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On December 2nd, the Institute of Medicine (IOM) released the report, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety." A committee chaired by Michael M.E. Johns, M.D., Emory University chancellor, conducted the study as charged in 2007 by Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, which funded the project. Recognizing that residents need to gain experience to practice safely and competently, the report recommends steps to create safer conditions within the existing limits established by the Accreditation Council for Graduate Medical Education: 80 hours per week and 24 hours of continuous duty, plus 6 hours for educational activities and handing over patient responsibilities.
The IOM report calls for:
The committee recommends a period of five hours of sleep at the end of sixteen hours on duty before continuing to a maximum of thirty hours, and additional days off in each month. It also recommends longer periods between shifts on duty. The report estimates that the national costs of personnel to substitute for the residents' reduced work would total $1.7 billion and calls upon health care payers to support the recommended changes.
In a December 2nd press release, AAMC President and CEO Darrell G. Kirch, M.D., responded to the report: "We agree with the IOM that we must examine duty hours as one of many factors in patient safety and quality of care. The AAMC and the nation's teaching hospitals have always been committed to providing safe, high- quality patient care while still ensuring that tomorrow's doctors receive the very best clinical education ... Moving forward, we will continue to work with the IOM and other stakeholders to make additional improvements to the processes that govern the well being, supervision, and workload of residents at every stage of their training."
AAMC Submits Comments on Cesium-137 Irradiators
On October 10th, the AAMC joined with the Federation of American Societies for Experimental Biology (FASEB) in a letter asking the Nuclear Regulatory Commission (NRC) to proceed slowly in developing regulations that might lead to a ban the use of radioactive cesium-137 chloride in research and clinical applications. On July 31, the NRC published a request for comments in the Federal Register (73 Fed. Reg. 44780) on the extent to which the medical and research communities rely on cesium irradiators and the potential impact a ban on these sources might have.
The NRC has been assessing security concerns about the use of radionuclide sources for several years. Moreover, in February 2008 a National Academies panel commissioned by Congress recommended that use of cesium-137 chloride be discontinued given that the compound is highly dispersible and would be almost impossible to remediate if it were intentionally released in the environment by terrorists. The cesium-137 isotope has a half-life of more than 30 years. The NRC also held a well attended workshop on the cesium issue on Sept. 29-30.
The AAMC, FASEB, and other organizations noted that cesium source irradiators are still widely and productively used in research and clinical applications. For some types of research (including some research projects relevant to homeland security), there currently is no effective substitute. For other types of research, alternative radiation sources, where they do exist, are often less reliable, more difficult to use, and more costly. In scientific investigation, switching to alternative sources would also make comparisons with controls and baseline data far more difficult. But the central argument of the AAMC-FASEB letter against an immediate ban is the concern that no system or plan currently exists for removing and storing existing cesium sources in a secure national repository. Several institutions reported extensive investment over recent years to improve security of irradiation facilities, including background checks for all personnel, 24-hour surveillance, and provisions for armed response in the event of unauthorized intrusion. The associations have therefore requested increased support for improving security of these facilities and support for development of alternative forms of cesium-137 that are less dispersible in the environment. The AAMC and FASEB also requested that any further proposal for disposition of these sources go through regular rulemaking with sufficient time for public comment.
On July 23rd, the House Energy and Commerce Committee amended and approved a health information technology (HIT) and privacy bill, known as the "PRO(TECH)T Act" (H.R. 6357). The Committee also debated a series of additional amendments that were withdrawn with an understanding that they will be clarified and negotiated as the bill moves forward. Most of the discussion at the mark-up centered on the privacy provisions in H.R. 6357, including a requirement that health care providers using electronic medical records obtain consent to use or disclose protected health information for "health care operations," a broad category including quality assessment and improvement activities, developing clinical guidelines, reviewing or evaluating provider performance, conducting residency or other health care training programs, and creating de-identified health information.
In anticipation of the mark-up, AAMC President and CEO Darrell G. Kirch, M.D., sent a 23 letter thanking Committee Chair John Dingell (D-MI) and Ranking Member Joe Barton (R-TX) for their leadership in promoting the adoption of interoperable health information technology, but expressing concern with how the bill's consent provision would affect health care quality and safety improvement efforts, among other activities. Describing the negative impact of such a provision, the letter notes that "this is an instance in which the right to privacy of an individual patient conflicts head-on with the duty of health care providers continually to assure and improve multiple aspects of the care they deliver to all their patients."
In their opening statements, Representatives Jay Inslee (D-WA), Tammy Baldwin (D-WI), and Darlene Hooley (D-OR) acknowledged the concerns of the teaching hospitals in their districts. Congresswoman Baldwin specifically noted that it was important not to hinder the efforts of biomedical researchers.
The committee adopted a handful of amendments, including one by Congressman Mike Rogers (R-MI) to extend eligibility for HIT clinical education grants to all graduate health professions programs, and another by Congressman Ed Markey (D-MA) that would require the Secretary of Health and Human Services to develop a "model informed consent" form that would explain "in plain language" how health information will be used and disclosed if the patient consents.
Congressman Rogers also offered an amendment that would modify the bill's requirement that health care providers maintain a log of internal, non-verbal communications using patients' protected health information. Arguing that such a requirement would impede quality care by discouraging physician-to-physician conversations about treatment options, he proposed to exempt the accounting of such disclosures for payment and treatment purposes. Ultimately though, he withdrew the amendment and agreed to work with Chairman Dingell to clarify its intent.
The Energy and Commerce Subcommittee on Health had previously approved the bill on June 24th. The bill also has been referred to the Committees on Ways and Means - which held a hearing on the subject and announced plans to introduce a separate bill - and Science and Technology. Additional information on H.R. 6357 is available on the Energy and Commerce website.
The Department of Health and Human Services (HHS) announced in the July 23rd Federal Register (73 FR 42743) that it is withdrawing a proposed rule that would revise the methodology for designating federal health professions shortage and medically underserved areas. The announcement described the receipt of "many substantive comments" that suggest "HRSA will need to make a number of changes in the proposed rule." Once the rule has been revised, HHS will publish in the Federal Register a new Notice of Proposed Rulemaking to solicit public comments.
HHS originally published the proposed rule on February 29th, providing a sixty day public comment period. At the urging of many stakeholders, the comment period was twice extended through June 30. AAMC President and CEO Darrell G. Kirch, M.D., sent a May 15th comment letter recommending that HHS extend the comment period by at least six months and convene a panel of affected stakeholders and community experts for a public discussion of the proposed new methodology.
On July 21st, The Senate approved by unanimous consent a bill (S. 901) that reauthorizes the National Health Service Corps (NHSC) through FY 2012. The bill authorizes funding from $131.5 million increasing each year to $185.6 million in FY 2012. The Consolidated Appropriations Act of 2008 provided $123.5 million for the NHSC.
The bill removes the current provision that requires health centers and clinics to demonstrate eligibility as a health professions shortage area every six years. The bill also requires that each qualifying site demonstrate "willingness to support or facilitate mentorship, professional development, and training opportunities for Corps members," and directs the Secretary of Health and Human Services to facilitate professional relationships among Corps members and other health professionals. Specifically, the measure emphasizes faculty appointments at health professions schools, and relationships with hospitals, academic medical centers, and Title VII Area Health Education Centers (AHEC) and Health Education Training Centers (HETC).
The reauthorization is part of a package that also reauthorizes the Community Health Centers Program and the Rural Health Care Programs. On June 8th, the House approved a companion measure (H.R. 1343) that did not include the NHSC reauthorization.
On July 16th, the House Judiciary Committee July approved by voice vote an updated version of legislation to amend the False Claims Act (FCA). Supporters of the "False Claims Act Correction Act" (H.R. 4854) say it addresses concerns that recent federal court decisions have narrowed the application of the federal False Claims Act since it was last amended in 1986.
The Manager's Amendment, offered by Congressman Howard Berman (D-CA), the author of H.R. 4854, narrowed the bill to limit lawsuits for hospital overpayments before periods of reconciliation when overpayments can be repaid to the government. Congressman Berman's amendment also set the statute of limitations for bringing a suit under the FCA to eight years, a compromise between the bill's original ten year limit and the current tiered system with multiple limits. The panel also adopted by voice vote an amendment by Rep. James Sensenbrenner (R-WI) that struck a section of the bill regarding the government's right to move to dismiss certain cases brought by federal employees.
In a July 16th statement, Lisa Rickard, president of the U.S. Chamber Institute for Legal Reform, indicated "the revisions would expand the FCA beyond simply those doing business with the government to include those doing business with any entity which receives government funds, creating whole new categories of targets for the plaintiffs' bar, including scientists and artists, health clinics and homeless shelters, state and local governments, and universities and colleges." The Senate Judiciary Committee approved similar legislation this past spring (S. 2041), sponsored by Sen. Charles Grassley (R-IA). The AAMC joined 20 organizations on a July 15th letter to Congressmen John Conyers, Jr. (D-MI), and Lamar Smith (R-TX), the chair and ranking member, respectively of the House Judiciary Committee, opposing H.R. 4854 as introduced.
On June 2nd, the Department of Health and Human Services (HHS) announced a second thirty day extension of the proposed rule, "Designation of Medically Underserved Populations and Health Professional Shortage Areas" (73 FR 21300). On May 15th AAMC President and CEO Darrell G. Kirch, M.D., had sent a comment letter urging HHS to extend the comment period by at least six months and to convene a panel of affected stakeholders and community experts for a public discussion of the proposed new methodology.
