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Health plans participating in the Medicare managed care program, now called Medicare Advantage, have historically attracted healthier enrollees than the traditional fee-for-service program. Medicare Advantage plans have gained financially from this favorable risk selection because until recently Medicare payments to plans were adjusted only minimally for the clinical characteristics of enrollees, such that payments systematically exceeded costs for healthier enrollees and were systematically lower than costs for sicker enrollees. To address favorable selection in Medicare Advantage, a new risk-adjustment system adjusting plan payments for clinical diagnoses was phased in from 2004 to 2007. Also, a lock-in provision was instituted in 2006 and strengthened in 2007 to limit midyear disenrollment by Medicare Advantage enrollees, particularly those experiencing health declines whose disenrollment could benefit plans financially. To determine if these reforms were associated with intended reductions in favorable selection in Medicare Advantage, we compared self-reported utilization and health for Medicare Advantage vs. traditional Medicare beneficiaries and for those who switched into or out of Medicare Advantage vs. non-switchers both before and after these reforms were implemented. In 2001-2003, differences in utilization and health between these groups suggested favorable selection in Medicare Advantage. By 2006-2007, however, most differences were substantially narrowed, indicating reduced selection. For example, Medicare Advantage enrollees reported 17.7% lower utilization than traditional Medicare enrollees in 2001-2003 but 8.1% lower in 2006-2007. Similar risk-adjustment methods may help may help mitigate incentives for Accountable Care Organizations participating in the Medicare Shared Savings Program and plans competing in health insurance exchanges to select patients with favorable clinical risks.
Managed care plans in the Medicare Advantage program receive prospective, or capitated, payments from Medicare that are determined from spending predictions for each enrollee. Medicare Advantage plans therefore have financial incentives to enroll and retain beneficiaries whose actual medical costs are lower than their predicted costs and avoid beneficiaries whose actual costs exceed predictions. Before 2004, prediction models used by Medicare adjusted per-enrollee payments for some demographic factors but only minimally for clinical diagnoses such as diabetes or ischemic heart disease. Consequently, incentives for plans to enroll healthy and avoid chronically ill beneficiaries were large. With these incentives at work, new enrollees in Medicare managed care plans in the 1980s and 1990s were less costly prior to enrollment than demographically similar beneficiaries who remained in traditional fee-for-service Medicare.1-8 Similarly, beneficiaries who disenrolled from managed care plans into traditional Medicare were often costlier after disenrollment than other traditional Medicare beneficiaries.1,2,6-8
Because enrollment and retention of beneficiaries with favorable health risks (favorable risk selection) contributes to overpayments to Medicare Advantage plans9,10 and may weaken plan competition based on quality and costs of care, a new risk-adjustment system was mandated in the Balanced Budget Act of 1997 and phased in from 2004 to 2007. The new Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model adjusts payments to Medicare Advantage plans for clinical diagnoses determined from inpatient and outpatient encounters as well as for demographic factors.11 Specifically, the model includes 70 HCC categories, each defined by a single condition or combination of conditions, and each condition defined by sets of diagnostic codes. For each Medicare Advantage enrollee in a given year, the model uses diagnostic information from the prior year to calculate a summary risk score proportional to the spending predicted by the enrollee's conditions. This risk score is then applied to an administratively set benchmark payment rate to risk-adjust payment for the enrollee.
An enrollment lock-in was also instituted, prohibiting Medicare Advantage enrollees from disenrolling during the second half of 2006 and the last 9 months of the year starting in 2007. Medicare Advantage enrollees had been previously free to disenroll on a monthly basis, allowing plans to benefit financially from midyear disenrollment by enrollees experiencing health declines.
The HCC model will be used to risk-adjust spending targets for Accountable Care Organizations in the Medicare Shared Savings Program, and similar methods will be used to risk-adjust plan revenues in health insurance exchanges.12,13 The potential benefits of exchanges and Accountable Care Organizations could be undermined if plans and provider organizations avoid chronically ill and costly patients for whom these reforms were intended to improve coverage and care. The performance of the HCC risk-adjustment system is therefore an important determinant of success not only of the Medicare Advantage program but also of these key programs established by the Affordable Care Act. The effectiveness of risk adjustment in reducing favorable risk selection in Medicare Advantage, however, remains unclear.
Risk-adjusting Medicare Advantage payments for clinical conditions could reduce favorable selection in Medicare Advantage through a variety of mechanisms. In response to lower payments for patients with lower predicted costs (lower HCC risk scores), Medicare Advantage plans might devote fewer resources to marketing efforts to attract beneficiaries with favorable health risks. Higher payments for patients with higher predicted costs could lead plans to reconfigure provider networks and redesign benefits in ways that attract more chronically ill beneficiaries – for example by increasing access to specialists, offering preferred provider organization (PPO) options with greater choice of physicians, providing disease management services, and aligning cost sharing and drug formularies with the needs of medically complex patients. Recognizing these enhancements, chronically ill beneficiaries might become more willing to forego unrestricted access to providers and unmanaged care in traditional Medicare in exchange for extra benefits offered by Medicare Advantage plans, such as lower premiums, less cost sharing, or additional covered services. The enrollment lock-in could additionally contribute to greater retention of Medicare Advantage enrollees in poor health, who might otherwise disenroll into traditional Medicare to have free choice of specialists and hospitals.
To determine if the implementation of the HCC model and the enrollment lock-in were associated with reduced favorable selection in Medicare Advantage, we used nationally representative data from the Medicare Current Beneficiary Survey to conduct several "stock and flow" analyses of Medicare Advantage and traditional Medicare enrollees. We estimated changes from 2001-2003 to 2006-2007 in differences in health care utilization and health status between beneficiaries who enrolled in or disenrolled from Medicare Advantage (flow) and those who did not (stock). We similarly examined how differences in utilization and health between all Medicare Advantage and traditional Medicare enrollees changed over these years.
We analyzed longitudinal survey and enrollment data for elderly community-dwelling Medicare beneficiaries from the 2001-2007 Medicare Current Beneficiary Survey Cost and Use files, available for up to 3 years for each participant. We excluded certain groups of participants from our main analyses for reasons described in the appendix.14 In a sensitivity analysis, we also excluded beneficiaries dually eligible for Medicare and Medicaid because they are exempt from the enrollment lock-in. Our study was approved by the Harvard Medical School Committee on Human Studies and the CMS Privacy Board.
Using monthly Medicare enrollment information starting in 2000, for each year from 2001-2007 we determined which participants switched from traditional Medicare to Medicare Advantage as of January or later in the year (new Medicare Advantage enrollees). Because enrollment information in December of the preceding year was required to determine if Medicare Advantage enrollment in January constituted a switch, we restricted analyses focused on new Medicare Advantage enrollees to participants' second and third years in the survey. We similarly identified participants who switched from traditional Medicare to Medicare Advantage during the year or effective January of the subsequent year (Medicare Advantage disenrollees).
In surveys, participants reported their use of medical care every 4 months by type of service: hospitalizations, emergency room visits, outpatient department visits, medical provider events, and prescription drug fills. To improve the accuracy of these self-reports, survey participants were instructed to record service use on a calendar and retain statements, receipts, prescription drug containers and other documentation related to their medical care.
We constructed a summary measure of total utilization equal to a weighted sum of annual utilization counts across service types. Service-specific weights were equal to the average additional traditional Medicare spending associated with an additional service event, as estimated by fitting a regression model predicting total traditional Medicare spending (assessed from claims) as a function of the set of self-reported utilization counts. All self-reported utilization counts significantly predicted traditional Medicare spending.
In addition to total utilization, we present analyses of annual hospitalization counts and prescription drug fills, components that reflect acute and chronic illness burden, respectively. We also analyzed annual self-reports of general health status and change in health, both as continuous variables and indicators of fair/poor or somewhat/much worse health. We describe in the appendix several methodological advantages of self-reported over administrative data for analyses of risk selection and why we would not expect reporting errors to bias our results.14
We compared new Medicare Advantage enrollees with beneficiaries staying in traditional Medicare (traditional Medicare stayers) and with those already in Medicare Advantage (Medicare Advantage incumbents). Similarly, we compared Medicare Advantage disenrollees with traditional Medicare incumbents and with Medicare Advantage stayers. Finally, we compared all Medicare Advantage enrollees (including new enrollees) with all traditional Medicare enrollees (including Medicare Advantage disenrollees). Exhibit 1 summarizes these comparisons and comparison groups.
We compared differences in self-reported utilization and health between these groups over three time periods: 2001-2003, 2004-2005, and 2006-2007. We divided the phase-in of the HCC system into two periods to assess gradual changes in risk selection, as HCC risk scores received steadily increasing weight in payment calculations from 30% in 2004 to 50% in 2005 to 75% in 2006 to 100% in 2007. To provide readily interpretable results, we present differences in utilization in relative terms (reported in Exhibits as relative utilization (RU)).
We compared new Medicare Advantage enrollees with both traditional Medicare stayers and Medicare Advantage incumbents to bound estimates of risk selection. Comparisons with incumbent Medicare Advantage enrollees may have underestimated favorable risk selection, because incumbent enrollees may have remained less costly than traditional Medicare beneficiaries indefinitely, as a consequence of their initially favorable health risks. Conversely, comparisons with traditional Medicare beneficiaries may have overestimated favorable risk selection because utilization in traditional Medicare was not influenced by care management strategies employed by Medicare Advantage plans to control utilization and improve quality of care.
To conduct stock and flow comparisons, we fitted regression models predicting utilization or health as a function of comparison groups, time periods, and interactions between the two. To control for geographic variation in utilization, we included survey primary sampling units in models (a set of metropolitan statistical areas or clusters of non-metropolitan counties consistently sampled over the study period). All analyses were adjusted for the complex survey design.14
For each Medicare Advantage enrollee since 2006, the Medicare Current Beneficiary Survey has included the capitated payment to the enrollee's plan, adjusted for the enrollee's county of residence, demographic factors (age, gender, disability status, and Medicaid eligibility), and diagnostic information included in the HCC model. Enrollee-specific capitated payments to Medicare Advantage plans are calculated by multiplying county-specific benchmark rates by enrollees' demographic factors and individual HCC risk scores, modified somewhat by plan bids relative to benchmark rates.15 Thus, to obtain individual risk scores for Medicare Advantage enrollees in 2006-2007 that approximated payment adjustments for demographic and diagnostic information, we divided capitation payments by county benchmark rates available from the CMS.16
For the years 2006-2007, we adjusted comparisons between new and incumbent Medicare Advantage enrollees and between Medicare Advantage disenrollees and Medicare Advantage stayers for these individual risk scores. Although we could not calculate comparable risk scores for traditional Medicare enrollees, these adjusted comparisons nevertheless addressed two important questions. First, we tested a previous study's conclusion that Medicare Advantage plans responded to the HCC risk-adjustment model by more intensively selecting favorable risks within HCC categories.17 If this were the case, controlling for risk scores would lower estimates of relative utilization for new vs. incumbent Medicare Advantage enrollees. Second, the adjustment allowed us to quantify remaining differences in 2006-2007 between new and incumbent enrollees and between disenrollees and stayers in Medicare Advantage that were not explained by the new risk-adjustment system.
As detailed in the appendix,14 several contemporaneous changes to the Medicare Advantage program from 2004 to 2007 also may have affected risk selection. Most notably, increases in benchmark payment rates during these years encouraged insurers to compete for enrollees by offering more generous benefits, lower premiums, less cost sharing, and broader provider networks. The Medicare Advantage program expanded as a result. In particular, private fee-for-service plans grew rapidly after 2005, offering similar or better coverage at a lower out-of-pocket cost (including premiums) than the combination of traditional Medicare plus supplemental Medigap insurance, on average, and with little restriction of provider choice.18 These enhanced offerings may have attracted beneficiaries with greater medical needs, or with some skew toward healthier beneficiaries if those with cognitive deficits were less able to recognize the advantages.18
To determine if changes in risk selection were related to increases in benchmark rates, we compared results for study participants living in counties where the benchmark rate increase from 2004 to 2007 was higher vs. lower than the median increase among all U.S. counties.16
Because we could not observe Medicare Advantage plan choices made by participants, we could not perform a sensitivity analysis excluding private fee-for-service enrollees. Instead, we conducted a separate supplementary analysis using 20% Medicare claims files and information on Medicare Advantage plan type from the Enrollment Database to determine if our results could be explained by growth of private fee-for-service plans. Specifically, we compared HCC risk scores and total annual non-drug medical spending in 2005 and 2006 for traditional Medicare beneficiaries who switched into private fee-for-service Medicare Advantage plans in the subsequent year (2006 or 2007) vs. those who switched into HMO or PPO plans. We adjusted these supplementary analyses for county fixed effects and applied the same inclusion criteria used in our main analyses of Medicare Current Beneficiary Survey data.
As described in the appendix Exhibit,14 annual rates of new enrollment in Medicare Advantage progressively rose during the study period from 0.8% in 2001-2003 to 6.3% in 2006-2007, while rates of disenrollment from Medicare Advantage progressively fell from 9.8% to 3.1%.
Exhibit 2 presents differences in self-reported utilization and health between new Medicare Advantage enrollees and traditional Medicare stayers, differences between new and incumbent Medicare Advantage enrollees, and changes in these differences over the study period. Compared with traditional Medicare stayers, new Medicare Advantage enrollees reported significantly lower total utilization and fewer hospitalizations and prescription drug fills in 2001-2003 but not in 2006-2007, as these differences were significantly and progressively narrowed or reversed. New Medicare Advantage enrollees also reported significantly better general health than traditional Medicare stayers in 2001-2003 but not in 2006-2007. Differences between new and incumbent Medicare Advantage enrollees in these utilization and health measures in 2001-2003 were similarly reduced, although some differences in 2001-2003 and reductions by 2006-2007 did not reach statistical significance.
Exhibit 3 presents differences in self-reported utilization and health between Medicare Advantage disenrollees and traditional Medicare incumbents, differences between disenrollees and Medicare Advantage stayers, and changes in these differences over the study period. Relative to both comparison groups, Medicare Advantage disenrollees reported higher total utilization and more hospitalizations and prescription drug fills in 2006-2007 but not in 2001-2003. Disenrollees were also more likely to report their health was fair or poor and somewhat or much worse in 2006-2007 but not in 2001-2003. Most of these differences widened significantly over the study period. Results were similar after Medicaid recipients were excluded (data not shown).
Comparisons of all Medicare Advantage enrollees with all traditional Medicare enrollees quantified the net effects of increasing enrollment rates, decreasing disenrollment rates, and changes in the relative health risks of new Medicare Advantage enrollees and Medicare Advantage disenrollees. As displayed in Exhibit 4, Medicare Advantage enrollees reported significantly lower utilization and better health than traditional Medicare enrollees across all measures in 2001-2003. Most of these differences were substantially reduced by 2006-2007, consistent with net reductions in favorable selection.
Risk scores calculated from capitation payments for Medicare Advantage enrollees strongly predicted self-reported utilization and health. For example, mean total utilization for enrollees in the highest decile of risk scores was 330% greater than for those in the lowest decile. The percentage of Medicare Advantage enrollees reporting fair or poor health rose progressively from 6.6% in the lowest decile to 45.0% in the highest decile of risk scores (data not shown in Exhibits).
