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Madam Chairman and Members of the Committee: I am pleased to appear before you today to discuss competition and antitrust enforcement in health care markets. This testimony and my responses to your questions represent the views of the staff of the Federal Trade Commission. They are not necessarily the views of the Commission or any individual Commissioner.
Competition in health care markets has benefited consumers. Antitrust enforcement has been a significant factor in the emergence of potentially procompetitive methods of delivering health care services, such as managed care. Statutory antitrust exemptions could permit behavior that injures consumers and the economy. We know of no antitrust orders prohibiting cooperative agreements to improve efficiency or enhance the quality of care. Thus, we question whether granting antitrust immunity is necessary to achieve the goals sought. Because it may be difficult to ensure that, once agreements are authorized under programs such as the proposal under consideration here, the agreements continue to operate as intended, we recommend that, if such programs are nonetheless adopted, measures be taken to make it easier to terminate agreements that fail to achieve those goals.
I. Interest and Experience of the Federal Trade Commission.
The Federal Trade Commission is empowered to prevent unfair methods of competition and unfair or deceptive acts or practices in or affecting commerce.(2) Pursuant to this statutory mandate, the Commission encourages competition in the licensed professions, including the health care professions, and in the delivery of health care services to the maximum extent compatible with other state and federal goals. For several years, the Commission and its staff have investigated the competitive effects of business practices of hospitals and health care professionals.(3) The Commission has investigated and taken action concerning the competitive effects of mergers between hospitals.(4) The staff of the Commission has also commented, in response to requests, on legislative and regulatory proposals concerning the health care industries that may affect competition and consumer interests.(5)
II. Proposed Antitrust Exemption For Cooperative Agreements in Health Care Industries.
One of the subjects of this hearing, and the one on which I will focus, is a proposal to grant immunity from antitrust oversight to certain kinds of cooperative agreements among hospitals or other health care providers.(6) The proposal would have the legislature find that, to implement strategies to reduce costs, improve access to services, and enhance prospects for further improvement in quality of care, cooperation among health care facilities and providers must be encouraged by state legislation.(7) The Secretary of the Agency of Human Services would be authorized to issue a "certificate of public advantage" covering such a proposed agreement if the applicants demonstrate, by clear and convincing evidence, that the likely benefits of the agreement outweigh disadvantages attributable to reduction in competition.(8)
The "cooperative agreements" subject to the proposal could deal with sharing, integration, allocation, or referral of patients, personnel, instructional programs, equipment, laboratory facilities or procedures or other services.(9) The possible benefits to be considered include enhancement of quality of health care, preservation of facilities near communities they have traditionally served, improvements in cost efficiency, improvements in resource utilization, avoidance of duplication of resources, and improved access to providers and services.(10) The possible disadvantages from reduction in competition to be considered include impairing the ability of HMO's, PPO's, managed care firms or other payors to negotiate payment and service arrangements, reduction in competition among providers or facilities (including providers or facilities that compete with, or supply goods or services to, those involved in the agreement itself), adverse impact on quality, availability, or price of health care services, and the availability of less restrictive arrangements.(11)
The intention is that a certificate would confer "state action" immunity from antitrust oversight.(12) The certificate would be subject to review every three years, and could be revoked, after notice and hearing, if the Secretary found that the benefits no longer outweigh the disadvantages.(13)
III. Competition and Antitrust Enforcement in Health Care.
Before examining this proposal more closely, let me set out the perspective we bring to the issues. The FTC enforces the antitrust laws to ensure that competitive forces will allow the development of health care delivery desired by consumers. The Commission does not favor one type of health care delivery system over another. The Commission does not advocate that consumers choose a managed care plan over a fee-for-service health care plan. Nor does the Commission take a position on which kind of health care plan provides better quality health care at lower prices. Instead, the Commission tries to ensure that each plan may develop and grow as it meets the wants and needs of consumers. The Commission seeks to ensure that anticompetitive behavior does not impede the development of health care alternatives that consumers might elect to use.
Many of the various health care reform proposals have envisioned some exemption from antitrust review for the health care industry. The Federal Trade Commission has taken the position that such exemptions are unwarranted and unwise.(14) The Commission believes that antitrust law enforcement has played a key role in opening up the industry for competition, and will be important to the success of any competition-based model for the future health care market.
The antitrust laws have been described by the United States Supreme Court as the "Magna Carta of our free enterprise system.(15) These laws reflect a judgment that competition generally promotes consumer welfare and produces the best mix of quality goods and services at the lowest prices. The antitrust laws also assure business people an opportunity to offer their goods and services in the marketplace, and to have their success or failure determined by consumers' preferences, not by the abuse of other competitors' market power. Indeed, experience from the Commission's health care enforcement program suggests that antitrust law enforcement plays an important role in preventing organized efforts to reduce price competition and to thwart cost containment efforts. For example, antitrust law enforcement by the Commission has been instrumental in enabling alternatives to traditional fee-for-service health care arrangements to enter health care markets in the face of opposition by some health care providers.(16) Other examples include Commission enforcement actions that have challenged anticompetitive rules that prohibited physicians from affiliating with health care plans, and enforcement actions that have halted organized boycotts by some health care providers against newly developing health care arrangements.(17)
The Commission's experience in health care markets has shown that, without the protection that antitrust law provides, efforts to contain health care costs, and to create innovative delivery systems to better serve consumers, sometimes can be frustrated by provider opposition. More broadly, to the extent that health care reform depends on market mechanisms to improve the price and quality of the health care Americans receive, antitrust enforcement will help make reform work by promoting and maintaining competitive health care markets.
IV. Consideration of Benefits and Costs in Health Care Antitrust Law Enforcement.
The premise of this proposal, and others similar to it, appears to be that antitrust litigation or prosecution, or the fear of antitrust liability, prevents or inhibits beneficial agreements among hospitals or other providers of health care services. It would be useful to review the record of antitrust law enforcement involving hospital mergers and cooperative agreements, to show how the kinds of benefits described in the proposal have been considered in that process.
The Commission's antitrust enforcement activities concerning hospital mergers and joint ventures attempt to maintain the competitive market forces needed to make the current health care system work, and provide opportunities for improvements in the system to make it work better.(18) The Commission believes that competition significantly improves the performance of hospitals within the existing health care system. Competition will continue to play such a role in foreseeable circumstances.
The Commission and the Justice Department have jointly issued merger guidelines which set forth the analytical framework the agencies use in determining whether a merger is likely to lessen competition.(19) Those Guidelines emphasize the need to look beyond market concentration to determine whether a particular merger is inconsistent with the federal antitrust laws' objective of preserving competition and thereby promoting competitively-priced, high-quality goods and services for the consumer. In any industry, it is necessary to look at a broad range of market characteristics to determine whether the increase in concentration and the elimination of a competitor through a merger would likely threaten consumer interests.(20) These other factors include efficiencies and other consumer benefits that the merger might make possible.(21) The Commission accordingly is careful to make sure that its enforcement actions in hospital markets in fact serve consumer interests.
Sound antitrust enforcement does not hinder efficient, procompetitive collaborations. This issue needs consideration in perspective. In a typical year, there are about 50 to 100 hospital mergers or other arrangements consolidating previously independent hospitals. Review of these transactions by Commission staff normally entails minimal or no direct contact with the parties and no delay in the transaction beyond statutory Hart-Scott-Rodino requirements. In the past decade, the Commission has conducted only about thirty formal investigations, mostly involving larger metropolitan hospitals, and, even after the recent flurry of merger activity, has challenged only about a dozen hospital mergers.(22)
The Commission's assessment of the impact of antitrust enforcement on hospital collaborations has been confirmed both by a substantial increase in such activity recently — which suggests that fear of antitrust enforcement has not dampened hospital mergers generally — and by other observers. A Health Care Task Force of the American Bar Association concluded that, "Overall antitrust enforcement has not deterred hospital mergers and in fact, the hospital industry has seen a recent wave of mergers.(23) Similarly, a Department of Health and Human Services task force examined the claim that enforcement agencies have become too adversarial in challenging hospital mergers, concluding that the assertion was not supported by the evidence.(24)
The enforcement record on hospital joint ventures similarly should not evoke concern. To date, the Commission has not challenged a single joint venture among hospitals. Indeed, in the context of merger enforcement, the Commission has taken particular care not to restrict types of hospital joint ventures that are unlikely to raise serious antitrust concerns. In a recent order blocking a hospital merger in a highly concentrated market, the Commission exempted from the order's reporting requirements any prospective joint ventures the hospitals might decide to undertake to provide data processing, laboratory testing, and health care financing.(25) These joint ventures appeared likely to achieve efficiencies and improve specific services, without endangering price and quality competition for other services, as a complete merger could.
The Commission not only has limited its enforcement actions to hospital mergers that could have been genuinely harmful, but also has made considerable efforts to publicize and clarify its enforcement policies in that area so as not to discourage legal, beneficial transactions. The Federal Trade Commission and the Department of Justice have issued Statements of Enforcement Policy and Analytical Principles Relating to Health Care and Antitrust specifically addressing areas of concern to members of the health care industry. A set of six statements was issued a year ago; last month, those statements were updated and expanded.
The "antitrust safety zones" that are included in most of the policy statements describe the circumstances under which the federal antitrust law enforcement agencies will not challenge certain collaborative activities by hospitals, doctors, and other health care providers. The policy statements go on to explain in detail, using illustrative examples, how the agencies analyze conduct that falls outside a safety zone. They emphasize that many activities falling outside a safety zone nevertheless are lawful and permissible.
Under the safety zone for mergers, the agencies will not challenge, except in extraordinary circumstances, hospital mergers where one hospital has fewer than 100 beds and fewer than 40 patients a day, and is more than five years old. They will not challenge joint ventures among hospitals to purchase or support high-technology or other expensive health care equipment, that involve only the number of hospitals necessary to support the equipment. If more hospitals are included, but the additional hospitals could not support the equipment on their own or through a competing joint venture, the agencies will not challenge the venture. One of two new examples with this statement explains how the agencies analyze joint ventures involving existing equipment in rural areas.
The statements make clear that the agencies will not challenge joint purchasing arrangements among health care providers, as long as they meet conditions designed to ensure they do not become vehicles for collusive purchasing or for price fixing. The purchases must account for less than 35 percent of the total market for the purchased items and, for arrangements among direct competitors, the cost of the jointly-purchased items must account for less than 20 percent of the total revenues of each purchaser. An example focusing on analysis of rural joint purchasing arrangements is now included.
The agencies will not challenge an exclusive physician network joint venture (that is, a venture that restricts the ability of physicians to affiliate with other such ventures or to contract individually with health insurance plans), as long as the physicians share substantial financial risk and the venture comprises 20 percent or fewer of the physicians in each specialty with active hospital privileges in the geographic market.(26) The agencies will not challenge a non-exclusive physician network joint venture (that is, a venture that does not involve limitations on the ability of participating physicians to affiliate with other ventures or to contract individually with health plans), as long as the physicians share substantial financial risk, and the venture comprises no more than 30 percent of the physicians in each specialty with active hospital privileges in the geographic market.(27) This safety zone has been expanded to reflect the agencies' experience that truly non-exclusive joint ventures generally raise less risk of foreclosure of competing plans than do exclusive joint ventures.
The agencies also have added a new statement that explains how they will analyze hospital joint ventures to provide specialized clinical or other expensive health care services. Under a "rule-of-reason" analysis, the agencies define the relevant market, determine how the venture would affect competition in that market, weigh any anticompetitive effects against any procompetitive efficiencies generated by the venture, and examine whether collateral restraints, if any, are in fact necessary to achieve the efficiencies sought by the venture. To date, neither agency has challenged an integrated joint venture to provide such services.
