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Accountable Care Organizations: What Do They Mean for Emergency Medicine? an Information Paper
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1 Accountable Care Organizations: What Do They Mean for Emergency Medicine? an Information Paper Developed by Members of the Emergency Medicine Practice Committee September 2012
3 Background Accountable Care Organizations: What Do They Mean for Emergency Medicine? an Information Paper With the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, the concept of Accountable Care Organizations (ACOs) became a model for the future of American health care. According to the Centers for Medicare and Medicaid Services (CMS), ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients." 1 The goal of an ACO is to create seamless, coordinated care that is intended to result in improvements in quality and cost efficiency by creating incentives for health care providers to work together to treat an individual patient across care settings, from doctor s offices to hospitals to long term care settings. 2 By participating in ACOs, providers of health care services will be better positioned to accept shared savings granted through gainsharing arrangements. The outlined plan calls for a group of health care suppliers and providers to formally apply to CMS for inclusion in the program as an ACO. There are certain features of potential ACOs that must be present in order to be considered for participation. The minimum number of patients covered by the ACO is currently set at 5000 Medicare beneficiaries. 2 ACOs must have invisible enrollment. 3 This means that patients do not have to choose to take part in the ACO and are not formally enrolled. It is the care providers who must meet the guidelines of the ACO, not the patients. Measurement of performance will be a key aspect of ACOs. 3 ACOs will need to meet specific quality, efficiency and patient satisfaction measures established by CMS. Organizations that fail to meet these standards will be disqualified from the third key aspect of ACOs, shared savings. 3 The ACO, if successful in controlling health care costs in comparison to historical controls, will be entitled to share the savings with Medicare (ie, gainsharing). How these financial reimbursements are distributed to health care providers is to be determined by the ACO. ACOs differ significantly from managed care organizations (MCOs) of the past. The responsibility for controlling health care delivery costs in MCOs lay primarily with the insurers themselves. These capitation systems allocated a fixed dollar amount per covered life to cover health care associated costs. Insurers who were able to limit costs by lowering beneficiary utilization were financially rewarded. In addition, in the MCO model, beneficiaries elected to participate in the MCO and abided by the rules set forth by the MCO. ACOs do not require patients to actively enroll in the program, and there is no requirement for patients to stay within the ACO for their care. While ACOs are designed to apply to Medicare patients, almost all payers are now requiring health care providers and suppliers to comply with set quality standards in order to qualify for payment. The Current State of ACOs Prior to the passage of the PPACA legislation, a handful of large integrated health care systems (eg, the Cleveland Clinic, Mayo Clinic, Intermountain Healthcare and Geisinger Health Systems) participated in
4 bundled payment pilot projects for selected disease or elective surgical conditions. 4 Presumably the success of these pilots was the reason for inclusion in the ACA legislation. However, none of these health care systems have chosen to participate in the Pioneer ACO Model, citing concerns about the regulatory burden and requirements that did not impact patient outcomes. 5 In January 2012, 32 ACOs were selected as part of the Pioneer ACO Model by CMS to begin reporting data and quality measures. They include: Allina Hospitals & Clinics Atrius Health Services Banner Health Network Bellin-Thedacare Healthcare Partners Beth Israel Deaconess Physician Organization Bronx Accountable Healthcare Network Brown & Toland Physicians Dartmouth-Hitchcock ACO Eastern Maine Healthcare System Fairview Health Systems Franciscan Health System Genesys PHO Healthcare Partners Medical Group Healthcare Partners of Nevada Heritage California ACO JSA Medical Group, a division of HealthCare Partners Michigan Pioneer ACO Monarch Healthcare Mount Auburn Cambridge Independent Practice Association North Texas Specialty Physicians OSF Healthcare System Park Nicollet Health Services Partners Healthcare Physician Health Partners Presbyterian Healthcare Services Central New Mexico Pioneer ACO Primecare Medical Network Renaissance Medical Management Company Seton Health Alliance Sharp Healthcare System Steward Health Care System TriHealth, Inc. University of Michigan To be eligible, organizations must provide services based via one of the following models: 3 providers in group practice arrangements, networks of individual practices of providers, partnerships or joint venture arrangements between hospitals and provider groups, hospitals employing providers, or Federally Qualified Health Centers (FQHC).
5 Additional requirements include: Participants must have a minimum number of 15,000 beneficiaries who must be enrolled in traditional Medicare (not Medicare Advantage plans); rural programs require only 5,000. Participating organizations must obtain 50% or more of their revenue from other payers, such as commercial insurers, employers or Medicaid. By the end of the second year of the program, the Pioneer ACOs will have to demonstrate similar cost savings with these payers. Participating ACOs that demonstrate cost savings in the first two years can then proceed to a bundled payment model. This is a per-beneficiary per-month payment intended to replace the fee-for-service (FFS) model. 6 By the end of year 2012, 50% or more of primary care providers in the ACO will have to attest that they have met requirements for meaningful use of electronic health records in order to receive further payment. 7 From a quality perspective, the participating ACO will be monitored under the same quality measures as the Medicare Shared Savings Program. The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by: Promoting accountability for the care of Medicare FFS beneficiaries Requiring coordinated care for all services provided under Medicare FFS Encouraging investment in infrastructure and redesigned care processes So how are they doing so far? Some ACOs have pointed out the importance of open communication with employees in their system about how health care delivery is changing, the eventual evolution of payment models, and the role of ACOs. 8 Other ACOs report that so far most of the advances have been operational, including programs for the elderly and developing nursing programs within the community. The most optimistic feel it will be many months before they are ready to see the results of their work. 9 In the first four months of 2012, the initial participating ACOs combined with Medicare Shared Savings Programs have achieved a 3% Medicare market share, representing more than 1.1 million Medicare beneficiaries. 10 In a recent article in the New England Journal of Medicine, authors surmise that because of geographic variations in spending growth, Medicare's use of national growth factors to set spending targets could cause ACOs in a particular hospital referral region to gain or lose financially without changing anything in the way they deliver care. Using data estimates from Dartmouth Atlas for each hospital referral region of the 32 Pioneer ACOs, they found that ACOs in low growth, low spending areas had the greatest advantage and those in high growth high spending area the least. The amount that could be gained or lost from the two groups varied by as much as 14% in their model. 11 As ACOs mature, many questions remain. Will there be enough cost savings to the organization to make the upfront expenses of starting an ACO viable? Which ACO model works best, ie, physician practice model, hospital based model, or an insurance carrier model? Will monitoring and reporting of stated quality indicators be onerous and restrictive to the way physicians wish to practice? Will patient care be improved? Will necessary testing be limited? Will patients like the concept or will it be so seamless that they are wholly unaware that they are even participating? And finally, where does emergency medicine fit into the model?