After adjustment for these risk scores, differences in utilization and health in 2006-2007 between Medicare Advantage disenrollees and Medicare Advantage stayers were consistently but not completely reduced. Adjusted relative utilization in 2006-2007 (data not shown in Exhibits) was 1.35 for total utilization (P=0.05 for test of relative utilization=1.0), 1.46 for hospitalizations (P=0.046), and 1.16 for prescription drug fills (P=0.13), and the adjusted difference in general health scores was 0.17 (P=0.18 for test of health score difference=0). Differences in utilization and health in 2006-2007 between new and incumbent Medicare Advantage enrollees were not appreciably altered by adjustment for these risk scores (e.g. adjusted relative utilization for total utilization: 1.03; P=0.81).
Exhibit 5 provides stratified results for participants living in counties with 2004-2007 payment increases above or below the median 3-year increase of 23.2%. On average, monthly payments increased by $154 up to 128% of traditional Medicare spending in high-increase counties over this period, and by $117 up to 110% of traditional Medicare spending in low-increase counties. As expected, Medicare Advantage enrollment in the study sample grew more in counties with high payment rate increases (+7.5 percentage points) than in counties with low increases (+4.2) over these years. Likewise, private fee-for-service enrollment increased more in high-increase counties (+4.6 percentage points) than in low-increase counties (+2.0). Key results from stock and flow comparisons, however, did not statistically differ by county payment rate increases. Unexpectedly, changes suggestive of reduced favorable selection into Medicare Advantage were statistically significant for low-increase counties but not high-increase counties.
In supplementary analyses of Medicare claims, differences in HCC scores and spending in 2005-2006 for traditional Medicare beneficiaries subsequently switching into private fee-for-service vs. HMO or PPO plans were small and opposite in direction (mean risk score difference: −0.013 or 1.3% lower for private fee-for-service enrollees; mean annual spending difference: +$52 or 0.9% higher for private fee-for-service enrollees). Thus, health risks of new private fee-for-service enrollees were similar to health risks of other new Medicare Advantage enrollees during these years, implying risk selection in private fee-for-service was similar to risk selection in other plans through 2007.
In this nationally representative study of elderly Medicare beneficiaries, differences in health care utilization and health status between new Medicare Advantage enrollees and other beneficiaries, and between all Medicare Advantage and traditional Medicare enrollees, were substantially narrowed from 2001-2003 to 2006-2007. Thus, improved risk adjustment of capitated payments and an enrollment lock-in were associated with reduced selection of beneficiaries with favorable health risks into Medicare Advantage.
One recent study, comparing Medicare spending for traditional Medicare beneficiaries who enrolled in Medicare Advantage in the following year versus those who did not, found, like our study, that differences in HCC risk scores significantly narrowed between comparison groups after 2003. Surprisingly, however, differences in Medicare spending significantly widened when risk scores were held constant.17 This latter finding implies Medicare Advantage plans responded to new risk-adjusted payments by selecting favorable clinical risks within subgroups of beneficiaries with similar HCC risk scores to an extent equal to or greater than was achievable before 2004 across groups with different risk scores. Our findings also suggest that favorable risk selection present before 20041-8,19-21 was subsequently reduced. In contrast to this other study, however, our risk-adjusted comparisons of new vs. incumbent Medicare Advantage enrollees did not reveal favorable selection in 2006-2007 within subgroups with similar risk scores.
We also found that the implementation of the HCC risk-adjustment model and enrollment lock-in were associated with lower rates of disenrollment from Medicare Advantage, but that in more recent years those disenrolling were substantially more likely to report health declines than other beneficiaries. The disenrollment of increasingly sick and costly enrollees was not explained by the exemption of Medicaid-eligible beneficiaries from the enrollment lock-in. A potential explanation for this finding is that some Medicare Advantage enrollees experiencing sudden health declines continued to switch into traditional Medicare (outside the lock-in period in concurrent or subsequent year) to have unrestricted access to medical services and providers to address their new health needs. As disenrollment rates fell, this group may have constituted an increasing fraction of disenrollees. Withdrawal of Medicare Advantage plans from markets in 2001-2003, a period of program contraction, may have also contributed to this finding by causing involuntary disenrollment of healthier enrollees in the baseline period relative to later periods. We were not able to discern reasons for disenrollment.
Differences in utilization and health in 2006-2007 between Medicare Advantage disenrollees and Medicare Advantage stayers were only partially explained by the HCC model, suggesting that HCC-adjusted payments for these disenrollees may have been lower than their costs had they remained enrolled. Thus, disenrollment by particularly costly beneficiaries may benefit Medicare Advantage plans financially. Although our findings for disenrollees suggest more clinically detailed risk adjustment could strengthen incentives for plans to retain particularly sick enrollees, features of managed care in Medicare Advantage (e.g. restricted provider networks and utilization management) may continue to prompt their disenrollment.
Nevertheless, changes in utilization and health differences between all Medicare Advantage and traditional Medicare enrollees indicated net reductions in favorable selection by 2006-2007, despite the disenrollment of increasingly costly enrollees and their designation as traditional Medicare beneficiaries in these comparisons. Due to unmeasured differences in coverage and care management between Medicare Advantage and traditional Medicare and a lack of comparable risk scores for Medicare Advantage and traditional Medicare enrollees, we could not precisely quantify the net amount of remaining risk selection that was unexplained by the HCC model.
Our study had several other limitations. Because the implementation of the HCC risk-adjustment system and enrollment lock-in overlapped in 2006-2007, we could not distinguish effects of these two reforms on risk selection. While the enrollment lock-in may have affected risk selection by limiting disenrollment, it did not likely attract less healthy beneficiaries into Medicare Advantage. Rather, the lock-in might have dissuaded chronically ill beneficiaries from enrolling in Medicare Advantage if they valued the option of switching to traditional Medicare in the event of a health decline.
Moreover, we could not distinguish effects of improved risk adjustment and the lock-in from potential effects of other contemporaneous changes in the Medicare Advantage program. Nonetheless, our supplementary analyses of Medicare claims described above and stratified analyses summarized in Exhibit 5 provide little empirical evidence that reductions in favorable selection into Medicare Advantage were explained by increases in benchmark payment rates, expansion of the Medicare Advantage program, or growth of private fee-for-service plans. We could not, however, entirely reject these trends as contributing factors to our findings. In particular, although reductions in favorable selection were not larger (and may have been smaller) in counties with higher payment rate increases, we could not definitively attribute results to the effects of risk adjustment because payment rates were increased in all counties concurrently with the implementation of the HCC model.
Overall our findings are encouraging for the success of key provisions in the Affordable Care Act, as they suggest that currently available risk-adjustment methods may help mitigate incentives for Accountable Care Organizations in the Shared Savings Program and for plans competing in health insurance exchanges to select patients with favorable clinical risks. Risk selection could be less problematic for exchanges and the Shared Savings Program than it has been for the Medicare Advantage program, because exchange plans and Accountable Care Organizations will be less variable with respect to provider choice. In contrast to differences between Medicare Advantage and traditional Medicare, all exchange plans will have restricted provider networks. Traditional Medicare beneficiaries assigned to Accountable Care Organizations will continue to have unrestricted access to providers, regardless of their assignment. Therefore, if favorable risk selection into Medicare Advantage has been driven in part by stark differences in provider choice between Medicare Advantage and traditional Medicare, it may be less pronounced in these other settings. Consequently, risk-adjustment methods similar to those used in Medicare Advantage may more fully address risk selection in exchanges and the Shared Savings Program.
On the other hand, inadequate risk adjustment would likely cause greater instability in exchange markets than in Medicare Advantage because there will be no option analogous to traditional Medicare that can withstand adverse risk selection without exiting the market. Under an individual mandate, the enrollment of healthy individuals by some exchange plans would mean the enrollment of less healthy individuals by others. Inadequate risk adjustment could lead to competition among exchange plans to attract and retain healthy enrollees, and to the withdrawal of undercompensated plans. Although our findings are encouraging, it remains to be seen if a risk-adjustment system similar to the HCC model will be sufficient to prevent such wasteful competition in exchanges.
In summary, adjustment of capitated payments for clinical diagnoses and an enrollment lock-in have been associated with reduced selection of less costly and healthier beneficiaries into private plans in Medicare. Similar risk adjustment of prospective or global payments may help address risk selection arising from other payment and insurance market reforms.
Supported by grants from the Beeson Career Development Award Program (National Institute on Aging K08 AG038354 and the American Federation for Aging Research) and from the National Institute on Aging (P01 AG032952)
We excluded participants in their first year of Medicare eligibility because the survey collects limited data on new beneficiaries and because Medicare does not adjust Medicare Advantage payments for new beneficiaries by the HCC model due to a lack of prior diagnostic information. We also excluded participants with end-stage renal disease and those residing in long-term care facilities because of low rates of Medicare Advantage enrollment among these groups. In a sensitivity analysis, we excluded beneficiaries dually eligible for Medicare and Medicaid because they are exempt from the enrollment lock-in and because they accounted for most of the growth in Medicare Advantage special needs plan enrollment during the study period.
Of 71,316 person-years of survey data for elderly Medicare beneficiaries from 2001 to 2007, we excluded 3,397(4.8%) for participants in their first year of Medicare eligibility, 450(0.6%) for those with end-stage renal disease, 4,861(6.8%) for those residing in long-term care facilities, and 155(0.2%) for those who both switched into and out of Medicare Advantage in the same year.
Comparisons of self-reports to Medicare claims suggest Medicare Current Beneficiary Survey participants significantly underreport use of medical services in general and hospitalizations to a lesser extent.1 Self-reported utilization counts were strong predictors of Medicare spending determined from claims, however, and we would not expect reporting errors to have changed systematically over the study period by Medicare Advantage enrollment in a manner that would bias our results.
Moreover, by providing information on Medicare Advantage enrollees and consistent measures of utilization and health across Medicare Advantage and traditional Medicare, the survey data supported several comparisons not feasible in previous studies of traditional Medicare claims. In particular, because we could assess utilization and health following Medicare Advantage enrollment or preceding disenrollment, our comparisons were less subject to bias from regression to the mean than analyses of traditional Medicare claims preceding Medicare Advantage enrollment or following disenrollment.2,3 Risk differences between new Medicare Advantage enrollees and beneficiaries remaining in traditional Medicare likely overstate favorable selection when ascertained from preceding claims, as these differences are likely to diminish somewhat after Medicare Advantage enrollment due to random changes in health (assuming Medicare Advantage enrollment is a marker of good health at the time). Finally, compared with risk scores derived from traditional Medicare claims or Medicare Advantage encounter data, self-reported measures of health and utilization are less affected by incentives under the HCC system for Medicare Advantage plans to code diagnoses more intensively.
To conduct stock and flow comparisons, we fitted regression models predicting utilization or health as a function of comparison groups, time periods, and interactions between the two. To improve model fit and provide more interpretable results in terms of relative differences in utilization (reported as relative utilization (RU)), we modeled utilization counts using generalized linear models with a log link and proportional-to-mean variance function. We used linear and logistic regression to model health scores and binary health indicators, respectively. To control for geographic variation in utilization, we included MCBS primary sampling units in models (a set of metropolitan statistical areas or clusters of non-metropolitan counties consistently sampled over the study period).
We adjusted all analyses for the complex survey design using STATA, version 11.2 (StataCorp LP, College Station, TX). We used robust design-based variance estimators to account for geographic clustering and repeated measures when calculating 2-sided P values and constructing 95% confidence intervals.
Several contemporaneous changes to the Medicare Advantage program from 2004 to 2007 also may have affected risk selection and thus the results of stock and flow comparisons. The Medicare Modernization Act of 2003 changed the formula for setting county-specific benchmark rates, leading to substantial increases in payments to Medicare Advantage plans for all enrollees. These payment increases encouraged insurers to compete for enrollees by offering more generous benefits, lower premiums, less cost sharing, and broader provider networks. The Medicare Advantage program expanded as a result.
In particular, private fee-for-service plans grew rapidly in 2006 and 2007 as a result of the payment increases coupled with an earlier provision authorizing private fee-for-service plans to pay traditional Medicare fees to providers who accepted Medicare patients, rather than pay potentially higher fees negotiated by providers.4 Although prohibited from medical management strategies employed by health maintenance organization (HMO) and PPO plans to lower costs, the high payments and ability to impose traditional Medicare fees on providers allowed private fee-for-service plans, too, to offer similar or better coverage at a lower out-of-pocket cost (including premiums), on average, than the combination of traditional Medicare plus supplemental Medigap insurance.5 Furthermore, because private fee-for-service plans were not required to establish provider networks until 2011, they offered these advantages to beneficiaries with little restriction of provider choice.
These enhanced offerings in Medicare Advantage may have attracted beneficiaries with greater medical needs, or with some skew toward healthier beneficiaries if those with cognitive deficits were less able to recognize the advantages.5 Therefore, both improved risk adjustment and higher benchmark payment rates may have affected risk selection through changes in Medicare Advantage plan features. We explored these competing explanations in our analyses, as described in the Methods.
The implementation of the Medicare Part D prescription drug benefit in 2006 also may have affected beneficiaries' decisions to enroll in Medicare Advantage or traditional Medicare. The effect of Part D on risk selection, however, should not have been substantial because Part D payments to prescription drug plans in both Medicare Advantage and traditional Medicare are based on the same national average bid. In other words, Part D financing supported roughly equivalent expansions in drug benefits across Medicare Advantage and traditional Medicare. Medicare Advantage plans have generally been able to offer more generous drug coverage at lower premiums than standalone drug plans in traditional Medicare primarily because of increased benchmark payment rates for Part A and B services, not Part D payments.6 Thus, our analyses exploring the contribution of payment increases to our results also indirectly addresses changes in selection mediated by greater expansions in drug coverage in Medicare Advantage relative to traditional Medicare.
J. Michael McWilliams, Department of Health Care Policy, Harvard Medical School, Boston, MA; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
John Hsu, Department of Health Care Policy, Harvard Medical School, Boston, MA; Mongan Institute for Health Policy, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Joseph P. Newhouse, Department of Health Care Policy, Harvard Medical School, Boston, MA; Department of Health Policy and Management, Harvard School of Public Health, Boston, MA; Harvard Kennedy School of Government, Cambridge, MA.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Elflympics - Autumn 2004
The Elflympics is a friendly series of events to promote friendly relations across the elven realms. Participants will select and complete challenges which will award points to their chosen realm, just for fun. Individuals compete only against themselves and their creativity. Competition will run from October 25 to December 25, 2004.
For the next few weeks, we are merely in the planning stages. Please bring your bunny suggestions and post them into the databases section. You will find the Artist event suggestions here. To suggest events for authors, please go to http://groups.yahoo.com/group/Elflympics - Thank you!
-Zhie, Elflympics Coordinator
Group Website
Group Information
- 5
- Tolkien, J.R.R.
- Sep 30, 2004
- English
Group Settings
- This is a restricted group.
- Attachments are permitted.
- Members cannot hide email address.
- Listed in Yahoo Groups directory.
- Membership requires approval.
- Messages are not moderated.
- All members can post messages.