A statement has been added explaining how the agencies analyze multiprovider networks, which are ventures among providers to jointly market their services to health benefits plans and others. If such networks involve agreements that allocate markets, fix prices or similarly restrict competition, the agencies will examine whether the members are sufficiently integrated to allow the agencies to weigh the anticompetitive effects and competitive benefits of the agreements. (Otherwise, such agreements would be illegal on their face.) If the networks are integrated, the agencies then will define the markets where the networks operate and have substantial impact, and examine the competitive effects of the networks in each of these markets. That examination will take into account any cost savings or other efficiencies that will be attributable to such networks.
The safety zones make explicit what our law enforcement activities have demonstrated: that we do not challenge activities unless they threaten competition or consumers, and that health care providers seeking to improve efficiency, reduce costs, or otherwise benefit consumers and competition through joint activities, need not be concerned about antitrust enforcement. Moreover, the policy statements commit the federal antitrust enforcement agencies to responding quickly to requests to review the legality of proposed activity through the FTC's advisory opinion and the Department of Justice's business review letter processes.
V. Effects of Proposed Antitrust Exemption.
We believe that antitrust enforcement action has not prevented cooperative agreements among hospitals or other health care institutions that would have been beneficial to consumers.(28) To the extent that the proposal would merely authorize the kinds of agreements that would not have been subject to antitrust challenge anyway, it would have no adverse effect on competition. However, the proposal could be interpreted to encourage or permit agreements that are more explicitly anticompetitive in intention and effect than those contemplated before. The chief source of concern would be agreements to allocate responsibilities that did not reflect efficiency-enhancing integration, but instead amounted to agreements to divide markets and refrain from competition. Such division and allocation of markets can be just as harmful to consumers as explicit price-fixing.
We recognize that policy concerns other than those considered in competition law enforcement may be important here. Some of the considerations listed as possible benefits to be weighed against the disadvantages of reducing competition may indeed be such different and independent considerations. Many of them, though, describe the kinds of issues that the Commission considers in its competition enforcement decisions. For example, two factors, increased cost efficiency and improved use of resources, could include the kinds of considerations of true efficiencies that the Commission usually considers in antitrust analysis.(29) Others may be ambiguous. "Preservation of facilities" and "avoidance of duplication", although perhaps intended to include similar issues of efficiency, might include less clearly desirable results as well. The goal of avoiding duplication, to improve efficiency, may contradict the goal of preserving facilities. Moreover, care may be needed to ensure that "avoiding duplication" does not become simply "avoiding competition" — that is, the "avoiding duplication" goal might be interpreted, paradoxically, to suggest that a reduction in competition should be counted as a benefit, to be weighed against itself as a cost.
Because an informed assessment would conclude that antitrust risks are not inhibiting desirable cooperative agreements, and because permitting the health care industry to become accustomed to agreements to eliminate competition could harm consumers' interests without producing clear countervailing benefits, we recommend caution in proceeding with programs such as this proposal. The very process of negotiation among competitors could lead to anticompetitive understandings and market behavior even where no agreement is ever requested and no certificate is granted. And once certificates are granted, it will be difficult to ensure that the agreements are implemented in ways that maintain the balance that justified their issuance.
The law sets two requirements for state action to remove the risk of federal antitrust liability for private actions such as these cooperative agreements among health care providers. First, the actions must be taken pursuant to a clearly articulated state policy to displace competition; and second, the state must actively supervise the policy.(30) The "active supervision" requirement means that supervision must extend to specifics of implementation.(31) The Supreme Court has said that the purpose of the requirement is to ensure that the state has determined the specific details of a scheme that supplants competition; the mere potential for a state supervisory action is not enough.(32) Applying this requirement to health care, it has been held that an authorizing certificate would not confer antitrust immunity, in the absence of post- certificate regulation of the parties' conduct to ensure that it was consistent with the state's policies.(33)
This proposal would require that applications for certificates be reviewed and specifically approved before the certificates would be issued, but does not call for subsequent scrutiny or regulation of the parties' actual operation, except by providing generally for "review" and the possibility of reexamination and revocation. More particularized scrutiny or regulation of actual conduct under these agreements may not only be desirable to ensure that they continue to serve their intended purposes, but might also be necessary to accomplish the apparent goal of conferring antitrust immunity.
One additional way to reduce the risk that anticompetitive agreements would become institutionalized would be to issue certificates only for defined, limited terms. The burden would then clearly be on the parties to demonstrate that the benefits continue to outweigh the disadvantages.
VI. Conclusion.
In summary, we believe that competition has been an important factor in bringing about beneficial changes in how health care services are delivered to consumers. Experience does not demonstrate that immunity from antitrust liability is necessary to permit hospitals or other institutional providers to undertake cooperative arrangements to improve the quality of care they provide and make their operations more efficient. Thus, we recommend that, if antitrust immunity is nonetheless considered desirable for other policy reasons, effective measures be included to ensure scrutiny of "agreements" and to terminate "agreements" whose net effect is detrimental to consumers' interests. We hope these comments are of assistance.
(1) This testimony represents the views of the staff of the Federal Trade Commission.
(2) 15 U.S.C. §§ 41 et. seq.
(3) See, e.g., American Medical Ass'n, 94. F.T.C. 701 (1979); Iowa Chapter of American Physical Therapy Ass'n, 111 F.T.C. 199 (1988) (consent agreement); Wyoming State Bd. of Chiropractic Examiners, 110 F.T.C. 145 (1988) (consent order); Connecticut Chiropractic Ass'n, 114 F.T.C. 708 (1991); American Psychological Ass'n, C-3406 (consent order issued December 16, 1992), 58 Fed. Reg. 557 (January 6, 1993)); Texas Bd. of Chiropractic Examiners, C-3379 (consent order issued, April 21, 1992, 57 Fed. Reg. 20279 (May 12, 1992)); National Ass'n of Social Workers, C-3416 (consent order issued March 3, 1992, 58 Fed. Reg. 17411 (April 2, 1993)); California Dental Ass'n, D-9259 (administrative complaint issued July 9, 1993); and McLean County Chiropractic Ass'n, C-3491, 59 Fed. Reg. 22163 (April 29, 1994) (consent order).
(4) See, e.g., Columbia Hospital Corporation, D. 9256 (complaint issued February 18, 1993; consent order, 59 Fed. Reg. 33296 (June 28, 1994)); FTC v. Columbia Hospital Corp., No 93- 30-CIV-FTM-23D (M.D. Fla., preliminary injunction issued May 21, 1993); University Health, Inc., D. 9246 (consent order issued September 9, 1992, 57 Fed. Reg. 44748 (Sept. 29, 1992)); FTC v. University Health, Inc., 1991-1 Trade Cas. (CCH) ¶¶ 69,400, 69,444 (S.D. Ga.), rev'd, 938 F.2d 1206 (11th Cir. 1991); Hospital Corporation of America, 106 F.T.C. 361 (1985), aff'd, 807 F.2d 1381 (7th Cir. 1986), cert. denied, 481 U.S. 1038 (1987); American Medical Int'l, 104 F.T.C. 1 (1984).
(5) See, e.g., letter to North Dakota Assistant Attorney General David Huey (March 8, 1993) (concerning bills, similar to the proposal being considered here, to grant antitrust exemptions to certain cooperative agreements among hospitals or other providers); letter to Illinois State Senator Judy Baar Topinka (March 12, 1993) (concerning bill to establish demonstration program to test feasibility of alternative health care delivery system).
(6) Another subject of this hearing is a bill about pharmacies and prescription drugs that was considered in the last legislative session and is expected to be introduced again in the next one. The staff of the Commission has commented several times, in other jurisdictions, about "any willing provider" features comparable to those in this bill. Copies of those recent comments are attached to this statement for your information.
(7) Proposed Section 9460.
(8) Proposed Section 9462(d).
(9) Proposed Section 9461(a).
(10) Proposed Section 9462(d)(1).
(11) Proposed Section 9462(d)(2).
(12) Proposed Sections 9460, 9465(a).
(13) Proposed Section 9462(e). Certificates would be granted only if "clear and convincing" evidence showed that benefits outweighed disadvantages, but they could be revoked if only a preponderance of the evidence showed that the balance had shifted the other way. Proposed Section 9465(b).
(14) See letters from Federal Trade Commission concerning H.R. 3486 and S. 1658 to The Honorable Jack Brooks, Chairman, Committee on the Judiciary, United States House of Representatives, and The Honorable Howard M. Metzenbaum, Chairman, Subcommittee on Antitrust, Monopolies, and Business Rights, Committee on the Judiciary, United States Senate (June 10, 1994). The Department of Justice has also taken a similar position. See letter from Anne K. Bingaman, Assistant Attorney General, U.S. Department of Justice, Antitrust Division, to The Honorable Howard M. Metzenbaum, (April 14, 1994).
(15)" U.S. v. Topco Associates, Inc., 405 U.S. 596, 610 (1972).
(16) See e.g., the "Cleveland Clinic" cases: Medical Staff of Holy Cross Hospital, FTC Docket No. C-3345, 56 Fed. Reg. 49184 (1991) (consent order); Medical Staff of Broward General Medical Center, FTC Docket No. C-3344, 56 Fed. Reg. 49184 (1991) (consent order); Diran Seropian, M.D., FTC Docket No. 9248, 57 Fed. Reg. 44748 (1992) (consent order).
(17) See e.g., Baltimore Metropolitan Pharmaceutical Association, Inc., FTC Docket No. D- 9262, 59 Fed. Reg. 15733 (1994).
(18) The Commission is not in a position to make broad predictions or recommendations about what the hospital industry will or should look like in the next century. The Commission's involvement in the health care field is limited to the enforcement of certain antitrust and consumer protection statutes. While that role is important, the Commission's experience with, and expertise in, health care is limited and specialized, as compared to agencies such as the Department of Health and Human Services.
(19) Department of Justice and Federal Trade Commission, Horizontal Merger Guidelines (April 2, 1992).
(20) Id.
(21) Claims of efficiencies will only be considered if they are realistic and supported by the evidence. Notably, in three of the four hospital merger cases decided after litigation in which potential efficiencies were a significant issue, the hospitals' arguments on that issue were rejected as factually unpersuasive. See FTC v. University Health, Inc., 938 F.2d 1206, 1223-24 (11th Cir. 1991); United States v. Rockford Memorial Corp., 717 F. Supp. 1251, 1287-91 (N.D. Ill. 1989), aff'd, 898 F.2d 1278 (7th Cir.), cert. denied, 111 S.Ct. 295 (1990); American Medical Int'l, 104 F.T.C. 1, 148-155, 218-20 (1984). However, the Commission has weighed potential efficiencies in reaching its decision not to challenge certain hospital transactions.
(22) A recent GAO study compiled the enforcement records of both federal antirust enforcement agencies. It found that, of the 397 hospital combinations for which pre-merger filings had been made between 1991 and 1993, only 28 resulted in formal "second requests" for additional information, and only 15 of those were challenged. United States General Accounting Office, Federal and State Antitrust Actions Concerning the Health Care Industry (August 5, 1994). The figures do not include combinations that did not require pre-merger filings.
(23)" American Bar Association Working Group on Health Care Reform, "Antitrust Implications of Health Care Reform" (May 14, 1993) at 4.
(24) Report of the Secretary's Task Force on Hospital Mergers, at 11 (Jan. 1993). The HHS task force specifically addressed the issue of rural hospital mergers. It found that there was no evidence that the possibility of scrutiny by the antitrust enforcement agencies adversely affected consolidation among hospitals in rural markets. The task force also found that very few such mergers are investigated, and concluded that there was "no need to exempt and therefore tacitly encourage mergers among hospitals in rural or ?small' urban settings." Id.
(25) University Health, Inc., D. 9246, 57 Fed. Reg. 44748 (1992) (consent order) (exempting a wide range of support service joint ventures). See also The Reading Hospital, 113 F.T.C. 285 (1990) (consent order) (the Commission determined that voluntary separation of the merged hospitals was sufficient to restore them as independent competitors, even though both hospitals continue to participate in hospital-sponsored health plan joint ventures, and to share laundry, laboratory, and biomedical equipment repair services).
(26) If there are fewer than five of one type of specialist in the market, the venture may include one of them on a non-exclusive basis.
(27) If there are fewer than four of one type of specialist in the market, the venture may include one of them.
(28) We know of no antitrust actions brought by private parties against cooperative agreements of the kind contemplated by this proposal. In theory, the risk of facing the costs of antitrust litigation or enforcement could discourage even some joint arrangements that would not be found illegal. In practice, though, the threat of government or private antitrust action has not, to our knowledge, discouraged beneficial cooperative arrangements. Reports in trade journals suggest that the threat of antitrust action has not chilled collaborations. See, e.g., D. Burda, Mergers thrive despite wailing about adversity, Modern Healthcare (October 12, 1992).
(29) For examples of consideration of such efficiencies in particular hospital mergers, see the cases cited in n. 21, supra. See generally Massachusetts Bd. of Registration in Optometry, 110 F.T.C. 549 (1988), for a discussion of how the Commission considers factors such as these in deciding other kinds of antitrust cases. These factors would not be considered in a case of pure price-fixing among competitors, but would be important in a case involving a joint venture or other combination.
(30) See California Retail Liquor Dealers Ass'n v. Midcal Aluminum, Inc., 445 U.S. 97 (1980).
(31) F.T.C. v. Ticor Title Insurance Co., 112 S.Ct. 2169 (1992).
(32) Ticor, supra n. 31 at 2177 (the state must have exercised independent judgment and control "so that the details of the rates or prices have been established as a product of deliberate state intervention, not simply by agreement among private parties"), 2179.
(33) See P.I.A. Asheville, Inc. v. North Carolina, 740 F.2d 274, 278 (4th Cir. 1984), cert. denied, 471 S.Ct. 1003 (1985) (certificate of need approval for hospital acquisition did not immunize from antitrust challenge; there was no active supervision of post-certificate conduct, and the federal program that the certificate of need process implemented did not displace the antitrust laws).