6 Potential Impact on Emergency Medicine By virtue of its prominence at the beginning of the cycle of care, it is difficult to imagine emergency medicine not playing a central role in the success of ACOs. However, the exact details of how the emergency department (ED) will operate within an ACO or in partnership with an ACO is speculative at this point. Emergency medicine has thus far received scant attention in both the initial guidelines for ACOs set forth in the PPACA as well as the final regulations released by the Department of Health and Human Services in October The effect ACOs could have on emergency care has yet to be determined. There are several broad areas to consider: utilization of emergency services, coordination of care, implementation and adherence to quality metrics and provision of mandated services, and the financial impact on emergency medicine. Emergency Care Utilization One important question to be addressed is whether the ascendancy of the ACO model will challenge the prudent layperson standard in which the patient determines what a medical emergency is. ACOs are often heralded as a mechanism through which unnecessary or inappropriate ED visits could be minimized. The implication is that within an ACOs bundled payment structure, financial incentives are such that patients may be directed towards alternative sites of care if the condition is deemed to be nonemergent. However, it remains unclear who will make this determination and what barriers patients who seek emergency care will face either directly or indirectly. A further question is whether this will conflict with the federal mandate to provide care under EMTALA. Care Coordination Coordination of care with primary providers will be an important component of working with or within an ACO. On the front end, triage systems will take on greater importance. Call centers or other services such as telemedicine are opportunities for growth and a potential role for emergency medicine. Likely, there will continue to be growth in alternative sites of care such as urgent care, fast-track units, freestanding EDs, retail minute clinics, etc. However, the challenge will not only be to provide timely and consistent care (particularly during weekends and evenings), but also to ensure that these services are well-integrated with each other and within the ACO. Of particular importance will be investment in information technology infrastructure in order to improve care coordination. Unfortunately, this may raise the upfront cost of establishing or participating in an ACO. Ultimately, in order to improve care coordination, emergency medicine may need to diversify the options available for management of patients evaluated in the ED who are not admitted as inpatients. Observation units are a promising area for growth, as are ED-run follow-up clinics and follow-up call centers staffed by physician assistants, nurse practitioners, or nurses. Home health services represent another opportunity for emergency medicine to improve transitions of care. EDs will most likely have to devote more resources to case management to coordinate referrals to rehab and skilled nursing facilities (SNFs), visiting nurse services, and other outpatient management tools and services such as Holter monitors or peripherally inserted central catheter (PICC) lines. Emergency medicine and ACO administrators will
7 need to coordinate efforts to identify additional opportunities for improving the value of care provided. For example, consideration should be given to lobbying CMS to exempt ACOs from the long-held requirement that Medicare beneficiaries be admitted to the hospital for a minimum of three days before they can be admitted to a SNF. There is reason for optimism that emergency medicine can rise to the challenge of integrating itself successfully within a broader system. Elliot Fisher has cited the success of emergency medicine in helping establish networks of regional trauma centers as well as working in close partnership with state and local EMS providers. 12 Another area in which EDs have begun to show dramatic ability to improve care management and control effective resource utilization is in the creation of community care plans. Many EDs have a small group of patients who constitute a disproportionate percentage of their ED visits and who could, through proper medical management in partnership with local community providers, be better managed with lower resource utilization. ED groups across the country have begun developing care plan programs, often with noticeable success when measured by decreased ED utilization and decreased medical costs. 13,14 Another potential area for ED involvement is in creation of accepted community standards of care. Patients with certain medical conditions (eg, COPD, CHF, cellulitis) tend to have recurrent exacerbations of their conditions that lead to frequent ED utilization. By working with ACOs to determine goals of ED care, including alternatives to admission such as observation admissions or next day community followup plans, EDs may be able to provide just as good, if not potentially better care at a much lower cost. Quality Indicators Improving health care delivery is a driver of ACO development. As quality indicators for care delivery are being developed, the measures used to evaluate care delivered within an ACO (including within the ED) have yet to be determined. For example, the role of emergency care in the acute management of a chronic disease episode has not been clearly defined. The exacerbation of chronic disease is often seen by payment policymakers as a potentially avoidable complication, 4 and the care delivered to these patients in the ED has yet to be valued appropriately. In addition, as payment policies increase pressures to decrease hospital re-admissions, there will likely be strong incentives to avoid or delay hospital admissions. How will this affect ED operations, as emergency physicians are often the decision makers regarding hospital admission? Furthermore, there may be different perceptions of risk among the physician groups that have a stake in the patient s cycle of care. Will the financial risk of failing to meet targets be spread evenly across groups within the ACO? What about the medico-legal liability of inappropriate or adverse disposition decisions -- will this also be shared across the ACO? What role will patients themselves and their families have in these disposition decisions? These are critical questions that must be addressed going forward. Another important consideration is the concept of ED mission-creep and the potential expectation that EDs provide a panoply of mandated screening, counseling and education to ED patients. Many such targets (such as depression screening, aspirin use and tobacco counseling) are perhaps best suited to the
8 primary care setting, as inclusion in the ED visit may undermine the ability of the ED to effectively carry out its core mission. Measured discussion regarding any such proposed ED requirements is essential. Financial Impact on Emergency Medicine There has long been a consensus that value-based and bundled purchases of medical care hold much promise in controlling costs and delivering better quality care. 15 However, important questions remain about how shared savings (and losses) will be distributed across the ACO, specifically with regards to the ED. The main body of experience with population-based, bundled payment emergency care comes from the pre-paid health care models of the late 1980s and 1990s. Unfortunately, much of this experience is unlikely to be directly applicable to ACO design since pre-paid care was based on a narrowly defined, risk-adjusted patient population while an ACOs patient population isn t known until after the measurement period. Pre-paid care also restricted the patient to a narrow choice of providers while ACOs must allow the patient to see any provider he or she wishes. Nevertheless, the pre-paid capitation model is the closest example available to assist in defining the value of emergency care in a bundled payment model, and should be examined when considering how emergency medicine might fare in an ACO model. A typical cost breakdown of a pre-paid managed care model for physician services included 23% of premium allocated to primary care, 56% to specialists (including EM), 14% to ancillary services and 7% to administration. 16 Individual per-member per-month capitation rates were calculated according to the following formula: (Per Member Utilization Rate x Fee for Service Rate)/12. The pre-paid capitation model valued all emergency care services, both facility and professional components, at something less than 4% of premium cost. 17 Emergency physician per-member per-month payments ranged between $0.44 and $1.50 with facility payments making up the balance of the 4% at an assumed utilization rate of 0.37 visits per member per year. 17 To calculate the appropriate capitation amounts today one would need to adjust for inflation, the current utilization rate and the increase in average emergency physician compensation. In an ACO model, age, risk and out-of-network adjustments would have to be made after the fact because it is only then that the measurement population is known. Given the potential variation and numerous unknown factors, accurately forecasting the financial impact on emergency medicine is difficult at best. Beyond calculating the value of emergency medicine within an ACO model, consideration must also be given to the impact of ACOs on ED utilization and revenue generation. Emergency medicine is a flowbased business and if decreasing ED utilization is a consequence of the ACO model, there are likely to be important financial repercussions for emergency medicine. Will reduced volume necessarily lead to a decrease in revenues? Will shared savings from participation within an ACO make up some of this difference? An interesting possibility is that the acuity mix may shift towards sicker patients and perhaps result in higher average margins for the ED that may partially offset the reduced volume. Finally, the concomitant introduction of expanded insurance coverage through provisions of the ACA may actually lead to an increase in national ED volume. The overall financial impact on emergency medicine is therefore uncertain at this point.