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251 comments found.
when you will update? thanks
hey will update soon.
hai… i interest with this aplication, but how i can change curency ?
please check your email Thanks.
costumer can add his address with map location ?
Sir this feature isn't In this application right now .
Hi, I've purchased but I can't get the Admin interface installed? is it PHP?
Hello sir, This app is in jsp not developed in php so you need to import using eclipse iDE build and run or upload to any Java tomcat server.
I've purchased but I can't get code for PHP and my server hosting not support jsp file . what i will do now ?
Hello, Thankyou for purchasing and this app is in jsp if you want information regarding php version you can contact at firstname.lastname@example.com
Can it except other currencies? How do you install the system? Can you set up the installation and if so how much ?
Hey, Yes currency can be changed also for installation contact email@example.com
Hello, any soon update? or even another new restaurant app? i trust your code. Thanks
Another question regarding to some comments above, do you have a php version?
Hello, Please contact email@example.com regarding other restaurant app and php version. Thanks
sent it 2 days ago
Please check your email thanks
where is that pro version?!
Please follow email for more details. Thanks
plz check ur email… my email firstname.lastname@example.com. plz send me the full installation procedure.
sent you email.
Are there any new updates coming soon. It's been a while since this was released, an update would be great.
Thank you
Hello, Thanks for asking yes there will be an update soon
i recently bought your app. the only problem i am having as of now is to import the sdwebimage framework again. could you guide me through it since the documentation didnt provide enough guidance
Hello, can you please tell me your license code because i didn't see you in buyer list Thanks.
Hi, i would like to know more details about the setting up the whole project and is there any possibility, if you can help me in customization the product?? looking forward to hear, tq
Hey, You need Apache tomcat server with mysql to setup this project web backend in you pc localhost that also work intranet based using static IP address. Yes I can do customization if needed please contact email@example.com regarding this Thanks.
hello my friend u there
hey, yes i'm here