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The last 12 months have seen some significant changes in the real estate industry as we prepared for and in November last, started working with, the Real Estate Agents Act 2008 which replaced the old and in many ways outdated 1976 Act.
The new Act has made sweeping changes to our controlling administration and greater accountability is demanded from those working in the industry. Gone is the previous Real Estate Agents Licensing Board, and membership of the Real Estate Institute of NZ is no longer mandatory but a matter of choice.
The Real Estate Institute, which was previously the watch dog and administrator of good practice, no longer has this role and in the future will be more involved in providing service and support for its members. The REI has at times come under strong criticism for its seemingly lenient penalties and attitude towards errant members. I believe that some of this criticism has been unfair and
judgments have been made by members of the public, at times, without a full knowledge of the facts and without appreciating the
limitations of the 1976 Act. TommyŌĆÖs has always supported the REI and will continue to do so, at least in the immediate future under the new regime of voluntary membership. Like all good business decisions though, this will be subject to annual review
as we see where their activities fit in with our own game plan.
We see membership of the REI as offering support to us in the areas of training, gathering and dissemination of statistics, setting high standards of good work ethics and in being the voice of the industry in discussions, negotiations and lobbying to Government and the new Real Estate Agents Authority. Just as dealing with a member of the Master Builders Assn provides the public with confidence in a builderŌĆÖs knowledge, experience and good work practices, so too should dealing with a member of the REI inspire public confidence.
On the subject of the Real Estate Institute of NZ, as a member company, we would like to publicly record our sincere thanks and respect
for their Wellington area Regional Manager, Mrs. Alison Lawson. Alison LawsonŌĆÖs current role terminates shortly but we hope that we may still see her in some industry support role in the future. Alison has held the position of Secretary and latterly Regional Manager for Wellington and Districts for 30 years and has given outstanding service to the membership over that extended period of time.
Alison was particularly helpful to TommyŌĆÖs Real Estate Ltd in its formative years and has willingly offered help and guidance in a variety
of situations. There would not be a person in New Zealand who has a better knowledge of the industry, its administration and the key people involved in it. Thank you Alison for everything you have done for us.And so on with the new regime. It is common knowledge that the Real Estate Agents Authority has far greater powers to administer and penalise errant agents and also that there are already a serious number of complaints on their files for determination. Unfortunately, one of those complaints was directed at this
Company and we have been through our first and I hope last, investigation of this complaint by the Complaints Assessment Committee. The process was incredibly thorough and I am pleased to say that the complaint was not proven and has been set aside as we hoped and predicted it would be.What I can say though, is that if this case is indicative of the lengths that the committee will go to to ensure
that their decisions are both fair and correct, then it must be comforting for both parties in any dispute to know that their concerns are not being taken lightly. In our situation, both sides of the dispute had ample opportunity to state their case, which is as it should be. The report on the findings of the Complaints Assessment Committee was comprehensive yet easily understood and above all, was carried out by an independent body, which should go a long way towards satisfying the increasingly litigious clients that we deal with daily.
Although we are in times of change, little has changed really in the way we deal with our clients and our foundation policies of professionalism, fairness and ethical practice will continue to be the path we follow and encourage at TommyŌĆÖs.
Best wishes
Managing Director
Pick up your copy from any one of the Tommy's stands around Wellington Region, or read it here.