9 Another challenge to consider will be how emergency groups will exist within the ownership and management structure of an ACO. Large hospital groups and integrated health systems are better organized and capitalized and therefore have a substantial advantage in forming and financing the transition to ACO. However, many emergency physicians are not hospital employees, but work for smaller independent practice groups that contract with hospitals. They may have limited leverage, both financially and with regards to governance, to become full partners within an ACO. Preserving the autonomy of these smaller practices as they attempt to integrate with larger hospital-owned practices will be a major challenge going forward. Recommendations We believe that emergency medicine groups must be at the table with their hospital and health care system during the design and implementation of an ACO strategy. Failure to actively participate as these programs are organized could have dire consequences for emergency medicine, as ED care is almost reflexively viewed as a high-cost service that should be limited. In addition, ACOs are uncharted territory, so there is ample opportunity for the emergency physicians to mold the program to better suit the needs of their patients and their groups. When considering participation in an ACO, emergency medicine groups should pay particular attention to the following: Patient diagnoses and clinical metrics that indicate the need for care. A complete picture of the patient s total health care experience, including clinical records, claims data, and information gathered from and shared with other area providers Comprehensive health plan and provider performance data. Payer analysis across various patient populations Accounting and allocation of all revenue as directed by the ACO reimbursement model. On a broader scale, as emergency medicine navigates through the development and implementation of ACOs, leaders must remain mindful of the myriad potential effects on the specialty, including alteration in the utilization of emergency services, creation of new opportunities for care coordination, introduction of new measures of quality, and the emergence of additional threats to revenue generation. Whether ACOs will achieve their shared savings objectives or become the dominant medical services delivery model of the future remains to be seen. The impact ACOs will have on emergency medicine is similarly difficult to predict. However, active participation in development projects helps to ensure that emergency care will be maximally valued within these new care delivery systems. Created by members of the ACEP Emergency Medicine Practice Committee June 2012 William P. Jaquis, MD, FACEP, Chair EMPC Heather L. Farley, MD, FACEP, Subcommittee Chair James M. Cusick, MD, FACEP Laurence R. DesRochers, MD, FACEP
10 Enrique R. Enguidanos, MD, FACEP Daniel Freess, MD Azita Hamedani, MD, MPH, FACEP Ronald A. Hellstern, MD, FACEP Shkelzen Hoxhaj, MD, MPH, MBA, FACEP Michael H. Lee, MD (EMRA) Howard K. Mell, MD, MPH, FACEP Andrew S. Nugent, MD, FACEP Jennifer L. Wiler, MD, MBA, FACEP Michael J. Zappa, MD, FACEP Leslie Zun, MD, FACEP Margaret Montgomery, RN, MSN, Staff Liaison References 1. Centers for Medicare and Medicaid Services. Accountable Care Organizations. April 5, https://www.cms.gov/medicare/medicare-fee-for-service- Payment/ACO/index.html?redirect=/ACO/. 2. U.S. Department of Health and Human Services. Accountable Care Organizations: Improving Care Coordination for People with Medicare. (Fact Sheet) March 31, HealthCare.gov. 3. Medicare Shared Savings Program: Accountable Care Organizations. 76 Federal Register 212 (2 Nov 2011), pp Wiler JL, Beck D, Asplin BR, et al. Episodes of care: is emergency medicine ready? Ann Emerg Med. 2012; 59(5): Pipes SC. Just Say No to ACOs. February 23, Wilson County News. 6. Centers for Medicare and Medicaid Services. Pioneer Accountable Care Organization Model: General Fact Sheet. December 19, Healthcare reform is here, like it or not. February 15, Kolbasuk-McGee, Marianne. Information Week. 8. Johnson C. Pioneer ACO Update: Q&A with Health IT Leaders from Eastern Maine Healthcare System. February 7, Cheung KM. Why Atrius Health signed up and future plans. February 24, Fierce Healthcare Daily newsletter. 10. MSSP's Initial 27 Applicants Draw Cautious Optimism, Show Variety of Approaches. May 7,2012. Business Daily, Volume 3 Issue McWilliams JM, Song Z. Implications for ACOs of variations in spending growth. N Engl J Med. 2012; 366(19):e Interview in: Berger E. Emergency physicians face uncertainty in accountable care organizations. Ann Emerg Med. 2011; 5: 3A-15A. 13. Michelen W, Martinez J, Lee A, et al. Reducing frequent flyer emergency department visits. J Health Care Poor Underserved. 2006; 17(1):S Henry Ford Health System. Social factors, 'super users' and urban emergency departments. ScienceDaily. June 3, Retrieved June 5, 2012, from 15. Porter M, Teisberg E. Redefining Health Care: Creating Value Based Competition on Results, Harvard Business School Publishing Kullman S. Capitation is for Specialists, Not Primary Care Physicians. Managed Care. April Stapczynski JS. Capitation for emergency physicians. Ann Emerg Med. 1996; 27(4):
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text: Konjou Akira was getting his weak keyster kiccked by my VAnessa . He was down 2 rounds ,2 zip. So what doe he do? He uses Akira's Ten foot toss and jab jab jab juggles me out the ring. Then he does it again the first chance he gets. He's is a cheap scrub. He was desperate for a win. So that basically mean if it was a high fence arena, he would have lost. Here'sthe match in question  here's my REVENGE

subset: commoncrawl


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Beauty is your duty
May 8th, 2005
Dr Petra
Today is the 50th Anniversary of VE (Victory in Europe) day – a time to remember all those who served in WWII, and those who lost loved ones, or whose lives were shattered by war.