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Just the tip of your breasts.
Years primal.
Fresher my wife's 34G breasts. I think boys.
Cock a place. Let the top-notch designer be your best friend is, and I thought maybe this forum to make sure you did for about 10 minutes of fucking her, he must have as great head, you don't have much of him you will ever need in order to keep him thinking about the varieties.


text: (Jackson, Wyo.) - The Miller Park Parking Lot Project will be starting back up again today, with installation of tree wells around the perimeter of the parking lot. According to the Town of Jackson, construction will continue with sidewalk installation, paver installation and paving over the coming month. Additionally, two new Electric Vehicle Charging Stations will be installed, providing charging for four vehicles at a time. Today, Deloney Avenue between Millward Street and Jackson Street will close to all vehicular traffic and remain closed until further notice. The parking lot will remain partially open with access from the Jackson Street entrance. Additional closure of on-street parking along Millward Street and Jackson Street along the perimeter of the project will close to parking and likely will remain closed for the duration of the project. "NO PARKING" signs have been placed on Jackson Street as well as within the parking lot for the spaces along Deloney Avenue. Construction of the Miller Park Parking Lot Project is expected to be completed prior to Memorial Day weekend. #buckrail #news


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A Residuary Bequest will come into play after all monies have been taken with regard to bills, taxes, expenses and specific bequests. This simply means that you will leave the remaining balance of your Estate, or a certain percentage of it, to an individual or individuals, or organisation.
A Pecuniary Bequest is a little more specific, indicating a gift of a nominated sum of money to someone or again, an organisation. This is often used when the deceased has left a gift to a particular charity in their Will.
A Specific Bequest works best when the testator wishes to leave an item to someone rather than a sum of money. It is then assumed that the beneficiary will either keep the item for its sentimental value, or go on to sell it, raising funds in this way.
A Reversionary Bequest can be extremely risky, and should therefore only be used by a professional Will writer. This type of bequest indicates that an individual or organisation should be the main beneficiary of your Estate, inheriting your property perhaps, or a large sum of money.