In a May 23rd letter to HHS Secretary Michael O. Leavitt, Senate Democrats urged HHS to provide an additional 120 days beyond the previous May 29 deadline for public comment. The letter also requests that the Health Resources and Services Administration (HRSA) provide states -at least forty-five days prior to the comment period deadline- additional analysis of the proposed rule, including:
HANYS Opposes Proposal to Merge Health Professional Shortage Areas and Medically Under-served Areas
The Health Care Association of New York State (HANYS) has weighed in against a proposal that would combine the Medically Under-served Area/Population (MUA/P) and Health Professional Shortage Area (HPSA) designations into one combined designation. HANYS' concern is that it is not clear how the allocation of resources will change under the designation system outlined in the proposed rule.
Providers with HPSA and MUA designation are eligible for federal programs and benefits related to serving under-served communities. Under the proposal, the number of eligible areas would decrease and there is insufficient information on impacts relating to the allocation of resources. HANYS believes adoption of this rule should be postponed until there is fuller understanding of its implications and the linkage to benefit programs is better defined.
HANYS contracted with the State University of New York School of Public Health, Center for Health Workforce Studies to analyze the impact of the proposed rule on HPSAs and MUAs/Ps. The analysis has found that using the proposed methodology, 16% of existing HPSAs would lose their designation and 15% of existing MUAs/Ps would lose theirs. HANYS sent a letter yesterday to the Health Resources and Services Administration (HRSA) opposing a proposed rule. (Excerpted from HANYS News)
House Passes Conrad 30 Physician Visa Waiver Program Extension
On May 22nd the House passed a bill (H.R. 5571) that reauthorizes the Conrad State 30 J-1 visa waiver program until June 1, 2013. In response to recommendations by the AAMC, the legislation also expands from five to ten the number of "flex slots," which allow states to place non-primary care international medical graduates in areas outside of federally designated health profession shortage areas- often academic medical centers.
Senator Kent Conrad (D-ND) introduced a Senate version of the reauthorization bill, the "Conrad State 30 Improvement Act" (S. 2672), on February 27th. The bill would permanently authorize the Conrad 30 program with a number of reforms designed to direct more physicians into underserved areas. AAMC President and CEO Darrell G. Kirch, M.D., sent an April 2nd. letter supporting the proposed reforms in S. 2672.
The current authorization for the Conrad 30 program is set to expire June 1st. The Senate Judiciary Committee is likely to start working on reauthorization shortly after the Memorial Day recess.
Senate False Claims Act Amendment Legislation Causes Concern about Effects on Research
Legislation that has cleared the Senate Judiciary Committee is causing concerns about the effect it would have on academic research. The False Claims Act Correction Act of 2008 (S. 2041) was introduced by Senators Charles Grassley (R-IA), Dick Durbin (D-IL), Patrick Leahy (D-VT), Arlen Specter, R-PA), and Sheldon Whitehouse (D-RI). Senators Leahy and Specter are the Chair and Ranking Member, respectively, of the Judiciary Committee. The bill was intended to correct recent decisions by various federal courts that have limited the scope and application of the False Claims Act (FCA). The FCA is a tool in the government's effort to combat waste, fraud, and abuse of federal funds and has been used quite often in cases involving hospitals and medical schools; however, the legislation in its current form could have serious and unintended consequences.
Among the concerns that major research institutions like Columbia have with the bill is the effect it could have on how damages are calculated. Currently, in cases involving the misuse of federally sponsored research funds, the institution that receives the grant is liable for three times the amount that was stolen or otherwise used improperly plus other costs, a significant penalty and a strong incentive for universities to prevent such misuse. The way the bill could be read however, damages would no longer be treble the amount misused, but three times the amount of the whole grant, creating a potential huge liability for any medical school. For example, on a $10 million grant, if an investigator, administrator, or other employee somehow managed to misuse a small amount of money, $15,000, under the bill as it currently stands, the grantee could be on the hook to the federal government, not for $45,000 (plus penalties) as would be true under existing law, but for upwards of $30 million.
There are other concerns with the bill as well. It would extend the Statute of Limitations form six to ten years and would interfere with the way the federal government sorts out minor discrepancies.
Columbia University Medical Center has been working very hard to prevent S. 2041 from passing in its current form. Dean Lee Goldman has written to Senator Charles Schumer (D-NY) expressing his concerns about the bill and we have met, in conjunction with colleagues from Cornell and other medical schools, with key House and Senate staff. The Association or American Universities and that Association of American Medical Colleges have also cosigned a letter with fourteen other organizations opposing S. 2041. The letter states that the bill would, "Dramatically expand the scope of liability under the statute, increase its financial penalties, and remove safeguards against unfounded qui tam lawsuits." The letter continues, "These amendments are unnecessary and will impose enormous burdens on non-profits, universities, hospitals, and small businesses, as well as virtually any organization that does business with the Federal government." Advocacy efforts continue in the House and Senate to ensure that S. 2041 does not pass or is amended in such a way as to remove the major concerns that hospitals and universities have with the bill.
AAMC Urges Senate Support for Genetic Nondiscrimination Bill
On April 16th, 2008, Association of American Medical Colleges (AAMC) President and CEO Darrell G. Kirch, M.D. sent a letter to all members of the Senate urging support for the Genetic Information Nondiscrimination Act (GINA). The bill seeks to prohibit discrimination on the basis of genetic information with respect to health insurance and employment. Approved unanimously by the Senate in the 108th and 109th Congresses, the measure has not progressed past the January 31, 2007, approval of the Senate Health, Education, Labor, and Pensions Committee in the 110th Congress. The House passed its version of the bill (H.R. 493) by a vote of 420-3 in April 2007, and last month approved mental health parity legislation (H.R. 1424) that included the text of H.R. 493. The AAMC letter notes that "if patients, researchers, clinicians, and industry are to realize the promise of personalized medicine and the use of genetic information in health care, Congress must pass GINA."
Federal Court Upholds Tax Exception of Medical Resident Stipends
On April 1st, the U.S. District Court for the District of Minnesota ordered the Internal Revenue Service (IRS) to refund almost $1.1 million, plus interest, to the University of Minnesota for Federal Insurance Contributions Act (FICA) taxes paid on medical resident's stipends during the second quarter of 2005.
Under the IRS rule for Student FICA Exceptions-effective for services performed on or after April 1st, 2005- residents are considered employees rather than students and do not qualify for the exception. In an earlier case involving the Mayo Clinic, the court found the IRS rule to be invalid. The court's decision is unlikely to set a precedent for courts outside the federal district covering Minnesota. To date, no other court has invalidated the IRS rule. Though the federal government has appealed the Mayo decision, at press time it had not announced whether it will appeal the most recent decision.
Senator Conrad Introduces Legislation to Reauthorize Physician Visa Waiver Program
Senator Kent Conrad (D-ND) has introduced the "Conrad State 30 Improvement Act" (S. 2672) to reauthorize and expand the Conrad State 30 visa waiver program, a national initiative that directs foreign medical graduates to underserved areas. S. 2762 significantly alters the size, eligibility requirements, and incentives of the current program. Senator Sam Brownback (R-KS) co-sponsored the legislation.
The Conrad State 30 program allows physicians on J-1 visas to waive the J-1 requirement to return to their home country for two years if they agree to serve for three years in an underserved area in the U.S. Each state is allowed 30 such waivers. The bill would:
The Association of American Medical Colleges joined a broad-based group of health and business organizations in a December 3rd letter urging the Senate to reject an effort to "impose expansive new privacy regulations on providers, health plans, employers and others" as part of pending legislation on health information technology. The Senate may consider the "Wired for Health Care Quality Act" (S. 1693) before it adjourns later this month. The letter expresses concern about a possible amendment based on the "Health Information Privacy and Security Act" (S. 1814), sponsored by Senator Patrick Leahy (D-VT).
Noting that the confidentiality of patients' medical records is currently protected by the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules, the letter states, "[C]omprehensive HIPAA regulations strike the appropriate balance between protecting the privacy of a patient's medical information while, at the same time, ensuring that necessary information is available for medical treatment and payment, quality assessment and improvement activities, disease management and care coordination, as well as medical research."
"By contrast, the Leahy privacy amendment would slow or prevent many of these activities, seriously affecting those with serious and chronic illnesses," the letter continues. "The requirement that patients be allowed to refuse the use of their information would jeopardize medical treatment, payment, research, chronic disease management, and other important activities." The letter points out that this approach was rejected by both the Clinton and Bush Administrations during promulgation of the HIPAA Privacy Rule because of its significant potential for negative impact on patient care.
The letter concludes, "Before making any modifications to the HIPAA Privacy Rule, Congress should be absolutely certain that additional requirements are necessary as broad and sweeping changes may dramatically affect patient care."
The letter was prepared under the auspices of the Confidentiality Coalition, which includes hospitals, health plans, pharmaceutical companies, medical device manufacturers, vendors of electronic health records, biotech firms, employers, health product distributors, and pharmacy benefit manufacturers and pharmacies. The letter was signed by the American Hospital Association, the Blue Cross and Blue Shield Association, the Federation of American Hospitals, the Healthcare Leadership Council, the National Association of Chain Drug Stores, the National Retail Federation, UnitedHealth Group, and the U.S. Chamber of Commerce, among other organizations.