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Logging opportunity for a non-stimulant fat loss stack. AI Sports has recently launched our green coffee bean extract, and we're coupling it with our Magic Matcha tea for a science supported 2 month fat loss stack. We'll be picking 2 people from this thread to log them to show the synergy the 2 products have. Each of the 2 selected will get 2 containers of Magic Matcha and 2 bottles of Green Coffee Extract
- Must be 18 or over
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- Must not be using along with any other fat loss products other than low doses of fish oil. If you are using something you aren't sure about, ask
- Must post here with basic info on your training, diet and experience. Being able to post bodyfat % from calipers would be a plus
And for the fun part, you have to either add in your application post how you like to drink your coffee or tea, or a picture of something coffee or tea related (have fun with it). Loggers will be chosen based on the other details in their application, but bonus points for fun pictures.
Here's a few to get you started


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- Ivan Ng '13
- Hometown: Penang, Malaysia
- Major: Communication
I think the presence of the international students here on campus allows for a cultural exchange that could further bridge the gap between people from around the world.
- Alina Selby '14
- Hometown: Finleyville, PA
- Major: Mechanical engineering
WRMU has teamed up with Gionino's Pizzeria to bring the Mount Union campus and the Alliance community another year of pre-game parties. The WRMU sports team will be broadcasting live from outside of the main gates of the Mount Union Stadium. WRMU will provide pre-game coverage before every Purple Raider Home Football Game this season.
The pre-game show includes complimentary pizza from Gionino's Pizzeria, giveaways from WRMU and the chance to win a free pizza from Gionino's.


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file instead? To be specific, I want to add a "h2" button that will add in a

into the body.
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It is almost code golf, but this is the smallest piece of code that I could up with that will create a button on the Visual editor to turn the current paragraph in a
It is based on a TinyMCE code sample and uses a trick to pass a function as the To add a button to the HTML editor you can extend the much simpler "quicktags" code by enqueuing this extra Javascript file:
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recipe reviews for:
"A sweet switch from the usual cheese ball. Cream cheese and butter are sweetened and blended with miniature chocolate chips, then rolled in chopped pecans."
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Get the season's best recipes for holiday feasting.
Holiday cookies, cakes, pies, and breads. Get recipes and inspiration.
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See how to make a pecan-studded cheese ball with Cheddar and cream cheese.
Creep 'em out completely with a cheese ball that's frighteningly good.
These amazing cookies are good for the heart AND for the taste buds.


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We just love this place, even if it is really small but the dishes are just excellent, their choice of tea fantastic and the service is at its best. Go for it!
We just love this place, even if it is really small but the dishes are just excellent, their choice of tea fantastic and the service is at its best. Go for it!
If you want to eat excellent vegetarian food, then you want to visit Lao Wai, they have found a style that is just wonderful, they cook food and serve love, and they do it with style! we are usually 2 people, and we take in 3 different dishes, and we just can't stop eating, don't forget to have their thé... More
Off the beaten track you'll fond this gem. They make the food when you order it, a la minute. No prefab, no microwave just directly from the wook to your plate. Be on time, it easily get crowded here, its a small place. Great, tasty food! I recommend the Mapotofu. Or the Gong Bao. Mmmm.
This place is very small and from memory I think there is space for about 25 people. The menu is all vegan and there's a good range of different dishes. There's a tofu section, vegetable section and soya protein section so that's a good start. The food tasted really good, rich and the portion was plentiful. I would say it... More
Much better than the vegetarian chinese buffet found all over the world. Great service and the food was above average, it did suffer a little from the overuse of soy/sweet and sour sauces as noted by others. Got in midweek without booking.
Serves 'only' gourmet Chinese vegetarian food. The owner-chef has chosen such a small place so he can prepare every dish individually - be sure to book! His passion for this food is tastable. Nice little wine list, and very reasonable prices.
If you've tried chinese veg cooking with soy substitute meat or fish, you will not rate this place as highly as some do. Very limited menu. As with much of this kind of cooking it is quite salty but tasty nonetheless. Really enjoyed my starter but the other reviews are over the top. It does get packed and is very... More
Vegetarian or not, I believe you should eat from this restaurant. You will not understand really the difference. We had 1. Ma Po Dou Fu (tofu dish with spicy and aromatic soya mince, chilibönsås, garlic, ginger, scallions and Sichuan Pepper) and 2. Gong Bao Su Ji (chicken dish with dried chilies, garlic, peppers, baby corn and roasted peanuts in a... More
This exciting little restaurant has wonderful vegetarian Chinese food. Always! Always! Full! Have to be prepared to wait or try to order a table before you go there. Here, you don't have to worry if they might be using fish or meat that we are not used to eating. Everything is vegetarian BUT you can order dishes with "vegetarian" fish... More
Visited after the TA reviews and it's simply the best vegetarian restuarant I've been to. Even as a meat eater it's in my top ten restaurants I've ever been to.
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1. Treating Mobile Users Like PC Users
Unlike PC users, mobile users don't want to download your entire seven-page report. Instead, they are looking for fast access to information since they are usually on the move. Mobile users are not interested in doing a lot of clicking around to get what they need. So your information should be exact with very few words, images and graphics.
2. Not "Targeting" An Audience
Mobile marketing with text messages only works when you send the message to the right people. Some companies make the mistake of treating SMS (Short Message Service) like a mass marketing media instead of the targeting tool it was meant to be.


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Dec 8 2013
First Page: Unpublished Manuscript
Welcome to First Page Saturday. Individual authors anonymously send a first page read and critiqued by the Dear Author community of authors, readers and industry others. Anyone is welcome to comment. You may comment anonymously. You can submit your own First Page using this form. The globe's surface was irregular, as if it truly was(…)


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What is JACK?
Have you ever wanted to take the audio output of one piece of software and send it to another? How about taking the output of that same program and send it to two others, then record the result in the first program? Or maybe you're a programmer who writes real-time audio and music applications and who is looking for a cross-platform API that enables not only device sharing but also inter-application audio routing, and is incredibly easy to learn and use? If so, JACK may be what you've been looking for.
JACK is system for handling real-time, low latency audio (and MIDI). It runs on GNU/Linux, Solaris, FreeBSD, OS X and Windows (and can be ported to other POSIX-conformant platforms). It can connect a number of different applications to an audio device, as well as allowing them to share audio between themselves. Its clients can run in their own processes (ie. as normal applications), or can they can run within the JACK server (ie. as a "plugin"). JACK also has support for distributing audio processing across a network, both fast & reliable LANs as well as slower, less reliable WANs.
JACK was designed from the ground up for professional audio work, and its design focuses on two key areas: synchronous execution of all clients, and low latency operation. More background information is available.
Understanding JACK in different ways
The term "JACK" doesn't really identify anything very precisely. What "JACK" means depends a little bit on your perspective. There are several ways of understanding the term, all equally valid:
- The JACK API
- The definition of the data structures, protocols and functions used by programs that use JACK
- An implementation of the API
- Actual software, including a server application, often called "jack", and a library used by clients. There are already two implementations of the API, known as "jack1" and "jack2" (formerly "jackmp"). Different implementations are (in almost every way) drop-in replacements for each other.
- A GUI control application
- The existing implementations do not come with any GUI at all. To make life easier for most users, GUI control apps exist that allow easy modification of JACK startup parameters, and ways to monitor the state of a running JACK system.
is the most widely used GUI control application. - A running instance of JACK with a variety of JACK-aware applications
- This will likely include the server application, the control GUI, and zero or more actual applications that use JACK, such as Ardour (a DAW), Hydrogen (a drum machine) or many, many more.
JACK on iOS
Submitted by letz on Sun, 2013-03-24 18:33JACK has been released on iOS thanks to the hard work of Christian Schoenebeck at crudebyte for the GUI control application and server, and GRAME on the server part. The server code is embedded in a control application that will launch the server, allow to adjust settings, and manage connections between applications. The application is free and can be downloaded here.
JACK 1.9.9 released
Submitted by letz on Mon, 2012-12-10 12:34Jack 1.9.9 is API compatible with latest Jack 0.121.3 version.
What is new:
- Adrian Knoth fix in midiseq.c.
- Fix library symbols export issue.
- Cleanup drivers and internals loading code.
- jackctl_driver_params_parse API moved in public control.h.
- More general drivers/internals loading model on Windows.
- Factorize code the server/client request in JackRequestDecoder class.
- More robust server/client protocol. Implement shutdown for in server clients.
- Better time-out management in NetJack2.
- Experimental system port alias use in Windows JackRouter.
MacBook running Linux: audio via JACK is distorted, audio via ALSA is not
As of April 2012 there seems to be driver problem that affects the audio interface on the Macbook when it is used in 24 or 32 bit mode. To avoid the resulting distortion, use the -S flag to the ALSA backend to force it to use 16 bit sample data format.
JACK 1.9.8 released
Submitted by letz on Mon, 2011-12-19 14:45Jack 1.9.8 is API compatible with latest Jack 0.121.3 version.
This is the first version that contains the new MIDI driver model developed by Devin Anderson in spring of this year. This includes the Linux FFADO driver, the Mac OSX CoreMIDI driver, the Windows WinMME driver, and a new Linux 'alsarawmidi' slave driver that can run alongside other master drivers (i.e. FFADO).
JACK 0.121.3 released
Submitted by paul on Wed, 2011-09-28 13:01JACK 0.121.3 is a bug fix release containing (almost) no new functionality. It is required if you want to use JACK1 on OS X with any clients that use weak linkage for JACK feature detection (e.g. Ardour).
Using JACK on Windows
As on other platforms, JACK on Windows is a multi-purpose application that connects audio and MIDI using the Windows system drivers... It connects (OUTPUT) to those audio drivers using the PortAudio project (so Jack can connect using dsound, wmme, WDMKS, ASIO, WASAPI, and WaveRT) depending on what the soundcard's drivers support. Currently Jack for Windows only supports 32-bit applications, but a new version is currently being tested that supports both 32-bit and 64-bit audio applications.
JACK 0.121.2 released
Submitted by paul on Wed, 2011-06-29 02:07JACK 0.121.2 has been released. This correctly includes changes made to jackd.py's device reservation handling. They were done before 0.121.0 was released but not included in that version. No functional changes to regular JACK functionality are present in this upgrade.
JACK 0.121.1 released
Submitted by paul on Tue, 2011-06-28 13:51JACK 0.121.0 released
Submitted by paul on Thu, 2011-06-23 16:08JACK 0.121.0 is now available. and it contains a couple of important bug fixes, a small but nice new piece of functionality, and some unfinished work. Read more below for the details.