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Have Relationship Questions? Ask a Counselor for Answers ASAP
Hi,I'm Jules, a LPC, and welcome to JustAnswer. I am reviewing your question now, and will post back with your thorough reply briefly :)
You know, I think it sounds like you have established your boundaries with him. I commend you for being able to do that. A lot of people forget to assert themselves in relationships and share what they mostly want. You guys have a lot of history, and people do mature and change. They also begin to take ownership and understand the repercussions of their actions. Do you have an intuitive feeling that he continues to engage in any lying, or is this just a fear? You may want to consider trying to discern what emotion is driving your concern? Love or fear?
I think that you also will want to keep each other accountable through communicating and sharing your fears or vulnerabilities with one another. You may have to let him know what you expect from him regarding temptations? What boundaries or parameters have you established?
I was meaning sort of like "rules" or expectations in the relationship in order to protect it. Sort of like an imaginary fence around a home, a boundary in a relationship offers security to keep people out or to make sure you guys don't hurt each other. If you know that you have certain insecurities you may need to tell him specifically what bothers you-- texts from other women, calls from other women, deleting texts, going to clubs, not answering calls, things like this. He may need to know what "fertilizes" the little seeds of doubt creating a greater sense of mistrust.
I am working from my desktop now, rather than my phone and it makes it easier to send resources. In order to really communicate about what is important to you in a relationship, I would encourage you to try is understanding your love language. Gary Chapman found that there are 5 patterns of emotional connections and how we demonstrate them. He calls these our "love languages." The Love languages are words of affirmation, gifts, physical touch, quality time, and acts of service. I will explain a bit of these. Words of affirmation are based on demonstrating appreciation, approval, recognizing efforts made by you or your partner- on the flip side if you recognize that you are sensitive to criticism or perceived criticism this can be a sign that your love language may be words of affirmation. Gifts are about little tokens or offerings that suggest that you are thinking of someone. It can be simple or elaborate, but it's the thought that counts. As far as acts of service, a quote comes to mind, "Actions speak louder than words." Acts of service may include mowing the yard, helping with laundry, starting the dishes, making the bed, helping load the car or unload the car of groceries. It could even be something that helps someone else in their career— anything that offers support someone through an action. Quality Time is based on providing undivided attention to your partner. Turning off the TV, making eye contact, turning toward them as they communicate with you— it is about focusing on your partner without allowing distractions to occur. Finally, physical touch, there is power in tenderness. This does not have to include sexual touch, but more or less, gentleness. It can be holding hands, a stroke of their hair, a massage, or a simple hug. You can take the quiz at the following link:
I wanted to check back in and ask how I can further support you? I didn't want to leave you feeling that your question went unanswered. If you have more that you would like to process, please feel free to write back. However, if you do feel satisfied I ask that you kindly accept the answer provided, or provide a positive rating (3 stars or better) so that credit is received for the answer given. Communication does not have to end even after a rating is provided, you are welcome to follow back up with additional questions related to the initial situation :)
Good morning! I came across a blog entry this morning that I thought was a really good read. I wanted to share it with you because you had mentioned your anxiety in the past and how it affects your relationship.... You can click on the link to read it. Please let me know if you receive it or if you feel that it is relatable!
Here is one excerpt of the article:
"Anxiety causes fear or worry that can make you less aware of your true needs in a given moment. It can also make you less attuned to the needs of your partner. If you're worried about what could be happening, it's difficult to pay attention to what is happening. When you feel overwhelmed, your partner may feel as though you aren't present.
… so train your brain to live in the moment. If you notice a fear or concern that causes your thoughts to stray from the facts or the present moment, pause and think about what you know (as opposed to what you don't know). Calm down before you act. You can make purposeful steps to build trust in your partner. Share openly when you're feeling worried, and consciously reach out to your partner (physically or verbally) when you might normally withdraw or attack in fear."
I know it has been a while, but I do want to follow up with you and ask that if you found the answers provided to be helpful. I hope that you were able to utilize the information given. Best wishes! Jules


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Dedicated to the education of the consumer about beeswax candles.
Does Beeswax Emit Negative Ions When Burned ?
Yes , it's true and finally there is a scientific study to back up the hype! For years
alternative health practitioners, entomologists and most notably beeswax candle makers
have celebrated the fact that beeswax is the only candle fuel that emits negative ions
which in turn cleanse the air. In a study performed by a Japanese laboratory comparing
the negative ion emissions of a paraffin candle versus a beeswax candle , the paraffin
candle did indeed emit negative ions but did so at a significantly lower rate than the
beeswax candle. So while beeswax is not the only fuel to emit negative ions it is definitely
superior to paraffin and does not contain the carcinogenic compounds that paraffin does.
The Japanese study was performed using a KST-900 made by the Kobe Electric Wave Company
in a room with room air temperature of 24.3 degrees Celsius , room air humidity was 41%
and the background negative ion count was 89 per cc. During the study , paraffin candles
produced an average of 72,972 negative ion particles per cc. of air while beeswax candles
produced 101,276 negative ion particles per cc. of air.
Some folks feel the preceding study is incomplete and inconclusive. We welcome any
contributions that might shed some light on this topic.
There is an urban myth that is being floated around by some candlemakers that only their
beeswax emits negative ions when burned. Since all beeswax is made by honeybees , then all
beeswax would have this ability to emit negative ions when burned.
Some folks believe that all materials emit negative ions when burned , after all combustion
is rapid oxidation producing heat and light - when you add oxygen to a any substance there is
an overabundance of negative ions.
Comments or Questions
candlemaking booklet
Without Prejudice. All Rights Reserved.


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Issue with functions.php & loading plugin
I'm having problems with this plugin. When I go to the site, all I see is the following:
Warning: include_once(option-tree/ot-loader.php) [function.include-once]: failed to open stream: No such file or directory in /home/content/45/9926145/html/tarabell/wp-content/themes/mono/functions.php on line 89
Warning: include_once() [function.include]: Failed opening 'option-tree/ot-loader.php' for inclusion (include_path='.:/usr/local/php5_3/lib/php') in /home/content/45/9926145/html/tarabell/wp-content/themes/mono/functions.php on line 89
Warning: Cannot modify header information – headers already sent by (output started at /home/content/45/9926145/html/tarabell/wp-content/themes/mono/functions.php:89) in /home/content/45/9926145/html/tarabell/wp-includes/pluggable.php on line 881
My site is now broken. Could you please tell me what I need to do to fix this? Thanks!
- The topic 'Issue with functions.php & loading plugin' is closed to new replies.


text: Posted September 3, 2011 · Report post Not too worried about colour, must be in good conditon (considering) and well lubed throughout its life. Bear in mind these are £80 new so im looking to pay around £50, cheaper would be wonderful! Thanks Share this post Link to post Share on other sites


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* Required Fields
Pointy toe slingback with ribbon, available in blue velvet or black leather.
Composition blue: upper covered in velvet, leather lining and leather bottom. Composition black: 100% genuine leather. Heel: 9,5 cm.
Handmade with love in Italy.
We ship exclusively with UPS and your order will usually leave our company in 48 hours.
However, for small orders to far countries sometimes we ship with SDA courier due to a better performing service. During sales orders could be dispatched in 3/4 days from the date of the order.
On an average control UPS takes 24/48 hours to deliver in Italy (all regions). It takes from 2 to 6 days for delivery in Europe and other countries.
You will receive a TRACKING code confirming your order so that you can keep track of the delivery.