House Panel Approves HEA Reauthorization Bill
The House Committee on Education and Labor unanimously approved the "College Opportunity and Affordability Act of 2007" (H.R. 4137) to reauthorize the Higher Education Act (HEA, P.L. 105-244). Authority for the HEA expired on Sept. 30th, 2003; however, several extensions have been enacted, making no policy changes but allowing uninterrupted administration of the programs authorized under the law. The current extension is set to expire March 30th, 2008.
The bill authorizes a loan forgiveness program for medical specialties with residency training programs that require more than five years of training and have fewer U.S. medical school graduate applicants than the total number of training and fellowship positions available.
Several provisions, pulled from the "Student Loan Sunshine Act" (H.R. 890), would dramatically affect medical education financial aid counseling. The Sunshine Act language would:
The bill also contains several provisions designed to curtail "unfair and deceptive private educational lending practices."
Several amendments were approved during the marathon ten hour mark-up. Congressman Tom Price (R-GA), an orthopedic surgeon -- on behalf of Congressman Charles Boustany (R-LA), a heart surgeon, and himself -- offered an amendment to require the Government Accountability Office (GAO) to conduct a study of education-related indebtedness of medical school graduates. The amendment was approved by a voice-vote.
The bill was referred to multiple House committees and it is unclear when it will reach the House floor. A final Manager's amendment of the bill with additional changes is expected to be released before the full House consideration. This past summer the Senate passed the "Higher Education Amendments of 2007" (S. 1642), its version of the HEA reauthorization.
On October 31st, President Bush signed the "Third Higher Education Extension Act of 2007" (P.L. 110-109) to extend temporarily the Higher Education Act (HEA, P.L. 105-244) through March 31, 2008. Authority for the HEA expired on Sept. 30, 2003; however, several extensions have been enacted, allowing uninterrupted administration of the programs authorized under the law. The most recent extension would have expired Oct. 31. Earlier this summer, the Senate passed the "Higher Education Amendments of 2007" (S. 1642) to reauthorize the HEA for five years. The House is expected to introduce a final HEA reauthorization bill shortly.
IRS Issues Draft Good Governance Practices for Charitable Organizations
March 13, 2007 - The Internal Revenue Service (IRS) has issued a preliminary staff discussion draft of possible good governance practices for 501(c)(3) charitable organizations. In the introduction to the document, the IRS states that "we believe that an organization that adopts some or all of these practices is more likely to be successful in pursing its exempt purposes and earning public support."
Among the topics discussed in the IRS document are:
Senate Confirms FDA Head
December 22, 2006 - On December 7th, the Senate voted 80-11 to confirm Andrew C. von Eschenbach, M.D. as Commissioner of the Food and Drug Administration (FDA). Originally nominated for the position in March, Dr. von Eschenbach has been serving as acting Commissioner since September 2005. For part of that time, Dr. von Eschenbach also led the National Cancer Institute (NCI) where he has been Director since January 2002, until leaving to head the FDA full time in June. President George W. Bush appointed John E. Niederhuber, M.D., Director of NCI in August.
Prior to his appointment at NCI, Dr. von Eschenbach was Executive Vice President and Chief Academic Officer of the University of Texas M.D. Anderson Cancer Center in Houston, where he also served as Vice President for Academic Affairs and held the Roy M. and Phyllis Gough Huffington Clinical Research Distinguished Chair in Urologic Oncology. A graduate of St. Joseph's University in Philadelphia, he received his medical degree from Georgetown University School of Medicine and completed his internship at Philadelphia General Hospital and his residency in urologic surgery at Pennsylvania Hospital in Philadelphia before serving as an instructor in urology at the University of Pennsylvania School of Medicine.
House Passes HEA Extension
October 9, 2006 - On September 27th The House passed by a voice vote the "Third Higher Education Extension Act of 2006" (H.R. 6138) to extend the Higher Education Act (HEA) through June 30, 2007. HEA was scheduled to expire September 30th. This nine month extension will allow for uninterrupted operation of the federal educational aid programs while the House and Senate consider new reauthorization bills in the 110th Congress. Unlike previous extensions, H.R. 6138 includes four non-controversial provisions to amend HEA. The Senate passed the bill on September 30th and President Bush signed the extension later that day.
House Committee Preserves Physician Visa Waiver Programs
October 9, 2006 - On September 27th, the House Judiciary Committee approved the "Physicians for Underserved Areas Act" (H.R. 4997) to reauthorize J-1 visa waiver programs through 2008. Participating entities include the Department of Health and Human Services, the Mississippi Delta Regional Authority, the Appalachian Regional Commission, and State Departments of Health through the Conrad 30 program. These waiver programs exempt foreign physicians who receive their graduate medical education in the U.S. from the 2-year home service requirement of the J-1 visa in exchange for practicing in a health professions shortage area.
Authority for the waiver programs expired June 1st, 2006, preventing participating entities from granting new waivers. H.R. 4997 will retroactively authorize the waiver programs during this lapse. The bill was included earlier this year in broader immigration reform legislation and was originally written to make J-1 visa waiver programs permanent, but was amended during committee mark-up to a 2-year extension. It is unclear if the House and Senate will pass H.R. 4997 before they adjourn later this year.
Senators Frist and Kennedy Introduce Health Disparities Bill
October 9, 2006 - On the last day, September 29th, before the Senate recessed until after the election Majority Leader Bill Frist (R-TN) and Senators Edward Kennedy (D-MA), Jeff Bingaman (D-NM), and Barrack Obama (D-IL) introduced the "Minority Health Improvement and Health Disparity Elimination Act" (S. 4024). This legislation seeks to improve the health and health care of racial and ethnic minority and other health disparity populations through enhanced cultural competency training for providers, grants to improve health care access and outreach to underserved populations, and increased research to reduce health care disparities, among other provisions.
The bill reauthorizes the Title VII Centers of Excellence, Health Careers Opportunity Program, Scholarships for Disadvantaged Students, and Faculty Loan Repayment programs, which are designed to improve the diversity of the health care workforce through recruitment, training and mentoring. The legislation also requires health professions schools to collect and report demographic data on applicants, matriculants, and graduates to the Department of Health and Human Services to be stored in a database and analyzed to assess diversity within the health professions.
The bill also creates a new grant program at the Agency for Healthcare Research and Quality for research to improve the health of racial and ethnic minority and other health disparity populations. It directs the Institute of Medicine to convene a summit to evaluate and report on federal efforts addressing health disparities. The bill reauthorizes the National Center for Minority Health and Health Disparities and strengthens its role in coordinating disparities research at the National Institutes of Health.
Senator Frist hopes to pass the bill in November before he leaves the Senate.
House Passes Health IT Bill
August 20, 2006 - On July 27th the House passed (270-148) the "Health Information Technology (HIT) Promotion Act of 2006" (H.R. 4157). Of interest to teaching hospitals and medical schools, the bill:
The bill, which contains several other related provisions, must now be reconciled with the Senate's HIT bill (S. 1418). The Senate bill does not include the AAMC-supported Stark and anti-kickback provisions. It also provides a higher level of funds for purchasing HIT.
Higher Ed Commission Comments on Physician Workforce Shortages
July 26, 2006 - The Secretary of Education's Commission on the Future of Higher Education released a second draft of its final report. The new draft is widely acknowledged as less critical of higher education than the original report. Among the additions, a findings section outlines concerns that "current and projected shortages in physicians, registered nurses, and other medical specialties may affect the quality of care for the increasingly aging population of Baby Boomers" and the report recommends "increasing federal and state investment in education and research in critical areas such as the STEM fields (science, technology, engineering and mathematics) teaching, nursing, biomedicine, and other knowledge-intensive professions." Additionally, the draft report broadly calls for increased transparency and accountability; developing - at the institutional level - new and innovative means to control costs and improve productivity; simplifying the financial aid process; and a shift to financial aid awards based on need rather than merit.
Senate Panel Approves Ryan White Reauthorization Bill
May 26, 2006 - The Senate Health, Education, Labor and Pensions (HELP) Committee approved legislation (S. 2823) to reauthorize the Ryan White CARE Act (P.L. 101-381). Sponsored by HELP Committee Chairman Michael Enzi (R-WY) and co-sponsored by Ranking Member Edward Kennedy (D-MA), the bill attempts to address changes in the AIDS epidemic since the act's last reauthorization in 2000.
Specifically, the bill includes a provision to include the number of HIV cases in addition to AIDS cases for funding formulas; requires that 75 percent of funds be spent on "core medical services;" and attempts to more evenly distribute funds between rural and urban areas, a contentious issue among lawmakers. The committee voted 19-1 in favor of the measure, with Sen. Hillary Clinton (D-NY) voting against it on the grounds that New York will lose $20 million under the new formula.