To mark the occasion, I thought I'd take a trip back in time, and look at what I'd be doing as an Agony Aunt in the 1940s.
I'd be advising young women to keep smiling. Telling them 'beauty is your duty', to make do and mend, and to do their bit for their country and their family. I'd be offering advice to women who had lost loved ones, or who would be caring for a husband or relative invalided out of the war. I'd also be asked how to cope with separation – a separation marked by the fear of never seeing a partner again. Things like jealousy, dealing with the temptation of pre or extra marital sex, venereal disease (which I'd have called 'VD') and pregnancy would have also featured in my postbag.
Overall my message would be one of advising women to be brave and not complain about their lot, whilst supporting our boys at the front.
Just because there was a war on didn't mean personal problems weren't an issue. In fact because there was a war on, relationship problems were a major difficulty for many men and women.
Here are a few examples of problems and replies sent to Agony Aunts in the 1940s (courtesy of 'Women in Wartime' by Jane Waller and Michael Vaughan Rees, Macdonald Optima).
Next Leave
'My husband has just been on leave; for 5 months I have had a baby tying me hand and foot. Now my husband has gone back bad friends with me because I told him he ought to get up and light the fire; he even asked me to clean his army boots for him, which is a job no woman should be asked to do. He will be home again in 3 months; how can I make him see his duty?'
'How can I make you see yours? How are you, in comparative peace and comfort, wanting him to wait on you hand and foot when he gets a much needed rest! You ought to be ashamed of yourself, my dear. Next leave, show how pleased you are to have him home again. It would be very nice if you gave him his breakfast in bed. Make every moment one of gladness that he can look back on happily for months to come' (Woman's Own, 4 January 1941).
Don't tell yet
'My husband is a prisoner of war, and I was dreadfully depressed and lonely until I met two allied officers who were very sweet to me. Now I realise that I am going to have a baby, and I don't know which is the father. My husband is shortly to be repatriated, and I don't know how to tell him'
'It is very difficult for me to advise you. I appreciate the loneliness and depression you were suffering, but that you could do such a thing – and with two men – passes my comprehension. But now the main thing to do is to avoid hurting him, isn't it? I advise you, as soon as you know he has reached the country, to write to the matron of the hospital, or the commander of the next camp to which he is sent, tell them the whole truth, and ask them how you can arrange some way of not seeing him until your condition is not apparent. Wait until his health is better before you tell him the truth. It might be the finish of everything for him if he knew it now' (Woman's Own, 10 December, 1943).
Goodnight kiss
'My friend and I go to dances where there are a lot of very nice Americans. They see us home and want to kiss me goodnight. We told them that girls here think it is cheap to kiss on such a slight acquaintance, and they seem really hurt, saying that in the States boys always kiss girls goodnight. We don't want to hurt them, but what do we do?'
'Well, I think they should take your explanation, and will probably like and respect you all the more for your exclusiveness. If you liked to be kissed there's no harm in it, provided you don't let the boys get silly and excited about you' (Woman's Own, 24 March, 1943).
Some things have changed a lot. Relationships advisors, 50 years after WWII are now expected to celebrate sexual difference and relationship diversity. Some things have changed for the better. Agony Aunts are expected to be more evidence-based and less judgemental, and can address issues like abortion, contraception, or pre and extra marital sex. Some things remain a problem including sexually transmitted diseases, jealousy and domestic violence. But looking at that last letter above, it seems like some things haven't changed at all.Tweet
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Kathleen Shaffer / firstname.lastname@example.com / (470) 388-6170
Vegas, by popular demand, a new Hot Dog on a Stick® has come to town! On Friday, Feb. 3, the beloved all-American brand, will celebrate the grand opening of its
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*Offer is valid on Friday, February 3 for one free original turkey Hot Dog on a Stick.
About Hot Dog on a Stick® - www.hotdogonastick.com
Established in 1946 in Southern California, Hot Dog on a Stick is known for its fresh, made-to-order hot dog on a stick and cheese on a stick products,
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quick service restaurant experience, catering services for events, party packs, and fundraisers. Hot Dog on a Stick has close to 100 locations in the U.S.
and internationally including Korea. Connect with us on Facebook, Twitter and Instagram.


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This attractive 15-story hotel opened in late 2009, and the new-car smell has yet to dissipate. Set amid the shops and restaurants that surround the Texas Tech campus, the Overton's location is ideal for visitors to the university. Cutting-edge technology and 20,000 square feet of meeting and ballroom space make the hotel's conference center popular for Texas-size business gatherings and weddings.
Star Rating
With soft leather headboards and chairs, earth-tone fabrics, and quirky Texas artwork, the Overton's 303 guest rooms and suites interpret the South Plains landscape in a warm and welcoming style. Lubbock may be cowboy country, but the roomy walk-in showers, fluffy towels, and plentiful pillows ensure you won't mistake this hotel for a bunkhouse.
West Texas soul, big-city style
Preferred Level guests stay on the top three floors and enjoy a bit of pampering with complimentary breakfast buffet, evening reception, and turndown service that includes a plate of cookies on your nightstand.
Innovation is big at the Pecan Grill: think crème brulee French toast for breakfast, chipotle corn pancakes layered with roasted pulled pork for lunch, and slow-smoked baby back ribs with warm potato salad for dinner. Follow with a cocktail and live music in the cheerful lounge.
Sports fans couldn't find a better place to stay in West Texas, with the Jones AT&T Stadium and United Spirit Arena right across the street.
Within 10 minutes of Lubbock Preston Smith International Airport, and a brief stroll away from Texas Tech University.


