portuguese Canadian Nelly Furtado or witnessing the achievements of the Portuguese Canadian Coalition for Better Education, it is clear the Portuguese Canadian community is thriving. On this historic day, I am honoured and pleased to congratulate the Portuguese community for 50 years of flourishing in Canada.
Mr. Speaker, I was pleased to represent my party and our leader at the luncheon you held today for the Prime Minister of Portugal. I say to other colleagues further down to my left that they should look at his political record and his willingness to lead a centre right coalition to form the government of Portugal.
Nature-Action Québec
Statements By Members
June 9th, 2003 / 2:05 p.m.
Yolande Thibeault Saint-Lambert, QC
Mr. Speaker, today I wish to pay tribute to Nature-Action Québec, an organization located in the riding of Saint-Bruno—Saint-Hubert involved in improving the quality of life of its people and those living in neighbouring communities.
The mission of Nature-Action Québec is to act as a concrete influence on society by promoting new ways of doing things that are more harmonious with a healthy and sustainable environment, both now and in the future.
Recently, the Government of Canada awarded the organization $149,877 to finish the shoring up of the banks of the Lamarre ditch, thus preventing flooding caused by poor irrigation practices on Chambly farmland, as well as to construct a noise barrier in a park.
Initiatives such as these have a positive impact on the environment. That is why my colleagues join with me in congratulating the Nature-Action Québec team and encouraging them to keep up the good work.
Montreal Holocaust Memorial Museum
Statements By Members
2:05 p.m.
Richard Marceau Charlesbourg—Jacques-Cartier, QC
Mr. Speaker, yesterday in Montreal, I and a number of my colleagues had the privilege of attending the opening of the Montreal Holocaust Memorial Museum.
This museum, the first one of international scope in Canada, was opened in the presence of men and women from a variety of backgrounds and political affiliations.
Montreal is known throughout the world for the size of its Jewish community. Moreover, it is home to the third-largest number of Holocaust survivors in the world. Needless to say, the choice of Montreal as the site of such an institution is particularly appropriate. Its Jewish community is lively, extremely dynamic and closely involved in the development of Montreal and Quebec as a whole.
The museum will help teach Quebeckers, particularly our youth, as well as other visitors to Montreal about the great horrors of the Shoah, not only for the Jews, but for humanity as a whole.
The opening of the museum to the general public will provide an opportunity to harmonize the national motto of Quebec, Je me souviens with the lesson that must be learned from the Holocaust, "Never again".
Montreal Holocaust Memorial Centre Museum
Statements By Members
2:10 p.m.
Marlene Jennings Notre-Dame-de-Grâce—Lachine, QC
Mr. Speaker, I wish to bring to the attention of all my colleagues the inauguration of the Montreal Holocaust Memorial Centre Museum. I had the privilege to attend this solemn, yet hopeful, ceremony last night.
The Holocaust is perhaps the darkest and most horrific moment of humanity's long history. Millions of Jews were mercilessly sent to concentration camps to be brutally murdered for the sole crime of being Jewish. The museum will show the Holocaust through the eyes of those who have lived and experienced it.
If I consider this event to be a source of hope, it is because the Holocaust museum will remind future generations of the terrible cost of intolerance and hate toward others.
Here in Canada, the sad lessons of the Holocaust will not be soon forgotten. I want to congratulate all the organizers of this event and wish them the best of success for the future.
The Economy
Statements By Members
2:10 p.m.
Progressive Conservative
Loyola Hearn St. John's West, NL
Mr. Speaker, the Prime Minister has been flitting around the world bragging about our great economy. The minister of culture and the two ministers of finance have been chasing each other around the country basically expressing the same views. We can talk about cops and robbers.
If we are so well off, why is it that the beef industry in the west must be begging for assistance? Why is it that the government of Ontario and the city of Toronto have to beg for help? Why is it that the east coast fishermen have been offered a paltry $325 a week?
Does the government want Canadians to be like Oliver Twist and ask "Please sir, could we have some more?" Remember that very soon the government will be going begging to them.
Citizenship and Immigration
Statements By Members
2:10 p.m.
Libby Davies Vancouver East, BC
Mr. Speaker, the government is choosing to allow the criminalization of dissent and diversity in an increasingly brutal fashion. I join a growing number of people who are calling for an independent public inquiry into police actions against non-status Algerians on May 29, 2003.