Senate Republicans Pull Medical Liability Bills
May 12, 2006 - Senate leaders pulled two Republican-supported medical liability reform bills from consideration on the Senate floor, following two unsuccessful votes to invoke cloture and avert filibusters. The 48-42 vote to limit debate over the "Medical Care and Access Protection Act of 2006" (S. 22) fell short of the sixty votes needed to invoke cloture. The cloture vote on the bill, which was introduced by Senator John Ensign (R-NV), was split primarily along party lines, with three Republicans voting against cloture. A subsequent 49-44 vote to limit debate over the "Healthy Mothers and Healthy Babies Access to Care Act" (S. 23) also fell short of the required sixty votes. As a member of the Health Coalition on Liability and Access, the Association of American Medical Colleges has endorsed S. 22 and S. 23.
Education Commission to Hold Open Meeting
(AAMC's Washington Highlights) The Secretary of Education's Commission on the Future of Higher Education plans to hold its fifth meeting on May 18th and 19th in Washington, DC. The Commission is charged with initiating a national dialogue about the future of higher education and how best to improve the country's system of higher education to ensure graduates are well prepared to meet future workforce needs. The agenda for the May meeting includes a discussion of preliminary findings, possible recommendations and a proposed format for the final report, which must be submitted to the Secretary by August 2006.
The meeting will be open to the public, but individuals interested in attending must register in advance by contacting Kristen Vetri at email@example.com. Opportunities for public comment and more information on the Commission are available on the Department of Education's Web site.
House Subcommittee Holds Fourth HIT Hearing
(AAMC's Washington Highlights) At an April 6th House Ways and Means Subcommittee on Health hearing, Chair Nancy Johnson (R-CT) expressed concern about the slow adoption of health information technology (HIT). Stating that "additional actions are needed by both the public and private sectors" to achieve the President's goal of providing most Americans with electronic health records (EHRs) by 2014, Rep. Johnson urged the witnesses to suggest ways to expedite HIT adoption.
Among those testifying was Brent Henry, Vice President and General Counsel for Partners HealthCare System in Boston. Mr. Henry stated that Congress should craft a Stark law exception and an anti-kickback safe harbor for the provision of HIT and related services. He commended Chairwoman Johnson for introducing legislation (H.R. 4157) that would assure these exceptions. According to Lewis Morris of the Health and Human Services (HHS) Office of the Inspector General, his colleagues are exploring whether and how HIT exceptions/safe harbors could assure a "balance between fostering the adoption of beneficial [EHR] systems and preventing fraud and abuse in the Federal health care programs."
Ken Kizer, M.D., M.P.H., Chairman and CEO of Medsphere Communications, suggested that the federal government "support and utilize open source software as the preferred option" whenever possible. Open source software is non-proprietary, available at no or minimal cost, and is designed to operate in collaboration with multiple systems. He also testified that the use of EHRs should be a condition of participation for Medicare providers. Ranking Member Pete Stark (D-CA) supported this option, explaining that it would eliminate the need to alter Stark and anti-kickback laws.
Also testifying at the hearing was David Brailer, M.D., Ph.D., HHS National Coordinator for Health Information Technology. Responding to privacy concerns related to remote monitoring technology, Dr. Brailer announced that HHS plans to initiate a demonstration project evaluating remote monitoring for multiple sites.
Congress Extends Mental Health Parity
January 3, 2006 - In December the Senate joined the House of Representatives in passing legislation that would extend for one year a mental health parity law under which health insurers are prohibited from placing caps on annual or lifetime mental health benefits unless they place similar caps on medical and surgical benefits. This means that if a health plan provides no lifetime limit on medical benefits, it could not impose one for mental health benefits either. The bill is an extension of the original 1996 law that was scheduled to expire December 31st.
January 2, 2006 - The final version of the Budget Reconciliation cuts a net $12.7 billion from student aid programs. The Senate had proposed attaching all of the Higher Education Act reauthorization, but only certain financial provisions were included in the final agreement. A majority of these provisions are designed to decrease mandatory spending, such as reducing lender subsidies. Other provisions recycle savings back into student aid, such as increasing unsubsidized loan limits for graduate borrowers from $10,000 to $12,000.
The conference report accepted the House's proposal to reduce borrower origination fees for both the Federal Family Education Loan (FFEL) and Direct Loan programs. Under this proposal, both types of loans will be incrementally reduced to a total origination fee of 1% in 2010. While the origination fee for Direct Loans is 1% higher during this period, the conference report requires FFEL lenders to charge an additional 1%. The final agreement does not include any changes to consolidation origination fees, thus allowing borrowers to continue to refinance their student loans without initial fees.
Like the Senate proposal, the conference report makes no changes to Stafford Loan interest rates. In July, 2006, interest rates are scheduled to change to a fixed 6.8 % rate, as opposed to the current variable rate formula based on the 90-day T-bill plus 2.3%. The final agreement also does not make any changes to consolidation loan interest rates, which will remain a fixed rate formula based on the weighted average of the loans to be consolidated, not to exceed 8.25%. Additionally, the conference report eliminates a loophole that allowed lenders to charge interest rates of 9.5% and, with the House and Senate in agreement, repeals in-school consolidation.
AAMC Comments on Accreditation Provisions of HEA Reauthorization
On November 15ththe Association of American Medical Colleges (AAMC), in coordination with the Liaison Committee on Medical Education (LCME) and in consultation with the American Medical Association, sent a comment letter to the House Committee on Education and the Workforce and the Senate Committee on Health, Education, Labor, and Pensions. The letter expresses concerns regarding the accreditation provisions of the Higher Education Act reauthorization bills ( H.R. 609, S. 1614).
The letter focuses on several changes in accrediting bodies' reporting requirements and recommends that public disclosure of sensitive findings remain at the discretion of the institution. This stems from concerns that release of this information or a summarized version without explanation or context could be easily misinterpreted by the public.
Additionally, the AAMC recommends the deletion of provisions that require accrediting associations or agencies to enforce standards based on the institution's mission. The ambiguity of this mission-related language could be misconstrued to suggest that the LCME compromise its standards in deference to a school's mission.
As a result of numerous school closings in the path of Hurricane Katrina, on September 8th, the House moved provide relief to students forced to withdraw from schools closed due to natural disasters. The House unanimously approved the "Student Grant Hurricane and Disaster Relief Act" ( H.R. 3668), proposed by Congressman Bobby Jindal (R-LA), which gives the Secretary of Education the ability to waive the Title IV federal assistance programs' repayment requirements when a natural disaster is recognized by the President. The Senate passed H.R. 3668 without amendment by Unanimous Consent on September 15th.
"This bill fulfills an urgent need to provide flexibility and assistance to students who have been forced to put their higher education on hold as a result of Hurricane Katrina," said Congressman Jindal. "Students in my district are facing hardships on numerous fronts, from the loss of their homes and communities to the damage and closure of college campuses. As students cope with these unprecedented challenges, we should not add to their burden by requiring those who have been forced to withdraw from college to repay student aid." Under current law, students with grants and scholarships offered under Title IV federal assistance programs (including Pell Grants, the Supplemental Educational Opportunity Grant program, Leveraging Educational Assistance Partnerships program, and scholarships offered under the GEAR UP and TRIO programs) must repay the awarded funds if they fail to complete the required academic year or semester.
On July 14th The House Education and the Workforce 21st Century Competitiveness Subcommittee approved, as amended, H.R. 609, the "College Access and Opportunity Act of 2005," which would reauthorize the Higher Education Act (HEA), by a party line vote of 18-15. Specifically, H.R. 609 contains several provisions of particular interest to medical schools and teaching hospitals. The bill seeks to increase loan limits, but limits increases in subsidized loan limits to freshmen and sophomores, and to a small increase from $10,000 to $12,000 in unsubsidized loans for graduate and professional students. H.R. 609 also includes provisions shifting all Stafford loans, including consolidation loans, to a variable interest rate. Full Committee Chairman John Boehner (R-OH) noted that he is working on compromise legislation that would allow borrowers a choice of consolidating student loans at a fixed or a variable rate, with the rates for each based on different underlying financial instruments. Chairman Boehner stated during the mark-up that he will continue his discussions and may have a compromise to announce at the full committee mark-up. The subcommittee rejected amendments offered by Ranking Member Dale Kildee (D-MI) that would have retained the fixed rate option for consolidation, and capped Stafford Loan interest rates at 6.8% rather than the 8.25% included in the bill.
Senate Majority Leader Bill Frist (R-TN) and Senator Hillary Clinton (D-NY) have introduced S. 1262, "The Health Technology to Enhance Quality Act of 2005." According to the bill's summary, it "will help harness the potential of health information technology (IT) and preserve patient privacy while reducing costs, enhancing efficiency, and improving the overall quality of patient care."
Specifically, S. 1262 would establish in statute the Office of the National Coordinator for Health Information Technology (ONCHIT), created by the Bush administration in 2004. ONCHIT is located within the Department of Health and Human Services (HHS). The bill directs ONCHIT to work with the National Institute for Standards and Technology (NIST) to establish a permanent electronic health information standards development working group to review existing standards, identify deficiencies and omissions working against a national goal of interoperability, and recommend to the HHS Secretary which standards should be adopted.
According to the legislation, ONCHIT would also direct and coordinate federal spending related to health care IT. The bill authorizes $125 million per year in grants to local or regional health care facilities over five years in order to create an interoperable system in which records could be stored electronically. S. 1252 also provides exemptions from "Stark" self-referral and anti-kickback laws to allow hospitals, health plans and other to offer health information technology equipment to physicians as long as its purpose is to "reduce medical errors, improve quality, reduce costs, improve care coordination, streamline administration, and promote competition and transparency." Relief from the physician self-referral and anti-kickback laws would apply only if the physician entity receiving support complies with final data standards for interoperability.