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100% of the CEO
Bill Lia Sr.
I worked at Lia Auto full-time for less than a year
Pros – nice employees ,and a beautiful facility with great product
Cons – management doesn't trust anyone to do their jobs
Advice to Senior Management – One size does not fit all
No, I would not recommend this company to a friend
I worked at Lia Auto full-time for less than a year
Pros – Good place to ruin your family life.
Cons – Salary plus bonus but bonus is not based on sales like the rate sheet says that you sign it is based on gross profits on those sales.
Advice to Senior Management – Need to be a bit more employee sensitive. Honesty would go a long way. Much further than sarcasm.
No, I would not recommend this company to a friend
I worked at Lia Auto full-time for more than 3 years
Pros – The Lia Family are great people, but unfortunately Corporate people were very hard to deal with. Could never understand why Lia Family tolerated this
Cons – Corporate management very jealous of sales Employees earnings
Advice to Senior Management – Treat your people Better
Yes, I would recommend this company to a friend – I'm optimistic about the outlook for this company
I worked at Lia Auto full-time for less than a year
Pros – Able to learn about automobiles.
Cons – Discouraged from making a sale. Reason for two stars is because able to learn about cars.
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- Highlights
Manufacturer's SKU F5341-72 Shipping Estimate Items from this manufacturer normally ship within 3 days. However from time to time backorders occur; if this happens we will let you know as promptly as possible. Manufacturer's Warranty "As Is" - No Warranty Brands Propper - Description
The PROPPER I.C.E. Performance Polo breaks the mold with its innovative wicking technology, engineered directly into the fabric and designed specifically to keep you cool, dry and comfortable on the job. The fabric dries 125% faster than cotton and 30% faster than polyester, so you'll stay comfortable even in the most heated situations. Breathable mesh underarms offer additional ventilation to help you maintain a professional appearance. Other features include hidden collar stays, two mic clips and a sunglasses clip under the placket.
• Advanced wicking fabric dries 125% faster than cotton, 30% faster than traditional polyester
• Fade, shrink and wrinkle resistant
• Low profile appearance for use both on and off duty
• Hidden collar stays provide a clean, professional look
• Mic clips on both shoulders and sunglasses clip under placket
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• Extended length for tucking into pant
• Two-channel pen pocket on left shoulderSizing:
Size Chest Neck S 34-36 14-14.5 M 38-40 15-15.5 L 42-44 16-16.5 XL 46-48 17-17.5 2XL 50-52 18-18.5 - Reviews
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Posted: Dec 28, 2012 3:20 PM by Meteorologist Mike Heard
Updated: Dec 28, 2012 4:05 PM
Early winter mountain snowpack is right on track for late December across Montana. The NRCS snow data for today is as follows:
Upper Clark Fork river basin is reporting 99% of average on snow/water content
Jefferson is as 113% of average.
Madison 117% of average.
Gallatin 119% of average.
Missouri Headwaters 115% of average.
Upper Yellowstone 112% of average.
Regionally snowpack conditions also look good across the Pacific NW, northern Rockies and down into the Sierra Nevada range of California. Snowpack conditions range from 90% to 200% of average.
There is a noticeable shortfall in snowpack across the central and southern Rockies in Colorado and New Mexico. Current snowpack data range is between 25% to 75% of average.
Frequent heavy wet snow storms in November helped boost the snow/water content across Montana and a continued chilly weather pattern into December is keeping most of the moist rich snowpack in place. This is a great way to start a new year!


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8 Best Flat WordPress Admin Themes
allie posted in Wordpress 4 days ago
Flat Wordpress dashboard will simplify your daily work as they are easy to look at for hours without any disturbances. These are actually plugins which change the total look of your wordpress login page, dashboard, admin bar etc. Grab the free ones to try out if it is your first time using these admin templates for wordpress, later you can decide on some serious flat ui which are premium.
Photography by Tomasz Zaczeniuk
anliberant posted in Photography 5 days ago
Tomasz Zaczeniuk was born in 1978, now beeing on the way to make photography the way of living in every aspect. Interested in creating parallel reality with help of photomanipulation and music.
Free Poster Mockup PSD
Enfuzed posted in Resources 5 days ago
A free poster mockup PSD for download created by Mike Delsing. This poster mockup includes various editable layers to change lighting and add fold creases to the poster.
How to Create Custom Brushes in Photoshop
creativebeacon posted in Tutorials 5 days ago
Searching online for just the right brush for your Photoshop work can be time consuming. Sure, sites like Brusheezy and Qbrushes have excellent collections of free Photoshop brushes, but what if you could make your own? If you know the look you are going for you can modify a shape or a image and capture that to use as your own brush. You can use almost anything to create a custom brush. You can use vector shapes or images as the basis for brushes. The video below will show you how to create your own custom brushes in Photoshop in minutes.
Create a Rotating Image Slider with Foundation 5 - Web Design Blog
creativebeacon posted in Dev 5 days ago
Have a rotating image gallery on your home page is a widely used trend right now. It just seems to make sense. You can convey a lot of information in a small amount of space. It isn't away easy to implement a jQuery image slider in your own site. Sometimes the code just doesn't work, or you have a script conflict, which means that it doesn't work well with other scripts. In the video below, I will show you how the slider works in Foundation 5, its advantages, its disadvantages, and how easy it is to control with a few simple parameters. In the video below, I will show you how to create a rota
Black and White Drawings by Lorenzo Mariani
anliberant posted in Inspiration 5 days ago
Lorenzo Mariani was born in Italy in 1984.Since he was a child he started to draw and paint using traditional tools such as pencils and oils.
Free Vector Retro Badge Designs - Creative Beacon
creativebeacon posted in Resources 5 days ago
Last week I shared a large collection of vintage floral vector designs and shapes. Not surprisingly, it was a big hit. This week I have gathered an awesome collection of retro badge designs. They could be used as badges for your print or web designs. They could also be used as labels for products, giving anything an instant vintage flair. These retro badge designs are all vectors, which means you can make them as large as you want. Also, you can easily change the colors to suit your needs and match your branding materials. There are tons of shapes and styles in this collection, so there is a
PHP Simple Update using PDO in Bootstrap Tutorial
crewow posted in Tutorials 5 days ago
Update Statement is very common and used to update or edit existing records in database. PHP Simple Update using PDO in Bootstrap is a tutorial in which we will learn how to update data in database using PDO (PHP Data Objects) prepared statements while using Bootstrap CSS Framework.


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RWJF Forum Series
The Power of Placebo
This forum series, co-sponsored by RWJF, brings physicians, neuroscientists and the public together to understand "the big question: why we have the placebo effect."
You are now viewing 1 - 4 of 4 results
October 2, 2012 | Video
The St. Vincent de Paul Society of Lane County, Ore., is changing the economics of community health. Through various programs, they are raising capital and providing stable employment for the community.
Topic, Video
Community development encompasses a range of efforts to improve physical, economic, and social conditions in low-income neighborhoods. There is a growing movement within the field to leverage these efforts as opportunities to improve health.
April 26, 2011 | Audio, Presentation Material
This webinar was the third in a three-part series exploring how conditions where we live, learn, work and play affect our health, built on the work of Robert Wood Johnson Foundation Commission to Build a Healthier America.
January 1, 2012 | Video, Presentation Material
What we're learning about coordinating health care for high-utilizers.