There are allegations that the tactical unit of the RCMP used excessive force against a dozen peaceful non-status Algerians occupying the offices of citizenship and immigration simply asking for a meeting with the minister.
Canada's Algerian community and its supporters are deeply concerned with the desperate fate of individuals and families at risk of deportation. The minister lifted Canada's moratorium on returns to Algeria back in April 2002. Many fear they will face danger and persecution.
Groups such as Amnesty International and the Quebec Human Rights League have expressed alarm at the excessive use of tasers, or high voltage electroshock weapons. Many of the Algerians received serious burns, head wounds and bruises during the police raid.
We in the NDP call on the minister to review these deportations and meet the individuals involved to hear their concerns.
Jonquière Taxation Data Centre
Statements By Members
2:10 p.m.
André Harvey Chicoutimi—Le Fjord, QC
Mr. Speaker, during celebrations to mark the 20th anniversary of the Jonquière Taxation Data Centre, Gilles Marceau, federal Liberal member over two decades ago, was honoured. Mr. Marceau will be remembered for fighting long and hard to make this project a reality.
In recognition of his contribution to this amazing achievement, the conference room was named the Salle Gilles Marceau.
Unable to attend for health reasons, Mr. Marceau was represented by his son Réjean. However, the following Wednesday, on June 4, 2003, the director, Diane Gagnon, made a presentation at his home. Mr. Marceau was very moved and honoured by this tribute in recognition of his contribution to the Jonquière Taxation Data Centre.
I also want to acknowledge all the employees of this centre for their professionalism.
Prime Minister of Canada
Statements By Members
2:15 p.m.
Canadian Alliance
James Rajotte Edmonton Southwest, AB
Mr. Speaker, let us compare the legacies of two prime ministers, the present one and his hero Sir Wilfrid Laurier.
Laurier understood the importance of allies and a strong national defence. As Prime Minister he increased defence spending and took tough stands in support of the British in the Boer War and World War I. This Prime Minister failed to stand with our British and American allies for the first time in our history and has failed to adequately equip our armed forces.
Unlike the present Prime Minister, Laurier understood that it was in Canada's best interest to have a healthy relationship with the United States and sought to expand this relationship, particularly through freer trade. Laurier understood the importance of western Canada and sought to populate it and develop its potential. This Prime Minister has never even attempted to understand the dreams and aspirations of western Canadians.
Sir Wilfrid Laurier is rightly honoured today as one of our finest prime ministers. It is truly sad that our Prime Minister, while holding up Laurier as his hero, has completely failed to emulate his courage, wisdom and national vision.
Oral Question Period
2:15 p.m.
Calgary Southwest
Canadian Alliance
Stephen Harper Leader of the Opposition
Mr. Speaker, the Prime Minister is returning to the country in the midst of the mad cow crisis.
Before the Prime Minister left the country he could not remember if he had discussed the mad cow issue. Now, four weeks later the government still does not have a plan. Apparently it will be another two weeks before it is able to come up with any kind of compensation package to address the industry's problem.
My question is very simple. Is the Prime Minister capable of understanding that this is an emergency and if he is not interested in doing his job, why does he not just leave office now?
Oral Question Period
2:15 p.m.
Jean Chrétien Prime Minister
Mr. Speaker, the Minister of Agriculture and Agri-Food has worked extremely diligently on this file. This morning we had a report by a group of international experts who reported that we have acted more diligently than any other government. They are complimenting the government for the action it has taken.
We are very happy that there was only one cow that was affected. A lot of animals had to be destroyed because of that and, of course, we have programs within the government to deal with emergencies in the agriculture sector. We are looking at whether these programs can apply. If not, we will see what can be done on top of the existing programs that very often are agreed upon with the provincial governments.
Oral Question Period
2:15 p.m.
Calgary Southwest
Canadian Alliance
Stephen Harper Leader of the Opposition
Mr. Speaker, we have already said that existing programs will not cover the severity and immediacy of the crisis. While the Prime Minister is studying this, people are going bankrupt.
I want to move to another subject. If he is so interested in these issues, let us discuss Toronto. We have had the outbreak of SARS now for the past three months. It is devastating Toronto's economy, but the government apparently says it is not a disaster and is reneging on its commitment to provide the Government of Ontario with emergency relief funding.
