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Antiques and comfortable furnishings in warm prints set the tone for the living room — casual yet elegant. J Gen Intern Med. Hospital billing offices tabulate lengthy itemized bills and charge a multitude of payers using inefficient, complex and separately negotiated rate schedules. Armstrong, Colby Lee and Nick Christoffersen. Koob [ 51 ] overlays a detailed biologic model onto the psychological opponent-process theory. Amanda Mora and Incorp Services Inc continue to provide outstanding customer service. You make little mention of the irrational variation in the level of medicare payments geographically.
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Antiques and comfortable furnishings in warm prints set the tone for the living room — casual yet elegant. Beautiful Saltillo tile sweeps underfoot through the back of the house, a private area that encompasses the kitchen, breakfast and den. Here, a view from the breakfast room looking into the kitchen.
This cute, perfectly purple bedroom with monogrammed initial As on the wall belongs to younger daughter, Ava. An upstairs wall is adorned with artwork created by daughters Anna Claire and Ava Learning is fun at home, too. An upstairs section of the gameroom is cleverly outfitted with school desks and a giant chalkboard.
Jennifer likes to bring nature indoors too. The Adam home is every bit as beautiful from the back, with striking angles that promote views of the pool and golf course beyond A fleet of fun, fanciful mushrooms add ornamentation in the shade garden. The bell-shaped flowers of the gorgeous African blue lily always catch the eye in a summer garden.
Front-Wheel Drive Starting price: Alexis Snapp with Rosemary and A. Gambino at the San Antonio Livestock Show The Survivor, made and donated by quilt artist Carolyn Crump, features a mother and daughter with beaded necklace and earrings. Steps Lighting the Way was made in honor of a woman who lost her battle with ovarian cancer.
The Wright house, located at Katy Historical Park. Swimming is one of the events at the Katy Triathlon at Firethorne. A piece of metal art and matching throw pillow add color to an otherwise bland room. From the Robert Allen Home Collection Designed to blend seamlessly with the ruggedly beautiful landscape, the Southern Ocean Lodge appears to float along its secluded clifftop setting. Traditional English style custom sofas provide supreme comfort.
Kendall and Kristin Bumbera. Troop on the highest peak in New Mexico, Baldy Mountain. Band members congregate at the Firethorne subdivision and play for donations. Examples of local telephone exchanges from ads in the Fort Bend Telephone Co. Eureka science coordinator Jill Wojciechowski helps two students identify rocks. The dance was choreographed by Mariana Luviano. Members of Pack perform a community service project at Exley Elementary.
Partially reclaimed brick was used in the front elevation of the home. The trim and column shape, along with the front door, are typical Arts and Crafts. The front door, South American mahogany, features a glass embellishment designed by a local Heights artisan. Landscaping by Bob Atwood Designs. Family skiing at Spanish Peaks m One of a pair of French porcelain vases, c.
Gift of Ima Hogg. At Ghost Ranch by Brandy Watkins, mixed media collage. Houston Rockets mascot, Clutch, with long-time volunteer Avadele Short. Girl Scouts were among those who read the names of those killed as a result of the events on Sept. Introduced in , lime Jell-O is now the bestsellling flavor. The Kraft package forever changed how Americans eat macaroni and cheese.
Smith proudly owns a copy of the Declaration of Independence that hung in the Library of Congress from until recently. Frank is renowned for his painted artwork. Bronze Chalice sink with wall-mounted brushed-bronze faucet from Stone Forest.
Sink is available in golden bronze, weathered bronze and white bronze. Jaime Sojos and Sgt. A lovely Christmas wreath stretched across this picture window, along with the holiday pillows mixed among the stylish day-to-day décor, bring just the right festive touch to the den.
Williams first-graders learn the importance of brushing teeth. Christin Vogel Attendees enjoy the Arbor Belles welcome luncheon. Peyton Lumpkin, District 17 senior vice commander. Posing with the last Katy passenger train: McDonald, Station Agent G. McGinnis, Leroy Wilkinson, Mrs. Charles Sheridan and children; Marie and Lee, Mrs. The conductor was Harry R.