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GREAT BARRINGTON - Housatonic-based author Gina Hyams and The Meat Market will host a chili contest to celebrate publication of Hyams's new book/kit, "Chili Cook-off in a Box: Everything You Need to Host a Chili Cook-off" on Sunday, Oct. 7 from 4 to 6 p.m. at The Meat Market, 389 Stockbridge Road. Admission is $10 at the door and free for chili contestants. Proceeds from the event will benefit Berkshire Grown's Share the Bounty project, which buys shares in local CSA farms to donate to area food pantries and kitchens. Everyone who attends the contest will get to sample various chili entries and vote for the best one.
"You don't need to be a chili expert to enter the contest, you just need passion for the spice of life," said Hyams. All kinds of chili are welcome: meat, poultry, vegetarian, or any combination. Contestants will need to deliver a gallon of their favorite chili to The Meat Market at 3 p.m. on the day of the contest in either in a crock-pot or disposable chafing set, as well as provide a serving spoon and a list of recipe ingredients. To enter the chili contest, send an email to firstname.lastname@example.com that states the type of chili you'll be entering and your phone number.
"Chili Cook-off in a Box" will be published by Andrews McMeel Publishing on September 11, 2012.
The Meat Market, which specializes in locally-raised meats, will have special chili grinds and blends available for sale. For more information about the shop and the author, see themeatmarketgb.com and www.ginahyams.com.


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We were there with friends the first weekend in October and got adjoining rooms on the 1st floor. Anna, the owner was very gracious, helpful and patient. The hotel was undergoing extended remodeling and the outside of the building was surrounded in scaffolding which made it a challenge to find. The windows had plastic over them to keep dust out... More
- Also Known As:
- Hotel Zur Schwalbe
- Official Description (provided by the hotel):
- Small, friendly, family-run hotels – the kind where one immediately feels as if one is at home or visiting good friends – really do still exist. And one of them is Vienna's Hotel Schwalbe. ... more less
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- TripAdvisor is proud to partner with Booking.com, Expedia, Priceline, Travelocity, Hotels.com, Budget Places, HostelWorld, Asiatravel.com Holdings and Tingo so you can book your Hotel Schwalbe reservations with confidence. We help millions of travellers each month to find the perfect hotel for both holiday and business trips, always with the best discounts and special offers.


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We have known for many years that Lower Paleolithic people were using shellfish, fish, and littoral resources at sites across the Old World, from Trinil [1], Koobi Fora [2], Gesher Benot Ya'aqov [3], and elsewhere. I've discussed the evidence several times (maybe most usefully in "The shells of Trinil"). As I wrote last year ("Fishy story at Koobi Fora"):
Aquatic animals aren't important because of their sheer numbers, but because they tell us about the flexibility of foraging behavior. Living hunter-gatherers eat turtles and reptiles when they can, and because they are usually small food packages, they often eat them where they find them instead of returning to a base camp first. Hunter-gatherers are flexible in what they eat and where they eat it. FwJj20 is showing at least a substantial taxonomic flexibility in the meat-eating of early Oldowan hunters.
So why do we keep seeing stories that make shellfish consumption look like news when it's done by Neandertals, MSA Africans, or anybody else?
I'm writing about this today because of a new paper in PLoS ONE by Miguel Cortés-Sánchez and colleagues, reporting on the shellfish remains in Bajondillo Cave, Spain [4].
Shellfish collecting has been well characterized in some Mousterian contexts. Mary Stiner treated it systematically in her 1993 monograph, Honor Among Thieves, which is part of the graduate education of most young Paleolithic archaeologists. Stiner spent a lot of text quantifying shellfish use and gave a good discussion of the biases that make archaeologists find less evidence of shellfish consumption than there probably was.
Most important, when you can walk along a shoreline and nosh shells, you're not very likely to haul many of them back to a cave several kilometers from the shore. In the Holocene, we find lots of archaeological localities where people were systematically collecting many shells and cooking them for large groups. For this purpose, the people carried baskets or sacks of shellfish for a good distance, and after they were consumed, the shells sometimes built up into large trash piles, or middens. We don't see shell middens in Mousterian or MSA contexts, but then we see very little of that kind of behavior with any kind of resources in MSA or Mousterian times. Here's what I wrote in 2008 ("Neandertal diet was not dolphin safe"):
[I]t was hard to understand the excitement that accompanied last year's paper by Curtis Marean and colleagues (2007), who found evidence for shellfish exploitation at Pinnacle Point, South Africa. The press reported the result as if there were a shell midden, with abundant evidence for consumption. But actually the number of shells is fairly small -- all the shells from all the layers reported weigh less than a kilogram. That looks similar to the pattern of exploitation that Stiner had reported for the Neandertals at Moscarini, and more or less like the pattern at Vanguard and Gorham's Caves.
The African MSA-era site with the most direct evidence of shellfish exploitation is at Abdur, Eritrea, where the stone tools are found in an ancient shore terrace, presumably at the very place where shellfish exploitation was happening [5]. That paper hinted at even earlier sites with similar evidence from Acheulean contexts along the Red Sea rift, where subsidence of the rift floor has left some ancient coral reefs exposed, Acheulean tools embedded within them. I should also point out indirect evidence on the basis of species abundance for human exploitation of giant clams in the Red Sea ("The ancient struggle for existence between humans and giant clams").
In other words, archaeologists have found quite a lot of evidence of coastal resource use by early people, despite the steep biases against it. In the case of aquatic animal exploitation, they've got it as early as the Oldowan, 1.95 million years ago [2].
Cortés-Sánchez and colleagues [4] add detail to this record but don't really broaden the picture. Mousterian shellfish acquisition around 150,000 years ago, well before the last interglacial, is earlier than many well-known instances of MSA shellfish utilization. But we know that much earlier humans were using these coastal resources, so it's hardly news. As at other sites, the mollusc remains are not very dense: a minimum of 16 shells in one layer, 66 shells in another, 80 in a third. If I were going to make a story out of it, I would direct more attention to the pearl, first I've ever heard of in a Neandertal site.
More important is the paper's demonstration that humans actually processed the shells. Cortés-Sánchez and colleagues contrast the condition of continental and marine molluscs in the same levels, to show the systematic breakage and burning of the marine species:
[A]lmost all of the marine mollusks exhibit intensive mechanical fracturing, with sharp edges on their shells suggestive of an absence of post-depositional transport, and very few appear complete (i.e., barely 7% at Bj19). Such fracturing, coupled with the absence of shells eroded by water, indicates that the marine mollusks from Bajondillo Cave, and in particular those from Bj19 do not represent "background fauna" from the nearby beach, a phenomenon that has recurrently caused problems in the association of early Middle Paleolithic shellfish deposits from the Mediterranean with paleo-human activities. In addition, a substantial percentage of the mussels exhibit burning marks (Figure 4: 1–6). These are recorded on 48% of the adult specimens from Bj19, the young mussels never exhibiting such traces. Thermo-alterations suggest consumption rather than passive burning, given that in most cases only the outer portions of the shells appear carbonized and/or flaked. An indirect line of evidence supporting this same hypothesis is provided by five of the epibiont barnacle remains that fire not only detached from the mussel shells but that in that process were thoroughly carbonized, as is the case of the four specimens from Bj18 (Figure 4: 8,11) or else calcined, as happens with the specimen from Bj19 (Figure 4: 12).
I appreciate the paper's list of 24 previously-published Neandertal sites that present mollusc remains. It would be useful to compile a broader list including MSA sites. Personally, I hope to never read again a headline about how surprising or significant was shellfish use by early humans.
- . Relevance of aquatic environments for hominins: a case study from Trinil (Java, Indonesia). Journal of Human Evolution. 2009 ;57(6):656-71.
- . Early hominin diet included diverse terrestrial and aquatic animals 1.95 Ma in East Turkana, Kenya. Proceedings of the National Academy of Sciences of the United States of America. 2010 ;107(22):10002-7.
- Spatial Organization of Hominin Activities at Gesher Benot Ya'aqov, Israel. Science [Internet]. 2009 ;326:1677–1680. Available from: http://dx.doi.org/10.1126/science.1180695
- Earliest Known Use of Marine Resources by Neanderthals . PLoS ONE. 2011 ;6(9):e24026.
- Early human occupation of the Red Sea coast of Eritrea during the last interglacial. Nature. 2000 ;405(6782):65-9.