Once again, if the Prime Minister and the government are not interested in dealing with this issue, why not just leave office now?
Oral Question Period
2:15 p.m.
Jean Chrétien Prime Minister
Mr. Speaker, we made some further announcements on this issue after Friday. We have done a lot of things to adjust to the situation. We face a very difficult problem and we are doing our best to solve it.
I do not think that it is advisable to try to score political points. It is difficult for the provincial government and we have to compliment the health workers in Toronto who are doing a fantastic job under extremely difficult circumstances.
Political Party Financing
Oral Question Period
2:15 p.m.
Calgary Southwest
Canadian Alliance
Stephen Harper Leader of the Opposition
Mr. Speaker, apparently the new announcement is the Rolling Stones concert. That is after the Prime Minister did the Chinese restaurant photo op. Frankly, this crisis needs more than dinner and theatre.
The Prime Minister's real priority appears to be getting more money so that the Liberals can pass Bill C-24. This seems to take precedence over the devastation that is affecting rural Canadians in the beef industry and the health care crisis that is gripping the city of Toronto and affecting its economy.
My question once again is simple. Why should Canadians want a PM who does not deal with their problems but instead needs money to buy the support of his own party?
Political Party Financing
Oral Question Period
2:20 p.m.
Jean Chrétien Prime Minister
Mr. Speaker, I recall the last leader of the Reform Party who challenged me to call an election. I was in the House and I obliged, and with quite good results.
We have a piece of legislation that has been before the House for months. There is a committee report on the bill dealing with electoral financing that has been presented to the House. The committee made recommendations to the government and the bill will be dealt with by the House this week. It is a bill that will serve democracy very well in Canada.
Political Party Financing
Oral Question Period
2:20 p.m.
Canadian Alliance
Scott Reid Lanark—Carleton, ON
Mr. Speaker, today the government tabled amendments to Bill C-24 that will raise the annual per vote subsidy to political parties from $1.50 to $1.75. The shortfall caused by banning corporate and union donations will now be entirely made up by public funds and an extra $1.2 million in taxpayer money will go every year to the Liberal Party of Canada.
Why does the Prime Minister insist on digging deeper into the pockets of Canadian taxpayers in order to line the chest of his party?


text:
In late July, JuiceBuzz (561-278-6122)—a boutique smoothie and juice bar—opened off Fifth Avenue in Delray Beach. Co-owners Jacqueline Pfeffer-Sheridan and Alexis Rhigas serve up cold-press juices and smoothies and promote a philosophy of real medicine.
"We're proponents of incorporating juice into daily life," Rhigas says. Customers can belly up to the bar and order one of Juicebuzz's creations—like the Intuition smoothie with kale, mint, banana, honey, oat milk, nut butter and cinnamon—or concoct their own blend of fruits, veggies and healthy shots. Everything is 100 percent organic and made to order, with juice cleanse programs also available.


text:
Area Police
Woman scoots away with motorized cart
WESTFIELD – A Brocton woman has been charged with fourth-degree criminal possession of stolen property following an incident at Tops in Westfield. The Chautauqua County Sheriff's Office, in conjunction with Westfield Police Department, charged Wendy M. Hallmark, 52, of Brocton after it was alleged that Hallmark stole a motorized scooter cart on July 11. Deputies located Hallmark the following day in possession of the scooter. Hallmark was released on an appearance ticket for Brocton Village Court.
Cattaraugus County Sheriff's Office
RANDOLPH – Lindsey M. Pulliam, 23, of Cherry Creek was charged with petit larceny on July 9. It is alleged that Pulliam stole property from the Dollar General Store in Randolph just after 8 p.m. She was released on an appearance ticket for Randolph Town Court.
Chautauqua County Sheriff's Office
FREWSBURG – A traffic stop on West Main Street in the village of Frewsburg resulted in charges placed against three youth. Deputies stopped the vehicle for having an expired registration and found three males smoking marijuana in the vehicle at 3:34 a.m. An 18-year-old from Panama and 19-year-old from Lakewood were charged with unlawful possession of marijuana. The driver, a 16-year-old from Ashville was found to be impaired and operating out of class after 9 p.m. The driver was charged with driving while ability impaired by drugs, unlawful possession of marijuana, unregistered vehicle and operating out of class. All three males were released on appearance tickets for Carroll Town Court.