Tidwell of Smithville and the brakeman was Bill DeLoach. Katy kids waited for the last train and waved as it went by on Nov. Pool by Pilot Pools. The Sea Beneath by Sherry Sullivan, oil and acrylic on canvas, One big happy family: Photo by Pam Francis Debbie and Roger enjoying a beautiful landscape. Roger enjoying golf at one of the lodges at the Renaissance course in Scotland Roger gives Cy a shampoo In winter, buy several small pots of hyacinths and transplant the bulb flowers into a larger pot.
Fragrant hyacinths are one of the joys of the indoor spring garden. Plant multiple pots of hyacinths from the supermarket or home center in one big attractive container. Stunning wood elfa décor Shelves beautifully store your accessories while elfa Hanging Drawers and Closet Rods keep clothing perfectly organized and easy to access.
Exclusive to Container Store. Griffin Elementary third-graders recognize veterans during its annual choral concert. How Brandon Wees feels about his 3-year-old sister, Ashlynn.
Balancing Act is a new exhibit on view through May The Shortbread package has a new look to celebrate the th anniversary of Girl Scouts. Steer roping takes time, talent, and a lot of nerve. Rodeo clowns come in handy when the bulls have a mind of their own!
Fans look forward to bronc busting every year at the Katy Rodeo. Barrel racing requires a good horse and plenty of practice. The formal living room, which opens fluidly to the outdoor entertaining space, offers this family more than ample room to gather comfortably with friends. Remarkable details like the antique Indian boat masts, which seem to float from the walls, the wooden folding chairs or the Indonesian shutter panel with the authentic Dutch seal in the middle can be found throughout the home.
The snow area was a huge hit with kids at the Katy Old Fashioned Christmas event. Members of the Beckendorff Choir spread holiday cheer with the gift of song.
Cinco Ranch High School Varsity swimmers collect gifts for wounded soldiers. Fourth- and fifth-grade Student Council members from Hayes Elementary. Hope Harris, already a veteran of many stage productions at age The Marquette bed from Hooker Furniture has a headboard and footboard featuring an Art Nouveau-inspired egg-shaped motif. While the bold pattern has a contemporary vibe, it also represents a return to tradition, playing off the age-old designs of grillwork and lattices, but in a way that works for 21st century homes.
Bagpipes and music greet visitors at the North Texas Irish Festival. The Girls U12 Four Hand team: The team placed 21st at the Southern Region Oireachtas. Aoife Ni Ghloinn, Rev. Harold Good, Lori Gallagher of St.
Max Triola is on the far left. Cass Academy Dancers at the Rocky Mountain competition. Celtic crosses appear here and there at the North Texas Irish Festival.
McKenna Sheedy hopes her story about living with psoriasis will help other parents and children. Members of Katy Students Run. Sean Payne receives a prestigous award from Boy Scouts of America.
A striking piece from South Africa sits atop an eclectic tabletop in the upstairs foyer. Far right bill oldham, a representative of the fort bend thrivent financial for lutherans board, presents a check to job ministry leaders l-r selina ponniah and jean marie huntington to help with expenses for the christ centered job fair. Members of Brownie Troop learned about Life Flight and even had the opportunity to sit in the helicopter.
Griffin Elementary students and staff at the Katy Rodeo Parade. Naval Academy dean of admissions; Johnathan Leyba; Lt. Science teacher Blake Lannom with student Symphony Yellowe. Stacy Levin is greeted by students after being named Teacher of the Year. Pergolas create a backyard destination perfect for relaxing or entertaining.
The sheltered cane headboard is presented here in antique white. The curves of the bed echo the shape of the windows and nightstand.
Sherry at Wimbledon, pointing to her favorite tennis player, Andre Agassi. The two were born the same year. Stewart with his car and driver in front of his home and office. Stewart sometimes rode his bike to make house calls. The Lyon family l-r: Andrew, dad Brandon, Lucy, mom Sara and Isaac. The views are heavenly at Ski Santa Fe which is nestled in the extreme altitudes of the beautiful Sangre de Cristo Mountains. Photo courtesy of Lee Klopfer. Oak trees on Second Street today.