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Chatham Tourism & Travel Guide
Trips and Itineraries for Chatham Islands Territory
8 Days
16.2k Views
Adventures in New Zealand
My journey to New Zealand started in the Bay of Islands, made up of 144 small islands which provide calm waters and sandy, golden beaches....
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8 Days
18.4k Views
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New Zealand tourism is slowly evolving, yet there is so much in this country that is yet untouched....
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Top Places To Visit in Chatham Islands Territory 1 Spots
Waitangi Wharf - Owenga Rd
Waitangi Wharf - Owenga Rd, Chatham Islands, New Zealand
From Kerikeri, I took a Boat Cruise through the Bay of Islands to Waitangi Wharf. The cruising boat is a totally unique way to experience New Zealand's world famous Bay of Islands with the Northland landscapes and marine environment. I enjoyed some kayaking with the on board kayaks and also went for some snorkelling! After spending the day on the cruise and Waitangi Wharf I went back to Kauri Cliffs.
Chatham Islands Territory


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Leading producer and owner of Gemini Film Circuit, A Ravi Shankar Prasad who had gone missing from a hotel in Yanam is found dead. Police found his decomposed body in Gogula Lanka village near east Godavari district of Andhra Pradesh.
Ravi Shankar Prasad was the grandson of renowned film producer L V Prasad, and he had gone for a morning walk from the Anand Regency Hotel on July 8 at 3am. A 'man missing' complaint was filed later by his family. Earlier, police were suspecting it to be a case of kidnapping and even investigated the family if they had received a ranson call, but now they are not ruling out the possibility of suicide.
"The businesses he had set up recently were running in losses. The high-end film processing business and the recently started Rs. 20 crore dairy farm in Yanam incurred losses. He was under lot of mental agony due to heavy losses," added the police official.
Ravi, the managing director of the Gemini Film Circuit, Anand Cine Services and Anand Regency Group, was said to be in debts, but friends and relatives said he wouldn't have committed suicide. "He had been in touch with all of us till last Sunday," said Ravi's sister Mano Akkineni. "He sounded normal."
Ravi Shankar has produced big-budget films like Shankar Dada MBBS, Mayakkam Enna and Nanban. He is survived by his wife and two daughters.
Industry sources said Ravi's companies ran into crores of debt, but he had enough properties to protect himself from a great fall. His death, hence, has shocked many and as a note of respect to him, FEFSI has announced a one-day cancellation of all shoots in Tamil today.


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Bluenest It Solutions
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Wanted Mechanical Trainee in Ernakulam Area ( 0 - 1 yrs)
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Housekeeping Executive ( 0 - 3 yrs)
RS 2,00,000 To 3,50,000 Kochi
We are searching for Housekeeping Executive to join our team(Five star Hotel). Responsible and accountable for maintaining and proper cleaning of rooms and appointments of guest rooms and public areas under his/ her control. Looking for the one who e...
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Wanted Site Supervisor in Aluva, Ernakulam Area ( Fresher)
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We Wanted Site Supervisor in Aluva, Ernakulam Area.
Key Skills : site supervisor,civil engineer,civil draftsman
Mechanical Graduate Engineer ( 0 - 4 yrs)
Power Group India Ltd
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Accommodations in SchwerinSee All
A place in Germany, Schwerin is an interesting place to visit, given its unique culture, history and character. When planning a trip to Schwerin, make sure you visit its near-by prime city of Hamburg. Take a short trip from Schwerin and set some time aside to explore the Hamburg. Dotted with places like St Michaels Church, Planten Un Blomen, Speicherstadt; it will definitely be a good idea. Also, to reach Schwerin, you'll have to take a flight to Hamburg; so its not really a detour. And even if it is, the city is worth paying at least a quick visit. To explore Schwerin, set aside 1 to 2 number of your days. You'll be coming back for more!
Don't just take a trip, let the trip take you! Have a enjoyable time at Schwerin.
Explore the best journey planner for your visit to Schwerin and create a flawless plan in few simple steps!


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|2007–08 Boston College Eagles
| National Champions
Hockey East Tournament Champions
Beanpot Champions
|NCAA Championship Game, W 4-1 vs. Notre Dame
Hockey East Championship, W 4-0 vs. Vermont
Beanpot Championship, W 6-5 (OT) vs. Harvard
|4th Hockey East
|USA Today/USA Hockey Magazine
|USCHO.com/CBS College Sports
|2007–08 Record
|Home Record
|Road Record
|Neutral Record
|Head Coach
|Jerry York
|Mike Brennan
|Kelley Rink
| Seasons
For previous season, see 2006–07 Boston College Eagles men's ice hockey season
For next season, see 2008–09 Boston College Eagles men's ice hockey season
The 2007-2008 Boston College Eagles men's ice hockey team represented Boston College in the 2007-2008 college hockey season. The team was coached by Jerry York, '67, his fourteenth season behind the bench at Boston College. The Eagles played their home games at Kelley Rink on the campus of Boston College, and competed in Hockey East.
Having lost in the previous season's national championship to Michigan State, Boston College made its third consecutive appearance in the title game and defeated Notre Dame 4-1 in the 2010 Frozen Four Championship Game, earning the school's third national championship and first since 2001. The Eagles defeated Minnesota and Miami (OH) in the Northeast Regional in Worcester, earning them a berth in the Frozen Four to be played at the Pepsi Center in Denver. BC defeated North Dakota 6-1 in the national semifinal before taking on the Irish in championship game.
The Eagles finished fourth in the 2007-2008 Hockey East Regular Season, which was good enough for the last home-ice spot in the Hockey East playoffs. After sweeping the quarterfinal series against Providence, the Eagles met regular-season champion New Hampshire in the conference semifinals. After trailing early on, the Eagles mounted a come back and eventually beat UNH on a Benn Ferriero goal early in the third overtime. BC went on to defeat Vermont in the championship game 4-0 for the school's eighth Hockey East tournament championship.
BC also won the 56th Annual Beanpot Tournament. After defeating defending champions Boston University 4-3 in overtime thanks to a Nathan Gerbe goal, the Eagles went on to defeat Harvard 6-5 in overtime on a goal by freshman defenseman Nick Petrecki. This was BC's 14th Beanpot title and first since 2004.