The bill requires the Medicare program to establish a budget neutral "value-based purchasing pilot program to encourage the reporting of health care quality data and facilitate the payment of providers based on performance." The pilot program could be expanded nationwide and implemented after two years. The bill also includes a "Sense of the Senate" that Medicare physician payment modifications should include provisions to encourage the adoption of health IT standards and reporting of quality measures. S. 1252 also directs HHS, the Departments of Defense and Veterans Affairs and other federal agencies to adopt uniform healthcare quality measures to assess "the effectiveness, timeliness, efficiency, patient centeredness and safety of care across federal health care programs" including Medicare, Medicaid and State Children's Health Insurance Program.
Medical Schools Support Legislation to Expand Liability Protections
On May 10th Association of American Medical Colleges (AAMC) sent a letter in support of the "Community Health Center Volunteer Physician Protection Act of 2005" (H.R. 1313), which would extend liability protections under the Federal Tort Claims Act (FTCA) to physicians who volunteer their services at Community Health Centers. The bill was introduced by Representative Tim Murphy (R-PA). Under H.R. 1313, physicians who volunteer at federally funded health centers would be deemed Public Health Service employees and thereby qualify for liability coverage under the FTCA. The AAMC letter applauds H.R. 1313 for providing "a meaningful incentive for physicians to volunteer their services at Community Health Centers (CHCs)." The letter states that such action "would help mitigate the shortage of CHC physicians and thereby improve healthcare access for many underserved Americans." In the letter, AAMC President Jordan J. Cohen, M.D., explains that CHCs "provide unique learning environments and experiences for many medical students and residents." It praises H.R. 1313 for helping "CHCs maintain these valuable patient care and medical education activities."
Senate Committee Passes Patient Safety Legislation
On March 9th, the Senate Health, Education, Labor, and Pensions (HELP) Committee passed patient safety legislation that would establish a voluntary and confidential reporting system in support of initiatives to reduce preventable medical errors. The "Patient Safety and Quality Improvement Act of 2005" (S. 544) is based on legislation that was approved by the Senate in the 108th Congress ( S. 720). The House passed similar legislation last year; however, the House and Senate did not reconcile subtle differences between the two bills before the 108th Congress adjourned.
By granting legal protections for reported data, S. 544 would encourage providers to report medical errors or "near misses" to "Patient Safety Organizations" (PSOs). The PSOs would compile and analyze the data with the intent of developing and disseminating "best practices" that could avoid subsequent errors and improve healthcare quality.
Slow-Down in Healthcare Spending Growth
According to a report in the January/February 2005 issue of Health Affairs, healthcare spending grew by 7.7% in 2003, versus a 9.3% increase the previous year. However, the proportion of national gross domestic product (GDP) related to healthcare spending increased from 14.9% in 2002 to 15.3% in 2003.
Slower growth in Medicaid payments helped moderate spending growth, according to the report. In 2003, Medicaid spending grew by about 7%, versus about 12% in 2002. The report identifies tighter eligibility requirements, reduced benefits, and decreased upper payment limit payments as major factors in the decline. In 2003, Medicaid spending growth for hospital services was 5.3%, about 6% lower than in 2002.
Medicare spending in 2003 grew by 5.7%. By contrast, in 2001 and 2002, program spending increased by 10.8% and 7.6% respectively. According to the report, the "slowdown in growth in 2003 was evident in Medicare spending for hospital services, which increased 5.3% in 2003 compared to a 7.0% growth in 2002."
While the growth in private spending on physician services increased from 8.2% in 2002 to 9.4% in 2003, the growth in public spending on physician services fell from 8.1% in 2002 to 6.7% in 2003. However, the growth in Medicare spending on physician services was higher in 2003 than in 2002 (6.9% vs. 5.7%). The increase reflected a significant difference in the Medicare payment update for CY 2002 (which was negative) and CY 2003 (when a legislative "fix" averted a negative update for CY 2003 Medicare physician payments).
According to the report, health insurance enrollment dropped in 2003, likely due to job losses and a reduction in take-up rates for employer-based coverage.
Senate Health, Education, Labor, and Pensions Committee Chairman Michael Enzi (R-WY) and Senate Finance Committee Chairman Charles Grassley (R-IA) joined Ranking Members Edward Kennedy (D-MA) and Max Baucus (D-MT) in signing a January 5 letter to Secretary of Health and Human Services Tommy Thompson encouraging him to "include in the 2006 budget a significant commitment to health information technology." The letter also was sent to Office of Management and Budget Director Joshua Bolton.
In the letter, the Senators praise the "ambitious and commendable agenda" of Dr. David Brailer, National Coordinator for Health Information Technology. They urge Secretary Thompson and Director Bolton to assure that Brailer's office receives "adequate resources…to continue its important work." According to the letter, Dr. Brailer has estimated that an interoperable health information technology system could "generate savings of about…$170 billion annually" and could improve "clinical trials and public health surveillance and response."
The Senators requested a "complete plan of action" to address "issues surrounding the adoption of health information technology," including "targeted financial assistance" for providers, assistance for regional/community health technology organizations, and "financial incentives" for providers who "implement and use" such systems to improve quality. According to the letter, Congress plans to explore pay-for-performance options, "and the use of technology may play a role."
Congress has approved S. 2302, legislation extending for two years the authority of states to provide up to thirty waivers per year for international medical graduates that complete residency training in the U.S. on J-1 visas to remain in this country in return for providing primary health care services in federally-designated health professional shortage areas. Without such waivers, J-1 visa physicians would be required to return to their home countries for two years before returning to the U.S. The legislation also includes authority for each state to offer up to five waivers to physicians who would not be serving in designated shortage areas. Under the bill, J-1 visa physicians that convert to H-1B visa status during their waiver period would not count against the statutory cap on H-1B visas.
On October 6th, the House of Representatives approved by voice vote a "clean" one-year extension of programs authorized under the Higher Education Act (HEA). The legislation, H.R. 5185, makes no policy changes, and allows uninterrupted administration of the programs through FY 2005 while the Congress continues to debate a longer reauthorization. A day later, the House also approved by a vote of 414-0 legislation (H.R. 5186) to close for one year a loophole in lending rules that allows lenders to collect a significant profit on certain types of loans. The savings associated with closing the loophole would be used to increase loan forgiveness for elementary and secondary school teachers of math, science and special education.
On October 6th, the House of Representatives approved legislation (H.R. 4453) extending for two years the J-1 Visa Waiver Program, which provides each state with authority to sponsor waivers permitting foreign physicians who complete their residency training in this country to avoid the two-year home country requirement associated with the J-1 visa program. In return, the foreign physicians are required to provide health care in underserved areas for a minimum of three years. An amendment offered in the House Judiciary Committee would allow up to five physicians in each state to work in areas that are not designated as underserved. Additionally, the bill, as approved, would clarify that physicians that transfer into the H-1B visa program do not count against the statutory cap on H-1B visas. The program expired on May 31.
Other Current Issues
Last updated 2/12/2009


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Today: Aaron Kennedy discusses how he uses the old noodle
Aaron Kennedy, founder of the Denver-based Noodles & Co., is the keynote speaker at the annual Cherry Creek Chamber luncheon that starts at noon today at the JW Marriott, 150 Clayton Lane.
Kennedy will no doubt discuss the "Eureka" moment he experienced in 1993, when he decided to start a chain of colorful, comfortable noodle joints. Since that moment, Noodles & Co. has successfully opened stores in more than a dozen states across the country. That, the company says, is why it's called "using your noodle."
For information on the luncheon, go to www.cherrycreekchamber.org.
For information on dozens of culinary events around town, visit our online Food & Drink listings.
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Wii U
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Here is my prediction:
XBOX One bombs in the 1st two years. Most of it's sales are from microsoft fanboys and wealthy families uninterested in games. Poor sales reduce 3rd Party ports. Microsoft begins to invest more of it's resources in the 360 and PC gaming while continuing to push the XBOX One, as they usually don't like to admit defeat. Eventually, they just kill the console and drop out of the console race. Especially considering how it hasn't profited them much. 10M consoles
Wii U sales begin to pick up in early august, and sales are steady by October. Nintendo limits Wii series titles to one per year and develops a more gritty franchise (still rated T, but the atmosphere and what-not are more "mature"). XBOX One's failure and increased sales lead to more 3rd Party multiplats to come to the console. Sales do decent: 60M consoles
PS4 has a fantastic launch. The console has usual Sony exclusives as well as great 3rd party support. Pretty much ends up like the PS1 and PS2 in dominating the market (and I'm a Nintendo fanboy). That said, declining interest in consoles causes sales to peak at 130M consoles.
Steambox does moderately well also, selling 25M units.
Nintendo releases a 9th gen console 5 years later while Sony waits 7-8 years because of diminishing returns. Apple partners with a hardware manufacturer to create a more powerful cloud gaming device
Not changing this sig until we get a new main series Tales game released on a Nintendo console in the US
CorruptedRPG 4 years ago#2
Wii U > PS4 > Xbox One
Wii U > Xbox One > PS4
There should no complaints now.