These trees were planted beside the Cobb Hotel on Second Street about Resort Entrance Cambridge Outdoor Fireplaces are available in a selection of styles and colors with options for firewood storage and even an illuminated water feature.
Bride and groom share a tender moment in their winter wonderland. Spa Tower draws on Renaissance architecture to create a feeling of elegance while accentuating the soaring tower design of the shower. Mark Johnson stands by a mural for his late daughter Teresa at Huggins Elementary school library, where he is a volunteer.
Lucy Chen with her trophy and winning artwork. More than individuals were in attendance at the Cosentino Center Grand Opening event. Katy franchisee Cosmo Parisi with his daughters at the Grand Opening event. Bob Boyette gets ready to make his famous omelets.
Katy Elks officers for The Cooper kids in March The depot in the s. The Drix Gourmet burger is topped with garlic aioli, avocado, cheddar, romaine, tomato and red onion. Drix offers martinis as part of its Happy Hour menu, which runs Tuesday through Sunday from 4 until 7 p.
Festive scarecrow in a pumpkin patch for custom order Custom orders for weddings, anniversaries and special events Sophia created a grand piano with a bench for a special order. Newborn Madeline Leigh Armstrong. Drix Restaurant and Lounge offers a lunch menu on Tuesdays through Fridays from 11 a. David Sander left and Charles Talab right with retired Maj.
Army, who was a guest speaker at the Scout Recognition ceremony. The Erickson family at the dedication of the Cindy W.
Troop scouts and leaders. Roxolana Krywonos with her wall of art awards. The identity of the bride and groom in this photograph are uncertain, but the preacher marrying them is Wm. Featherston came to Katy in and became the first preacher for the Baptist Church. The home he lived in is now located in Katy Heritage Park.
The smiling couple enjoyed a toast. The group will appear in a special one-night-only concert at Jones Hall July Freedom Fest attendees enjoy the parade.
In the Wildlife on Wheels program, children will learn about the animals that are native to Texas. Tatyana Panchishna took First Place for grades K The Regatta Gospel Concert was the brain child of Dr.
Patricia Barbieri and her daughter, Ashanti, found that Camp Cinco was just what they were looking for this summer. Swimming is a major part of summer camp each week. The blue confetti from the balloon pop told the very happy couple that they are expecting a son.
Yard sale items ready for the big day. With its sleek look and innovative features, this KOHLER Bellera pull-down kitchen faucet combines an elegant, versatile design with exceptional ergonomics and functionality. The high-arch spout rotates degrees and reaches over the tallest pots, while the compact, three-function sprayhead pulls down into the sink for up-close tasks, or out of the sink to fill pots.
The room makes a memorable, dramatic impression, especially the stunning arced onyx sink with gold fixtures and a rustic Asian-themed wood frame on the curved mirror. The couple share a kiss in front of a Texas flag barn in Needville, Texas.
The Resort at Pelican Hill A departing kiss for the guests. Mayo, of course, is in an excellent position to negotiate aggressively for better payments from private insurers since it is, after all, the Mayo Clinic. Second, it is my impression that Medicare Advantage payers do not necessarily pay more than Medicare or less than Medicare.
Some Medicare Advantage players seem to pay quite a bit less. In my city, the largest provider system recently created a tempest by refusing to accept four Medicare Advantage insurers which had become popular with enrollees by issuing policies that had monthly fees lower than Medicare Part B. According to the health care system, one of the ways they were doing that was by paying providers and hospitals less than Medicare. Medicare Advantage comes in three flavors, as far as I can see.
Second, there are systems that entice clients with frills like gym memberships and so on, which they buy in bulk for low costs, partly because so few of their clients actually take advantage of the frill. They can be good, bad, or indifferent. Third, there are systems that entice clients by offering their coverage for less than the cost of Medicare Part B premiums. In addition to the usual subsidy from the government, those systems do that partly by paying out less in claims, like the offenders in my home town.
Pat S, Thanks for the info. In your state, do private plans bundle there hospital payments, as Medicare does, or is it more like fee-for-service. JRossi — That varies with the arrangement that the insurers have with the hospitals. As I say, the most basic arrangement is fee for service with discounts, either negotiated or imposed, but almost every form of payment exists.