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Home > Babies > Personalized Baby Bibs > monkey-bib
Monkey Baby Bib
A little brown monkey is swinging on a green leafy vine on this baby bib! Personalize with your own text! Fine 1x1 rib knit bib made of 100% cotton.
artist: Amy Adele
style: t-shirt
size: t shirt
paper type: heavy
printing method: Digital Direct to Garment
printing method: Digital Direct to Garment
font shown: Tweedledee
font color shown: dark blue
item code: tsbib067
(see matching items below for return address printing)


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Results 21 to 28 of 28
Thread: MAP sensor fell into manifold
What the hell were u torquing to 40lbs? Hope u ment in-lbs and not ft-lbs
02-03-2013, 09:57 PM #22You prob ruined the gaskets and warped the intake with 40lbs. Was it 1/2" drive?
line-x'd front brush guard with KC Daylighters, 6000k HID lows and highs, rewired highbeams, Trans-go mild shift kit, custom stainless duals, 3500 dually OEM taillights, K&N CAI. Still have OEM fender flairs and leveling kit in boxes waiting for time.
02-04-2013, 08:36 AM #23X2- That is waay to much, If I remember right it's around 12lbs of torque.
The Hayne's manual is probably out of date, they come out with torque revisions all the time. If we would have followed the Haynes manual when doing our engine rebuild, 90% would have been incorrect.Last edited by TRPLXL2; 02-04-2013 at 08:56 AM.
2004 Chevy Colorado
LS1 5.7 swap/TBSS rear axle swap
02-04-2013, 04:44 PM #24Haynes was right, I just didnt realize it was Inch/lbs. I was right around 40lbs....it did crush one of the rubber grommets on one of the bolts, as well as broke another.
- - - Updated - - -
Just being in a hurry not paying attention to detail, in the freezing cold.
- - - Updated - - -
Gaskets look alright, intake looks alright.
- - - Updated - - -
According to this conversion calculator thing, It should be around 8lbs. Damn. ...I ordered a new set from the dealer today.
- - - Updated - - -
Thats the final torque spec. I believe it has 2 steps, 1 is 44 and 2 is 89 inch/lbs
- - - Updated - - -
1999 Chevrolet Suburban LS K1500
1991 Chevrolet S10 4.3L 4x4
2005 Suzuki Forenza (GM/Daewoo)
02-05-2013, 08:18 AM #25My gasket surface OCD is screaming looking at that picture but since I live in n. ohio and its about 19* highs I won't break your balls. Those are fel-pros just warranty them out, they dont care if you fudged it and even if they did they wouldnt know.
02-05-2013, 05:17 PM #26Warranty the gaskets out? I pulled them off and see nothing wrong with them.
- - - Updated - - -
Unless I am missing something, which is likely given my track record on this project...I got a good look at the new gaskets before I put them on. After this mishap I pulled everything back off immediately and they looked no different.
02-05-2013, 08:11 PM #27why risk an intake leak just because you didnt "see" a problem with them. take the taime and get new gaskets.
"i dont think you got the picture. i got a beautiful picture. this baby happens to have an extra turn of speed, which is the only thing i care about. you dont understnad what happens do you? they make cars. they make 'em exactly the same way. one or two of 'em turn out to be something special. nobody knows why. i know why. i may be kiddin' myself, but i think i can make somethin' out of that sad little bucket of bolts." ~ Tennessee Steinmetz
02-06-2013, 04:34 PM #28So looking at the bolts and the way the manifold gaskets have rubber that goes around the bolt holes, I am assuming that the bolts and the sleeves on the bolts are designed to seal the manifold when tightened. I just had to order a whole new set of bolts because most of the rubber seals on them were slightly torn.
- - - Updated - - -
Also, what can I use to clean the injectors with while I have everything out.
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Nickelodeon Gak is back! The Nickelodeon Gak - Blue is the incredible squishable, squeezable, squashable, stretchable, bounceable, ploppable, poppable stuff! Once you pick it up, you won't want to put it down. Gak's awesome "Splat" container lets you make all sorts of wacky sounds when you squish the Gak around. Smoosh it, Twist it, Bubble It, Mix it...you've got the knack for Gak!
"R"Web#: 376927
Manufacturer #: 13010
Product Weight:0.4 pounds
Product Dimensions (in inches):8.0 x 6.0 x 1.8
Shipping Info:
Average Customer Rating:
(based on 10 reviews)
Ratings Distribution
5 Stars
4 Stars
3 Stars
2 Stars
1 Stars
of respondents would recommend this to a friend.
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Most Helpful Positive Review
Great Toy for all ages
I owned the Original Gak made by Mattel when I was 7. This brings back the memories and it is still a fun toy to play with even though I am now 18 and going...Read complete review
I owned the Original Gak made by Mattel when I was 7. This brings back the memories and it is still a fun toy to play with even though I am now 18 and going into college. This is a toy for all ages.
Most Helpful Critical Review
Absolutely horrible!
I took my allowance together to buy Gak and the result was horrible! It just stuck to everything and was not even nearly as squishy and stretchy as in the commercials and videos. Also,...Read complete review
I took my allowance together to buy Gak and the result was horrible! It just stuck to everything and was not even nearly as squishy and stretchy as in the commercials and videos. Also, there was no way to bounce it, stretch it, or do anything fun with it at all. The Gak that glows, barely worked and every time I tried to stretch this item it just fell apart! It was horrifying! Absolute garbage! After the first couple of minutes, I threw it away! One thing I'm wondering right this second is why I can't do ZERO stars or NEGATIVE STARS!
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(0 of 1 customers found this review helpful)
By Cathy
from Dallas, TX
About Me Avid Gamer, child
Comments about NSI International 1012089 Nickelodeon Gak - Blue:
Comment on this review
Texture is awful
By toymom
from moorpark
About Me Parent
The texture of this Gak is awful. Sticky. Will be returning it.
By Ashley, mom of 2 boys
from Elkhart, Indiana
We got tons of Floam and Gak for our boys for Xmas, Unfortunatly every single package didnt work like the old Gak & Floam! It falls apart, it doesnt stick together and after hours of trying to get them to stick together they never did. Very Disappointed!!!!
Absolute garbage
By McSweede
from NY
About Me Avid Gamer, Parent
Wow if I could give negative stars I would. I bought a few different color Gak for my kids, one color was so watery it just stuck everywhere and was totally disgusting, could not do anything with it. The other colors just crumbled apart. Could not even remotely do anything similar to the commercials. This product should just disappear. About a year ago I bought a dollar store version of similar stuff, worked as this stuff should!
Garbage!!! Bad customer service from NSI
By Jolene
from Pittsburgh, PA
I purchased several packs of this for Christmas and none of it is usable!! Yellow is chunky and the rest is sticky. I followed the directions after I called the customer service number and it did not work. They will not answer the phone and my email was rejected. I dialed an extension hoping to speak with someone and he answered "Hello" and I told him I needed to speak with customer service and he hung up on me.
What a mess!
By StarFoot
from Nanuet NY
My daughter received this as a gift and was so excited but after 5 minutes did not want it...IT was stuck all over her hands...took several minutes for us to basically wash it off of her hands. I would have no problem if it stuck to things like furniture, carpet...etc. Thats to be expected...but your skin...what fun is that?
(2 of 2 customers found this review helpful)
I would never recommend
By boss gamer
from Enterprise, Al
About Me Gamer
This product is bad. Me and my two friends bought this and is was hard to get off our hands, carpet, and furniture. I would not recommend this product.
I wouldn't buy it again.
By busy girl
from Las Vegas NV
About Me None
It was very hard to get of yor skin, carpet, and cabnet this prouduct is awfull.
(1 of 1 customers found this review helpful)
Dreadful toy.
By Stella
from Alexandria, VA
Unlike other squishy, doughy toy materials, Gak sticks to everything. It's okay if the kids are older, dressed in disposable play clothes, and surrounded by hard surfaces. Otherwise, be aware that the material easily gets into and is impossible to remove from clothes and hair. It is intrinsically water insoluble but, worse, also insoluble with soap/detergent. It's a mess not worth getting into.
(2 of 3 customers found this review helpful)
By Nick
from Eatontown, NJ
About Me Avid Gamer, Thrifty
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Electronic Media and Broadcasting
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A major in Electronic Media & Broadcasting will teach you how to craft effective stories and give you experience with using the latest technology to create your stories elecronically to share them with the world. Whether you're interested in radio or video, digital cinema or live television, you will leave the program with an impressive portfolio of your own media productions to share with prospective employers.
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Get this version on iTunes: https://itunes.apple.com/us/album/i-knew-this-would-be-love/id683329366 Imaginary Friend (who you may recognize if you've seen me on tour) kindly let me steal a verse from this song so we could sing it as a duet. Check out the original version as well, along with his new album, where I had the honor of singing all the harmonies :) Fire Escape album on iTunes: https://itunes.apple.com/us/album/fire-escape/id634457130 IMAGINARY FRIEND: Facebook: http://www.facebook.com/imaginaryfriendmusic Twitter: http://www.twitter.com/imaginarytweets Youtube: http://www.youtube.com/imaginaryfriendmusic Official Website: http://www.imaginaryfriendmusic.com KINA GRANNIS: Facebook: http://www.facebook.com/kinagrannis Twitter: http://www.twitter.com/kinagrannis Youtube: http://www.youtube.com/kinagrannis Official Website: http://www.kinagrannis.com LYRICS It's funny how we met on the telephone You and I on the edge of the unknown Oh, in only a moment's time I knew my heart was yours and yours was mine When I saw you waiting at your place Something felt familiar in your face Oh, you smiled as if to say I knew my heart was yours from the first day We were right We stood through it all Holding tight Whenever we fall What we found is second to none I knew, I knew, I knew this would be love I knew, I knew, I knew this would be love There were days when I thought I'd lost you I read the letter aloud, what could I do? Now, we're right back where we belong Don't second guess your heart, it's never wrong CHORUS
Call of Duty Ghosts Gameplay Walkthrough Part 1 includes mission 1 of the Campaign Story for the Xbox 360, Playstation 3, PS4, Xbox One, and PC version in HD quality. This Call of Duty Ghosts Gameplay Walkthrough Let's Play will feature funny commentary as I review and show my journey to the ending of the game. Let's aim for 15K likes to start of this series! I'm ready to splash your sub box with this series. My Call of Duty Ghosts Playlist! Stay up to date with the series! http://tinyurl.com/lm9du7u Giveaway Winners YouTube Names PS3 = 29thedream, Mikalem23, TheClutchMJ. 360 = TheMadFisher12, Daniel Percival, Apollo Creed Jr. Check YouTube inbox to receive the game! My Facebook and Twitter http://www.facebook.com/ChrisSmoove http://twitter.com/#!/Chris_Smoove Call of Duty Ghosts Gameplay Walkthrough Part 1 Call of Duty Ghosts Gameplay Walkthrough Part 1 Call of Duty Ghosts Gameplay Walkthrough Part 1 Call of Duty Ghosts Campaign Walkthrough Part 1 Call of Duty Ghosts Campaign Walkthrough Part 1 Call of Duty Ghosts Campaign Walkthrough Part 1


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Bingham to miss a month with medial knee ligament injury.
Defender Kevin Feely has returned to Charlton Athletic for treatment on a hamstring problem that has prevented him from making his AFC Wimbledon debut.
Essex Senior Cup: Dagenham & Redbridge 5 East Thurrock United 1
New Dagenham & Redbridge chairman Dave Bennett admits if he can enjoy anywhere near the same success as predecessor Dave Andrews, then he'll be a happy man.
Former Dagenham & Redbridge chairman Dave Andrews admitted the "time was right" to stand down and end his 37-year stint at the helm.
Dagenham & Redbridge's Zavon Hines is delighted his hard work is being noticed after picking up the League Two player of the month award for November.
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Rhys Murphy went into double figures at the weekend with his 10th goal for the Daggers in their 2-0 home win over Wycombe Wanderers.