IcedEarthaholic 4 years ago#3
Wii U sales pick up and begin taking off, bringing some third party support back to the console once the games begin hitting. Ultimately ending up finding it's stride by September and not looking back. Ultimately I feel a price drop coming around November/December and a couple nice bundles as well. It will get plenty of exclusives that you can't get anywhere else throughout it's lifetime too, exclusives that will appeal to various people, and end up propelling the thing along.
My prediction: 60 - 80 Million
PS4 will start off strong, but ultimately when people begin to notice the flaws it has, will begin picking the thing apart. It will have a good, strong software line-up throughout it's lifespan, and no, I do not expect it to reach PS2 levels at all, but I expect it to have a strong showing in the end.
My prediction: 70 -75 Million
XB1? The games looked decent, and it will be sharing multiplats with PS4, but the 500 dollar price, DRM issues, used game fees, and every horrible decision they've made with this system will bite them in the ass.
My prediction: 20 - 30 Million
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CasualGamers 4 years ago#4
N getting 3rd party support? Some devs are M$/Sony fanboys and they will not come to the Wii U even though it is a unique and compelling experience.
The PS4 could be successful more successful than the Wii U, but it is tough to say. I mean, how can we tell when N hasn't brought out the big guns like smash and Mario kart?
CasualGamers 4 years ago#5
IcedEarthaholic posted...
Wii U sales pick up and begin taking off, bringing some third party support back to the console once the games begin hitting. Ultimately ending up finding it's stride by September and not looking back. Ultimately I feel a price drop coming around November/December and a couple nice bundles as well. It will get plenty of exclusives that you can't get anywhere else throughout it's lifetime too, exclusives that will appeal to various people, and end up propelling the thing along.
Another thought. I don't think the ps4 will break 50 million. You have to remember that a sizeable chunk of those sells are repeat buyers due to YLOD issues.
The_Hyphenator 4 years ago#6
I think the Wii U is going to take off this holiday season, while the PS4 and Xbone both have fairly slow launches (the Xbone more so). The Wii U will continue to sell steadily after that, and will see the return of a fair number of third parties to the platform, but won't really start seeing truly impressive sales figures until a price drop a few years down the line.
Meanwhile, the PS4 will have a hot holiday season next year, and begin to pick up steam, with new exclusives helping to drive sales. But again, they won't start pushing really big numbers until a price drop happens.
The Xbone will continue to struggle in the States, and will be virtually dead in the UK, Europe and Asia. A price drop and some key titles will help move it, but the stigma surrounding the platform and the lack of overseas sales will keep it from gaining any real traction.
As for the final shakedown, I'm going to be generous and guess that we'll see double the amount of consoles sold from the previous gen (it's a pretty safe bet: Gen 6 did about 160 million, all told, and Gen 7 has already hit 260 million and still counting), so we'll call the total 520 million. I'm going to go out on a limb and guess that Nintendo is going to stick with a 5-to-6-year cycle and release a new system in 2018, while the other two consoles may try to go for another 8-to-10-year cycle. So I'll say the Wii U will sell 160 million, the PS4 300 million, and the Xbone a paltry 60 million (again, remember that I'm predicting little to no overseas sales for the Xbone).
Sony will be saved, Nintendo will skip into the sunset after another profitable generation, and Microsoft Corporate, sick of wasting billions on a division that has never turned a long-term profit, will finally pull the plug on the Xbox division.
FFXIgaiaknight 4 years ago#7
PS4 - between 70-100 million
Xbox 1 - between 70-100 million (dont underestimate the human race)
Wii U - 50-60 million (will probably be my most played platform this gen)
NNI: Gaiaknight
kdognumba1 4 years ago#8
I predict that all the consoles will be plagued by red rings and a swarm of angry bees will mob you once you leave your homes. MWAHAHAHAHA
backloggery: http://backloggery.com/kdog254 twitch: http://www.twitch.tv/kdognumba1
3DS: 1676-3698-5986 PSN: jotaroxtreme NID/XBL: kdog254 Steam: kdognumba1
PS4: 100 million
One: 75 million
Wii U: 30 million
Warmonger222 4 years ago#10
Wii U 65M
Valve <2M
Ouya <1M
Wii U will pick up later this year, people will see the $100 price difference and not be as interested in PS4 until late next year. XBox One will sell a bit lower than Wii U did at launch, but rather than sales increasing after the post launch slump, they will only get worse over time. Valves console (assuming it even exists) will fail, wont even get a niche (maybe a SMALL PC/Valve fanboy one), Ouya will outright fail.
Sega is what EAin't - Crazy_Tank51
Wont buy a non-Nintendo console until people stop pretending Nintendo doesn't count.
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Gaki were a "hungry spirit", ghosts that ate blood, eyes, desire, ... [1]
Origin Edit
Gaki were a form of undead that were created when a person, having lived a life of selfishness or dishonor died, and were cursed to an existance in Gaki-do, the realm of the hungry dead. Also called hungry ghosts, they were spirits in agony from a constant need which they sought to satisfy--though they never could. The hunger drove them mad. [2]
Attacking the Kumo Edit
The gaki feasted on the power of Jigoku and on that of mortals, and had no desire to share their prey with another race. When the kumo race, denizens of Chikushudo, willingly allowed to become susceptible to the taint in exchange for passage into the realm of mortals, the Gaki attacked them where they were moving between realms. [3]
Appearance Edit
Their forms were ephemeral and ghost like. Moonlight made them glow softly. [4] There were many specific kinds of gaki which had been categorized, though quite often unique gaki were encountered. Exposed to the taint of Jigoku due to the proximity of the two realms, many gaki suffered horrible mutations often resulting in strange insectoid characteristics. [2] The Gaki had no true forms in their own realm, so they borrowed their forms from the closest Spirit Realm, Chikushudo, taking these insectoid aspect. [5]
Abilities Edit
The gaki were vampires who prey on the sleeping bodies of the living. They could easily move through solid objects, and only were affected by jade and crystal weapons, or Spirit Ward Magic. [4] Dogs, horses, cats, Nezumi, and Sodan-senzo could aIways see the gaki. [6]
Known types of gaki Edit
Toritaka Iemasa catalogued thirty-six varieties of gaki. [5]
Aoandon Edit
The "Blue Lantern Ghost" was a Shozai-gaki revealed to Rokugani in the 5th century, feeding from a distance upon fear and stories of spirits. It was summoned in Ningen-do when one hundred blue lanterns were lit on a moonless night, and one lantern was doused after each ghost story was completed. The ritual of the lanterns bound them to the mortal plane until sunrise. [7]
Skull Tide Gaki Edit
Drawn of the souls of drowned sailors, the Skull Tide Gaki manifested itself as a mass of chattering skulls, attacking ships by biting at the hull and tossing the ship about through sheer weight of numbers. Those sailors who fell overboard were ripped and torn in the jaws of the many skulls of the gaki, their tormented souls joining that hungry undead host. [2]
Shikko-gaki Edit
The spirits of those punished for the defilement of graves were cursed with a terrible hunger for dead flesh, becoming hulking primative creatures that skulked in graveyards, devouring corpses. Shikko-gaki resembled hunched, ape-like creatures with gray skin, long claws, bulging segmented eyes, and no legs. Though Shikko-gaki were extremely intelligent, they had no desire for conversation. [8]
Kwaku-shin-gaki Edit
Those who were guilty of allowing the destitute to freeze in winter storms, unwilling to be charitable out of greed or cruelty sometimes were punished to wander the world as these gaki, their lower bodies contained in flaming cauldron-shaped braziers--their upper bodies scorched continually by the blazing fires, but driven nonetheless to gather fuel for their continued torment. [2] Kwaku-shin gaki never spoke or otherwise communicated, and pursued their prey by hopping, [9] slamming into their prey and knocking them to the ground, pinning them and either consuming them with their cauldron mouth or belching out boiling liquid to destroy an enemy. [10]
Gakimushi Edit
Those who lived lives of mindless slaughter were condemned to short unlives as horrible rampaging insect monsters similar to mutated ant-lions, pincering and ripping apart everyone in their path until their tortured existance can be brought to an end by a large and skilled enough group of bushi. [2] They fed on pain, so they captured mortals and tortured them, feeding on their delicious agony. [9]
Night Moths Edit
Moths with dark and black coloration were the souls of wives who died poorly, and those who forsook maintaining their household in order to pursue their own agenda. These insects were the bane of silk, as the gaki was forced to eat this fabric and exposed herself to other households and relive their failures. [11]
Jiki-Kwa Edit
These gaki with the form of small flying insects [7] were forced to burn themselves and consume the fires of lamps and torches, destroys the form it had taken in Ningen-do and was forced back into Gaki-do for a period of time. This was usually the fate of those who caused fires in their life. [11]
Jikiketsu Edit
Those gaki where blood-drinkers, and they were the most dangerous. [5]
Jiki-Min Edit
Souls of those who have stolen from temples became pitiful insects that consumed nothing but the false hair on temple and shrine idols. Many times, they were swatted and destroyed by temple caretakers, and forced back into the Realm of Hungry Ghosts. [11]
Fujo-ko-Byaku Edit
An Usai-gaki [7] also known as flesh eaters, these insects were usually maggots or beetles and feed upon the skin of both the living and dead. Those who donated dirty and unwholesome food to shrines and temples suffered the fate of becoming a Fujo-ko-Byaku. [11]
Ju-Chu Edit
Ju-chu-gaki were almost always Muzai-Gaki, and could only appear in the mortal world inside trees. The growing of grass and grain around them caused them pain, and that was their punishment for cutting down the trees and flowers on holy ground. [11]