Sorry to slander you with being in California. As I recall, you have moved around a lot, but thought you were based in LA area now. Where are you now? Thanks for the info, Pat. Wow, this insurance stuff sounds too complicated for a dumb family doc like me.
An MRI was ordered. The MRI building was 70 steps from the main building. Afterward, the procedure was reversed. We got a copy of the ambulance bill from Kaiser: If billed to Medicare, I know why that program is going broke. The neurosurgeon also failed to recognize the characteristic symptoms of hydrocephalus on the return visit, until prompted to look at a CT scan taken that morning.
He denied that the hydrocephalus had anything to do with the slip in surgery and damaging the dura. But he put in a shunt the next morning, though he could not tell us what model valve he had used. Marc— I know that some readers —you, in particular— know far more than I do about Medicare. I rmemver that you have worked for Medicare in Washington.
So I greatly appreciate your confirmation that Pat has covered this subject very well. EVeryone— Let me add that this post began when Pat wrote a comment on this blog about Medicare payments that told me more than I had ever been able to find out about the subject.
Art Appraisor— Like you, I had done research on this topic, but hit blank walls— thank you, for your comment. It also confirms my take that Pat S.
He is a doctor and so understands the story from the inside. Gunther— I am very, very sorry about what happened to your wife.
Would you be willing to tell this story to a very good reporter represnting a large news outlet? Pat, you are quite right about ICU beds driving demand.
This also occurs with hospital beds in general. The high availability of VA beds drives admission to the barely ill. It is likely the explanation for the low readmission rates at VA hospitals. Health systems that cater to the employed, such as Kaiser, have the advantage of low disease prevealence and high payments.
Hospitals where medicare dominates the payer mix have the opposite problem. You have made an excellent point regarding outliers. These rare events tend to dominate overall costs. Many of these outliers are hopeless cases which will require EOL reordering, significant costs paid by the patient to discourage futile care and tort reform to bend the curve.
You make little mention of the irrational variation in the level of medicare payments geographically. Hospital featherbedding is a much larger problem that is never mentioned. Our hospitals have literally dozens of vice presidents with secretaries who themselves have secretaries and assistants, but no actual responsibilities. Pat Thanks for the reference. ICU patients a likely source of pay disparity, but I would be willing to bet that hospital geography, case mix, type and size of hospital may change equation.
The paper is more of a 30K feet looksie. Again, more than just hypothesis generating, but not quite the last word. When Medicare writes about outliers they tend to focus on outlier payments, but their focus is budgetary and is on the payments as a percentage of all Medicare payments, not on numbers of patients. In general, Medicare believes their payments are adequate, and that overpayments for patients who are managed at a lower cost than the DRG payment cover underpayments for most outliers.
They are charged with creating DRG payments that cover costs appropriately, and base their payments on empirical data. It is the hospitals and private insurers who argue that underpayment is a problem, and their organizations and academic studies by sympathetic researchers are responsible for most of the literature on the topic. Most of the literature from MedPAC and other government sources focuses on the idea that claims of losses are related to poor management and errors.
I would be very interested in seeing a breakout on outliers that included the frequency of outlier status being due to preventable management problems and errors. The only other thing I will add is that during 30 years of medical practice I must have sat through at least meetings in which hospital executives have exhorted the assembled medical staff to make every possible effort to control the costs of outliers because they account for most losses on clinical services.
Get out there and improve management of those patients and save the hospital bottom line. You seem to have a wealth of knoiwledge on this subject. Regional variations of Medicare payments are an issue that causes a lot of controversy among politicians and health care professionals. The variation for hospital payments is due to the calculation of the weighting factor for wages, the weighting factor for academic training centers, and the weighting factor for high populations of Medicaid and non-paying patients.
In some areas of the country these variation factors are partly mitigated by other weighting factors for critical access and regional referral status for hospitals in low population areas. Medicare believes that their weighting system is fair, and reflects real costs of hospital operation as well as protecting the financial position of hospitals providing critical services in low income areas, in rural areas, and of training institutions.