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As such, links may appear that were valid originally, but no longer are.
Images that the Drudge Report links to often expire
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after serveral weeks. You can still click on the link to see if the original image is still available.
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La Disfida di Barletta
Finally! In Puglia, in the heart of the Medieval historical centre of Barletta and specifically, in an old building (1592) completely renovated, La Disfida di Barletta Bed & Breakfast offers the possibility to stay spoiled by always attentive hospitality in the heart of city, it combines history, art, culture and celebration.
Full Details & Contact Information
B&B at a rustic Moulin
B&B in a beautiful, rustic old Moulin in the heart of the French countryside
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Casa Christiana B&B
family run B&B in the heart of the Abruzzo hills of Italy, close to beach resorts. Offering high class accommodation, including gardens to relax in, guests terrace with superb views of Gran Sasso and the Maiella mountains
Full Details & Contact Information
Casa Perez Country Guest House
Hi we are Ros & Ant Eastwood and we have a B&B in the beautiful, unspoilt and undeveloped region of Murcia A Friendly Family Run B&B in Los Perez. Located in the campo between the historic city of Cartagena & Puerto de Mazarron in the beautiful region of Murcia Spain.
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B&B La Girandola
La Girandola offers Bed & Breakfast and a holiday apartment, and is situated on the edge of the medieval village Poggio Cupro, part of Cupramontana. This farmhouse, restored with love for the characteristic details, offers you an unforgettable relaxed and peaceful stay. The kindness and courtesy of the people of the area will be yet another highlight of your vacation. At La Girandola everything is possible; .... you won't be bored.
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Maison Lussais
Superbly renovated house offering Bed and Breakfast (Chambres d'hotes) in 2 double and l a Family suite comprising a double bedroom, with a twin bedded room on mezzanine floor room Open all year. Use of covered pool and games room in the season. Prices from 50 per room (2 persons) Stays of 2 nights or more receive a 10% discount. Full board option available. Self catering also available. Room to park a motorhome with hook-up facilities
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Cortijo Corcho
A renovated old Spanish Cortijo in a quiet area
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Bed and Breakfast in Brittany
Les Touches is a 350 year old detached country house set in over 3 acres of beautiful gardens and woodland, outstanding views and with a wide variety of wildlife.
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Les Chardonnereux Chambre à Beaune
Graham and Candida offer you a warm welcome to their home Les Chardonnereux. Les Chardonnereux is a large traditional French house which was built between 1900 and 1910 for a local wine making family (the climat which bears the same name can still be located in the vineyards to the rear of the house). Being only a short 5 minute stroll to the Old Town and now within an even shorter stroll to two Michelin starred restaurants.
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Chateau De La Lanette Chambres D'Hotes
Russell, Heather, Louis and Henry welcome you to stay in the distinguished comfort and luxury of their stunning 19th century Chateau. Located in the beautiful village of Salechan, nestling at the foothills of the Pyrenean Mountains this lovingly restored home away from home can offer you a choice of 5 large luxurious rooms all with en-suite facilities, and stunning views of the mountains.
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Les Amandiers Bed and Breakfast near Carcassonne Southern France
Welcome to Les Amandiers, a luxury villa with pool, open for B & B from mid-June to mid-September. We have stunning views over vineyards and fields of sunflowers towards the Pyrenees and Andorra. Situated in the 'circulade' village of Cailhau, in the wine growing area of the Aude, we are only 25 minutes from Carcassonne and 15 minutes from the Canal du Midi. See our website for full details.
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B&B La Dolce Vita Cagliari
Jurga and Roby welcome you at their Bed and Breakfast, located only at 200 meters far from the beach of Flumini of Quartu Sant Elena and few km from all the most beautiful places of the south west coast of Sardinia.
Full Details & Contact Information
Agriturismo la Grotta
Well positioned on the top of a hill of pisan's mountains, the farmhouse La Grotta is the ideal place where relax in a direct contact with nature in a classical Tuscan environment.
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BB Palazzo Reale
In the heart of the old city of Palermo, few steps away from the main tourist attractions, stands the Palazzo Reale B&B. A place that transmits a genuine sense of hospitality and reveals the city. With its typical scents and colors and especially through the arts that make it unique. Each of the three rooms, Literature, Cinema and Painting is furnished in a plain, essential but also innovative style. A stimulating and homely balance. A harmony ca
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Pavillon de Galon, B&B in Provence, Lubéron
Finest B&B in Provence. More intimate than an hotel, we offer you the most comfortable en suite bedrooms, all with panoramic views on the landscapes of Provence, an awarded remarkable garden with an infinity pool.
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Villa Mirella Beach | Holidays in the Marche Region
An ancient colonica house on the Adriatic sea of the Marche, encircled to the green and with, at the shoulders, a medieval village of 10th century, will allow You to pass a relaxant vacation, but that, at the same time, it will offer to You many cultural and sport activities. The Bed & Breakfast Villa Mirella Beach offers to its hosts the possibility to pass an amazing holiday on the sea or on the swimming pool.
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Tournesol Chambre d' Hote
Welcome to Tournesol, our Chambre d'Hote located in the rural hamlet of La Rallerie near to the town of Gouex which nestles in the heart of the Vienne valley. A very pretty place to stay with many places of interest all around!
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Chambre d'Hotes
Our 16th century converted barns are set in one acre of tranquil open countryside. The gentle rolling countryside waits to be explored. The quiet country lanes, paths and bridleways offer ideal walking and cycling conditions. Or may be just relax by the swimming pool. We are ideally located just a few kilometres south from the Dordogne between the Bastide town of Villeneuve-sur-Lot and the celebrated Bastide town of Monflanquin.
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Bed and Breakfast Fano prestigioso bandb
Elegante e prestigioso B&B nel centro di Fano nel quale ottenere il massimo del comfort e il top del servizio ad un prezzo interessante
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B&B Naples Italy Last Minute
The B&B La Bouganville is a very warm and charming B&B with a wonderful terrace that we enjoyed each evening. Quietness of the room. The location was great even though it was not in the Historic District because it was a nice part of town and was easy to get where we wanted
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You would wonder if US Citizens have been propagandized with fake news telling us that we are roughly energy independent. Why aren't oil prices continuing to collapse? The real question becomes, "Are a hand-full of American citizens being treasonous in aiding a foreign country to financially rape the American people? We need a free market for oil because each drop in price is tantamount to a pay raise for American Citizens.
As Production Cuts Fail To Raise Prices, Saudis Look At Exports
Current Status: Blessed (1)
Seeded on Sun Jun 18, 2017 3:47 PM
keyboard shortcuts: V vote up article J next comment K previous comment


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We hit Roberto's for breakfast. It was my first time and wow is it great. The menu has many interesting choices to go with the standards. I chose a combo of eggs, bacon and blueberry pancakes. Everything was great. We were a large party (15)...More
1 - 10 of 348 reviews
We hit Roberto's for breakfast. It was my first time and wow is it great. The menu has many interesting choices to go with the standards. I chose a combo of eggs, bacon and blueberry pancakes. Everything was great. We were a large party (15)...More
Went for lunch with our 8-month-old, and they took great care of us! Authentic Cuban food (in fact, we had to ask what a few menu items were!), & excellent Cuban sandwich. The yuca frita is also a MUST!
Dined at Roberto's for my birthday dinner. Was initially worried when we entered the restaurant in a downpour about 5:50p and realized we were the only customers in the house. The wait staff greeted us warmly, and even offered us paper towels to dry off...More
Roberto's has been around for decades and has a very loyal following. The food, even their native Cuban cuisine, is mediocre and bland. The service leaves a lot to be desired. Unless you're a loyal local, there is an atmosphere of don't bother us. There...More
We were a large group that was accommodated easily and with a smile. The prices were good as was the food.
Two hour wait with a 90 minute park service . Ive seen snails move faster and the waitress did not keep up with the drinks , slow with the food to the point that when it did arrive it was cold but even then it...More
I'm so sorry about your experience. We are a family owned restaurant since 1980 and take pride in our business. It is the focal point of our lives & when ever there is a bad experience we like to correct it with the upmost urgency!...More
It was with great anticipation that we went to Roberto's Cuban restaurant however in a world of such rich Cuban food tradition, it is a crying shame that this restaurant would get away with such a fraud and imitation. It wasn't even a simulation of...More
On holiday from the UK, looking for somewhere for a good breakfast, we asked a young guy a few blocks away from Roberto's, if there was a good place to go, and he had no hesitation in recommending Roberto's. This was Sunday morning and Roberto's...More
Best lunch for a flavorful meal in downtown Cocoa Beach! Will be back! The service was great and the recommendations by our server were delicious!!!
I was born and lived in cuba for 25 years I know Cuban food. I cook and eat Cuban food everyday . So I can tell you exacly how Cuban food taste This restaurant for a tourist place is not bad . But still not...More