Junior forward Nathan Gerbe, who led the nation in scoring, narrowly missed out on winning the Hobey Baker Award. Gerbe was however named US Hockey National Player of the Year, and also earned NCAA Tournament Most Outstanding Player and Hockey East Tournament Most Valuable Player honors.
Boston College added five freshmen for the 2007-2008 season, including one defenseman, two forwards, and two goalies.
|John Muse
|United States
|East Falmouth, MA; Earned US Hockey Report Goaltender of the Year honors as a senior at Nobles.
|Joe Whitney
|United States
|Reading, MA; Gained All-NESPAC East honors as a junior at Lawrence Academy.
|Brian Gibbons
|United States
|Braintree, MA; Earned All-Founder's League first-team honors as senior center at Salisbury in 2006-07.
|Nick Petrecki
|United States
|Clifton Park, NY; Selected 28th overall by SJS in 2007 draft.
|Andrew Margolin
|United States
|Mahwah, NJ; Two-time Founder's League All-Star.
2007-2008 RosterEdit
Departures from 2006-2007 TeamEdit
2007-2008 EaglesEdit
Awards and honorsEdit
|Hockey East
Men: Boston College |
Boston University |
Maine |
Merrimack |
New Hampshire |
Northeastern |
Providence |
UMass |
UMass-Lowell |
|This page uses content from Wikipedia. The original article was at 2007–08 Boston College Eagles men's ice hockey season. The list of authors can be seen in the page history. As with Ice Hockey Wiki, the text of Wikipedia is available under the Creative Commons Attribution-Share Alike License 3.0 (Unported) (CC-BY-SA).


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French Determined To Keep D-Day Memories Alive
The small villages in Normandy have a long tradition of honoring the American, British and Canadian soldiers who fought and died on the D-Day beaches in 1944. As the generation who witnessed those landings dies out, the French are determined the next generation will continue that tradition.
SCOTT SIMON, host:
All week the seaside villages along the Normandy coast have been celebrating the D-Day anniversary. This year's occasion is seen as especially important because it may be one of the last times that living witnesses of D-Day will take part in commemorations.
Eleanor Beardsley sends this report.
(Soundbite of the ocean)
ELEANOR BEARDSLEY: In the tiny village of Ville-Sur-Mer, hundreds of people are gathered on the boardwalk along Omaha Beach to listen to the memories of American veterans who fought here. In former years, dozens of veterans took part in ceremonies like this one. Today, there are only a handful.
Mr. HAROLD BAUMGARTEN(ph): My name is Harold Baumgarten. I'm from Jacksonville Beach, Florida. And this was the smallest but most heavily defended part of Omaha Beach. It was portrayed in two motions pictures - "The Longest Day" and "Saving Private Ryan" - and I was there.
BEARDSLEY: While a D-Day anniversary is about remembering, it's also clearly about having a good time.
(Soundbite of music)
BEARDSLEY: For the last week, World War II buffs, old car fans, and men who just want to play soldier have poured into Normandy from across Europe and North America. The usually quiet villages above the landing beaches have the atmosphere of a country fair. Antique dealers trade in World War II paraphernalia and people tool around in World War II-era vehicles.
Planes fly overhead. The whole scene has the feel of a Hollywood set with everyone dressed to play a part.
(Soundbite of laughter)
BEARDSLEY: A group of English people in full battle regalia picnics in the grass on the side of the road. Bill Betts(ph) of North Hamptonshire shows off his ambulance.
Mr. BILL BETTS: The World War II American ambulance - a Dodge, 1943 - and I restored it all myself to get it here this weekend. And this is with stretchers in the back and with a first aid kit.
(Soundbite of bells)
BEARDSLEY: But behind the gaiety here there is also a sense of urgency to hear from those who experienced this historical invasion, whether as soldiers or civilians.
In the village of St. Laurent(ph) Sur-Mer on Omaha Beach, there are only a few elders left who witnessed the invasion. Today, these octogenarians lead a walking tour through the village while they tell their story. Dozens of people have shown up to follow and listen, including parents who want their children to know what happened here.
Eighty-seven-year-old Andre Laroute(ph) was 22 years old in June 1944. He remembers that everyone was anxious for the Americans to arrive after four long years of German occupation.
Mr. ANDRE LAROUTE: (Through translator) And we kept wondering why are they taking so long, but then when we saw the massive amounts of material and equipment they brought, we understood. It was staggering, unthinkable. You have to remember, at that time there were only two cars in the village.
BEARDSLEY: Since that day, St Laurent Sur-Mer has welcomed Americans back with open arms.
Unidentified Man #2: (French spoken)
Unidentified Woman #1: (French spoken)
BEARDSLEY: Two of those Americans are 87-year-old Edward and Jean Tierney(ph), who met here while serving as a pilot and a nurse. They have come back to 15 D-Day celebrations in St. Laurent Sur-Mer. Today they're being honored with a ceremony high on a bluff where their air strip used to be.
Mr. EDWARD TIERNEY (WWII Veteran): Remembering those flights coming in over that ravine, landing on this field - it's always a wonderful experience to be back here. It's a very significant spot for us in our lives. You speak.
Mr. JEAN TIERNEY (WWII Nurse): It's too emotional.
Mr. TIERNEY: Too emotional.
Unidentified Woman #2 (Mayor): (French spoken)
BEARDSLEY: The mayor thanks Edward and Jean for their courage. Then, standing side-by-side, they lay a wreath at the foot of the new monument in the middle of wheat fields looking over a vast blue sea.
(Soundbite of "The Star-Spangled Banner")
BEARDSLEY: As the Stars and Stripes is hoisted, "The Star-Spangled Banner" drifts out over Omaha Beach.
For NPR News, I'm Eleanor Beardsley in Normandy, France.
Copyright © 2009 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.
NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR's programming is the audio record.


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text:
The next thing Simon knew was a vague feeling of floating. This went on for a while, from what he remembered – but for how long, he was later unable to recollect.
Just as he was later unable to remember how exactly he came to find himself in an atmosphered airlock, fully spacesuited, looking at the boots of the merc he knew he both distrusted and hated.
But find himself thus he did. In an airlock, he soon discovered, that was one of the many carried by the Alliance HQ.
At the moment of waking however, Simon was both disorientated and wary. Blinking quickly, he groggily raised his eyes to look more closely at his companion. Jayne was standing, already half out of his suit, his eyes peeringkeenly through the internal airlock door.