Vows by politicians to refuse to vote for needed programs unless their regions get more money are common features of political discourse on health care. It is absolutely true that every single health care administrator in the US believes their hospital is being cheated by the system, and should get more money. The issue that is valid in examining this question is whether calculations of wage costs and of service to low income patients are correct.
Those variations, which are based on cost of living calculations which in turn are largely based on wage and real estate costs with a contribution from politics, cause a lot of dissatisfaction. I spent my entire career in areas that were on the low end of the payment scale, and often felt that the calculations were unfair.
Your other points are largely true. The VA also sees a lot of very sick older vets with complex underlying health problems that have been neglected for years. I would be willing to bet that COPD, congestive failure, type 2 diabetes, and liver disease are much more prevalent among VA patients than the general population.
These patients result in a level of acuity in VA admissions that rivals or exceeds that of suburban hospitals that send some patients home that the VA might admit. My best guess is that the reason private insurers pay more is for competitive reasons having to do with offering coverage that allows them to secure clients.
Private insurers have to deal with the possibility that health systems will refuse to accept their insurance. That creates all sorts of potential problems with sales.
Medicare, of course, has its famous partial monopsony status. One piece of evidence that this is true is the large variation in payments by private insurers. Christopher, Don, Everyone Christopher— Your assertion that the large number of available beds drives VA hospital admission for patients who are barely ill is simply not true.
As a result of the Gulf War, and now the War in Iraq—not to mention aging Vietnam Vets—we have a huge number of Vets needing all types of care. In most areas, capaciy is strained. In particular, we have many Vets from the IRaq war suffering from serious psychological problems and post-stress trauma.
Many need to be hopsitalized. One would think that since private insurers are payors, they would be arguign that hospitals are over-charging and could care for patients for less if they were more efficient. They can always pass excessive costs on to the cutomer. This is why we need a public plan to look out for the public good. Higher quality care at a lower cost. Pat makes very good points about Kaiser and the VA in his Aug 26, 11 32 a.
Kaiser now has many Medicare Advantage patients. And we know that low-income people are far less healthy than the rest of the population. Also, while many Vietnam Vets were drafted into the army the effects of being in Vietnam trauma, stress, psychological problems drug addiction thanks to the wide availability of drugs made many of them unemployable or only barely employable when they came home.
So today, at age 60, they are poor and have little in the way of a support system. Thus the VA does become a nursing home for Vets who otherwise might be living on the street.
I disagree with you that Medicare cannot just pass the costs on, for it would have to raise taxes. They have very creative ways to handle deficits, such as borrowing from the Treasury, and not paying back principal or interest, or simply taking from general revenues and increasing the debt. Far from borrowing from the treasury, the treasury is borrowing from it. Granted, Part B, Medicare Advantage, and Part D are large users of government subsidies, partly, in the cases of Part D and Advantage, to give largess to various private companies that are major beneficiaries of the programs.
It is also true that Part A is going to go into the red sometime within ten years unless something is done. This is what makes the assertions that reform will hurt Medicare so ludicrous, since far from hurting Medicare, the reforms are necessary to save it, the only other choice being to increase costs and cut services to the beneficiaries to the extent that the program would be destroyed.
The Trust Fund Perspective is nothing other than accounting, as if you were putting debits and credits in your calculator. It is not dealing with actual cash. Don — You are right. The obligation to find the money to fund Medicare and Social Security is an obligation of the general fund, and the taxes, mostly income taxes, it uses. The government has spent every penny of the Medicare and Social Security trust funds on tax cuts for high bracket payers and on misadventures in the Islamic world.
But they still owe that money to the programs. I know that is popular idea among people of some political orientations, mostly because they would like to explain away the taxes that the general fund will have to raise to pay those obligations. Just watch what happens to the ability to sell other government obligations and to any politicians who try to sell the idea that the trust funds have vanished with a poof. You can follow any theory of voodoo accounting you choose, but the government is stuck with the obligation because it is politically and economically impossible for them not to honor the obligation.
The people who saved billions in taxes at the expense of the trust funds better get used to the idea that the taxman is coming back, and start saving up now, because the government is going to have to put that actual cash they borrowed back. Meanwhile, we should return to our regularly scheduled programming, a discussion of the relationship between hospitals and Medicare, and the facts governing that relationship.