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Holly Waste, Cleobury Mortimer, DY14 - 5 bed - £765,000 - Halls Estate Agents - Kidderminster
Get involved! Send your photos, video, news & views by texting WN NEWS to 80360 or e-mail us
Property details
Holly Waste, Cleobury Mortimer, DY14 £765,000
Marketed by:
Halls Estate Agents - Kidderminster
Phone the agent:
01562 820880
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Property details
Bedrooms: 5
A character detached cottage with independent two storey attached annexe. The property has been vastly improved and offers spacious accommodation benefitting from generous formal gardens, a small orchard, separate paddock approximately 5.5 acres & detached work shop (70ft x 40ft) with separate access and parking. There is planning permission for separate detached building/garage. The property, land and outbuildings offer potential for family living as well as the potential for commercial usage. This unique opportunity is set in the beautiful Shropshire Countryside with access into Bewdley, Ludlow and Cleobury Mortimer.
Local information for this property
Abberley Parochial VC Primary School
Alveley Primary School
Astley CofE Primary School
Bayton CofE Primary School
Bewdley Primary School
Bishop Hooper Church of England Primary
Bitterley CofE Primary School (Aided)
Brown Clee CofE Primary School
Burford CofE Primary School
Burlish Park Primary School
Clee Hill Community Primary School
Cleobury Mortimer Primary School
Clifton-upon-Teme Primary School
Corvedale CofE Primary School
Far Forest Lea Memorial CofE Primary School
Farlow CofE Primary School
Great Witley CofE Primary School
Highley Community Primary School
Hopton Wafers CofE (Controlled) Primary School
Kimbolton St James CofE Primary School
Kinlet CofE Primary School
Lickhill Primary School
Lindridge St Lawrence's CofE Primary
Ludlow Junior School
Martley CofE Primary School
Orleton CofE Primary School
St Anne's CofE VC Primary School
St Bartholomew's CofE VC Primary School
St Laurence CofE Primary School
St Wulstan's Catholic Primary School
Stottesdon CofE Primary School
Stourport Primary School
Tenbury CofE Primary School
Upper Arley CofE VC Primary School
Compare all 34
Learning for Life Education Centre
Ludlow Church of England School
Saint Michael's College
Tenbury High School
The Bewdley School and Sixth Form Centre
The Chantry School
The Lacon Childe School
Compare all 7
1 Hollywaste Villa Holly Waste Sep 18 2009 £430,000
Hollywaste Cottage, 5 Holly Waste Oct 10 2006 £525,000
See all 2
Average sold prices for Holly Waste
Type | Sales | Sold Price |
Detached | 2 | £477,500 |
All | 2 | £477,500 |
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Film Showing: "Scarred Lands and Wounded Lives"
Submitted by Anonymous on Tue, 02/21/2012 - 8:00pmThe scale of environmental damage over the last half century is unprecedented. Falling water tables, shrinking forest cover, declining species diversity -- all presage ecosystems in distress. These trends are now widely acknowledged as emanating from forces of humanity's own making: massive population increases, unsustainable demands on natural resources, species loss and ruinous environmental practices. Ironically however, war, the most destructive of human behaviors, is commonly bypassed.
Screening of "Ghosts of Rwanda"
Submitted by Anonymous on Tue, 02/21/2012 - 7:30pmGhosts of Rwanda is a highly acclaimed two-hour documentary on the social, political and diplomatic failures that converged to enable the 1994 genocide in Rwanda to occur.
Through interviews with key government officials, diplomats, soldiers and survivors of the slaughter, Ghosts of Rwanda presents groundbreaking, first-hand accounts of the genocide from those who lived it, including Carl Wilkens, the only American to remain in Rwanda during the entire genocide. Wilkens' choice to stay and try to help resulted in saving the lives of several adults and preventing the massacre of hundreds of children.
This film screening is free and open to the public. Viewer discretion is advised.
This event is co-sponsored by the Center for Holocaust and Genocide Education and by UNI-STAND.
Suzuki Faculty Recital
Submitted by music on Tue, 02/21/2012 - 7:00pmThe UNI School of Music Suzuki School will present a recital featuring Suzuki faculty artists. This event is free and open to the public.
9/11 Film Series - Ghosts of Abu Ghraib
Submitted by Anonymous on Mon, 02/20/2012 - 8:00pmScreening of the film Ghosts of Abu Ghraib will be followed by a discussion in the use of torture in the "War on Terror."
Earth Science Seminar
Submitted by Anonymous on Mon, 02/20/2012 - 5:00pmJames Walters, earth science department, will present "Permafrost Degradation In the Tanana Flats of Interior Alaska." Walters will discuss the various research projects involving this area of Alaska and how the degradation of the permafrost has impacted the ecosystems. Free and open to the public.
University Museum Saturday Film Series: The Power of an Illusion
Submitted by unimuseums on Sat, 02/18/2012 - 2:30pmThese films are presented in conjunction with the exhibit RACE: Are We So Different? on display at the University Museum February 6 through June 9. Showings begin at 1:30 and run for 56 minutes.
Episode 2: The Story We Tell, February 18
Episode 3: The House We Live In, February 25
Tallcorn Jazz Festival and Sinfonian Dimensions in Jazz Concerts
Submitted by music on Fri, 02/17/2012 - 1:00amThe Beta Nu Chapter of Phi Mu Alpha Sinfonia and the UNI School of Music invite you and your band to the 57th Annual Tallcorn Jazz Festival and 61st Sinfonian Dimensions in Jazz Concerts to be held on February 17 and 18 on the UNI campus. Concerts will be held on Friday, Feb. 17 and Saturday, Feb. 18 at 7:15 p.m. in Bengtson Auditorium at Russell Hall. Peter Apfelbaum, avant-garde jazz pianist, tenor saxophonist, drummer and composer, will be the featured guest artist at this year's event. For more information, click here. Concerts for this event are ticketed. For tickets, call (319) 273-4TIX, or visit www.uni.edu/tickets .
Film Screening: "American Meat"
Submitted by Anonymous on Thu, 02/16/2012 - 8:00pmThe Center for Energy & Environmental Education will host filmmaker Graham Meriwether and show his film American Meat. A time of discussion will follow. Free and open to the public.
Planetarium Shows
Submitted by Anonymous on Thu, 02/16/2012 - 8:00pmPlanetarium shows at 7 and 8 p.m. lasting about 30 minutes each. Free and open to the the public.
Rho Epsilon Meeting
Submitted by Anonymous on Thu, 02/16/2012 - 6:00pmRho Epsilon will host Peoples Company, a leading provider of land brokerage, land auctions, land management, land valuation, crop insurance and land development services. Learn about the company and opportunities available. They employ a number of UNI graduates who support Rho Epsilon. After the meeting free pizza and beverages will be served at the Other Place. All majors are welcome. Contact Charlie Peterson at email@example.com for more information.


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David Ingordo, a well-respected bloodstock agent known across the country, will be speaking to NARA and FCPS students in the Equine Studies program at Locust Trace AgriScience Farm Dec. 10.
Lexington mayor Jim Gray held a press conference at BCTC's Newtown campus to talk about the improvements on West Fourth Street as the road opened to two-way traffic.
The Course Evaluations for Fall and Fall II 2013 are up and available. This survey is completely anonymous. The identity of who did or did not complete the survey is not released. The survey will close on December 6, 2013.
Baker Iron & Metal graciously donated thousands of pounds of metal, selected by Expressive Program artists, which was then transported to the BCTC welding department where students have created 16 unique artistic panels as a semester long project.
More than 700 Latino, immigrant and refugee students are expected to attend the 9th Latino/Multicultural College Fair (LMCF) at the University of Louisville Student Activities Center from 9:30 a.m. - 2:00 p.m., Friday, Nov. 15.
Nearly 500 active military and veteran students are currently taking classes at Bluegrass Community and Technical College.
Central Kentuckians can have their names on a beautiful brick path leading to the future BCTC Administration Building on the Newtown Campus. Money raised through brick sales will be used to fund scholarships and a variety of campus development projects.
For the second consecutive year, BCTC-NARA has been invited to participate in the HH Sheikh Mansoor Bin Zayed Al Nahyan Global Arabian Horse Flat Racing Festival November 6 – 11.
BCTC's Newtown Classroom Building has been recognized by the U.S. Department of Energy as part of the Better Buildings Challenge.