text:
Pictures: Pattinsonlife | RPLife
Video: Source | Youtube
He looks gorgeous! That's how I like his beard!
we can see his beautiful face this way!!:)
oh his is shaven, great!!!!!ReplyDelete
Quick stop in Japan??????ReplyDelete
Georgeous Rob coming home to BBG!ReplyDelete
What is a BBG?Delete
Yeah, what is BBG?Delete
Lol... Baby GirlDelete
Rob seems more younger than Kristen.ReplyDelete
The Aussie pappz seem far less intrusive than the Americans! I can't believe the difference. I still can't forget The vid of Kristen at LAX a few months ago!ReplyDelete
i noticed that he still listen to the music.kristen influence?..hehehe i think its great if he doesn't want to hear the paps i guess.ReplyDelete
How polite those papz were ? so difference from the one in LAReplyDelete
I think that LA promos are going to be more tense and the premiere to because thats where only robert fans are going to be and theres going to be mix fans like...
Robsten fans
Kristen fans
Robert fans
Man he looks nice.... Very handsomeDelete
oh wow, didn't realise he was still here in Sydney, thought he had already left. :)ReplyDelete
Where he's going now???????ReplyDelete
probably LA. he has to start doing those interviews soonDelete
I hope he and Kristen would go somewhere like a private island where there are no paps around.Delete
Wow I have the same Bose head phones I wonder if they are the same type -they're very comfortable, Boy Rob does look younger, smooth and yummy! I can't wait for USA promo very exited and sad it will be their last one.ReplyDelete
oh my god!!!!!!! rob looks super hot.. this much beard suits him.. he looks gorgeous.. luv his shirt too.. wish he had turned this way for the fan events too.. he looked lil dull n tired during the photocall too.. in these pictures he is looking heavenly.. kristen has left tokyo n he sydney,they'l b together nw.. god bless u guys.. luv u rob!!!ReplyDelete
Promote what you love instead of bashing what you hate <3
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America: History and Life (AHL) abstracts journal articles, book reviews, media reviews, and dissertations on all aspects of American and Canadian history from prehistory to the present. Sources in AHL are almost all in English and include state and local history journals as well as major history journals. Search the index by keyword and limit the search by desired time-period covered in the article. For additional help in searching use the link in AHL.
Miami University has a long and proud tradition of student involvement in both radio and television productions. This exhibit will celebrate five decades of students in broadcasting. Many of these productions can be found online in the WMUB Archives. For questions about the exhibit, contact Marcus Ladd at firstname.lastname@example.com or (513) 529-0462.
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A man of many hats, Bricker reflects on his Miami Libraries career
Grabach maps an ambitious course for retirement
Havighurst Special Collections included in $2.3 million estate gift
Staff Spotlight—Thom Gerrish


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Extended maintenance of Ruby 1.9.3 ended on February 23, 2015. Read more
A utility module for conversion routines, often handy in HTML generation.
A utility method for escaping HTML tag characters in s.
require "erb" include ERB::Util puts html_escape("is a > 0 & a < 10?")
is a > 0 & a < 10?
# File erb.rb, line 911 def html_escape(s) s.to_s.gsub(/&/, "&").gsub(/\"/, """).gsub(/>/, ">").gsub(/</, "<") end
A utility method for encoding the String s as a URL.
require "erb" include ERB::Util puts url_encode("Programming Ruby: The Pragmatic Programmer's Guide")
# File erb.rb, line 930 def url_encode(s) s.to_s.dup.force_encoding("ASCII-8BIT").gsub(/[^a-zA-Z0-9_\-.]/n) { sprintf("%%%02X", $&.unpack("C")[0]) } end
Commenting is here to help enhance the documentation. For example, code samples, or clarification of the documentation.
If you have questions about Ruby or the documentation, please post to one of the Ruby mailing lists. You will get better, faster, help that way.
If you wish to post a correction of the docs, please do so, but also file bug report so that it can be corrected for the next release. Thank you.
If you want to help improve the Ruby documentation, please visit Documenting-ruby.org.