Doku Edit
Spirits of those who sold and used poison, they became doku-gaki, the poison eaters. These gaki often became leeches and slugs in Rokugan, and were used by clever shugenja for both the benefit of the gaki and a poison victim. [11]
Yoku-Shi Edit
The ghosts of those who felt victim to the sin of desire became yoku-shi-gaki. These ghosts rarely appeared as insects, instead choosing to show themselves as comely women and men, leading others down their dark path and feeding off of their desire. [12]
Ubume Edit
Also known as "mourning ghosts," ubume were the spirits of those who had forsaken their loved ones and those who depended on them in life. They could feed off of only sorrow, and often appeared as despairing humans wandering the Empire and moaning in a low howl. [12]
Shokujinki Edit
The "Human-Eating Ghost," or "Eater of the Dead,", they were selfish men who after their death they were cursed to devour those who die as they had devoured in their life the livelihood of the living. [13]
Classification by Style Edit
Muzaigaki Edit
The "seekers"'were bitter and ashamaed gaki, cursed to always hunger and never feed, wandering in constant agony without the possibility to sate themselves. They sometimes became frustrated or violent, but never directly harm humans, just if angrey they caused objects to spontaneously break or hurl themselves through the air. Their only cure was time; when they have suffered long enough, they would join the shiryo. [14] They were the most common of all gaki. [15]
Usaigaki Edit
The "scavengers" were allowed to feed upon the waste and refuse of mortals, or even the upon the offerings left at shrines. They often travel in large packs, never harm humans, and sometimes could be quite helpful, exchanging information for food. When these gaki consume enough food, their punishment was lifted. [14] They were once the souls of mortals who succumbed too often to minor vices. [16]
Shozaigaki Edit
The "feeders"' were the most dangerous, cursed to feed only upon impure or living substance, seeking out blood, sweat, lille, tree pulp, or other such substances. For them mortal were anything but a source of food. Some shozaigaki invisibly entered a human body to feed, causing fevers and chills by their presence. All shozaigaki claimed a certain area as their territory, until their hunger was appeased. [14] Bayushi Shoju and Matsu Hiroru became Shozai-gaki, but they recalled everything about their previous lives. [17]
See also Edit
- Gakimushi/Meta
- Kwaku-shin gaki/Meta
- Shikko-gaki/Meta
- Muzai-Gaki/Meta
- Shozai-Gaki/Meta
- Usai-Gaki/Meta
External Links Edit
- Gaki (Winds of Change)
- Gaki of Desire (Honor's Veil)
- Essence of Gaki-do (Reign of Blood)
- ↑ Roleplaying in the Emerald Empire, p. 10
- ↑ 2.0 2.1 2.2 2.3 2.4 Creatures of Rokugan, pp. 23-25
- ↑ Secrets of the Crane, p. 87
- ↑ 4.0 4.1 Roleplaying in the Emerald Empire, p. 192
- ↑ 5.0 5.1 5.2 Winter Court: Kyuden Kakita, p. 70
- ↑ Winter Court: Kyuden Kakita, p. 71
- ↑ 7.0 7.1 7.2 Secrets of the Empire, p. 193
- ↑ Creatures of Rokugan, p. 23
- ↑ 9.0 9.1 Enemies of the Empire, p. 274
- ↑ Creatures of Rokugan: Third Edition, p. 105
- ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Fortunes & Winds, p. 41
- ↑ 12.0 12.1 Fortunes & Winds, p. 42
- ↑ Book of Void, p. 134
- ↑ 14.0 14.1 14.2 Winter Court: Kyuden Kakita, p. 71
- ↑ Fortunes & Winds, p. 40
- ↑ Creatures of Rokugan: Third Edition, p. 107
- ↑ Creatures of Rokugan: Third Edition, p. 106
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Ranks 8, 17, and 22: Use of External, Non-Medical Triggers for Medical Reviews
Use of external, nonmedical triggers for medical reviews was weighted 7.26, placing it 7th in importance among the 16 components listed in the middle column of the RVA. The four components evaluated in this area included: (1) law enforcement/courts, (2) family, (3) social services, and (4) the general public.
Reports by law enforcement are a credible source of informationthe officer was there, saw what happened, and asked the driver questions that possibly provided information about medical conditions. All meeting attendees were in agreement that referrals by law enforcement are important in the identification of at-risk drivers.
Jurisdictions reported varying figures estimating referrals that come from law enforcement, ranging from "very few" to "the majority." One jurisdiction reported it receives as many as 40 to 50 a week. These are not crashes; these are observations. Law enforcement officers make referrals after they see a driver almost hit another car (or perform some other unsafe maneuver), follow the driver, make a stop, and then find out that the driver has poor physical health, or admits to being disoriented, etc. One jurisdiction said 35 percent of its referrals come from law enforcement. Reports come in as a "request for re-exam" as opposed to a ticket. Thirty percent of the law enforcement referrals are for conditions including drivers who blacked out, are confused, or are dazed. When an officer requests an exam, the DMV temporarily suspends the license (and an investigator physically takes the license away) until the MAB can review the case. Several meeting attendees stated that in their jurisdictions, they do not immediately suspend a license when a police report is received.
Timeliness of law enforcement reporting is important. In some jurisdictions, the police officer's supervisor must sign off on the law enforcement request for reexamination, which slows down the process and can be problematic when an emergency suspension should have been placed on a driver after the observed event/behavior (e.g., for the dazed, confused, blacked-out conditions).
Law enforcement officers have requested feedback from DMVs regarding the outcomes of police reports to DMVs. One MAB physician said communication between the DMV and the police is importantif law enforcement refers drivers to the DMV, law enforcement deserves to know which drivers are reentering the driving public.
Comments regarding reporting by family members centered on confidentiality issues. Many meeting attendees thought a person should have the right to know who the "accuser" is, so the DMV should not accept anonymous reports or allow reports to remain confidential. In a jurisdiction that favors anonymous/confidential reporting, it was stated that on average, family members have struggled with these decisions for well over a year before they report the driver. When family members begin the struggle with the decision to contact the DMV, the driver is already having some problems. There could be severe consequences to family members for reporting their loved ones if the reports cannot be kept confidential.
Several attendees said investigations could weed out the cases reported anonymously that are not valid. One attendee said that unless a DMV has the resources to put into investigating reports that are not signed, anonymous reports should not be accepted. Although some anonymous reports are legitimate (and would not have been submitted if not confidential for fear of retaliation by the driver), many are submitted by "bad family members" such as angry spouses/ex-spouses trying to get back at each other or greedy children trying to get possession of a parent's car or get them off of the road for other ulterior motives. Investigations to validate claims received a weight in the RVA that placed in the bottom half of the components in terms of importance (rank = 43); however, meeting attendees said follow-up of reporting sources was important. Funding for this activity is a barrier in some jurisdictions.
One attendee responded that her State has a very liberal open-records law, and consequently confidentiality is fraught with problems. In that jurisdiction, drivers can make their Driver Condition and Behavior Reports confidential but have to "jump through a couple of extra hoops" to do that. If an action begins with a confidential Driver Condition and Behavior Report, it can get thrown out if the case goes through a judicial review process, because the DMV, by law, cannot release the information.
Reports by social services agencies did not receive much discussion; however, social workers in a continuing-care retirement community concerned about drivers in that community, are considered an important referral source by at least one jurisdiction present at the meeting.


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1. N.W.A - Efil4zaggin (Ruthless, 1991)
Roc Marciano: I was into this immediately. I was already a fan from Straight Outta Compton so I checked this out as soon as I could. I was still real young then and it was the first album that I remember getting excited to get to the end. It was like an action movie to me. It taught me that you need to entertain throughout the entire duration of an album. "Alwayz Into Somethin" is one of my favorite Dre instrumentals ever. It's ridiculous. And the video of them in the Benz and everything? Wow, it's one of the most smoothest beats but it's also so hard at the same time. The production and the topics it all covered went together so smoothly. It was the first time I really started looking up to Dr. Dre and all the little things he puts into his releases.
2. GZA - Liquid Swords (Geffen, 1995)
Roc Marciano: It's one of my favorite albums and the beats here are some of my favorite ever in all of music - not just rap. It's really is just dope beats and rhymes. I already respected RZA because all those early Wu albums are just genius. And GZA just shows that he took time and studied rapping and just personifies what an emcee is. He didn't just smoke a blunt and write this in an hour. I smoke a lot of blunts so I don't remember exactly where I was or how old I was [when I first heard it], but I know it left an impression on me early on. To me, [Raekwon's] Only Built 4 Cuban Linx is neck-and-neck with this, but at the end of the day, I feel Liquid Swords for whatever reason doesn't get mentioned as much. And how GZA starts off "Duel Of The Iron Mic" is just so visual. It grips you and never lets you go.
3. D'Angelo - Voodoo (Virgin, 2000)
Roc Marciano: [D'Angelo]'s someone I kind of pattern my rap career after. He's a brave artist to me and stands out amongst the crowd. He made R&B that didn't sound like any R&B out at the time. He made stuff that had moments that sounded like it was from my mom's record collection, not from a modern singer. Even though I dig a lot of the tracks, "The Root" is what stands out to me on this one. Cats already sample D'Angelo but I think younger cats will be sampling this album more and more as time goes on for sure.