His hands were quickly unwrapping Vera from the rucksack that he carried. Checking her. Loading. Looking for men to shoot.
It soon dawned on Simon where they were. They were in. Somehow, they had made it into the station. "What the hell…" murmured the Doctor, his voice barely audible through his suit's helmet visor, "happened…?"
Jayne's eyes flitted from the door window to Simon, to Vera, and then back. " I tell y'what happened, you ruttin' dumbass," he growled, a hint of amusement in his voice, " I saved y'gorram sorry-ass life. How's that for smarts?"
At which point Simon soon regained his composure, pulled off his helmet, and raised himself to his feet. All the time asking the merc how they had managed to escape, what the hell happened...how?
"S'easy," the big man finally retorted, as he packed his suit tightly into the bag from which he had previously hidden his gun, "No easier way to get a man offa your back than make out he killed y'already. I knew they'd gorram blast us once they saw who we were on the monitor. Afterall -who needs the brother and some other sommbitch when they've got the main prize already? That is, the..girl. So I figured, let 'em blast us, think us dead, while we make with the escapin' - jus' before the artillery hits home."
Simon stood for a moment, uncomprehending. But slowly, as the realisation of what had just happened infiltrated his mind, his jaw dropped. Slowly, a dull rage moved into his eyes.
"You mean – your whole plan – was based on – a hunch?" he spat. "The whole 'breaking and entering' – on a guess they wouldn't capture us, but rather kill us?"
Jayne looked at the airlock window one last time, before once again flitting his eyes toward the younger man. There was a look of defiance in his eyes as he replied: "Pretty much. Problem?"
He reached into his jacket pocket again to nonchalantly pull out another cigar."I mean, afterall, we are on the gorram station ain't we?We just jumped offa the shuttle and floated away to the nearest airlock hatch. And so far, no gorram purplebelly's come lookin'." Jayne smiled. His mind was already searching for the girl. "I'd say we pulled it off."
Simon could hardly believe it. He'd put his faith in this man to survive, to get them on board. But not with such a risk. Such disregard for what could have so easily happened. Them, being boarded, taken prisoner – killed. Where would that have left River?
"How could you be so – stupid?" he barked, unable to rein back his true feelings. And then – perhaps due to the relief, or the tension - Simon vocalised the question he had for so long decided to avoid.
"Why the hell are you here anyway? Why do you want to help my sister at all?"
Almost instantly, Jayne's eyes levelled themselves directly at the Doctor.
"Whaadya mean?" he asked, threateningly. But despite himself, there was a hint of something else in his voice. Something that Simon – at least subconsciously – now recognised.
"No, Jayne - I'm asking the questions." The younger man was also now stripping off his suit, as he also searched for the pistol that he had previously pushed into the back of his pants. His mind knew that they needed to move, get started. But his heart was still recovering from the shock of what had just happened. It needed answers, answers he realised he had been reticent to ask before, for fear of what the merc may have done.
Now - at that moment - he didn't care.
"Why are you here anyway?" spat Simon. "It's not as if you give a damn what happens to either of us anyway. It was fair enough when you helped me get this far, to get her back. But that last stunt – that wasn't the act of a man helping. That was the act of a man desperate. Or stupid. What's it all for?"
Jayne looked down at his feet. He had been all ready to start up, out of the airlock, start firing. Not talking. So he was totally caught off guard by the Doctor's sudden, emotional attack. There was enough already to deal with. This was a conversation he didn't want at the best of times, let alone now.
In any normal circumstance, he would have simply laughed. Perhaps allowed himself to strike the younger man. But somehow, the Doctor's words had struck a chord within him, touched on an emerging vulnerability yet explored. A chord which now made him feel as if he needed to offer an explanation.
"Well, maybe I felt bad, y'know, 'bout Ariel," he murmured, lamely. "Maybe I felt like helpin'."
As he said it however, he knew it didn't ring true. He tried again.
"I mean, I gotta idea what the girl copes with…."
Simon's eyes widened. "You think you have an idea of what she copes with?" His voice was incredulous. "Do you realise, that without me, she has no one? And without her – I have no one either? We're both – alone."
Jayne shifted uncomfortably in his boots. "Look, not that we got time for this ruttin' gosa, but you do got them fancy parents o' yours..."
"Those 'fancy parents' to whom you allude - gave up on me the day I decided to come for River. No doubt they're still under the illusion she's still studying at the Academy. Imagining the real use of the word – not the 'studying' that involves cutting into her brain over and over again, until she.."
"Okay, Doc, get the picture." The merc shook his head angrily. He knew well enough what she had been though. It just wasn't his style to dwell on it. I mean, she had seemed happy enough - when she had been screwing him. He lived for the moment, afterall.
"Do you, though Jayne? Do you? You say to me now you're sorry, but are you really - for what you tried to do?"
The younger man took a step forward. "You tried to hand her over. Despite the fact you saw as clearly as I did what they did do her.What sort of man would want to hand us back."
Again, Jayne felt another surge of anger. He had acted wrongly, then, he knew. But only because he hadn't realised until then what a cat she was. How gorram gorgeously her legs fitted around his waist.
"Well, hell, that was before I got to know her some…"
Again, Simon looked incredulous. "But you've barely spoken to her. Which is why I still can't figure out why you're here at all. You don't do things for people. Especially not those who don't pay you or you don't know."
The mercenary knew that already he should have stopped talking. Afterall, it wasn't for this man to know why he was here. But somehow, the fact that this man was questioning him - his actions, his intentions - was irritating him. Worse, he was talking about something he knew nothing about. Treating him like gosa, when the fact was that his sister had been coming to him for weeks to get her thrills.
So he growled menacingly as he replied: "I speak to her some! Just not with the words. With the eyes."
He had meant to unsettle Simon, to somehow hint that perhaps he did not know his sister as well as he thought. But the tone at which he had actually said the words had come out wrong. Rather than sounding sly, he had sounded defensive. Partly because, as he said it, he realised how true that had been, back on the ship.
He missed her body, yes. But he also did miss those big dark eyes.
Simon failed to hear the glaring admittal in Jayne's words however. Instead, he snapped: "Really. What on earth would she say to someone like you. Besides – A is for apple…B is for.."
"Careful." Jayne also now stepped up toward the younger man, his hand gripped tightly around his gun."You don't know everything she does. She's said stuff to me."