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Former vice president, Atiku Abubakar has revealed how former President Olusegun Obasanjo tried to become a life President and not 3rd term.
Speaking with zero tolerance, a magazine published by the Economic and financial Crimes Commission, EFCC, and the former vice president alleged that Obasanjo tried to amend the constitution to create way for his agenda.
Abubakar insisted that his former principal under the pretense of trying to amend the constitution carefully removed the side of tenure limitation but he kicked against it.
He said, "My offense was that I disagreed with him on the amendment of the constitution to get rid of tenure limits or what was popularly known as the '3rd term agenda'.
"In fact, he sent the then Attorney-General and professor Jerry Gana to my office to bring the draft amendments to the constitution. After going through (them), I noticed that tenure limits had been removed. In other words, he could be President for all times.
"I then asked them that 'if I send you to the President, can you deliver this message?' They said yes. I said 'go and tell him i will not support it and, i will fight it'."
Atiku said because of his disagreement with Obasanjo, the ex-president decided to tag him as a corrupt person.
The former vice-president said Mallam Nuhu Ribadu, the then former Chairman of the EFCC had accused him of corruption but later came to him to apologize.
He said, "When he came to ask me for forgiveness, I said if you want me to forgive you, Nuhu, go to the same television stations where you said i was corrupt and say you now (have) realized that i am not corrupt.
"Then he said 'sir, you have forgiven so many people who have offended you publicly without them going to Television stations to apologise to you' and i said, 'your case is different because first of all, I helped to found the EFCC'.
"I was instrumental to your appointment, so, i believe I have contributed to your development and this is how you are paying me back. In any case, he kept on apologising and i said, 'okay, no problem. That closed the chapter'."
Atiku denied media reports that a U.S Senate report accused him of laundering $40m in the United States between 2000 and 2008.
The former vice-president confirmed that he did transfer money to the United States but it was not illegal.
He added, "It was an allegation which was not proved. it was my legitimate money that I transferred to the US; there was nothing (wrong) about it. More so, i was not indicted in that report. They only said suspicious funds but I proved before the Senate committee that they were not suspicious."
Atiku explained that the accusations emanated from his dealings with a Louisiana congressman, William Jefferson.
He explained that Jefferson had approached him for a communications project but he referred the American to the minister of communications.
Atiku said the United States lawmaker collected $100,000 from a woman under the pretext of using it to bribe him.
The ex-vice-president said he, however, rejected the money which he described as too little for a man of his repute.
He said the Federal Bureau of Investigation subsequently searched his wife's United States home but nothing incriminating was found.
Culled from: Dailypost


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In 1997 a story of mine called "Matters Arising" was placed second in the South Island Writers' Association's Dame Ngaio Marsh competition. Three years later, trawling through the bottom drawer, I found it and thought it might find a wider readership in the real world and I sent it to a modest little quarterly magazine. I was a subscriber to the magazine to indicate support for its efforts to showcase New Zealand writing, even though the short fiction it published was not particularly to my taste. Also, I was sometimes disturbed by the tone of the editorial content, which was couched in language that was routinely brusque and sometimes offensive.
The story came back to me. The title page had the following scrawled over it:
"Thank you for your submission. Unfortunately we cannot use it. Joan, we scan stories. Your leaving 2 double space lines between every paragraph means we have to spend time adjusting every page. We DON'T have the time and WON'T do it. The Editorial Board felt your story lacked 'bite', tension & a main character. It also needed a good edit & cutting. A decent sized envelope for the return of your script – or a disposable script – would save you time & money."
In January 2001 Takahe magazine (issue 41) published "Matters Arising" without changing or cutting a word. The story attracted considerable attention and in the years since has become almost viral, having been copied and distributed many times. [Feel free, everybody, spread the word.]
The cautionary tale doesn't end there. In February 2001 I received a plea from the editorial team of the little magazine asking me, as a subscriber, to renew my subscription as times were tough and the magazine was in danger of folding. They wanted an "instant response" plus $24 for four issues.
I was really, really calm and polite when replying. I said that I wouldn't be renewing my subscription because I thought the magazine was "mumsie" and the stories rather tired. I considered the editorial taste unsophisticated. And I objected to the tone in which readers, subscribers and potential contributors were addressed by editorial staff, and that offending just about everybody on whom they depended for support was probably not the best way forward.
Judge the story for yourself. The link is up there on the left, on the story page.


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Finance Analyst PQ CIMA/ACCA - Construction/Energy
- Recruiter
- Orion Group
- Location
- West London, London
- Salary
- 38000.0000
- Posted
- 07 Jul 2017
- Closes
- 06 Aug 2017
- Sector
- Accountancy
- Contract Type
- Permanent
- Hours
- Full Time
Are you PQ CIMA/ACCA?
Finance Analyst?
Do you have experience within the construction/energy or engineering sector?
Are you seeking a permanent opportunity in London?
If you tick all of the above please read on...........
A leading construction organisation is seeking a Finance Analyst, ideally PQ or someone who is early in their studies with good strong experience within the field/sector. The Finance Analyst will be involved in both the financial reporting to the board, financial accounting and management of the purchase ledger.
- Development and reporting monthly board pack
- Detailed analysis with commentary for monthly report
- Presentation of monthly report/results including any project progress
- Provide ad-hoc financial data and analysis to management
- Business partner with construction project leads and the rest of the business both financial and non financial
- Provide monthly cost centre & business unit reports, reviews and analysis
- Play a key role in developing budgets and forecasts
- Work closely with budget holders, tracking spend v budget and explain any variances
- Monthly analysis and review of assigned balance sheet accounts
- Payments administration ie account payable invoices and other payments
- Assist in the preparation of cash flow forecasts
- Assist in the preparation of monthly UK and France VAT returns
- Assist in the preparation of annual financial statements
- Provide financial information to the wider finance team
- Document policies and ensure all procedures and financial control processes in place
Highly analytical with great attention to detail
Strong, confident and articulate communication skills - ability to interact at all levels
Advanced MS Office - with demonstrable skills within MS Excel
Exposure to working in a multi-currency environment
Good understanding of IAS16
Sage 200
Team player
Call Sarah to discuss in more detail!
Our role in supporting diversity and inclusion
As an international workforce business, we are committed to sourcing personnel that reflects the diversity and values of our client base but also that of Orion Group. We welcome the wide range of experiences and viewpoints that potential workers bring to our business and our clients, including those based on nationality, gender, culture, educational and professional backgrounds, race, ethnicity, sexual orientation, gender identity and expression, disability, and age differences, job classification and religion. In our inclusive workplace, regardless of your employment status as staff or contract, everyone is assured the right of equitable, fair and respectful treatment.


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Northeastern State University basketball records
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Get info about Northeastern State University basketball records, and registering for discussion sections and departmental electives. Not all recruiting is done like NCAA Division I teams. College coaches want to see you play. A lot of the time college coaches may have only one chance to see potential recruits play, so be ready to shine if you are visiting the campus in person. Finally, check with your major department for assistance with prerequisites, tuition payment deadlines, and Northeastern State University Basketball information. Please use the form above to request admissions info for Northeastern State University.
You don't have to quarterback the university football team to a state championship to earn an athletic scholarship. Most major sports that field a team in intercollegiate competition have sports scholarships available. From women's gymnastics to men's track and field, coaches are seeking players to build a team around. Further, that leadership role often is accompanied by a full-scholarship.
The best time to begin searching for scholarships is before your senior year, in order to meet deadlines. Schools confirm that it is important to file financial aid forms such as the CSS Profile early in the school year. There are many sports scholarships that focus on less tangible qualities, such as the ability to lead a team, motivate others, and learn new skills rapidly. Take stock of your athletic abilities as you mature through high school. Minnesota State University baseball coaches may indicate that it's an option to delay college entrance by a year. An extra year in high school or prep school can allow players to mature mentally, bring grades and SAT test scores up, put on weight and gain strength. Beyond consideration for Northeastern State University basketball records, you may think about San Jose State University test requirements for complementary electives to your primary course of study.
Athletic Equipment Specialist/Driver
Irvine Valley College
Replace basketball, volleyball and tennis nets; Work closely with coaches and instructors to make sure events run smoothly.
3 days ago Performance Coach
International Leadership of Texas
Position requires coaching assignment (1 sport minimum) Major Responsibilities and Duties:. 2+ years of Teaching and/or coaching experience preferred Experience.
13 hours ago Boys Head Soccer Coach
Parma City School District
In several instances, the head coach must advise, coordinate and support a staff of high school assistant coaches and middle school coaches in conjunction with..
3 days ago Head Basketball Coach: Girls
School Board of Broward County, Florida
Athletics/Head Basketball Coach:. Florida State Statute mandates that all high school coaches hold a valid Florida Educator Certificate. Girls Date Posted:..
13 hours ago FLAG FOOTBALL COACHES NEEDED
Fit Kids America
FLAG FOOTBALL COACHES NEEDED. Wants Youth Coaches. Be able to mentor and coach children ages 5-10.
1 day ago


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8 Pages Posted: 15 Jul 2012
Date Written: April 1, 2012
For a broad class of linear biased estimators, we establish conditions under which the F statistic based on biased estimators is identical to the F statistic based on least-squares estimator. Several biased estimators in the literature are shown to satisfy these conditions.
Keywords: Biased estimator, F statistic, ridge estimator, shrinkage factor
JEL Classification: C2, C12
Suggested Citation: Suggested Citation
Deng, Ai, Hypothesis Testing When a Linear Regression is Estimated by Biased Estimators (April 1, 2012). Available at SSRN: https://ssrn.com/abstract=2106192 or http://dx.doi.org/10.2139/ssrn.2106192