An excellent informative post. Makes me want to read your book. My overall impression from reading your blog is the huge intricacy and complexity of the payment system. DRG payments are based on individual patients, and it seems inevitable that providers will game that kind of system to increase reimbursements. Reimbursements could be calculated for large numbers of patients grouped into broad categories.
The stability and predictability of aggregate-based payments would be greater. And because the variance of the group decreases with size, it should be more difficult to game the system—outlier billing would be detected quickly and could be audited. To discourage cherry-picking, payments based on broad categories could be adjusted by statistics on the overall health of the population served. That is essentially what the DRG system is. I am sorry if that was not clear in the original post.
The problem being encountered is that like all collections of statistical data, there are some patients — outliers — who do not fit well in the general data. For hospitalized patients those tend to be either people with underlying health problems that complicate their stay and lead to longer admissions with more intense treatment, or people who suffer misadventures while in the hospital, either unavoidable or avoidable, that lead to them requiring longer stays with more intensive management.
This outlier status is pretty close to what would be expected in any statistical analysis of data based on humans, with outliers fairly near the first and second standard deviations, although the curve is slightly shifted from an absolutely standard distribution. However, the big news is that better management techniques by hospitals can decrease outliers, especially programs designed to provide effective care and avoid marginally effective or ineffective care, efforts to improve the baseline health of patients who are regular repeat users of hospital services, and programs to decrease occurrence of untoward events that complicate patient care.
There are programs on the shelf to begin accomplishing all these things, and certainly new ideas should be developed based on good research. However, compliance with these things is not uniform or even widespread, for a variety of reasons mostly due to culture in health care and to the reluctance to recognize that up to this point a hospital may not have been doing the best possible job for some of its patients.
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The Heritage Foundation took into consideration everything from the estimated cost of immigrants accessing welfare programs like food stamps, which they are not eligible to do for 13 years, to the cost of providing health care and education for immigrants and their children.
Pleased to meet you www. One would also hope the Ministry of Justice would support him as well. This would set an unfortunate, dangerous precedent if this woman is allowed to hide her face from the jury. Not only has it got his unmistakable genius behind it, it is totally wearable and will make you the coolest girl of the party season. He returned in April after a disastrous stint by RonJohnson, a former Apple Inc retail executive who Ackmanhad picked to turn around the company.
An accountancy practice spooool. There are universal gestures for victory, defeat and stress that appear to transcend country and region. An accountancy practice www.
Her friend Jamie McDaniel told WUSA-9 that she saw soda cans and bottles filled with paint when they discovered the vandalism and reported it to police.
Have a great day. Some feel this behavior further alienates the few female graduates in STEM fields science, technology, engineering and math who wind up getting jobs in the tech sector. Redmond also got an inning-ending double play from Wil Myers with two on during the sixth. The policemen they were all men kept reminding us to keep our doors and windows locked; the burglars, however, seemed to favour removing the glass from a windowpane. They became best known for blowing a record point lead in a playoff game against the Bills at Buffalo on Jan.
A jiffy bag itintellectuals. The federal government says the entire ratification and approval process on both sides of the Atlantic will take between 18 and 24 months. July business inventories rose more than expected. I want to report a spooool. Tests found, however, that the two novel viruses, plus another from Hangzhou province, bind to human receptors, a factor the researchers said may be critical for the viruses to transmit in ferrets.
Maybe they did that just for me, lowered the cap just for me. Then Apple and Samsung ushered in the age of the touch-screen smartphone, and Lazaridis and his team were slow to adapt to the shift in consumer preferences. Hold on for dear life. With one man clinging to the side of the raft and the other knocked unconscious by the raging rapids, the whitewater rafting trip quickly became a rescue attempt by off-duty river guide Russ Cole. Cole managed to pull the man to shore.
The man was rattled but there were no signs of physical injury. There were a lot of folks who were surprised by the bipartisan votes that came out of this markup this morning. TransCanada said the ,bpd line is 85 percent complete and expected to be in service bythe end of the year. I work for myself prontoprinterofnewington.