4. Main Source - Breaking Atoms (Wild Pitch, 1991)
Roc Marciano: There are so many good fucking songs on here. I always really loved "Just a Friendly Game of Baseball" and Large Professor was like a mad scientist. That's why I love it so much, especially how it flows from beginning to end. Large Pro just makes everything come together perfectly and his beats are just so gripping. Hearing Nas on there for the first time ["Live At the Barbeque"] is something I think most listeners would never forget - I mean, I never did. This album introduced so many legendary things to hip-hop but at the time you as the listener didn't know it. That just makes it better to me. It's just truly legendary.
5. The Notorious B.I.G. - Life After Death (Bad Boy, 1997)
Roc Marciano: Man, Biggie had the writing ability of a genius. He could make you feel like death is in the room, like the grim reaper is right next to you. "Long Kiss Goodnight" was produced by RZA too. I mean, Wu-Tang already had the entire East believing in them. They were all over the place and Big just matched the beat so damn great. RZA is a genius beatmaker and talk about rising to the occasion. Big's rhymes on here are ridiculous. What can I say man? Biggie Smalls, the illest!


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|Message view
|« Date » · « Thread »
|« Date » · « Thread »
|Jonathan Ellis <jbel...@gmail.com>
|Re: Thrift out of memory crashes
|Fri, 26 Mar 2010 14:44:23 GMT
The workarounds we can apply at the Cassandra level have too high a cost:benefit ratio. The long term fix is to move to Avro. 2010/3/26 Ted Zlatanov <firstname.lastname@example.com>: > On Fri, 26 Mar 2010 07:48:43 -0500 Jonathan Ellis <firstname.lastname@example.com> wrote: > > JE> 2010/3/26 Ted Zlatanov <email@example.com>: >>> I know this has been discussed in tickets and here previously. I just >>> wanted to comment on it because of the upcoming 0.6 release. >>> >>> In my environment I patch Cassandra to prevent the OOM errors from >>> malformed incoming Thrift data, which as everyone knows let anyone crash >>> the servers hard with a netcat invocation. For those who don't know the >>> story, see https://issues.apache.org/jira/browse/THRIFT-601 >>> >>> I think the OOM guard should be in the Cassandra releases, at least as >>> an option. Just because Thrift doesn't give us airbags doesn't mean we >>> don't need brakes. > > JE> Catching OOME is a bug, not a fix. OOME is the JVM saying "I give up; > JE> you're screwed." The JVM isn't stable anymore. > > I didn't know that, thanks for explaining. I thought the JVM could > recover. > > Can we patch the Thrift-generated Java code, at least, set the read > length, or do something else? I hate to give up on this just because > Thrift is broken (as we've discussed, there's no viable Thrift > replacement yet, and we won't allow users to replace the Thrift API with > their own implementation as I proposed with IPluggableAPI). > > Thanks > Ted > >
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"A Halloween Thriller" Dance Extravaganza hosted by Chita Rivera - New York City Center
Ages: All
Price: Performance-only tickets start at $45
131 West 55 Street - 212-889-0808
New York, NY 10019
Description: Rolex presents Career Transitions For Dancer's 26th Anniversary Jubilee, A HALLOWEEN THRILLER: A Dance Celebration of Ghosts, Ghouls, Vampires & Wilis. The event will be hosted by Tony Award winner Chita Rivera and will kick off with an astonishing performance from Broadway and some of America's greatest dance companies - woven together in a 'spook-tacular' celebration of dance. During the show, Nigel Lythgoe from 'So You Think You Can Dance' will be presented with the Rolex Dance Award and Victor Elmaleh, Chairman and CEO of The World-Wide Group, will receive Career Transition for Dancers? Outstanding Contributions to the World of Dance Award. Following the performance, guests will enjoy a 'Masquerade Supper with the Stars,' a live auction, and dancing 'til the witching hour at The Grand Ballroom at The Hilton New York.


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By Spc. Ian ValleyJuly 28, 2014
FORT HUNTER LIGGETT, Calif. - Medics supporting the Warrior Exercise (WAREX) 91 14-03 stand by on every forward operating base on Fort Hunter Liggett, California, to assist any Soldier who needs medical attention. WAREX 91 14-03 provides training for Army Reserve Soldiers in a tactical environment. Most Army Reserve Soldiers only get this kind of training when they are actually deployed. With this duplication of a war-like environment comes the risk of bodily harm. These medics must be ready to aid any Soldier in need.
"We are not [role] players at all," said Staff Sgt. Joshua Mariconi noncommissioned officer in charge of the medical clinics during WAREX 91 14-03, and assigned to the 7214th Medical Support Unit in Garden Grove, California. "Our primary mission for the WAREX is to provide real-world medical support for the exercise."
Soldier safety is a priority during WAREX; even so, accidents can happen. The medics must be able to treat common injuries that may occur during the exercise.
Mariconi said the biggest concerns are weather-related injuries, sprains, dermatological issues and allergies. For most of these, medication is available in each clinic to treat the Soldiers. Other, more serious injuries must be treated at the medical center on post or a local civilian hospital.
Capt. Qunkiu Yuen, a nurse with the 7214th MSU, and assigned to the FOB Schoonover clinic, says there is a new trend though.
"We are starting to see a lot of upper respiratory infections, mostly due to Soldiers coming from different regions," said Yuen. "They are coming to this dusty area and haven't got used to the environment."
No matter what ailment the Soldier suffers from, the first step in patient care is the initial assessment, said Yuen. Soldiers will fill out information sheets, just as they would in any hospital to better help the medical staff evaluate their health.
After this, a member of the medical staff will interview each patient, said Yuen. The medic will check the patients' basic vital signs, such as blood pressure and temperature.
The medics want to find out what is wrong with the patient and how long have they been in that condition, says Yuen.
"I will follow the medics. They will give me a short synopsis of what's going on with the patient."
The medics will do their best to treat the Soldiers on the FOB, if it is something they can take care of, Yuen says. In other cases, the patient must be taken elsewhere.
Yuen, who is the primary health care provider for FOB Schoonover, has the final say on where patients will be treated.
"For stuff that I can't do here, I will send them forward to the TMC [Troop Medical Clinic] or outside to the hospital," said Yuen.
Although the medics can only help Soldiers with issues within their skillset, Yuen says the medics' job is still very important.
"In the military, most of our medical care on the frontline is medics," said Yuen. "They have a basic education on how to take care of immediate stuff."
This includes controlling bleeding and breathing.
Yuen says patients must be stabilized once in the clinics until they either get flown out of theater or are deemed healthy enough to return to duty.
Sgt. Christopher Price, of the 7214th MSU and the NCOIC of the FOB Milpitas clinic, says that he couldn't do his job successfully without the help of his medical staff.
"They're doing a phenomenal job," said Price.
He says he has seen them grow and be very proactive throughout this exercise. As a leader, he takes pride in the fact that his Soldiers display maturity and discipline.
"I can walk away from my aid station for a few hours, and I wont have any issues," said Price.
Whether going for sick call or needing treatment for an injury during training, all Soldiers participating in WAREX can expect a first-rate level of care and attention from the medical clinics.


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EMOTIONS ran high during a planning meeting at Horwich Town Council.
Residents spoke out against the re-submission of an application for a building on green belt land at Cotswold Drive, Horwich.
The land has previously been described as "similar to a concentration camp" by neighbours.
The applicants, Kevin and Gillian Gaskell, of Pennine Road, Horwich, want to build a portal-framed building for housing livestock, storing agricultural equipment and stabling horses as well as a manege for excercising the horses.
Gillian Gaskell said: "This application is for personal use and is not a commercial venture, we just want to provide a healthy environment for our animals and that allows us to pursue our lifestyle.
"This process has caused us anxiety and distress, particularly with some of the hurtful comments residents have said, like the comparison to a concentration camp."
Several residents spoke out against the plans, John Lawton said: "The applicants priority is their lifestyle but this is about everyone in Horwich, it is bigger than one family, there are open aspects to the land that other people enjoy."
Cllr Richard Silvester criticised the applicants, stating: "What you have done is antagonise residents for no reason, you have already carried out unauthorised work in the green belt and I don't blame these residents for objecting to the plans."
The council voted to recommend that the plans are rejected when they go before Bolton Council's planning committee.


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SALON.COM: Asked why opening up marriage to gay people would threaten Minnesotans, Bachmann responds: "Schools will then be teaching that homosexuality, or lesbianism, or same-sex marriage, or group marriage, or polygamy is normal, natural and maybe kids should try it." [Read more…]
Bachmann Blames "Big Love" For Normalizing Polygamy
July 21, 2011 by
DADT ended, but that doesn't mean same-sex military weddings…
July 8, 2011 by
USA TODAY: "Can military chaplains wed same sex couples in states where such marriages are legal? Yes? No? Not yet? The answer is murky." [Read more…]
Is Polyamory The Next Battle? Archbishop Dolan Thinks So
July 8, 2011 by
WaPo ON FAITH: "New York Archbishop Timothy Dolan says he's worried that the next step in the marriage debate will be another redefinition to allow multiple partners and infidelity." [Read more…]