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Years Active
2000 – present (17 years)
Bridge To Solace is a Hungarian hardcore/metalcore band. Their unique sound features the devastating speed of hardcore punk, heavy metal-influenced guitar melodies and both heartfelt and political lyrics.
They currently have three releases: the debut album "Of Bitterness And Hope" features spoken word interludes by Greg Bennick (ex-Trial singer) and sung choruses; the slightly conceptual EP "Kingdom of the Dead" features female vocals. Their second full-length "Where Nightmares And Dreams Unite" was released on their European tour in May 2006.
History 2006
On a wasted night in early 2000, the idea of a band that gives wings to their musical dreams made three young men (guitarist Krisztian, bassist Laci and drummer Tamas) form the group under the name Joy's Pride. With the addition of Adam Fellegi, a drummer maniac and member of the semi-legendary Hungarian hardcore band Newborn, the lineup was nearly complete. However, Tamas and Adam being musical masterminds (both play drums and guitars) the band was unsure if they should look for drummers or singers as Adam grabbed the microphone originally and Tamas hit the chords. Trying out an ocean of friends on different instruments followed, and 2 mostly inactive years passed when Newborn called it a day and decided not to play anymore. Zoli, the singer of Newborn was a logical idea to fill the vacant position of the singer and with the swansong of their original bands (Tamas played drums for an influential melodic punk band, who were about to call it quits as well), the side-project was set to finally make it out of the rehearsal room.
Still called Joy's Pride, the band performed its first show on the 18th November, 2002, supporting Bane and the video tape of the show made Chris Z sign the band to his Munich based hardcore label, Let It Burn Records. Things suddenly started to speed up and 5 months after their first show the band, under the new moniker "Bridge To Solace" already sat around in Parkplatz studios, recording the debut full-length "Of Bitterness And Hope", 9 songs of metal spiced hardcore punk with the addition of former Trial singer and current activist-filmmaker Greg Bennick's spoken word tracks. The record had a surprisingly good feedback and in september 2003, only after 5 local performances the band was about to start it's first European tour, together with Paint The Town Red from Germany and Razor Crusade from Holland. Later that year, the band returned to Europe for a week-long tour supporting Walls Of Jericho.
2004 saw the band's 2nd release coming, which was supposed to be a split CD with California hardcore heroes A.18, but due to the lineup troubles of the Californians, the split never happened, but Bridge To Solace thought they have three good new songs, so with the addition of a rerecorded and a bit rethought old song and adding a female opera singer to spice up the songs of the EP, the band wandered further in metal. 2004 was a metallic year so to say, the band opened for Cradle Of Filth and Testament in Budapest, and performed it's first ever Sziget Festival (one of Europe's biggest cultural events) appearance among local buddies and Children of Bodom. 2004 brought a summer tour with Nothing Gold Can Stay, and mostly weekend shows in support of "Kingdom Of The Dead", the band's 5-track EP, which saw the light late September.
2005 was definitely THE year for Bridge To Solace. An amazing 4-week tour with Undying in April made the band speed up a lot and brought the first loss to the family, as Krisztian Alberti, guitarplayer and all around good guy decided to quit the band after the month-long tour, focusing on his commitments as a husband and a dad. The band had to decide quick and took Balint Szollar, an extremely talented, but long-time unemployed guitarplayer. With Balint in their ranks, the band was all set to destroy. Some local festival appearances followed, another Sziget festival with probably the biggest wall of death in the history of Hungarian hardcore, a sold out Budapest show with friends The Idoru, maniac and alcohol-filled weekends all around Europe, and a new record deal with the ever-growing Dutch hardcore label GSR Music. The band had a cancelled 12 day tour, but as half of it could be saved, they decided to rock around Europe for a week in December.
2006 brought the 2nd Bridge To Solace full-length, the debut for GSR Music. The band spent some stressed out, but fun 6 weeks in studio, recording the new masterpiece, 9 tracks of metal spiced modern hardcore.
Just in time for the release of "Where Nightmares And Dreams Unite" the band hit the road for a 20 show trip, spent most of it together with Swedish hardcore machine Raised Fist. The tour ended in a cathartic record release show in Budapest, where the band sold out the Budapest downtown venue Süss Fel Nap. July 2006 took the band on the road again, this time only 9 very hot shows, on the 9 hottest days of this summer. The stage has been shared with Finnish legends and brothers Endstand.
The band is currently playing Hungarian club shows, something they never really did throughout their early years. Teamed up with Watch My Dying and Septic, this is a package tour Hungarians should keep their eyes on!
Artist descriptions on Last.fm are editable by everyone. Feel free to contribute!
All user-contributed text on this page is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply.


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About Ben Gurion University Eilat Campus
Why Choose Ben Gurion University?
Ben Gurion University operates the International Laboratory for Dolphin Research in Eilat. The scientific research examines different aspects of dolphin behavior, communication and dolphin-human interaction. It is important to note that all research with the dolphins is non invasive, and nothing is done to harm or harass the animals in any way. Not only does Ben Gurion aspire to become one of the leading interdisciplinary research universities in the world, it already hosts hundreds of colleagues and guest visitors from other universities and institutions each year. This helps to achieve the goals of collaboration and advancement.


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About Networking. We are a Business Networking Organisation Connecting Trades, Services and Professionals in a structured networking environment.
Next meeting: Wednesday 4 October 2017 – 7.00am to 8.15am
Meets fortnightly at: Blue Rose Café | 414 Sandringham Road | Sandringham | Auckland 1025
Speaker: Auckland Kiwisaver Specialist Keita Suzuki from Ikonik
Current Member Categories: Accountant, Business Banking, Home Staging, IT Services, iwisaver Specialist, Lawyer, Life/Risk Insurance, Meth Testing, Mortgage Broker, Property Manager: Residential, Real Estate Agent
Area Group Manager: Rawinia Matthews | 0274 353 489 | email@example.com
For information about our Sandringham networking group please contact firstname.lastname@example.com or register below for the next Auckland meeting.
Interested in visiting TNG Sandringham's next meeting? Please register:


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Click for weather forecast
Estrella Foothills football coach Derek Wahlstrom gives instruction during a preseason scrimmage August 9 against Agua Fria. (West Valley View photo by Ray Thomas)
By Casey Pritchard
The Estrella Foothills High School football team will take the field Friday with a new face at the helm.
Hall of Famer Tim Raines, who has lived in Goodyear for 11 years, throws the ceremonial first pitch at the D-backs/Dodgers game on August 9. (Photo courtesy of Arizona Diamondbacks/Sarah Sachs)
By Christina Fuoco-Karasinski
Former baseball player and 11-year Goodyear resident Tim Raines stands on the steps of the Diamondbacks' dugout prior to their August 9 game.
Nick Thyfault, middle linebacker for the Agua Fria High School Owls, takes part in blocking drills before the first game. (West Valley View photo by Ray Thomas)
By Casey Pritchard
Coach Ross Crow had a rough first season with Agua Fria in 2016. The Owls went 2-8, failing to make the state playoffs for the third year in a row.
Moving forward in his second campaign, Crow sees a few things that the team could improve upon to find success.
The goal of USA Basketball Open Courts, presented by Nike, is to provide children a safe and fun environment in which to play basketball. (Photo courtesy USA Basketball)
By West Valley View staff
West Valley children ages 6 to 17 can participate in the USA Basketball Open Court program starting August 13 at Estrella Foothills High School.
Westview High School head football coach Nick Gehrts instructs players and fine-tunes plays during practice. (West Valley View photo by Ray Thomas)
Westview's football team went through a change last year when Nick Gehrts took over the program, but the Knights finished 8-3 in his first season at the helm, and will look to improve on that in 2017.
PIR officials are excited for the track's changes, which will make for a better fan experience. (Photo courtesy PIR)
Racing teams are constantly making adjustments to their cars to make sure they're running at optimum performance. In similar fashion, Phoenix International Raceway in Avondale is doing that to its racetrack.
The Buckeye Hawks went to camp early this summer. (Photo special to WVV)
The Hawks will go to Hawaii in August. (Photo special to WVV)
Buckeye's football team had good results in summer competition, and one that was not so favorable. However, coach Kelley Moore and his team talked at length about the less-than-desirable showing, and what they've learned from it.
Tony Cluff, above, is succeeding Kelly Epley as football coach at Youngker. (West Valley View Photo by Ray Thomas)
Tony Cluff is experiencing déjà vu.
Photo by Mike Rincon
Desert Edge is coming off of a 9-1 regular season and a playoff appearance. (Photo courtesy Desert Edge)
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Coriander Infused Rapeseed Oil ingredients: Cold pressed rapeseed oil, coriander oil.
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