Jayne thought of the time he had last slept with her, in his bunk. How she had pushed her hands across his naked chest, her fingers gripping the hair as she had come. But then afterwards, how she had smiled. Her face like a bright light in hisdark, empty room.
His voice lowered as he murmured: "She looks me in the eyes. You don't know nuthin'."
And then, almost meekly: "Now let's just stop this gorram waste o' time and get goin'."
Simon meanwhile, hesitated. He was beginning to regain his composure. And because of this, finally he had noted the tone of voice that had begun to creep into Jayne's words. And it had begun to register that something, somehow, was amiss. Jayne's strange selfless actions. His foolhardy plan to get into the space station. And now, some kind of attempt to argue that he had a connection with a woman Simon knew was many, many times his intellectual superior.
This is strange, he thought. Jayne is fighting me, but not. It's almost as if - he trying to tell me...
Slowly, realisation dawned across his face. His jaw dropped.
"Have you got some kind of crush on her?" he asked, letting out a small, slightly hysterical, laugh."Is this what this is all about?"
Now it was Jayne's turn for his eyes to widen."No. Gorram it. I don't get gorram crushes," But as he said it, he knew then and there that somehow, somewhere, a sort of truth had just been spoken. The realisation unsettled him - and Jayne hated being unsettled. His eyes darkened.
Angrily, he barked: "I kill people."
"I know you do," Simon laughed. "But you still do have a crush on her. I can see it now. It's so obvious, if sickening. This isn't about money. Because it's about your sad and pathetic attempt to get something nice and clean - to care for a filthy dog like you."
Jayne's head started to whirr. Up until this point, everything had been so clear. He was going to come on board, find her, escape - so he could fuck her again. But now, although he couldn't deny the strong physical urge he had for her - he knew also in his heart that there was another driver also at play.Something else was driving him to find her, something unfamiliar.Something he did not want to think about.
So he growled: "Shut UP."
But Simon was on a roll. He sensed he had hit on a vulnerability."Do you think this will impress her? Because when we come though that door there's only going to be one of us who she runs for, Jayne. Me."
Again, the merc growled: "So what?" But his eyes spoke a different story.
"Yes, go on, Convince yourself. But you know it's true. It's why you hated that fact Kaylee likes me. Because you know, no woman in their right mind would ever come for you. Not unless," Simon added, "You paid them."
Finally, it was too much. Jayne had heard enough.
"I fucked her," he muttered.
"I've been fucking your sister for weeks. And she's ruttin' loved it."


text: About Smurfing time (Curse you Teletoon Retro). Finally we get to see why Leonardo was the most dangerous of the TMNT. And finally get to see Leonardo Kill The Shredder. ((This won't be a kid fridendly comic either if they really digging into the TMNT orgions.. yayyy)) A little research, the right actors, and old school can bring back any comic book charater. How else do you explain how sucessful Batman Begains and Batman Dark Knight was. Take note


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Spencer Koehler
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About Spencer Koehler
I am a full-cycle Software Engineer and Information Sciences Researcher with a strong background in applied mathematics and statistics specializing in innovative solutions to difficult real world problems using Artificial Intelligence algorithms and techniques.
My interests include Natural Language Processing; Knowledge Representation; Machine Learning; Information Extraction, Retrieval, Classification, and Summarization; Question Answering; Data Mining; Search; Expert Systems; Parallel Distributed Processing; Computational Linguistics.
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Ready 03/19/2015. What beautiful creamy blond girls in this roly-poly litter of F1B goldendoodle pups, they are gorgeous. They have have black nose and pads, beautiful, healthy, pretty color. They are funny little pups. The whole litter looks great, developing right on schedule, growing just a little and getting bigger every day. Eyes are bright, bellies look good, they are toddling around with each other, still figuring things out when it comes to play, but that is normal at this age. Their dam standard poodle Angelica is a great mom to her pups, taking great care of them. They are still mainly dependent on her but soon weaning and getting ready for their own new homes toward the last part of March. Both ICA registered first generation doodle sire Cooper and AKC registered dam Angelina stand 21" and weigh about 45 pounds, so nice medium sized dogs. Angelina is a good mom, sweet dog, is taking good care of her pups who are chubby 6.5 week olds, wiggly and clean and well tended. Charming and adorable, a more non-shedding breed of pooch with a fun, playful and gentle disposition. 7% Ind sales tax charged. ICA registration 12 month health warranty. Dewclaws removed. She will be to date on shots, wormed, weaned and will have a good healthy puppy vet check to go to her new home. We advocate spay/neuter for the best health and behavior of your dog. Email or call me for more pictures, or to arrange a viewing. MORE INFO: You have 3 working days to have your own vet look them over and "give them a clean bill of health". IF there are unknown health issues at that check we refund the purchase price. If shipping pup comes with a vet checked health certificate. We are not responsible for and do not cover vet costs, shipping expenses or anything beyond the cost of the puppy. We deal in quality puppies, honestly & with integrity. We would love to help you find the right pet for your family. Email me for complete details on shipping and deposits. I sometimes have trouble W/ My Emails, either getting them or you receiving on your end, so feel free to call Me At 574-825-9836 or my cell 260-350-3264 Shipping Details: The best option is for you to personally pick up your new pup, but if necessary: we can deliver or arrange to meet buyer within 100 miles of Middlebury, In. Buyer pays additional $100. Barring summer heat restrictions in the extremely hot parts of the country, we can also ship on American, Delta or Continental Airlines in the continental US (This is subject to which airports these carriers do fly into, and have cargo hubs that handle live animals. I cannot fly into airports that may be closer to you if they do not accept animals) for an additional $350 at 8-10 weeks. This price would include everything needed including kennel & vet check with health certificate. I will also fly into Canada or Alaska if you live near enough to a major airport. Charges will vary according to duties & fees. Some restrictions apply during excessive cold and heat for the health of the pup. Payment Method : I am willing to work with people, but I find the following to be viable forms of payment: 1) Cash if you are personally picking your pup up. 2) A personal check that clears my bank before taking possession of the pup. 3)A POSTAL money order as they are trackable for both of us. 4) Paypal happily accepted but add 3.7% on to the total for handling fees 5) CVS or Wal-mart money gram 6) CredIt Card (small fee, have a paypal swiper) 7) Bank Wire transfer. Whatever method you use must clear prior to taking possession of puppy.